Aviata At Fletcher
Inspection history, citations, penalties and survey trends for this long-term care facility in Tampa, Florida.
- Location
- 518 W Fletcher Ave, Tampa, Florida 33612
- CMS Provider Number
- 105644
- Inspections on file
- 29
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Aviata At Fletcher during CMS and state inspections, most recent first.
The facility failed to maintain complete and accurate medical records for three residents following alleged abuse and resident-to-resident incidents. In one case, a cognitively intact resident with diabetes and multiple comorbidities reported a verbally abusive interaction with an RN during insulin administration, but no nursing progress note or SBAR entry was made. In another case, a cognitively intact resident with complex cardiopulmonary conditions was involved in an agitated episode where he reportedly pushed another resident’s walker; although psych services documented the event, nursing staff did not complete any progress notes, SBAR, or care plan updates. In a third case, a resident with schizoaffective disorder and other chronic conditions was bumped in her wheelchair and threatened by another resident; psych and medical providers evaluated the residents, but there was no corresponding nursing documentation or care plan revision for either resident involved, contrary to facility policy and stated expectations.
Three residents experienced significant medication errors, including one who received a morphine overdose due to improper measurement by an RN, and two others who were given each other's medications during a distracted med pass. The errors were confirmed through interviews and record reviews, with failures in proper medication administration, documentation, and notification as required by facility policy.
A nurse administered a resident's roommate's Tylenol without a request, and the provider was not notified of the medication error as required by facility policy. The resident, who had multiple medical conditions and was cognitively intact, did not experience adverse effects. Staff interviews confirmed the provider was unaware of the incident, and the facility lacked a specific policy for medication error notification.
A resident with multiple complex conditions was administered Vancomycin without consistent monitoring of required trough levels, as lab draws were missed or not performed and results were not communicated to the pharmacy or providers. The pharmacy continued to dispense the medication without receiving necessary lab results, and nurses administered doses without confirming therapeutic levels, resulting in critically high Vancomycin levels and the resident's transfer to the hospital.
A facility failed to verify employment history and references for a CNA, leading to allegations of sexual abuse by two residents. The facility's policy requires screening for abuse history, but no documentation showed efforts to verify the CNA's past employment or references, which were relatives. The DON was informed of the allegations, and the police and DCF were notified. The HRG confirmed the lack of verification, contributing to the deficiency.
A resident with chronic pain conditions did not receive appropriate pain management due to the unavailability of prescribed Percocet in the medication cart, and the absence of a narcotic log. Staff interviews revealed lapses in following procedures for managing narcotic medications, leading to the deficiency.
A resident experienced a medical emergency and was administered Naloxone HCl by the DON, but this was not documented in the MAR. The resident, with a history of chronic pain and anxiety, was admitted to the hospital after her face turned blue during a medication pass. Despite the administration of Naloxone and removal of a fentanyl patch, the incident was not recorded, indicating a failure to maintain accurate medical records.
The facility failed to follow planned food menus for two residents, serving different items than listed due to a shortage of bacon. The menu change was not communicated to staff, residents, or the dietician, violating facility policy. The Resident Council had previously raised grievances about food quality and lack of follow-up, but no documented action was taken.
The facility failed to implement an effective QAPI program, leading to deficiencies in following food menus and addressing resident grievances. Residents frequently did not receive meals as listed, with substitutions made without proper documentation or dietician approval. The Kitchen Manager admitted to ordering errors and lack of documentation, while the Registered Dietician was not consulted for substitutions. Ongoing issues with meal service, including the use of Styrofoam plates and missing menu items, were highlighted by staff and residents.
A facility failed to assess a resident for the safety of self-administering nebulizer treatments. The resident, who was cognitively intact and had a history of cerebral infarction, was observed using a nebulizer without a nurse present and without a care plan or physician's order for self-administration. The DON confirmed that the required assessment and documentation were not completed, violating the facility's policy.
A facility failed to follow enhanced barrier precautions during urinary catheter care for a resident. An LPN moved a catheter bag from the floor without wearing gloves or a gown, despite the resident being on enhanced precautions. The resident had a urinary catheter due to medical conditions, and the facility's policy required the use of gowns and gloves during high-contact care activities.
A resident with a Full Resuscitation order was mistakenly identified as having a DNR order during an emergency, leading to a failure to provide CPR. The error was discovered after the resident's death, revealing that the DNR paperwork belonged to another resident. This incident highlights a deficiency in the facility's handling of advance directives and emergency procedures.
A resident with a Full Code status did not receive CPR due to a mix-up with another resident's DNR order. The nursing staff mistakenly believed the resident was a DNR, leading to a failure to initiate CPR when the resident became unresponsive. The error was discovered after the resident's death, revealing a critical lapse in verifying advance directives.
The facility failed to honor resident rights regarding health insurance choices for three residents. Residents were encouraged to switch from a Medicare HMO to straight Medicare without ensuring they fully understood the changes. Incomplete attestation forms lacked necessary signatures, and residents expressed confusion or were unable to make informed decisions. This highlights a failure to respect residents' rights to make informed choices about their health insurance.
The facility failed to maintain a sanitary condition for one of its ice makers used in the main dining room, as observed by surveyors. The ice maker showed heavy oxidation and bio-growth on the inner chute, which was confirmed by the Dietary Manager. The facility's policy requires cleanliness in food service areas, but there was uncertainty about who was responsible for cleaning the ice machine.
The facility failed to provide a safe smoking area for residents, lacking shade and hydration on the smoking patio. Observations revealed residents seeking minimal shade from the building and no fluids available during smoking sessions, despite high temperatures. Staff confirmed the absence of drinks and cooling devices, and residents expressed concerns about the lack of shade and hydration. The administration acknowledged these issues but had no clear plan to inform residents about fluid availability.
A resident with intact cognition and significant care needs reported being hit by a CNA, but the allegation was not investigated or reported according to facility policy. Staff interviews revealed a lack of communication and follow-up, and the incident was not documented in the facility's logs.
A resident with significant dental issues, including a toothache and broken teeth, was inaccurately assessed in the MDS as having no dental problems. Despite the resident's reports of pain and difficulty eating, the facility's MDS Coordinator/LPN acknowledged the coding error. The resident did not receive necessary dental care due to financial constraints, as the referred provider did not accept Medicaid. The facility failed to provide a policy on accurate assessments.
A resident with a self-care performance deficit and risk for pressure injuries was not provided with prescribed protective heel boots while in bed, as observed over several days. Despite the resident's willingness to wear the boots, staff failed to assist in their application, and documentation inaccurately indicated compliance with the care plan. Interviews revealed a lack of awareness and responsibility among staff regarding the resident's care requirements.
A resident admitted with a urinary tract infection and sepsis had an IV line that was not properly labeled or managed according to the facility's standards. The IV dressing was not changed upon admission, and there was no documentation of a dressing change. The Director of Nursing confirmed the dressing was not labeled, and there were discrepancies in the type of IV line documented. The facility's policy required all tubing and dressings to be labeled, and the lack of labeling indicated the dressing was out of date.
A resident with significant dental pain and difficulty eating did not receive timely dental care due to financial constraints and inadequate facility response. Despite being cognitively intact and having a care plan for dental issues, the resident's needs were not met, and the facility failed to document and address the dental concerns effectively.
A facility failed to maintain infection control during medication administration when an RN used bare hands to remove and replace medication tablets, touching other tablets in the process. This occurred while administering medications to a resident with multiple prescriptions. The DON confirmed that staff should not use their hands for this task and that medications should be disposed of using a drug buster, but the facility lacked a specific policy for medication disposal.
Failure to Document Abuse and Resident-to-Resident Incidents in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to alleged abuse and neglect incidents for three residents. For one resident with osteomyelitis, diabetes, mood disorder, history of falls, hypertension, lymphedema, and a left below-knee amputation, the resident reported a verbal altercation with a night RN during medication administration involving fast-acting insulin. The resident, who was cognitively intact per a BIMS score of 15, stated the nurse told him not to tell him how to do his job, made an explicit comment, and repeatedly returned and harassed him. The Nursing Home Administrator (NHA) later confirmed through interview with the nurse that the nurse admitted to disrespectful verbal exchanges and name-calling. Despite this, there was no documentation in the resident’s medical record—no progress note or SBAR entry—describing the incident, the nursing assessment, or notifications, even though the facility’s own leadership stated such documentation was expected. For a second cognitively intact resident with multiple diagnoses including interstitial pulmonary disease, COPD, diabetes, asthma, cognitive communication deficit, depression, dialysis, CHF, and hypertension, staff requested a psychiatric evaluation following an episode of agitation in which the resident reportedly pushed another resident’s walker. The psychiatric note documented the episode and the resident’s response during the evaluation, including that he was newly admitted for rehabilitation, had a hard year, became paranoid during the interview, and declined psychiatric medications. However, the resident’s medical record contained no nursing progress notes or SBAR assessment related to this resident-to-resident incident. Additionally, there were no care plan updates to address the behaviors or the incident, despite the occurrence of an altercation between residents. For a third resident with schizoaffective disorder, bipolar type, COPD, seizures, chronic pain, anxiety, depression, and hypertension, a psychiatric progress note documented that the resident was seen following a resident-to-resident incident in which she was bumped in her wheelchair by another resident. The note stated the resident was calm, cooperative, had no adverse effects, denied abuse or neglect, and had no psychosocial distress or injuries. Interviews with the NHA and Nurse Consultant clarified that the incident involved one resident bumping another’s wheelchair on the smoking patio and making a threatening statement, after which the residents were separated and monitored. Despite this, the medical record for the resident who was bumped contained no nursing progress notes, SBAR, or assessment documenting the incident. The record for the resident who did the bumping also lacked any documentation of the incident, including progress notes, SBAR, assessment, or care plan updates, even though facility leadership stated they expected such documentation and care plan revisions after incidents. The facility’s own policies on abuse, neglect, exploitation, and plans of care require thorough nursing evaluation, documentation of incidents, and care plan review and revision in response to changes in resident needs or incidents. The NHA and Nurse Consultant acknowledged that there was no documentation in the medical records for these incidents and that nursing staff had not been educated on documentation requirements post-incident, including progress notes, SBAR, assessments, and care plan updates. The NHA also acknowledged that although the reportable investigation form indicated that progress notes had been reviewed, the progress notes related to the incidents were not actually present in the records. This lack of required documentation for alleged abuse and resident-to-resident incidents constitutes the cited deficiency in maintaining complete and accurate medical records in accordance with accepted professional standards.
Significant Medication Errors Affect Multiple Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by three separate incidents involving three different residents. In one case, a resident with multiple complex diagnoses, including cerebrovascular disease, chronic kidney disease, and terminal status under hospice care, was administered morphine sulfate at a dosage ten times higher than ordered. The nurse responsible used a medication cup instead of a syringe, resulting in the administration of 2.5 ml instead of the prescribed 0.25 ml for three doses. This error was discovered during a narcotic count discrepancy, and the nurse admitted to the incorrect measurement method. Interviews with facility leadership and medical staff confirmed the error, though it was unclear if the overdose contributed to the resident's subsequent decline and death, as the resident was already in a terminal state. In another incident, a resident reported that she and her roommate were given each other's medications by the assigned nurse. The resident received three Tylenol tablets and one Gabapentin tablet intended for her roommate, while her roommate received her medications. The resident did not experience any negative effects but found the situation concerning. Review of physician orders and interviews with the DON and the nurse involved confirmed that the medication mix-up occurred during a medication pass when the nurse became distracted. The nurse did not notify the provider about the error, rationalizing that the resident had a PRN order for Tylenol. A third resident also reported receiving her roommate's medications, including Midodrine, Amlodipine, and Gabapentin, while her own medications were given to her roommate. The error was identified when the resident questioned an unfamiliar pill, prompting the nurse to realize the mistake. Documentation and interviews revealed that the incident was not clearly detailed in the incident report, and the medications given were not fully documented. The facility's policies require verification of resident identity, proper documentation, and notification of providers and families in the event of medication errors, but these procedures were not consistently followed in these cases.
Failure to Notify Provider of Medication Error
Penalty
Summary
A medication error occurred when a nurse administered a resident's roommate's medication, specifically Tylenol, to the resident without a request. The resident, who had a history of multiple medical conditions including an open abdominal wound, stage 3 pressure ulcer, and cardiac issues, did not experience any negative effects and was cognitively intact at the time of the incident. The nurse became distracted during the medication pass, which led to the error. The incident was reported to the Director of Nursing (DON), who confirmed that there was no documentation indicating that the resident's provider was notified about the medication error. Interviews with facility staff and the resident's provider revealed that the provider was not informed of the medication error, despite facility policy requiring prompt notification of the resident, physician, and representative when there is a change in status or condition. The DON and Regional Nurse Consultant acknowledged the lack of a specific policy for medication error notification but stated that such incidents should be treated as a change in condition. The provider expressed an expectation to be notified of all incidents involving her patients, but no notification was made regarding this event.
Failure to Obtain and Communicate Vancomycin Lab Results Leads to Medication Toxicity
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice related to the administration of Vancomycin. The resident, who had multiple complex medical conditions including cellulitis, chronic ulcers, MRSA, end stage renal disease, and diabetes, was admitted with orders for Vancomycin and required regular laboratory monitoring, including Vancomycin trough levels, to guide dosing and prevent toxicity. Physician orders specified the timing and frequency of these labs, and the pharmacy was to dose Vancomycin based on lab results. However, the facility did not consistently obtain the required Vancomycin trough levels prior to administration, and there were multiple instances where lab draws were missed or not performed as ordered. There was a lack of communication and follow-through among nursing staff, providers, and the pharmacy regarding the missing or delayed lab results. Documentation shows that when lab draws were unsuccessful or not obtained, there was no evidence that the physician or pharmacy was notified in a timely manner. Orders for Vancomycin troughs were sometimes entered incorrectly or not clarified, and some lab orders remained in a pending status and were not transmitted to the lab for collection. The pharmacy continued to dispense Vancomycin without receiving the necessary lab results, and nurses administered the medication without confirming that current trough levels were within the therapeutic range. This led to the resident receiving Vancomycin despite the absence of critical lab monitoring. Ultimately, the resident developed critically high Vancomycin levels, which were only identified after a delayed lab draw. The elevated levels prompted discontinuation of the medication and transfer of the resident to the hospital for further care. Interviews with facility staff, providers, and pharmacy consultants confirmed that there was a breakdown in the process for obtaining, documenting, and communicating lab results, as well as a lack of oversight in ensuring that Vancomycin was administered safely and according to orders.
Failure to Verify Employment History and References Leads to Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse, Neglect, Exploitation, & Misappropriation Policies and Procedures by not attempting to verify information from former employers prior to hiring a Certified Nursing Assistant (CNA), identified as Staff A. The facility's policy requires screening of applicants for history of abuse, neglect, exploitation, or misappropriation of resident property, which includes verifying employment history and references. However, the personnel file of Staff A showed no documentation of efforts to verify employment history with any of the listed providers or the private employers mentioned in the application. Additionally, the references provided by Staff A were relatives, and there was no evidence of attempts to contact them. An incident involving Staff A led to allegations of sexual abuse by two residents. The Director of Nursing (DON) was informed by the Assistant Director of Nursing (ADON) that a resident had accused Staff A of inappropriate touching. The police were notified, and during their investigation, another resident reported a similar incident involving Staff A. The Department of Children and Families (DCF) was also notified, and both residents' accounts were consistent. A third resident reported a separate incident of inappropriate behavior by Staff A during a quality assurance questionnaire. The Human Resource Generalist (HRG) confirmed that part of the hiring process was to verify references, but there was no documentation to show that this was done for Staff A. The HRG provided a checklist used for new hires, which included sections for reference checks, but admitted that the form was newer and did not specify when it was initiated. The lack of verification of employment history and references for Staff A contributed to the facility's failure to adhere to its policies and procedures, resulting in the deficiency.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with a history of spinal stenosis, morbid severe obesity, chronic pain syndrome, and intervertebral disc disorders. The resident was on a scheduled pain medication regimen and received PRN pain medications, experiencing pain almost constantly, which affected her sleep and daily activities. Despite having physician orders for Percocet to manage moderate and severe pain, the medication was not available in the medication cart, and there was no narcotic log for it. Interviews with staff revealed a lack of adherence to procedures for managing narcotic medications. Staff I, an RN, confirmed that narcotic medications should be in the medication cart with a corresponding log. Staff K, another RN, described her process for managing narcotics, including reordering medications and checking the emergency drug kit, but failed to ensure the availability of Percocet for the resident. The ADON and Staff J, RN, acknowledged the oversight, with Staff J noting that the pain management team visits the facility twice a week and that she communicates with the physician to reorder medications when necessary.
Failure to Document Naloxone Administration in Medical Records
Penalty
Summary
The facility failed to ensure the accuracy of the medical record by not documenting the administration of Naloxone HCl for a resident who experienced a medical emergency. The resident, who had a history of spinal stenosis, morbid obesity, anxiety disorder, chronic pain syndrome, and intervertebral disc disorders, was admitted to the hospital after an incident where her face turned blue following a medication pass. The resident reported that she was told by the ER physician that she had overdosed. Despite the administration of Naloxone HCl by the Director of Nursing (DON) during the incident, this was not recorded in the resident's Medication Administration Record (MAR). Interviews with staff revealed that the DON administered Naloxone HCl and removed the resident's fentanyl patch after noticing the resident's low oxygen levels and blue lips. The DON confirmed that the Naloxone HCl administration should have been documented in the MAR, but it was not. The Regional of Clinical Services also confirmed the absence of documentation regarding the administration of Naloxone HCl and the resident's subsequent transfer to the ER. This lack of documentation represents a failure to maintain accurate medical records in accordance with professional standards.
Failure to Follow Food Menus and Address Resident Grievances
Penalty
Summary
The facility failed to adhere to the planned food menus for two residents, resulting in discrepancies between what was served and what was listed on the menu slips. Resident #5 received scrambled eggs and an untoasted English muffin instead of the double protein buttermilk pancakes, bacon, and other items listed on her menu slip. Similarly, Resident #4 did not receive the ground sausage patty as indicated on her menu slip, receiving pureed English muffin and oatmeal instead. These deviations from the menu were observed and confirmed during interviews with the residents. The Certified Dietary Manager (CDM) and the cook acknowledged the menu changes, citing a shortage of bacon as the reason for swapping Thursday's menu with Friday's. However, this change was not communicated to the staff, residents, or the dietician, as required by the facility's policy. The dietician was not informed of the menu swap and expected the kitchen staff to follow the planned menu or notify her of any changes. The facility's policy mandates that any menu changes be logged and communicated, which was not done in this instance. The Resident Council Committee had previously raised grievances about the food quality and lack of follow-up on menu discrepancies, as documented in their meeting minutes. Despite these complaints, there was no documented action or resolution from the facility. The facility's policies on menu planning, resident council meetings, and grievance handling were not followed, contributing to the ongoing issues with food service and resident dissatisfaction.
Failure to Implement Effective QAPI Program for Dining Services
Penalty
Summary
The facility failed to establish and implement an effective Quality Assurance and Performance Improvement (QAPI) Program, which led to deficiencies in following food menus for several residents. The facility did not act upon grievances from the Resident Council Committee regarding food menus and failed to collaborate with the Registered Dietician for menu substitutions. Observations and interviews revealed that residents frequently did not receive the meals as listed on the menu, with substitutions being made without proper documentation or approval from the dietician. For instance, residents reported receiving deli turkey instead of a cooked turkey for Thanksgiving, and there were instances where tomato soup was not served as per the menu. The facility's policy on QAPI, revised in 2022, outlines a comprehensive, data-driven program focusing on care outcomes and quality of life, including dining services. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and systematic analysis of food service issues. The Kitchen Manager (KM) admitted to ordering errors and not maintaining proper records of food committee meetings or menu substitutions. The Registered Dietician was not consulted for substitutions, and there was no documentation of the food committee meetings, which were supposed to address residents' concerns. Interviews with staff and residents highlighted ongoing issues with meal service, including the use of Styrofoam plates due to a malfunctioning dish machine and the absence of certain menu items. The facility's failure to monitor and document food service operations, as well as the lack of effective communication and collaboration between the kitchen staff and the dietician, contributed to the deficiencies. The facility's leadership, including the Nursing Home Administrator and Regional Vice President of Operations, acknowledged the shortcomings in staff education and documentation, which further exacerbated the issues with meal service.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess and determine the safety of a resident self-administering medications, specifically nebulizer treatments. During an observation, the resident was seen independently using a nebulizer without the presence of a nurse, despite not having been assessed for self-administration capabilities. The resident, who was cognitively intact with a BIMS score of 15, had a history of cerebral infarction, aphasia, and hypertension. The resident's medication administration record indicated regular nebulizer treatments, but there was no care plan or physician's order for self-administration. The Director of Nursing confirmed that the resident had not been evaluated for self-administration of medication, which is a requirement according to the facility's policy. The policy mandates an assessment and physician approval before a resident can self-administer medication, along with proper documentation and care planning. However, these steps were not followed for the resident in question, leading to a deficiency in the facility's adherence to its own procedures for medication self-administration.
Failure to Follow Enhanced Barrier Precautions for Urinary Catheter Care
Penalty
Summary
The facility failed to adhere to standard and enhanced barrier precautions during urinary catheter care for a resident. During an observation, a resident's urinary catheter bag was found lying on the floor, which is against the facility's protocol. A Licensed Practical Nurse (LPN) moved the catheter bag from the floor to the bed without wearing gloves or a gown, despite the resident being on enhanced barrier precautions due to the presence of a urinary catheter. The LPN acknowledged the oversight, stating that enhanced barrier precautions require the use of gowns, gloves, and hand sanitization when providing care. The resident involved had a medical history that included heart failure, cirrhosis of the liver, hypertension, and Benign Prostatic Hyperplasia (BPH). The urinary catheter was inserted shortly before the incident, and the facility's policy required catheter care every shift. The Director of Nursing confirmed that the staff should have been fully dressed in personal protective equipment when handling the catheter bag and that the bag should not have been placed on the floor. The facility's policy on Enhanced Barrier Precautions, dated August 2022, outlines the necessity of using gowns and gloves during high-contact resident care activities, such as device care, to prevent the spread of multi-drug resistant organisms.
Failure to Honor Resident's Advance Directive for CPR
Penalty
Summary
The facility failed to protect a resident's right to receive Cardiopulmonary Resuscitation (CPR) as per their advance directive. The incident involved a resident who was admitted with multiple diagnoses, including Type I Diabetes Mellitus and major depressive disorder. The resident had a documented order for Full Resuscitation, but during an emergency situation, the nursing staff mistakenly identified the resident as having a Do Not Resuscitate (DNR) order. This error occurred because the DNR order in the resident's chart belonged to another resident with a similar name. On the night of the incident, the resident became unresponsive, and the nursing staff assessed the situation and called Emergency Medical Services (EMS). Before EMS arrived, the staff reviewed the medical record and incorrectly determined that the resident had a DNR order. As a result, CPR was not initiated, and the resident was provided with oxygen and sternal rubs, but no further resuscitation efforts were made. When EMS arrived, they confirmed the resident had no heart rate or respirations and pronounced the resident deceased. Interviews with staff revealed confusion and miscommunication regarding the resident's code status. The error was discovered when the resident's family member questioned the DNR status, leading to the realization that the DNR paperwork in the chart was for a different resident. This failure to verify the correct advance directive resulted in the resident not receiving the desired life-saving measures, highlighting a significant deficiency in the facility's handling of advance directives and emergency response procedures.
Failure to Perform CPR Due to Incorrect DNR Order
Penalty
Summary
The facility failed to perform cardiopulmonary resuscitation (CPR) on a resident according to their expressed Advance Directive, which indicated a Full Code status. This failure occurred when the nursing staff mistakenly believed the resident had a Do Not Resuscitate (DNR) order, which actually belonged to another resident. As a result, CPR was not initiated when the resident became unresponsive, leading to the resident's death before emergency medical services (EMS) arrived. The incident involved a resident who was admitted with multiple diagnoses, including Type I Diabetes Mellitus, muscle weakness, and major depressive disorder. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. Despite having a Full Code order in their medical record, the nursing staff did not perform CPR due to the incorrect DNR order found in the resident's chart, which belonged to a different resident. Interviews with staff revealed confusion and miscommunication regarding the resident's code status. Staff members reported that the resident was breathing and had a pulse when EMS arrived, but the EMS team was informed of a DNR status, leading them to refrain from performing CPR. The error was discovered after the resident was pronounced deceased, highlighting a critical lapse in verifying and honoring the resident's advance directives.
Failure to Honor Resident Insurance Choices
Penalty
Summary
The facility failed to honor resident rights related to health insurance choices for three residents. The Business Office Manager (BOM) explained that residents were encouraged to switch from a Medicare HMO to straight Medicare as they approached the 20-day mark of their stay, based on clinical needs. However, the facility did not force residents to disenroll from their Medicare HMO. Despite this, the facility did not ensure that residents fully understood the changes or had the opportunity to ask questions, as evidenced by incomplete attestation forms lacking signatures from the Administrator or Designee. Resident #21, who was cognitively intact, had his insurance changed from a Medicare HMO to straight Medicare without recalling signing the attestation form. The form lacked a witness signature, and the resident expressed confusion about the change, indicating he did not see the benefit of the new insurance. Similarly, Resident #26, who was deemed incapacitated, had his insurance changed without proper authorization. The resident's ex-wife was informed about the insurance options, but the attestation form was signed by the resident, who was unable to make decisions, and lacked a witness signature. Resident #50, also cognitively intact, initially declined to sign the insurance change form until consulting with his sister. He was informed that staying on his HMO would not cover his facility stay, prompting the change to straight Medicare. The attestation form was signed by the resident but lacked the required witness signature. These incidents highlight the facility's failure to ensure residents' rights to make informed choices about their health insurance were respected and properly documented.
Ice Maker Sanitation Deficiency
Penalty
Summary
The facility failed to maintain one of its two ice makers in a sanitary condition, leading to a health deficiency. During multiple observations over several days, surveyors noted that the ice maker in the main dining room exhibited heavy oxidation and calcification on its exterior. More concerning was the presence of heavy black discoloration and bio-growth spotting on the inner plastic ice chute, which was confirmed by the Dietary Manager. This ice machine was used to serve ice to residents, indicating a direct impact on food safety and hygiene. The facility's policy, last revised in September 2017, mandates that all food preparation and service areas be kept clean and sanitary. The policy outlines responsibilities for the Dining Service Director, including ensuring that all employees are knowledgeable about cleaning procedures and that a routine cleaning schedule is in place. However, the Dietary Manager was unsure who was responsible for cleaning the ice machine, suggesting a lapse in adherence to the facility's established procedures. Photographic evidence was taken to document the condition of the ice machine.
Lack of Shade and Hydration on Smoking Patio
Penalty
Summary
The facility failed to establish a policy to ensure a safe smoking area for residents, which resulted in a lack of protection from excessive heat and no access to hydration for nine residents identified as smokers. Observations from 7/8/2024 to 7/11/2024 revealed that the smoking patio lacked a covered area to provide shade, and residents were observed seeking relief from the sun by lining up against the building where only a small amount of shade was available. Additionally, there were no fluids provided to ensure hydration during smoking sessions, despite high temperatures recorded during the observations. Interviews with staff and residents confirmed the absence of shade and hydration on the smoking patio. Staff members, including a CNA and the Activities Director, reported that they only brought out cigarettes, lighters, and smoking aprons, but no drinks or cooling devices. Residents expressed concerns about the lack of shade and fluids, with some stating they had to bring their own drinks if they wanted hydration while smoking. The facility's administration acknowledged the lack of shade and fluids but did not have a clear plan to inform residents about the availability of fluids. The observations and interviews highlighted the facility's failure to provide a safe and comfortable smoking environment for residents, particularly during hot weather conditions. The lack of adequate shade and hydration posed a risk to the residents' well-being, as evidenced by the high temperatures recorded during the survey period. Despite the presence of cognitively intact residents, as indicated by their BIMS scores, the facility did not take appropriate measures to address these environmental deficiencies on the smoking patio.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to identify and report an allegation of physical abuse involving a resident with intact cognition who required significant assistance with daily activities. The resident, who had a history of cerebrovascular accident, aphasia, hemiplegia, depression, and legal blindness, reported discomfort during care provided by a CNA. The resident alleged to a staff member that the CNA had hit him, but this allegation was not properly investigated or reported as required by the facility's policy. Interviews with staff revealed a lack of clear communication and follow-up on the resident's complaint. The CNA involved in the incident was not suspended pending an investigation, and the Nursing Home Administrator did not recall the incident. The facility's grievance log and reportable log showed no record of an abuse report being completed for the resident, indicating a failure to adhere to the facility's procedures for reporting and responding to allegations of abuse.
Inaccurate MDS Assessment of Resident's Dental Status
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, which did not reflect the resident's dental status accurately. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, reported experiencing significant dental pain, including a toothache, a hole in a bottom tooth, and a cracked top tooth. Despite these issues, the MDS assessment inaccurately indicated that the resident had no dental problems such as cavities, broken teeth, or mouth pain. The resident expressed that the cream provided by the facility for his dental pain was ineffective and that his general pain medication did not alleviate his mouth pain. The Social Service Progress Notes indicated that the resident had complained of tooth pain, and a referral was made to an outside provider. However, the resident did not attend the dental appointment due to financial constraints, as the provider did not accept Medicaid and the resident had no money to pay for the services. The Social Service Director confirmed that the resident was not on a list for dental services and that the resident had only three teeth. The MDS Coordinator/LPN acknowledged that the assessment coding was inaccurate and that she was aware of the resident's dental issues from the interview. The facility was unable to provide a policy related to accurate assessments when requested.
Failure to Implement Care Plan for Protective Heel Boots
Penalty
Summary
The facility failed to implement care plan interventions for a resident with an activity of daily living (ADL) self-care performance deficit, potential for pressure injury development, and peripheral vascular disease (PVD). The care plan required the resident to wear protective heel boots while in bed to prevent pressure sores, but observations over four days revealed that the boots were not being used as prescribed. The resident confirmed that staff did not offer assistance to put on the boots, despite his willingness to wear them. Throughout the observation period, the resident was repeatedly seen in bed without the protective boots, and the boots were consistently found stored on a shelf above the television. Interviews with staff indicated a lack of awareness and responsibility regarding the application of the boots. The Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) involved were not fully informed about the resident's care plan requirements, and there was no documentation of the resident refusing the boots, despite claims of past refusals. The facility's documentation, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), inaccurately reflected that the resident wore the boots as required. Additionally, the care plans did not address any behaviors related to the removal or refusal of the boots. This lack of adherence to the care plan and inadequate documentation contributed to the deficiency identified by the surveyors.
Failure to Properly Label and Manage IV Line
Penalty
Summary
The facility failed to provide care according to standards of practice related to the labeling and identification of an intravenous (IV) line for a resident. The resident was admitted to the facility from an acute care hospital with diagnoses including a urinary tract infection, artificial openings of the urinary tract, and sepsis due to E. Coli. Upon admission, the resident had an IV line in the right upper arm, which was not properly labeled with the date, time, and signature as required by the facility's policy. The resident reported that the dressing had not been changed since being in the hospital, and there was blood in the IV line. Observations and interviews revealed inconsistencies in the documentation and management of the resident's IV line. A registered nurse stated that the dressing should be changed on admission if it was not changed the day the resident arrived at the facility. However, the dressing was not changed upon admission, and there was no documentation of a dressing change. The Director of Nursing confirmed that the dressing was not labeled and questioned whether the IV was a midline as indicated in the physician's orders. The facility's policy required all tubing and dressings to be labeled, and the lack of labeling indicated that the dressing was out of date and should have been changed. Further review of the resident's records showed discrepancies in the type of IV line documented and the absence of physician orders for dressing changes. The resident's care plan included monitoring for side effects and effectiveness of antibiotic therapy, but there was no specific order for changing the IV dressing. The Director of Nursing noted that if antibiotics were to be administered for longer than three days, a peripheral line should be changed to a midline, which was not done in this case. The facility's failure to adhere to its IV therapy policy and ensure proper labeling and management of the IV line led to the deficiency.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to provide timely dental services for a resident who was readmitted with diagnoses including Ataxia, Chronic Obstructive Pulmonary Disease, and Hyperlipidemia. The resident, who was cognitively intact, reported experiencing significant toothache pain that was not alleviated by the cream provided by the facility. Despite having a care plan in place to monitor and report dental issues, the resident's dental concerns were not adequately addressed, as evidenced by the lack of documentation and follow-up care. Interviews with the resident revealed ongoing dental pain, difficulty eating, and a high level of discomfort, which was not effectively managed by the facility's interventions. The resident's physician orders included topical treatments and acetaminophen for pain, but these measures were insufficient to address the resident's dental needs. The facility's records showed that the resident's dental issues were not properly documented in the Minimum Data Set (MDS) assessment, and the resident was not placed on a list for dental care due to insurance concerns. The Social Services Director (SSD) and nursing staff were aware of the resident's dental pain but failed to ensure the resident received necessary dental care. The SSD attempted to schedule an appointment with an outside dentist, but the resident declined due to financial constraints. The facility's policy stated that alternative funding sources should be sought for residents unable to pay for dental services, but there was no evidence that this was pursued. Consequently, the resident's dental issues remained unaddressed, highlighting a deficiency in the facility's provision of dental care services.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to administer medications in a clean and sanitary manner, leading to a deficiency in infection prevention and control. During a medication administration observation, a registered nurse (RN) was seen using her bare hands to remove and replace medication tablets from a medication cup, which resulted in touching other tablets with her hands. This occurred while administering medications to a resident with multiple prescriptions, including carbidopa-levodopa, amlodipine besylate, furosemide, multivitamin, clonazepam, and docusate sodium. The RN acknowledged her mistake and mentioned she was instructed to dispose of pills in the trash rather than down the toilet. The Director of Nursing (DON) confirmed that staff should not use their hands to remove pills from medication cups and that medications should be disposed of using a drug buster located in the medication room. However, the facility lacked a specific policy related to the disposal of medications. The facility's infection control policy, revised in October 2018, emphasized maintaining a safe and sanitary environment to prevent disease transmission, but the RN's actions during the medication administration task did not adhere to these guidelines.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
