Aviata At Greenacres
Inspection history, citations, penalties and survey trends for this long-term care facility in Green Acres, Florida.
- Location
- 6414 13th Rd S, Green Acres, Florida 33415
- CMS Provider Number
- 105611
- Inspections on file
- 26
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Aviata At Greenacres during CMS and state inspections, most recent first.
Two residents were not treated with dignity during care activities. A post-surgical resident who was cognitively intact and required substantial/max assistance with ADLs reported that urine splashed on the floor and on her body while using a bedside commode at the bedside, which appeared to lack the correct collection container; multiple commodes in storage areas were later observed without buckets or drainage collection. Another resident with mild cognitive impairment and dependent in ADLs was observed near the nurses’ station, slouched in a wheelchair and calling for help to be repositioned, and was then handled roughly by two staff members while being repositioned in front of others.
Surveyors identified multiple failures including nonfunctioning call lights in five rooms without a written protocol for timely response, missed wound and catheter care for a cognitively impaired resident with a right hip wound and indwelling catheter, and numerous omissions in medication and treatment administration for two other residents. One resident with complex conditions and heart failure did not consistently receive ordered daily weights, diuretics, IV antifungal therapy, diabetes injectables, vital sign monitoring, PICC/MID line measurements, or Hepatitis A and B vaccines as documented on the MAR. Another post‑surgical resident with a pain management care plan received PRN Naproxen for moderate to severe pain, but there was no documentation explaining why ordered PRN Oxycodone was not offered or given, nor whether the pain medication administered was effective.
A resident who was cognitively intact but required substantial to maximum assistance with ADLs following knee replacement surgery was discharged home with orders for OT, PT, home health, and DME including a standard walker. Although the SSD faxed home health orders to an agency, there was no confirmation that services were accepted or scheduled, and no documentation in the record regarding the status of home health arrangements at discharge. The resident later reported still waiting for home health treatment, indicating the resident was discharged without verified home health services in place.
The facility failed to secure medications as required by its own policy and professional standards. A resident with acute respiratory failure, incomplete quadriplegia, dysphagia, and moderate cognitive impairment had hydrocortisone and clobetasol creams stored in an open bedside nightstand drawer without any documented assessment or MD order for self‑administration; staff acknowledged the creams were intentionally kept at the bedside for CNA application. At one nursing station, two unopened bottles of melatonin were left on the counter with no staff present and residents nearby, and at another station an enema saline laxative was found unsecured with no staff present and several residents in the area; a RN manager confirmed medications are required to be secured at all times.
A resident with severe cognitive impairment and an order for a dysphagia mechanical soft diet was observed coughing in the hallway while eating a chewy granola bar, with staff passing by without intervening until prompted by a surveyor. The resident’s care plan identified risk of malnutrition and the need for a mechanically altered diet, including monitoring for dysphagia symptoms. In the resident’s room, a breakfast tray labeled for another resident contained remnants of hard scrambled eggs and crispy hashbrowns, and the CNA present could not explain the tray. The ST and RD later confirmed that the granola bar and crispy hashbrowns were not appropriate for the ordered mechanical soft diet.
Two residents with cognitive and physical impairments were fed by CNAs who stood at the bedside rather than sitting, despite staff awareness of proper feeding protocols. This practice failed to uphold resident dignity during meals.
A resident who was unable to perform activities of daily living independently did not receive the necessary care and assistance from facility staff.
A resident with dementia, Parkinson's disease, and bipolar disorder was prescribed multiple psychotropic and antipsychotic medications, but there was no documented behavior monitoring for these drugs in the MAR. The DON was unable to locate any records of behavior monitoring, resulting in a deficiency related to the lack of interventions to ensure the resident's drug regimen was free from unnecessary medications.
The facility failed to provide adequate portion sizes for the main lunch entree, affecting 46 residents on Regular diets. Three residents reported insufficient food portions, and an observation revealed that dietary staff used a 6-ounce scoop instead of the required 8-ounce scoop for serving Shrimp & Sausage Jambalaya.
A resident with a moderate cognitive deficit and known elopement risk managed to leave the facility undetected by loosening a window lock. The resident traveled three miles along a busy roadway before being found by an off-duty staff member. Lapses in communication and supervision, including a delay in initiating the elopement protocol, contributed to the incident.
A facility failed to adequately monitor a resident identified as an elopement risk. Initially, interventions included electronic monitoring and identifying wandering patterns. When the resident exhibited active exit-seeking behavior, additional measures like checking the Wanderguard were added. However, more frequent monitoring and one-to-one observation were only implemented after the resident eloped, highlighting a delay in addressing the risk.
A resident with cognitive impairment and identified as an elopement risk managed to leave the facility and travel 1.3 miles along a busy roadway. Despite being placed on 1:1 observation after showing exit-seeking behavior, the resident exited through a door, climbed a fence, and was found running along a main road. The staff's failure to maintain proper supervision and adhere to the facility's elopement risk policy led to this incident.
Failure to Maintain Resident Dignity During Toileting and Repositioning
Penalty
Summary
The deficiency involves failures to treat residents with dignity and respect for their rights. For one resident admitted post–knee replacement surgery, a comprehensive assessment documented that the resident was cognitively intact and required substantial to maximum assistance with ADLs. During a phone interview, the resident reported that while using a bedside commode placed next to her bed, urine splashed onto the floor and her body, which she described as humiliating. She stated it appeared the bedside commode did not have the correct bottom or collection container attached. Subsequent observation of the facility’s supply closet and shower room revealed multiple bedside commodes stored without attached buckets or drainage collection containers, and the Nursing Home Administrator (NHA) acknowledged these findings. A second resident with mild cognitive impairment and dependence for ADLs was observed sitting in a wheelchair next to the nursing station, slouched over to the right side, and yelling for help to be repositioned. The resident was then observed being handled roughly by two staff members as they attempted to reposition and adjust the resident in the wheelchair in front of others who were watching. This interaction occurred in a public area near the nursing station, and the NHA was made aware of the observation.
Nonfunctioning Call System, Missed Wound/Catheter Care, and Medication Administration Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, resident preferences, and goals, including failure to ensure timely staff response to call lights due to a nonfunctioning call system in multiple rooms. The facility’s policy on inoperable call bell systems required immediate notification of Maintenance and the Executive Director of Clinical Services, placement of hand or tap bells within reach of affected residents, education on their use, and 15‑minute checks with documentation when a large number of residents were affected. During a tour of the South unit, surveyors observed that call lights were not functioning in five specific rooms at various times, and the Director of Maintenance later stated he had only been made aware of the nonfunctioning call lights the previous day. The DON also stated there was no written policy or protocol for answering call lights timely, despite having referenced a call light policy in a grievance response. The facility also failed to provide ordered wound care and catheter care for a resident with significant medical conditions. This resident had diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, and cognitive communication deficit, with a BIMS score indicating severe cognitive impairment. Physician orders included catheter care every shift and right hip wound care with betadine and a bordered dressing three times weekly and as needed. Record review showed no documentation of right hip wound care from 02/19/26 to 02/24/26, and the DON acknowledged that wound care orders were not entered until 02/24/26 and that there was no documentation of wound care on 02/23/26. On observation, the resident was disheveled, partially uncovered, with a visible darkened area on the right hip under a brief, and the indwelling urinary catheter tubing was not secured, with the call light on the floor and out of reach. The ADON acknowledged the need to cover the resident, the presence of the right hip wound without a dressing, and the unsecured catheter tubing, and the wound care nurse acknowledged that wound care was not completed on one of the ordered days. The facility further failed to administer medications and treatments as ordered for two other residents. For one resident with discitis, type 2 diabetes mellitus, and heart failure, physician orders included daily weights for congestive heart failure, Bumex, Micafungin IV, Ozempic weekly, Victoza daily, vital signs every shift, PICC/MID line measurements, and Hepatitis A and B vaccines. The MAR showed multiple omissions, including missing daily weights on two days, missed doses of Bumex, Micafungin, Ozempic, and Victoza, lack of documented vital signs and PICC/MID line measurements on a specified date, and non‑administration of ordered Hepatitis A and B vaccines on several dates. The DON acknowledged that this resident had several medications that were not given in the month and also acknowledged that all medications had to be locked at all times. For another resident admitted post‑knee replacement surgery, with a care plan for pain medication therapy, orders included PRN Naproxen every six hours for pain and PRN Oxycodone every four hours for moderate to severe pain levels 5–10. The MAR documented administration of Naproxen on several occasions for pain levels of 5–6, but the record did not show why the ordered Oxycodone was not administered or offered for moderate to severe pain, nor did it document whether the administered medication was effective. The DON acknowledged these findings.
Failure to Arrange Ordered Home Health Services at Discharge
Penalty
Summary
The facility failed to ensure ordered home health services were arranged for a resident at discharge, resulting in the resident returning home without confirmed home health care. The resident had been admitted after knee replacement surgery, was cognitively intact, and required substantial to maximum assistance with activities of daily living. A comprehensive assessment documented these needs, and a physician’s order dated 01/30/26 directed discharge home with OT, PT, home health services, and DME including a standard walker. The Social Services Director reported that the resident’s discharge was initially delayed because the ordered walker had not been delivered, and stated she faxed the home health orders to an agency on 01/29/26 but did not obtain or document confirmation that services were accepted or scheduled. The resident reported in a phone interview nearly a month after discharge that she was still waiting to receive home health treatment, and record review showed no documentation regarding the status of home health arrangements or follow-up on the referral at the time of discharge. Record review and interviews confirmed that the resident was discharged home without verified home health services in place, and the facility’s documentation lacked any evidence of confirmation or tracking of the home health referral, despite the resident’s identified need for substantial assistance and ordered post-acute services.
Unsecured Medications at Bedside and Nursing Stations
Penalty
Summary
The deficiency involves the facility’s failure to secure medications in accordance with its own policy and accepted professional standards. The facility’s undated Medication Storage policy stated that, with the exception of emergency drug kits, all medications must be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. For one resident, identified as having acute respiratory failure with hypoxia, incomplete C5–C5 quadriplegia, dysphagia, and a Brief Interview of Mental Status score indicating moderate cognitive impairment, surveyors found hydrocortisone 2.5% cream and clobetasol propionate 0.05% cream in an open nightstand drawer at the bedside. Record review showed no assessment or physician order authorizing this resident to self-administer medications. Nursing staff, including an RN and a CNA, acknowledged during a side‑by‑side observation that the creams were kept at the bedside so the CNA could apply them during care. Additional unsecured medications were observed at both nursing stations. At one nursing station, surveyors observed two bottles of melatonin (3 mg and 5 mg, 200‑count) left on the nursing counter with no staff present and three residents nearby; the ADON acknowledged the medications had been left at the station, noting they were unopened. At another observation of the North nursing station, an enema saline laxative containing dibasic sodium phosphate 7 g and monobasic sodium phosphate 19 g was found unsecured with no staff present and four residents nearby. A RN Unit Manager confirmed that medications should be secured at all times and stated she did not know who left the enema at the station before removing it.
Failure to Provide Diet Consistent With Ordered Mechanical Soft Requirements
Penalty
Summary
The deficiency involves the facility’s failure to provide food in a form consistent with an ordered dysphagia mechanical soft diet for a resident with severe cognitive impairment and high assistance needs for ADLs. The resident had a care plan identifying risk of malnutrition related to the need for a therapeutic and mechanically altered diet, with interventions to explain and reinforce the importance of maintaining the ordered diet and to monitor, document, and report signs and symptoms of dysphagia such as pocketing, choking, coughing, and drooling. Despite these orders and care plan interventions, the resident was observed sitting in the hallway near the nursing station, coughing, while holding and eating a chewy granola bar. During this observation, staff walked past the coughing resident without intervening until the surveyor inquired about what was in the resident’s hand, at which point the resident revealed the chewy granola bar. A CNA stated the resident had obtained the granola bar from a drawer and commented that it was the last one. When the surveyor checked the resident’s room, no food was found in the drawer, but a breakfast tray labeled with another resident’s name was present on the bedside table, containing remnants of scrambled hard eggs and hashbrowns with crispy, crunchy edges. When questioned about this tray, the CNA, who was assisting the roommate, shrugged her shoulders. In a subsequent interview, the speech therapist and registered dietician both agreed that the resident should not have had the chewy granola bar or the crispy hashbrowns, confirming that these items were inconsistent with the ordered mechanical soft diet.
Failure to Maintain Dignity During Dining
Penalty
Summary
Staff failed to ensure dignity during dining for two residents with significant medical needs. One resident, who was severely cognitively impaired and dependent on assistance for eating, was observed being fed by CNAs while the staff stood at the bedside on two separate occasions. The resident's diet required special considerations due to dysphagia and other medical conditions. Despite being aware of proper feeding protocols, staff continued to feed the resident while standing. Another resident, who had mild cognitive impairment and required a dysphagia puree diet with honey thickened fluids, was also observed being fed by a CNA while the staff member stood. Upon noticing the surveyor, the CNA retrieved a chair and sat down. These observations were confirmed through interviews and record reviews, indicating a failure to maintain resident dignity during mealtime.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
A deficiency was identified in the facility's provision of care and assistance with activities of daily living (ADLs) for residents who are unable to perform these tasks independently. The report notes that care and assistance were not provided as required for at least one resident who was unable to complete ADLs without help. This failure to provide necessary support directly affected the resident's ability to perform essential daily activities.
Failure to Monitor Behaviors for Psychotropic and Antipsychotic Medications
Penalty
Summary
The facility failed to implement interventions to monitor behaviors related to the use of antidepressant and antipsychotic medications for one resident. The resident, who was admitted with diagnoses including dementia, Parkinson's disease, and bipolar disorder, was prescribed multiple psychotropic and antipsychotic medications, such as Zonegran for agitation, Venlafaxine for depression, Nuplazid for hallucinations, and Mirtazapine for major depressive disorder. Review of the resident's Medication Administration Record (MAR) for July 2025 showed a lack of documentation regarding behavior monitoring associated with these medications. During interviews, the Director of Nursing (DON) was unable to locate any behavior monitoring records for the resident, either on paper or within the MAR. The absence of documented behavior monitoring for the administration of antipsychotic and psychotropic medications constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs, as required by regulation.
Inadequate Portion Sizes for Regular Diets
Penalty
Summary
The facility failed to provide adequate portion sizes for the main lunch entree for residents on Regular diets, potentially affecting 46 residents. During the survey, three residents expressed concerns about inadequate food portions. Resident #3, who has diabetes and potential nutritional problems, stated that the facility did not provide enough food. Resident #8, diagnosed with brain neoplasm, also reported insufficient food portions. Resident #9, with a cutaneous abscess, mentioned that he often had to order food from outside due to inadequate portions provided by the facility. An observation of the lunch tray line service revealed that the dietary staff was serving only 6 ounces of Shrimp & Sausage Jambalaya instead of the 8 ounces specified in the menu. Staff B, responsible for plating the food, used a 6-ounce scoop instead of the correct 8-ounce scoop. This discrepancy was confirmed by Staff A, the food service manager, and further verified by examining prepared trays, which all contained only 6 ounces of the entree.
Resident Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to provide appropriate supervision to prevent an elopement, resulting in a resident leaving the facility and traveling along a busy roadway. The resident, identified as having a moderate cognitive deficit and diagnosed with conditions such as encephalopathy and anxiety disorder, was known to be at risk for elopement. Despite being identified as an elopement risk upon admission and re-evaluated as such when exhibiting exit-seeking behavior, the resident managed to exit the facility undetected. The resident was able to leave the facility by loosening the screws on a window lock, removing the device, and climbing out. This incident occurred between late at night and early morning, and the resident walked approximately three miles before being found by a staff member off duty. The staff member, a housekeeper, noticed the resident walking along a busy roadway and managed to convince him to return to the facility. Interviews with staff revealed lapses in communication and supervision. The primary nurse on duty did not notice the resident's absence until early morning, and a CNA who noticed the resident's bed was empty did not report it. The facility's elopement protocol was not initiated until the resident was reported missing, indicating a delay in response. The lack of communication between shifts and inadequate monitoring contributed to the resident's ability to leave the facility unnoticed.
Failure to Adequately Monitor Elopement Risk
Penalty
Summary
The facility failed to appropriately care plan for a resident identified as an elopement risk. The resident was admitted to the facility and identified as an elopement risk due to exit-seeking behavior. A comprehensive care plan was initiated, which included interventions such as electronic monitoring every shift and identifying patterns of wandering. However, when the resident was determined to be actively exit-seeking, additional interventions like checking the Wanderguard every shift and monitoring its expiration date were implemented. Despite these measures, it was not until after the resident eloped that more frequent monitoring every 30 minutes and one-to-one observation were added. The deficiency lies in the delay of implementing adequate monitoring measures despite clear indications of the resident's exit-seeking behavior.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident identified as an elopement risk. The resident, who had a cognitive impairment with a BIMS score of 6 out of 15, was able to leave the facility and travel approximately 1.3 miles along a busy roadway. The resident had been evaluated as an elopement risk upon admission and had an elopement bracelet placed. Despite these precautions, the resident was able to exit the facility between 8:12 PM and 8:18 PM, after showing exit-seeking behaviors earlier in the evening. The incident occurred when the resident was agitated and attempted to leave through the exit doors, triggering the alarm. Staff members attempted to redirect the resident back to his room and were instructed to place the resident under 1:1 observation. However, the resident managed to leave the facility, climb a 6-foot-high fence, and run along a main roadway. The staff's failure to maintain 1:1 eye contact with the resident, who was actively seeking to exit, was identified as a root cause of the incident. Interviews with staff and residents revealed that the resident was agitated and seeking to leave the facility, and despite efforts to contain him, he was able to exit and travel a significant distance before being located by staff. The facility's policy on elopement risk was not effectively implemented, leading to the resident's unsupervised departure and subsequent risk of harm. The Immediate Jeopardy was ongoing at the time of the facility exit, indicating a serious deficiency in the facility's supervision and safety protocols.
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.
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