Aviata At Harts Harbor
Inspection history, citations, penalties and survey trends for this long-term care facility in Jacksonville, Florida.
- Location
- 11565 Harts Rd, Jacksonville, Florida 32218
- CMS Provider Number
- 105632
- Inspections on file
- 33
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Aviata At Harts Harbor during CMS and state inspections, most recent first.
A resident with dementia and impaired safety awareness, identified as an elopement risk and requiring a wander guard and supervision, was able to leave the facility unattended after signing out at the front desk. Staff involved were not familiar with the Leave of Absence process or the resident's elopement risk, and had not received proper training or participated in relevant drills. Required assessments and documentation were not completed as per facility policy, leading to the resident's unsupervised exit.
A resident identified as an elopement risk was allowed to leave the facility unescorted after removing a wander guard, due to staff not following established protocols and lacking training on elopement prevention and LOA procedures. Staff were unaware of required risk assessments and documentation, and audits of at-risk residents were infrequent, leading to inconsistent implementation of elopement prevention measures.
The facility failed to maintain a clean environment for residents receiving enteral feedings, with dried food product and debris observed in multiple rooms. Staff interviews revealed unclear cleaning responsibilities between housekeeping and nursing staff, leading to unsanitary conditions. Despite scheduled cleanings, the facility's cleaning protocols were not effectively followed.
The facility failed to complete timely Quarterly MDS Assessments for seven residents. An MDS Nurse confirmed that assessments for two residents were overdue, with the last assessments transmitted months prior. The facility's 30-day MDS scheduler report revealed that seven residents were overdue for assessments, contrary to the policy of conducting assessments every three months.
A resident's call light was repeatedly found out of reach, preventing them from requesting assistance. Despite being capable of using the call light, it was clipped away after care and not returned to an accessible position. Staff confirmed the oversight, which contradicted facility training emphasizing call light accessibility.
A facility failed to conduct a required Level II PASARR for a resident with serious mental health diagnoses, preventing the incorporation of necessary care recommendations. The resident was initially exempt from a Level II due to a 30-day hospital discharge exemption, but the facility did not complete the evaluation within the required timeframe. The DON and DSS were responsible for reviewing PASARRs but did not ensure the necessary screening was conducted.
A facility failed to update the care plan for a resident receiving dialysis, despite a change in the dialysis port site from the left arm to the right upper chest. The care plan inaccurately reflected the presence of an arteriovenous fistula in the left arm, even though the resident's medical records noted the chest port as early as April. This oversight was confirmed by an LPN during a survey, highlighting a lapse in adhering to the facility's policy of updating care plans based on changing resident needs.
The facility failed to provide adequate ADL care for two residents, resulting in poor grooming and hygiene. A diabetic resident had unclean, overgrown nails, and another resident, who is blind, reported not receiving regular bed baths. Documentation of care was inconsistent, with missing records for showers and nail care. The facility's procedures for ADL care were not followed, leading to these deficiencies.
The facility failed to provide appropriate respiratory care to two residents by not adhering to physician's orders for oxygen therapy. One resident received a lower oxygen flow rate than prescribed, while another received a higher rate than ordered. These discrepancies were observed over several days and confirmed by staff, indicating a failure to comply with the facility's policy on oxygen therapy.
A resident with multiple chronic conditions was not provided with necessary medically-related social services, resulting in missed medical appointments and loss of financial benefits. The resident, who had no income or safe discharge location, received inadequate assistance from the facility's social services and business office. The facility failed to provide necessary follow-ups with cardiology and neurology, contributing to the deficiency.
A facility's medication error rate was found to be 8%, exceeding the acceptable threshold of 5%. An LPN administered Torsemide incorrectly by giving one tablet instead of three and failed to instruct a resident to rinse and spit after using Advair, contrary to physician's orders and facility policy.
A facility licensed for 180 beds failed to employ a qualified social worker full-time. The Director of Social Services (DSS) L was found to lack the necessary credentials, holding a degree in Interdisciplinary Studies not focused on social work. The HR Director confirmed the degree was invalid for the DSS role, and the facility had no other qualified individual in the position.
A facility failed to properly clean and disinfect a glucometer used for a resident during medication administration. An LPN was observed wiping the glucometer for only 30 seconds and placing it back in the pouch while still wet, contrary to the facility's policy and manufacturer's guidelines, which require a two-minute wet contact time for effective disinfection.
The facility's pest control program was ineffective, as evidenced by the presence of cockroaches and flying insects in resident rooms and the activities room. Observations and interviews confirmed the issue, with a resident expressing frustration over the ineffective measures. Financial difficulties led to the cessation of services by the contracted pest control company, and a new contract had not been secured.
Failure to Prevent Elopement Due to Inadequate Supervision and Staff Training
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who had been identified as an elopement risk. The resident, with a history of metabolic encephalopathy, dementia, impaired safety awareness, and other medical and psychiatric conditions, was care planned as an elopement risk and required a wander guard and supervision when leaving the facility. Despite these interventions, the resident was able to sign himself out at the front desk and exit the facility unattended, after removing his wander guard. The receptionist, unaware of the resident's elopement risk and the proper Leave of Absence (LOA) process, allowed the resident to leave after he signed the book, without verifying with nursing staff or ensuring an escort was present. Interviews revealed that both the Human Resource Coordinator (HRC) and the receptionist were not familiar with the facility's LOA process or the specific protocols for residents at risk for elopement. The receptionist had not received training on the LOA process or participated in any drills related to elopement prevention. The HRC assumed the receptionist knew the process and did not intervene when the resident requested to go outside. The resident was later found across the street, having left the facility without his wheelchair or supervision, and was assisted back by staff and a neighbor. Further review indicated that required elopement assessments were not completed according to facility policy, and documentation of elopement drills prior to the incident could not be produced. The facility's policies required that residents at risk for elopement have individualized interventions, regular assessments, and that staff be trained on LOA procedures. These protocols were not followed, resulting in the resident's unsupervised exit from the facility.
Failure to Implement Elopement Prevention Protocols and Staff Training
Penalty
Summary
The facility failed to implement appropriate plans of action to correct identified quality deficiencies related to elopement. A resident with a history of metabolic encephalopathy, dementia, impaired safety awareness, and other medical conditions was identified as an elopement risk and was care planned to require an escort and a wander guard when leaving the facility. Despite these interventions, the resident was permitted to sign out of the facility without an escort and exited through the main entrance. The resident removed his wander guard prior to leaving, and staff did not verify its presence or function at the time of the incident. The receptionist and Human Resource Coordinator involved were not fully aware of the elopement risk protocols or the leave of absence (LOA) process, and the receptionist had not received training or participated in drills related to elopement prevention or LOA procedures. Record review revealed that the resident's care plan and physician orders specified the need for a wander guard and supervision when leaving the facility. However, the required elopement assessments were not completed according to policy, and documentation of elopement drills prior to the incident could not be produced. The facility's elopement binder and risk assessments were not consistently updated, and audits of residents at risk for elopement were infrequent, with only three audits documented. Additionally, there was confusion among staff regarding the LOA process, and the receptionist was unaware of the elopement binder and related protocols. Further review of other residents' records indicated inconsistencies in care planning and risk assessment for elopement. For example, one resident was care planned as an elopement risk with a wander guard in place, despite having no documented wandering behaviors or cognitive impairment. Interviews with staff revealed a lack of consistent training and understanding of elopement prevention procedures. The facility's Quality Assurance Performance Improvement (QAPI) program and Performance Improvement Plan (PIP) identified these systemic issues, but the corrective actions outlined were not fully implemented or monitored, contributing to the deficiency.
Failure to Maintain Sanitary Conditions for Residents Receiving Enteral Feedings
Penalty
Summary
The facility failed to maintain a sanitary and comfortable living environment for residents receiving enteral feedings, as observed during a survey. Specifically, the rooms of four residents were found to be unsanitary, with dried enteral food product splattered on various surfaces, including gastrostomy tube poles, pumps, tubing, floors, walls, bed frames, bed rails, privacy curtains, tray tables, floor mats, and nightstands. Disposable tubing caps and other debris were also observed on the floors and under beds, indicating a lack of proper cleaning and maintenance. Interviews with staff revealed a lack of clarity and coordination between housekeeping and nursing staff regarding cleaning responsibilities. Housekeeping staff were responsible for cleaning most surfaces, but only nursing staff were permitted to clean the enteral feeding pumps. Despite this division of labor, the enteral feeding product was not cleaned promptly, leading to dried residues that were difficult to remove. The Director of Environmental Services expressed a desire for better communication between nurses and housekeepers to address spills immediately, as dried food product required strong chemicals for removal, necessitating the temporary relocation of residents. A review of the facility's housekeeping schedule and policies highlighted inconsistencies in cleaning practices. Although certain rooms were scheduled for deep cleaning, observations indicated that these tasks were not completed effectively. The facility's policies outlined specific cleaning and disinfection procedures, but the observed conditions in the residents' rooms suggested these protocols were not followed adequately. This failure to adhere to established cleaning standards contributed to the unsanitary conditions observed during the survey.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) Assessments were completed in a timely manner for seven residents out of a sample of 33. During a review on June 27, 2024, it was found that there was no evidence of Quarterly MDS assessments for two residents. An interview with MDS Nurse J confirmed that the last MDS assessment for one resident was transmitted on January 15, 2024, with a quarterly assessment due on April 16, 2024, which was never opened. Similarly, for another resident, the last assessment was transmitted on February 15, 2024, with a quarterly assessment due on May 17, 2024, which was not completed. MDS Nurse J stated that the assessments were tracked using a 30-day electronic MDS scheduler report run each month. A review of this report showed that seven residents were overdue for quarterly assessments, indicating a failure to adhere to the facility's policy of conducting assessments no less than every three months.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident by not ensuring that the call light was within reach at all times. Observations on multiple occasions revealed that the call light was clipped out of reach, preventing the resident from using it to request assistance. Interviews with staff confirmed that the resident was capable of using the call light and that it should have been within reach. The staff acknowledged that the call light was likely moved during care and not returned to an accessible position. The resident involved had a complex medical history, including chronic respiratory failure, malnutrition, and other conditions affecting mobility and self-care. Despite these challenges, the resident was able to use the call light to communicate needs. The facility's training materials and competency assessments emphasized the importance of keeping the call light within reach, yet this was not adhered to, as confirmed by photographic evidence and staff interviews.
Failure to Conduct Required Level II PASARR
Penalty
Summary
The facility failed to obtain a Level II Pre-Admission Screening and Resident Review (PASARR) for a resident, which prevented the incorporation of necessary recommendations into the resident's assessment, care planning, and transitions of care. The resident was admitted with diagnoses including anxiety, schizoaffective disorder, bipolar disorder, and major depressive disorder. A Level I PASARR was completed, but it did not include all relevant diagnoses, and a Level II PASARR was not conducted as required. The resident was initially exempt from a Level II due to a 30-day hospital discharge exemption, but the facility did not follow up to complete the Level II evaluation within the required timeframe. The Director of Nursing and the Director of Social Services were responsible for reviewing PASARRs for accuracy upon admission. However, they failed to ensure that a Level II screening was conducted for the resident, despite recognizing the need for it. The facility's policy required that if a Level II screening was indicated after admission, Social Services should coordinate with the appropriate agency to conduct the screening. This oversight resulted in the facility not adhering to its policy and federal/state guidelines for pre-admission screenings for residents with serious mental illness or intellectual disabilities.
Failure to Update Dialysis Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident receiving dialysis treatment, which was identified during a survey. The resident, who was cognitively intact and receiving dialysis off-site three times a week, had a change in the dialysis port site from the left arm to the right upper chest. Despite this change, the care plan was not updated to reflect the new port site, as confirmed by the East Wing Unit Manager/LPN during an interview. The care plan still indicated the presence of an arteriovenous fistula in the left arm, which was no longer accurate. The resident's medical records showed that the port in the chest was noted as early as April 3, 2024, yet the care plan dated June 4, 2024, did not reflect this change. The facility's policy requires that care plans be updated based on changing resident needs and interventions, but this was not adhered to in this case. The failure to update the care plan could result in unmet resident needs and negatively impact the resident's health, as the care plan did not address the current dialysis access site.
Deficiency in ADL Care and Documentation
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADL) to two residents, resulting in poor grooming and personal hygiene. Resident #24, who is diabetic and dependent on staff for bathing and personal hygiene, was observed with unclean fingernails that had grown significantly. Despite expressing a desire to have his nails trimmed, there was no documentation of nail care being provided. The facility's process for documenting ADL care was inconsistent, as evidenced by the absence of shower forms for Resident #24, which were supposed to be completed by certified nursing assistants (CNAs) and reviewed by nurses. Resident #59, who is legally blind and has a right below-knee amputation, reported not receiving regular bed baths as preferred, and his nails were observed to be jagged and unclean. Despite his cognitive intactness and ability to communicate his preferences, there was a lack of documentation for the bed baths he received, and his nail care was neglected. The CNA responsible for his care confirmed the absence of documentation for recent bed baths and nail care, indicating a lapse in the facility's adherence to its own procedures for documenting ADL care. The facility's policy for nail care was not effectively implemented, as evidenced by the lack of documentation and the residents' reports of unmet ADL needs. The failure to maintain proper records and provide consistent care as per the residents' care plans contributed to the deficiency. The facility's procedures for ensuring ADL care, including nail trimming and bathing, were not followed, leading to the observed deficiencies in resident care.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care to two residents, as observed during a survey. Resident #109 was consistently receiving oxygen at a flow rate of 1.5 liters per minute, despite a physician's order for 2 liters per minute. This discrepancy was noted over several days, and the resident's care plan indicated a need for continuous oxygen therapy due to chronic respiratory failure. The MDS assessment for this resident was also incorrectly coded, failing to reflect the use of oxygen therapy. Resident #18 was observed receiving oxygen at a flow rate higher than the physician's order of 2 liters per minute. The resident was receiving hospice care for end-stage congestive heart failure and had severe cognitive impairment. Despite the physician's order for oxygen at 2 liters per minute, the resident was observed receiving 2.5 to 3 liters per minute. This inconsistency was confirmed by an LPN who checked the electronic medical record and the flow meter. The facility's policy on oxygen therapy requires adherence to physician's orders, including specific guidelines for PRN orders. However, the facility failed to comply with these standards, as evidenced by the incorrect oxygen flow rates administered to the residents. This failure to follow physician's orders for oxygen therapy could negatively impact the residents' medical status and functional abilities.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services to Resident #64, who was observed sitting in his wheelchair and expressed concerns about missed medical appointments and loss of financial and insurance benefits. The resident, who had a history of cerebral infarction, alcoholic cirrhosis, and other chronic conditions, had not seen a cardiologist or neurologist since his admission. He received a discharge notice for non-payment and was offered a temporary hotel stay, despite having no income or safe place to go. The resident's requests for financial assistance were not adequately addressed by the Social Services Director and Business Office Manager. The Business Office Manager stated that benefits were applied for but not approved due to the resident's external financial obligations. Medicaid covered his room and board, but he was denied financial benefits from another state agency. A notice from the Social Security Administration indicated that additional information was needed from the facility, which was not provided. The Business Office Manager claimed to have contacted the SSA but could not provide documentation or details of the communication. The resident was taken to the SSA office, where he walked in without his wheelchair, which was cited as a reason for denial of benefits. The Director of Nursing confirmed the discharge notice and stated that the facility could not meet the resident's financial needs. The resident had expressed concerns about transportation to medical appointments if discharged. The DON was unaware of any additional information requested by the SSA and could not confirm the last cardiologist visit, although the resident was seen during the survey. The resident had not seen a neurologist despite having conditions warranting such care. The facility's failure to provide necessary social services and medical follow-ups contributed to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during a survey. This deficiency involved a resident with congestive heart failure and chronic obstructive pulmonary disease. During medication administration, an LPN administered Torsemide incorrectly by giving only one tablet instead of the prescribed three tablets. Additionally, the LPN failed to instruct the resident to rinse and spit after administering Advair, as required by the physician's orders. These actions were not in accordance with the facility's medication administration policy, which mandates adherence to prescriber orders, including any specific instructions such as rinsing the mouth after inhalation of certain medications.
Failure to Employ Qualified Social Worker
Penalty
Summary
The facility, licensed for 180 beds, failed to employ a qualified social worker on a full-time basis. During a review of the personnel file for the Director of Social Services (DSS) L, it was found that there was no documentation verifying DSS L's credentials for the position. The Human Resources Director (HRD) provided documentation indicating that DSS L held a Bachelor of Science degree in Interdisciplinary Studies, which the HRD acknowledged was not valid for the role of Director of Social Services. The HRD confirmed that DSS L was hired as the DSS despite lacking the necessary credentials and that the facility did not have another individual staffed as the DSS. A phone interview with the educational institution revealed that DSS L's degree was from a program intended for missionary work, not social work or psychology, further confirming the lack of appropriate qualifications for the position.
Improper Cleaning and Disinfecting of Glucometer
Penalty
Summary
The facility failed to prevent the development and transmission of infections by not properly cleaning and disinfecting a glucometer used for a resident during medication administration. An observation was made of an LPN cleaning the glucometer with an antibacterial wipe for only 30 seconds and placing it back in the pouch while still wet. During an interview, the LPN admitted to not knowing the exact duration required for wiping the glucometer or the necessary drying time before placing it back in the pouch, as per her training and the facility's policy. A review of the facility's Skills Competency Assessment and policy for Blood Glucose Monitoring and Disinfecting revealed that the glucometer should be cleaned and disinfected following a specific two-step process, including maintaining the surface wet for the manufacturer's recommended contact time. The Assure Prism Multi Blood Glucose Monitoring System instructions and the Super Sani-Cloth Germicidal Disposable Wipe Technical Data Bulletin specify that the surface must remain wet for two minutes to effectively remove blood-borne pathogens. The LPN's actions did not comply with these guidelines, leading to the deficiency.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program, as evidenced by the presence of cockroaches and flying insects in resident rooms and the activities room. Observations on multiple occasions revealed live cockroaches in the activities room and gnats and a black fly in a resident's room on the East Wing. Photographic evidence was obtained to document these findings. Interviews with residents and staff confirmed the presence of pests, with one resident expressing frustration over the ineffective pest control measures, despite the facility's attempts to spray for pests. The facility's pest control program was compromised due to financial difficulties, as the facility filed for bankruptcy, leading to the contracted pest control company ceasing services due to unpaid bills. The last pest control service was provided on 05/30/2024, and the facility had not secured a new contract with another company at the time of the survey. The facility's policy and procedure for pest control, which includes maintaining a contract with a licensed exterminator and immediate reporting of pest sightings, was not effectively implemented, contributing to the deficiency.
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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