Aviata At North Florida
Inspection history, citations, penalties and survey trends for this long-term care facility in Gainesville, Florida.
- Location
- 6700 Nw 10th Place, Gainesville, Florida 32605
- CMS Provider Number
- 105460
- Inspections on file
- 33
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 8 (3 serious)
Citation history
Health deficiencies cited at Aviata At North Florida during CMS and state inspections, most recent first.
A facility failed to ensure that nurses had the required IV certification and did not follow protocols for IV medication administration, physician notification, and obtaining stat orders. As a result, a resident with a complex medical history missed multiple doses of critical IV antibiotics, received an incorrect dose, and developed altered mental status, leading to hospital admission for sepsis. Staff interviews revealed confusion about medication availability, equipment use, and communication with providers, while documentation was incomplete or missing.
A resident with a complex medical history, including osteomyelitis and recent surgery, did not receive prescribed IV antibiotics as ordered, resulting in missed doses and an incorrect dose. Nursing staff failed to follow medication administration protocols, did not properly notify providers or document actions, and were unclear about procedures for obtaining medications and equipment. The resident developed altered mental status and was later hospitalized with sepsis and subtherapeutic antibiotic levels.
A resident with a history of osteomyelitis and other complex conditions was not administered physician-ordered IV antibiotics as prescribed, resulting in multiple missed doses and an incorrect initial dose. LPNs and other staff failed to follow facility policy for obtaining urgently needed medications, did not document missed doses or provider notifications, and did not utilize available pharmacy stat delivery options. The resident developed altered mental status and was transferred to the hospital, where sepsis was diagnosed and the lack of proper antibiotic administration was identified as a contributing factor.
A resident with multiple complex medical conditions experienced several episodes of low blood pressure, but neither the physician nor the resident's representative were notified as required. Staff interviews confirmed that no notifications or follow-up actions were taken, and documentation was lacking, despite facility policy mandating prompt notification and recordkeeping for significant changes in condition.
Two residents with midline and central venous access devices did not receive dressing changes and flushing according to professional standards. One resident's midline catheter dressing was not changed as ordered, and the insertion site was obscured by gauze. An LPN administered IV medications without confirming catheter patency. Another resident's PICC line dressing was overdue for change, and a dressing change was falsely documented as completed. Facility policies for dressing changes and catheter patency checks were not followed.
A resident with multiple medical conditions received Metoprolol despite physician-ordered parameters to hold the medication for low systolic blood pressure. Medication records showed repeated administration of the drug when blood pressure readings were below the specified threshold. Interviews with LPNs revealed a lack of adherence to the parameters, and facility policy requiring medications to be given as prescribed was not followed.
The facility did not ensure accurate documentation for IV therapy and medication administration for three residents. One resident's IV insertion and care were not recorded, another resident's IV removal was undocumented, and a third resident's missed IV antibiotic doses lacked corresponding nursing notes. LPNs and the DON confirmed that required documentation and provider notifications were not completed as per facility policy.
Two residents with chronic pain conditions did not receive scheduled opioid pain medications as ordered, with an LPN omitting doses because the residents were asleep. Medication administration records confirmed multiple missed doses, and both residents reported not receiving their pain medication as prescribed.
The facility failed to maintain proper repair of handrails, cleanliness of resident rooms, and application of protective pipe coverings. Missing handrail caps exposed jagged metal, and a resident's room was not regularly cleaned, with debris observed on the floor. The Maintenance Director and Environmental Services Manager acknowledged these issues, but they were not prioritized.
The facility failed to complete accurate Level I PASRR screens for two residents with serious mental disorders. One resident's PASRR did not document their diagnoses of depression, anxiety disorder, and bipolar disorder, while another resident's PASRR lacked documentation of schizoaffective disorder and adjustment disorder with anxiety. The DON confirmed the omissions and that no revised PASRRs were completed.
The facility failed to administer oxygen therapy as ordered for three residents, with incorrect flow rates observed. Additionally, respiratory masks for three residents were improperly stored, either left unbagged or on the floor, contrary to facility policy. Staff confirmed these discrepancies, and the DON emphasized the expectation for adherence to orders and proper storage protocols.
A facility failed to ensure the accuracy of an MDS assessment for a resident with a complex medical history, including sepsis and cellulitis. The resident was prescribed Rifaximin, an antibiotic, but the MDS did not reflect this under Section N - Medications. This inaccuracy was confirmed by the ADON and the MDS Coordinator during interviews.
A resident with hemiplegia and contractures did not receive necessary nail care, resulting in overgrown nails pressing into their palms. Despite the care plan and facility policy requiring regular nail maintenance, staff interviews revealed a lack of adherence to these guidelines.
A facility failed to provide proper wound care to a resident, who had multiple diagnoses including a skin infection and necrotizing fasciitis. The wound care nurse did not follow the correct wound care orders and failed to document the wound's size and condition as required. The Director of Nursing expected updated orders after physician appointments, but this was not done, leading to inconsistencies in care.
The facility failed to provide necessary lab services for two residents, impacting medication management. A resident on Depakote had no documented orders or results for required Depakote and ammonia levels, while another resident on Atorvastatin lacked lipid panel results since early 2024. Communication gaps and ineffective policy implementation contributed to these deficiencies.
The facility failed to store food items according to professional standards, with a brown buildup found in the Emergency Food Storage room and temperature issues in the freezer. The Food Services Manager was unaware of the buildup's origin, and the Maintenance Director was not informed of the issues. The facility's policy on maintenance was not followed, leading to lapses in communication and adherence.
The facility failed to ensure proper PPE use during medication administration and wound care, leading to potential infection control breaches. An LPN did not wear a gown while administering medication to a resident under enhanced barrier precautions, and another LPN did not perform hand hygiene between glove changes during wound care. These actions were contrary to the facility's infection control policies.
A resident with type 1 diabetes experienced medical neglect when the facility failed to implement insulin administration policies. The resident's blood sugar was critically high, and despite refusing medications until receiving proper insulin, staff failed to communicate or document new orders. The resident called 911 twice, eventually being hospitalized with Diabetic Ketoacidosis. Interviews revealed a lack of communication and adherence to professional standards, leading to Immediate Jeopardy.
A resident with type 1 diabetes experienced a critical incident due to the facility's failure to administer insulin according to professional standards. The resident's blood sugar was recorded at 552, and despite notifying the on-call provider, the new insulin orders were not communicated or documented. The resident called 911 twice, expressing concerns about incorrect insulin administration, and was later hospitalized with Diabetic Ketoacidosis. Interviews revealed a lack of communication and documentation, leading to a determination of Immediate Jeopardy.
A resident with Type 1 Diabetes Mellitus experienced a critical incident due to the facility's failure to implement medical neglect policies and ensure proper insulin administration. The resident's blood sugar level was 552, and despite new orders for increased insulin, the orders were not communicated or documented. The resident called 911 twice, resulting in hospitalization for Diabetic Ketoacidosis. Interviews revealed communication and documentation failures among staff, and the facility did not promptly address the incident or follow abuse and neglect policies.
A resident with type 1 diabetes experienced a critical care deficiency due to the facility's failure to manage insulin administration and communication effectively. The resident's high blood sugar was not properly addressed, leading to a hospital admission for Diabetic Ketoacidosis. Staff failed to document and communicate new insulin orders, and there was a lack of reassessment and follow-up, resulting in neglect.
A resident with Type 1 Diabetes Mellitus experienced neglect due to the facility's failure to implement policies and procedures. The resident's high blood sugar was not properly addressed, and communication breakdowns led to a lack of appropriate medical intervention. The resident eventually called 911 and was hospitalized with diabetic ketoacidosis. Staff failed to document and communicate effectively, and the facility did not follow its abuse and neglect policies.
A resident with multiple medical conditions refused medications until receiving proper insulin, but staff failed to document physician orders and used personal cell phones to communicate sensitive information. Despite facility policies prohibiting such actions, staff routinely used personal devices to share PHI, compromising resident confidentiality.
Failure to Ensure Staff Competency and Adherence to IV Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies and certifications to safely administer intravenous (IV) medications, and did not follow established policies and procedures for IV medication administration, physician notification, and obtaining stat orders for medication and equipment. Specifically, two of six reviewed LPNs did not have the required IV certification to administer IV medications, and four of six reviewed LPNs did not adhere to the facility's protocols for IV medication administration. This resulted in multiple missed and incorrect doses of critical antibiotics for residents requiring IV therapy. One resident, admitted with a complex medical history including subacute osteomyelitis, spina bifida occulta, hydrocephalus, paraplegia, and other significant conditions, was ordered to receive Vancomycin 1500 mg IV every eight hours for infection. The resident received an incorrect initial dose of Vancomycin and subsequently missed eight consecutive doses over several days. Documentation and interviews revealed that staff were uncertain about medication availability, IV pump functionality, and the process for obtaining stat deliveries from the pharmacy. There was a lack of timely physician notification and inadequate documentation of missed doses and provider communications. The resident developed altered mental status, which was first identified by a family member, and was later transferred to the hospital where he was diagnosed with sepsis, with hospital records noting subtherapeutic vancomycin levels and missed antibiotic doses as contributing factors. Interviews with staff, pharmacy representatives, and providers highlighted confusion regarding medication administration responsibilities, stat order procedures, and the use of available resources such as the automated medication dispensing machine and IV pumps. The DON and medical providers confirmed that they were not appropriately notified of missed medications or equipment issues. The facility's failure to ensure staff competency and adherence to medication administration protocols resulted in significant lapses in care, including missed and incorrect antibiotic doses, delayed treatment, and a subsequent hospital admission for sepsis.
Failure to Administer Prescribed IV Antibiotics and Ensure Staff Competency
Penalty
Summary
The facility failed to protect a resident from medical neglect by not ensuring the administration of prescribed intravenous (IV) antibiotics according to physician orders. The resident, who had a complex medical history including subacute osteomyelitis, spina bifida occulta, hydrocephalus, paraplegia, and a recent surgical intervention, was admitted with orders for Vancomycin 1500 mg IV every 8 hours and Cefepime 1 g IV every 8 hours. Despite these orders, the resident received an incorrect dose of Vancomycin (1000 mg instead of 1500 mg) and subsequently missed eight consecutive doses of Vancomycin over several days. There were also missed doses of Cefepime. Documentation and interviews revealed confusion among nursing staff regarding medication availability, order entry, and the process for obtaining stat deliveries or alternative medications from the pharmacy. Nursing staff failed to follow facility policies and procedures for medication administration, physician notification, and documentation. Several nurses reported uncertainty about whether medications could be administered without a pump, whether stat deliveries could be requested, and whether alternative sources for medications or equipment were available. There was a lack of timely communication with providers regarding missed doses, and documentation of provider notifications and orders was inconsistent or absent. The pharmacy confirmed that stat deliveries and replacement IV pumps were available upon request, but staff did not utilize these options appropriately. Additionally, there were concerns about staff competency, including whether nurses had the appropriate IV certification to administer the medications safely. The resident began to exhibit a change in condition, including altered mental status, which was first identified by a family member. Despite the family member's concerns and requests for hospital transfer, facility staff did not recognize or respond to the change in condition in a timely manner. When the resident was eventually transferred to the hospital, he was diagnosed with sepsis and found to have subtherapeutic Vancomycin levels, as well as evidence of ongoing infection and abscess formation. Interviews with facility leadership and providers confirmed that the expected processes for medication administration, provider notification, and documentation were not followed, resulting in significant medication errors and harm to the resident.
Failure to Administer Ordered IV Antibiotics Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering physician-ordered intravenous (IV) antibiotics as prescribed. The resident, who had a complex medical history including subacute osteomyelitis, spina bifida occulta, hydrocephalus, paraplegia, and other conditions, was admitted with orders for Vancomycin 1500 mg IV every 8 hours and Cefepime 1 g IV every 8 hours. Despite these orders, the resident received an incorrect initial dose of Vancomycin (1000 mg instead of 1500 mg) and subsequently missed eight consecutive doses of Vancomycin over several days. There were also missed doses of Cefepime. Documentation and interviews revealed confusion and lack of clarity among nursing staff regarding medication availability, administration times, and communication with pharmacy and providers. Multiple staff interviews indicated that medication orders were not promptly entered or administered due to issues such as medication and pump availability, lack of stat delivery requests, and unclear communication with pharmacy and providers. Nurses reported uncertainty about the process for obtaining urgently needed medications and did not consistently document missed doses or provider notifications. The pharmacy confirmed that stat deliveries and replacement IV pumps were available upon request, but staff did not utilize these options effectively. Facility policy required immediate action and provider notification when medications were unavailable, but these procedures were not followed. As a result of the missed antibiotic doses, the resident experienced a change in condition, including altered mental status, and was subsequently transferred to the hospital, where he was diagnosed with sepsis. Hospital records and provider notes indicated that the lack of proper antibiotic administration contributed to the resident's acute condition. The facility's failure to administer essential antibiotics as ordered, document actions taken, and communicate effectively with pharmacy and providers led to significant harm and was identified as an Immediate Jeopardy situation.
Failure to Notify Physician and Representative of Resident's Low Blood Pressure
Penalty
Summary
The facility failed to notify a resident's representative and physician of significant changes in the resident's condition, specifically repeated episodes of low blood pressure. The resident had multiple complex diagnoses, including pneumonia, COPD with acute exacerbation, respiratory failure, dehydration, and hypertension. On several occasions, the resident's blood pressure readings were notably low, with values in the 80s/40s-60s mmHg range. Despite these abnormal findings, there was no documentation in the nursing progress notes that the resident's representative or physician were notified of these changes on the dates the low blood pressures were recorded. Interviews with facility staff and the resident's representative confirmed that no notifications were made regarding the low blood pressure readings. The DON acknowledged that staff are expected to notify the physician and representative of such changes and document these actions, but this was not done. The LPN involved admitted to not notifying the representative or provider and did not recheck the blood pressure. Both the physician and APRN stated they were not informed of the low blood pressure episodes and emphasized the need for notification and follow-up. The facility's policy requires prompt notification and documentation when there is a significant change in a resident's condition, which was not followed in this case.
Failure to Follow IV Catheter Dressing and Flushing Protocols
Penalty
Summary
The facility failed to ensure that midline and central venous access device dressings and flushing were completed according to professional standards of practice for two residents receiving intravenous therapy. For one resident with a midline catheter for IV antibiotics, the dressing was not changed 24 hours after insertion as ordered, and gauze was placed under the transparent dressing, preventing observation of the insertion site. The medical record lacked documentation of the required dressing change, and the resident reported the dressing had not been changed since insertion. During medication administration, an LPN failed to check for blood return to confirm catheter patency before administering saline and antibiotics, contrary to facility policy. For another resident with a peripherally inserted central catheter (PICC), the dressing was not changed as scheduled, with the dressing date indicating it was overdue. The medication administration record documented a dressing change that staff later admitted was not performed, and the staff member acknowledged the documentation was inaccurate. Facility policies required dressing changes at specific intervals and confirmation of catheter patency before medication administration, but these were not followed for the residents involved.
Failure to Follow Medication Parameters for Antihypertensive Administration
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for antihypertensive medication administration were followed for a resident with multiple complex medical conditions, including hypertension, respiratory failure, and hypercalcemia. The physician's order specified that Metoprolol should be held if the resident's systolic blood pressure (SBP) was less than 110 or heart rate (HR) was less than 70. Despite these clear parameters, medication administration records showed that Metoprolol was given on multiple occasions when the resident's SBP was below the ordered threshold, with documented readings as low as 80/48. Interviews with several LPNs revealed uncertainty or lack of recall regarding adherence to the medication parameters, and some staff indicated they would have held the medication if aware of low blood pressure or the specific parameters. The DON and prescribing providers confirmed that medications should not be administered outside of ordered parameters and that they were not notified of these occurrences. Facility policy required medications to be administered as prescribed, including adherence to any parameters, but this was not followed in the resident's case.
Failure to Document IV Therapy and Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for three residents who received intravenous (IV) therapy. For one resident with multiple diagnoses including pneumonia, respiratory failure, and dehydration, there was a physician order for peripheral IV insertion, but no documentation was found in the nursing progress notes regarding the insertion, site, or care of the IV. The DON confirmed that documentation should have included details such as the location of the IV, number of attempts, success of the procedure, fluids administered, and site condition, but these were missing. Nursing staff interviews revealed confusion about the presence of orders and a lack of documentation regarding IV care and communication with the resident's representative. Another resident, admitted with acute osteomyelitis, diabetes, and a history of stroke, had documentation indicating a peripheral IV was present and a physician order for its removal. However, there were no nursing progress notes documenting the removal of the IV during the relevant period. This lack of documentation failed to meet the facility's own policy requirements for recording vascular access procedures and care. A third resident, admitted with complex medical conditions including osteomyelitis, spina bifida, and paraplegia, had physician orders for IV antibiotics. The Medication Administration Record (MAR) showed multiple missed doses of vancomycin and cefepime, with chart codes indicating to see nurses' notes, but the corresponding nursing notes were absent. Interviews with LPNs revealed that medication orders were not entered promptly, medications were not available, and provider notifications were either not made or not documented. Staff acknowledged that they should have documented provider notifications and actions taken regarding missed medications, but this was not done.
Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
The facility failed to provide adequate pain management for two residents who were prescribed opioid pain medications. One resident, admitted with multiple diagnoses including bilateral above-knee amputations, Parkinson's disease, and diabetic polyneuropathy, reported not receiving scheduled oxycodone doses every four hours as ordered by the physician. Medication administration records confirmed missed doses on several dates, and the resident stated that staff did not wake him to administer the medication. The resident's care plan specifically included administering analgesia as per orders. Another resident, with diagnoses including paraplegia, chronic pain, and major depressive disorder, also did not receive scheduled oxycodone-acetaminophen doses as ordered for pain rated 7-10. Medication records showed missed doses, and the resident reported not receiving the medication and that staff did not address his concerns. Interviews with the Assistant Director of Nursing and the LPN involved revealed that the LPN did not administer the medications because the residents were asleep, and this action was not in accordance with physician orders.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to ensure the proper repair and maintenance of handrails in two wings, cleanliness of resident rooms, and the application of protective pipe apron coverings under the sink in a resident's room. During a tour, it was observed that several handrail caps were missing in both the 100 and 200 halls, leaving jagged metal exposed. The Maintenance Director acknowledged the issue but stated it was not a priority, while the Administrator recognized it as a safety concern. Additionally, the protective pipe apron covering under the sink in a resident's bathroom was repeatedly found on the floor over several days, despite the Environmental Services Manager indicating that staff had been shown how to replace it. Furthermore, a resident's room was observed to have a significant amount of debris, napkins, and crumbs on the floor on multiple occasions. The resident expressed that their room was not swept regularly. The Environmental Service Manager stated that the expectation was for resident rooms and floors to be swept as a priority. The facility's policy on General Hospitality Services mandates daily cleaning of resident rooms, including dust mopping and wet mopping floors with a disinfectant solution, and dusting furniture. However, these procedures were not followed, contributing to the deficiency.
Inaccurate PASRR Screens for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASRR) screens were completed for two residents diagnosed with serious mental disorders. Resident #18's Level I PASRR, dated 12/24/2024, did not document any mental illness in Section I: PASRR Screen Decision-Making, despite the resident being admitted with diagnoses of depression, anxiety disorder, and bipolar disorder, all with onset dates of 12/24/2024. Similarly, Resident #77's Level I PASRR, dated 4/22/2024, lacked documentation of mental illness, even though the resident was admitted with schizoaffective disorder and adjustment disorder with anxiety. The Director of Nursing confirmed during an interview that the mental health diagnoses for both residents had not been included in their preadmission screening and resident reviews, and no revised PASRRs had been completed to document these diagnoses.
Deficiencies in Oxygen Therapy and Respiratory Equipment Storage
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for three residents. Resident #4 was observed receiving oxygen at a flow rate of 3.5 liters per minute, contrary to the physician's order of 2 liters per minute. Staff K, an RN, confirmed the incorrect setting and acknowledged that the flow rate should be checked at the beginning of each shift. Similarly, Resident #10 was receiving oxygen at 2.5 liters per minute, despite a physician's order for 4 liters per minute as needed. Staff B, an LPN, confirmed the discrepancy, and the DON expressed the expectation that orders should be followed. Additionally, the facility failed to properly store respiratory masks for three residents. Resident #83's nebulizer mask was repeatedly observed on the bedside table without a protective bag, which Staff J, an LPN, confirmed was against protocol. Resident #18's nebulizer mask was found on the floor multiple times, and Staff J acknowledged it should be stored in a plastic bag. The DON reiterated the expectation for masks to be kept in bags. Resident #17's nebulizer unit and tubing were found without a date label and not stored in a bag, which Staff G, an LPN, confirmed should have been done. The facility's policies on oxygen therapy and infection prevention were not adhered to, as evidenced by the improper oxygen flow rates and inadequate storage of respiratory equipment. The facility's policy required oxygen therapy to be administered as ordered by the physician and for respiratory equipment to be stored in plastic bags with date labels to prevent infection. These lapses in following established procedures contributed to the deficiencies observed during the survey.
Inaccurate MDS Assessment for Antibiotic Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident, who had a complex medical history including sepsis, cellulitis, urinary tract infection, and other conditions, was prescribed Rifaximin, an antibiotic, as per a physician's order. However, the MDS assessment did not reflect that the resident was receiving antibiotics under Section N - Medications. This discrepancy was confirmed during interviews with the Assistant Director of Nursing and the MDS Coordinator, both of whom acknowledged the inaccuracy of the assessment.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #12, who was unable to perform activities of daily living due to medical conditions including hemiplegia, hemiparesis, dysarthria, and muscle contractures. Observations on two separate occasions revealed that the resident's nails were overgrown, curling, and had a brown substance underneath, causing them to press into the palms of both hands. Despite the resident's care plan specifying that nail care should be performed on bath days and as necessary, this was not adhered to. Interviews with staff members, including a CNA, an LPN, a Restorative CNA, and the Director of Nursing, confirmed that the responsibility for nail care was understood but not executed. The CNA admitted to not having cut the resident's nails, while the Restorative CNA had repeatedly informed other CNAs about the need for nail care. The facility's policy on nail care, which includes trimming and cleaning nails, was not followed, leading to the deficiency observed by the surveyors.
Failure to Adhere to Wound Care Orders and Documentation
Penalty
Summary
The facility failed to provide wound care to a resident in accordance with professional standards of practice. The resident, who was admitted with multiple diagnoses including a local infection of the skin, cutaneous abscess, type 2 diabetes mellitus, polyneuropathy, and necrotizing fasciitis, had specific wound care orders from a hospital discharge and subsequent orders from a wound care provider. However, there was a lack of consistency and adherence to these orders. The wound care nurse admitted to not following the correct wound care orders and failing to document the wound's size and condition as required by the facility's policy. The deficiency was further compounded by the lack of updated orders following the resident's physician appointments, as expected by the Director of Nursing. The facility's policy required weekly documentation of non-pressure skin conditions, which was not adhered to, as evidenced by missing wound measurements on several dates. The wound care nurse acknowledged the oversight in documentation and order management, which contributed to the deficiency in providing appropriate wound care to the resident.
Failure to Provide Timely Laboratory Services for Residents
Penalty
Summary
The facility failed to provide necessary laboratory services for two residents, leading to deficiencies in medication management. Resident #20, who was admitted with severe dementia, major depressive disorder, and other conditions, was prescribed Depakote for mood instability. The Psychiatric Services Provider recommended monitoring Depakote and ammonia levels, but no orders for these tests were documented, and no results were available. The Psychiatric Services Provider acknowledged issues with obtaining ammonia levels due to them being send-out labs, and the Director of Nursing (DON) noted a communication gap in translating psychiatric notes into actionable lab orders. Resident #35, diagnosed with hyperlipidemia, hypertension, heart failure, dementia, Alzheimer's disease, and major depressive disorder, was prescribed Atorvastatin and required a lipid panel every 180 days. However, no lipid panel results were documented since January 2024, despite an active physician order. The DON admitted to previous issues with the lab company but emphasized the expectation to follow physician orders. The facility's policies on drug regimen review and physician orders were not effectively implemented, contributing to the failure in providing timely laboratory services.
Food Storage and Maintenance Deficiencies
Penalty
Summary
The facility failed to store food items in accordance with professional standards, as observed during a kitchen tour. A brown buildup was found on the floor of the Emergency Food Storage room under a food storage crate, located over a floor drain. The Food Services Manager, who had been in the position for seven months, was unaware of the buildup's origin and mentioned that the area was not frequently visited. Additionally, ceiling vents in the emergency food storage room and over the food preparation area had a dark substance around their perimeters, with some areas showing cracked and peeling material. The Maintenance Director was not informed of these issues and noted that the brown buildup was dry, suggesting it might have been from a previous drain overflow. The facility's Freezer Temperature Log for January 2025 showed temperatures above the freezing point on multiple occasions, with no corrective actions documented. The District Manager for Food and Nutrition Services stated that food was moved from the emergency food supply room after discovering the drain, and the freezer's contents were relocated due to temperature issues. The facility's policy on maintenance emphasized preventative maintenance and prompt action for repairs, but the Director of Environmental Services was not informed of the issues, indicating a lapse in communication and adherence to the policy.
Infection Control Breaches in PPE Usage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) during medication administration and wound care, leading to potential infection control breaches. In the first instance, a Licensed Practical Nurse (LPN) prepared medications for a resident with a gastrostomy tube, who was under enhanced barrier precautions. Despite signage indicating the need for both gloves and a gown for high-contact activities, the LPN administered medication using the feeding tube without donning a gown. The Assistant Director of Nursing confirmed that the expectation was for staff to adhere to the enhanced barrier precaution policy, which includes wearing a gown. In a separate incident, another LPN, serving as a Wound Care Nurse, failed to perform hand hygiene between glove changes during wound care for a resident. After rinsing the resident's groin wound, the nurse changed gloves without washing hands, contrary to the facility's policy that requires handwashing after glove removal. The Director of Nursing stated that the expectation is for staff to wash hands before donning gloves and after doffing them, regardless of the task being performed. These lapses in infection control practices were observed and documented, highlighting deficiencies in adherence to established protocols.
Failure to Implement Insulin Administration Policies Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to protect a resident from medical neglect by not implementing policies and procedures for insulin administration. On the morning of October 6, 2024, a resident with a history of type 1 diabetes and other significant health issues had a blood sugar level of 552. The resident refused medications until he received the proper insulin. Staff A, an LPN, did not communicate the new insulin orders to Staff B, another LPN, nor did they transcribe these orders into the medical record. Consequently, Staff B did not follow up with the provider, reassess the resident's blood glucose, or address the need for any orders. The resident called 911 twice on the same day, with the first call being dismissed by Staff B, who instructed EMS that the resident did not need help. However, during the second call, the resident was transferred to the hospital and admitted to the ICU with a diagnosis of Diabetic Ketoacidosis (DKA). The facility's failure to implement the policy and procedure for medical neglect and ensure residents requiring insulin administration received treatment in accordance with professional standards of practice led to a determination of Immediate Jeopardy. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and treatment. The Director of Nursing acknowledged that the nurse in charge did not act within professional standards of practice for treating hyperglycemia in a type 1 diabetic. The Medical Director and other medical staff indicated that the professional standard of practice would have been to recheck the blood glucose after high readings and notify the provider of the resident's refusal of treatment. The facility did not follow its abuse and neglect policies, and there was a failure to conduct a thorough investigation or implement corrective actions promptly.
Removal Plan
- The Executive Director completed a 30-day look back at all reportables to ensure proper investigation was conducted.
- The Director of Nursing completed all hospital transfers, conducted a facility wide audit of change in conditions pertaining to insulin with no additional concerns related to blood sugars.
- Education was provided to the Executive Director by the Regional President on Abuse/Neglect policy and procedure to include investigations.
- The Regional Nurse Consultant provided abuse/neglect education, as well as investigation to the nurse management staff.
- Education included: abuse/neglect policy and procedure related to neglect for failure to reassess, notify the physician, not documenting physician's orders, not documenting communication to the physician, not documenting the transfer of the resident to the hospital, not following physician orders, and lack of shift-to-shift report.
- All incidents to be called to the Regional President, Regional Director of Clinical Services, and Risk Manager with a timeline of events on any incident to determine if reportable.
- Investigations to be started immediately on any complaints or incidents.
- The grievance log was reviewed for concerns related to change of condition, insulin, abuse or neglect.
- The Director of Nursing conducted a facility wide audit of all hospital transfers and change of condition pertaining to insulin with no additional concerns related to blood sugars.
- Education was provided for all staff by the Director of Nursing/designee on the abuse neglect policy.
- Facility personnel received education related to the abuse/neglect policy to include preventing abuse, identification, protection, investigating and reporting inappropriate resident behaviors to the nurse.
- Key staff were educated on reporting process of a potential deficient practice or suspected abuse/neglect to the Quality Assurance performance Improvement (QA/PI) by notifying the Executive Director and/or the Director of Nursing.
- An Ad Hoc that included the Executive Director, Medical Director, Director of Nursing the root cause analysis was the facility failed to initiate/implement the abuse/neglect policy including a complete investigation.
- Education has been completed on licensed nurses on medical neglect, accuchecks, insulin, Type 1 and 2 diabetes, and Change of Condition policy.
- Certified Nursing Assistants and ancillary staff were also educated.
Failure to Administer Insulin Properly Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident requiring insulin administration received treatment in accordance with professional standards of practice. On the morning of October 6, 2024, a resident with a history of type 1 diabetes mellitus and other significant health conditions had a blood sugar level of 552. The resident refused medications until he received the proper insulin. Staff A, an LPN, notified the on-call provider but failed to communicate the new orders to Staff B, the LPN who assumed care later that morning. Staff B did not follow up with the provider, reassess the resident's blood glucose, or address the need for any orders. The resident called 911 twice on the same day, expressing concerns about not receiving the correct insulin. Despite the resident's calls, Staff B instructed EMS that the resident did not need help. Later that night, the resident was transferred to the hospital and admitted to the ICU with a diagnosis of Diabetic Ketoacidosis. The facility's failure to implement the policy and procedure for change of condition and physician notification, along with the failure to ensure proper insulin administration, led to a determination of Immediate Jeopardy. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and treatment. The Director of Nursing acknowledged that the nurse should have notified the doctor immediately when the resident refused insulin and that the orders should have been transcribed. The Medical Director and other staff members confirmed that the professional standard of practice was not followed, as the resident's blood glucose was not rechecked, and the refusal of insulin was not properly communicated to the physician.
Removal Plan
- An Ad Hoc was completed in the presence of the Executive Director, Medical Director and the Director of Nursing, to identify the root cause analysis was that the facility failed to ensure residents were free from complications of a change in condition due to not reassessing residents, not transcribing and administering ordered medication, not properly notifying the physician and not properly identifying the change in condition.
- Licensed staff were educated on the change of condition process notifying the provider of abnormal blood glucose levels, notification of change, refusal of medications, assessment and reassessments for abnormal glucose levels and other change in condition, and transcribing and administration of physician orders.
- The Director of Nursing completed a full house audit of hospital transfers and changes in conditions with no deficient practice noted related to blood sugars, insulin, and transcribing/administering.
- An in-service on the topic of abuse/neglect presented by the Regional Director of Clinical Services was provided to the nursing management staff, the Director of Clinical Services, Assistant Director of Clinical services, and two Unit Managers.
- The Executive Director received education on abuse and neglect training (reporting requirements) from the Regional President of Operations.
- Licensed staff, Certified Nursing Assistants, and ancillary staff received training on Abuse and Neglect, assessment and reassessment of residents, change-in-condition process, hospital transfer process, communication during shift-to-shift report, insulin administration, abuse/neglect identification and process and communication between staff and providers.
- Staff interviews verified receiving the training and verbalized understanding of the abuse and neglect, changes in condition policies and procedures, resident reassessment after changes in condition.
Failure to Implement Medical Neglect Policies Leads to Resident's Hospitalization
Penalty
Summary
The facility administration failed to effectively manage resources and implement policies and procedures for medical neglect and resident change of condition, leading to a critical incident involving a resident with Type 1 Diabetes Mellitus. On the morning of October 6, 2024, a resident had a blood sugar level of 552, and the on-call provider was notified. The resident refused medications until he received the proper insulin. Staff A, an LPN, did not communicate the new orders for increased insulin and sliding scale insulin coverage to Staff B, another LPN, nor were these orders transcribed into the medical record. Staff B assumed care of the resident at 7:00 AM but did not follow up with the provider, reassess the resident's blood glucose, or address the need for any orders. The resident called 911 twice, first at 6:30 PM, when EMS was instructed by Staff B that the resident did not need help, and again at 11:15 PM, leading to the resident's transfer to the hospital. The resident was admitted to the Intensive Care Unit with a diagnosis of Diabetic Ketoacidosis. The facility's failure to implement the policy and procedure for medical neglect and ensure residents requiring insulin administration received treatment in accordance with professional standards of practice resulted in a determination of Immediate Jeopardy. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and treatment. The Director of Nursing acknowledged that the nurse in charge did not act within professional standards of practice for treating hyperglycemia in a type 1 diabetic. The Medical Director emphasized the importance of glucose monitoring and sliding scale insulin for diabetic residents. The facility's administration did not file a report or implement the abuse and neglect policies promptly, and there was a lack of thorough investigation and follow-up on the incident.
Failure in Insulin Management and Communication
Penalty
Summary
The facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process effectively, leading to a significant deficiency in the care of a resident with type 1 diabetes. On the morning of October 6, 2024, the resident had a critically high blood sugar level of 552, and the on-call provider was notified. However, the resident refused medications until he received the proper insulin. Staff A, an LPN, did not communicate the new orders for increased insulin and sliding scale coverage to Staff B, the LPN taking over the shift, nor were these orders transcribed into the medical record. Consequently, Staff B did not reassess the resident's blood glucose or follow up with the provider, leading to the resident calling 911 twice and eventually being admitted to the hospital with Diabetic Ketoacidosis. The deficiency was further compounded by a lack of proper documentation and communication between staff members. Staff A failed to document the text message communications with the on-call medical doctor in the resident's medical record. Additionally, there was no documentation of further blood glucose checks after the initial high reading. Staff B, who took over care, was not informed of the specific blood sugar level and did not take steps to reassess or address the resident's condition, despite the resident's complaints and eventual call to emergency services. Interviews with facility staff revealed a breakdown in following professional standards of practice and facility policies. The Director of Nursing acknowledged that the situation should have been avoided and considered it neglect. The facility did not conduct a thorough investigation or implement the abuse and neglect policies promptly. The administrator and other staff members admitted to not fully understanding the severity of the situation until after the resident's daughter raised concerns, highlighting a systemic failure in communication and adherence to established procedures.
Removal Plan
- The Executive Director received education from the Regional President on the CMS Five Elements of Quality Assurance Performance Improvement (QA/PI) and reviewed the findings indicating facility failed to identify areas not in compliance regarding the nurse failing to reassess the resident, failed to document the change-in-condition, lack of shift-to-shift report, insulin administration, Abuse and Neglect identification and process, failed to follow policies and procedures when transferring resident to the hospital, and lack of communication between staff and providers.
- The Executive Director was educated on the Quality Assurance Performance Improvement (QA/PI) process to include education on identifying a problem, starting and completing an investigation, and implementing a Performance Improvement Plan (PIP) and Plan of Correction (POC).
- The Executive Director was educated on the reporting process of a potential deficient practice to the Quality Assurance Performance Improvement (QA/PI) by notifying the Executive Director and/or Director of Nursing.
- Key staff (including the Medical Director, Director of Nursing, Infection preventionist, Wound Care Nurse, Activities Director, Medical Records, Human Resources, Business Office Managers, and the Environmental Services Manager) were educated on the CMS Five Elements of Quality Assurance Performance Improvement (QA/PI) and reviewed the findings indicating facility failed to identify areas not in compliance regarding the nurse failing to reassess the resident, failed to document the change-in-condition, lack of shift-to-shift report, insulin administration, Abuse and Neglect identification and process, failed to follow policies and procedures when transferring resident to the hospital, and lack of communication between staff and providers.
- Key staff were educated on the Quality Assurance Performance Improvement (QA/PI) process to include education on identifying a problem, starting and completing an investigation, and implementing a Performance Improvement Plan (PIP) and Plan of Correction (POC).
- An Ad Hoc that involved the Executive Director, Medical Director, Director of Nursing identified the root cause analysis was the facility failed to initiate/implement the abuse/neglect policy including a complete investigation.
Failure to Implement Policies Leads to Resident Neglect
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse and neglect, specifically in the case of a resident with multiple complex medical conditions, including Type 1 Diabetes Mellitus. The resident was admitted with a regimen that included insulin management, but there was a failure to administer the correct insulin as per the resident's needs. On a particular day, the resident's blood sugar was recorded at a dangerously high level of 552, and the resident refused medication, stating he was not receiving the proper insulin. Despite this, the staff did not take appropriate action to address the resident's refusal or the high blood sugar level. The LPN on duty communicated with the on-call medical doctor via personal text messages, but the orders received were not transcribed into the electronic medical record. The resident's blood sugar was not rechecked after the initial high reading, and the resident eventually called 911, leading to his transfer to the hospital where he was diagnosed with diabetic ketoacidosis. The facility's Director of Nursing and Administrator acknowledged that the situation was not handled according to professional standards, and the neglect was not reported or investigated as required by the facility's policies. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition and the orders received. The staff involved were not suspended during the investigation, and there was no disciplinary action taken. The facility's policies on abuse and neglect were not followed, and a root cause analysis was not conducted promptly. The failure to adhere to established procedures and the lack of a thorough investigation contributed to the neglect of the resident's medical needs.
Breach of Resident Information Confidentiality
Penalty
Summary
The facility failed to safeguard medical record information against unauthorized use, maintain complete and accurate medical records, and ensure the confidentiality of the medical record for a resident. The resident, who had multiple medical conditions including diabetes mellitus type 1 and chronic kidney disease, refused all medications until receiving the proper insulin. Despite the resident's refusal, the staff did not document the physician's orders in the electronic medical record, nor did they record the text message communications regarding the physician notification or orders. The staff used personal cell phones to communicate with the on-call medical doctor about the resident's condition and medication refusal. This communication included the resident's full name and medical information, which was shared via unsecured text messages. The facility's policy prohibits the use of personal electronic devices for sharing protected health information (PHI), yet staff members routinely used their personal phones for such communications, citing convenience and the lack of a company-issued device. Interviews with various staff members, including the Administrator and Director of Nursing, revealed a lack of adherence to the facility's policy on cell phone use and the handling of PHI. The staff admitted to using personal devices to text medical information, often deleting messages after receiving orders. The facility's policy clearly states that PHI should never be stored or shared on personal devices, highlighting a significant breach in maintaining the confidentiality and security of resident information.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
