Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At North Florida during CMS and state inspections, most recent first.
A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Respiratory care was not provided in accordance with standards for several residents receiving oxygen and nebulizer treatments. Staff observed outdated oxygen tubing and humidification equipment, a nebulizer mouthpiece left out with tubing touching the floor, and oxygen supplies not stored properly. One resident’s oxygen was running at a higher flow than ordered, and staff confirmed the tubing and humidification items should be changed weekly and documented.
Incomplete Dialysis Communication Records: The facility failed to maintain ongoing communication and collaboration with the dialysis provider for two residents receiving HD. For one resident with ESRD and hemiplegia, and another resident with CKD and rib fractures, dialysis communication forms were left incomplete and unsigned on multiple occasions, including sections for pre-transfer and post-return information. An HD RN reported difficulty reaching the facility and said the communication book had not been filled out for a long time, while the DON confirmed the nurses were not completing the dialysis communication forms even though vital signs were available.
Failure to control pest activity and maintain sanitary conditions. Live pests were observed in resident rooms and a common area, and residents reported seeing roaches in their rooms for months. Pest logs documented repeated roach sightings, pest control reports noted heavy German roach activity and recurring entry points such as cracks, voids, and gaps around pipes, and a critical work order for pest control and hole closure was never completed. The Administrator confirmed live pests were present, and the DPO stated the repair recommendations were not being addressed.
A facility failed to ensure MDS assessments accurately reflected resident status for multiple residents. One resident’s oxygen use was not captured in Section O despite PRN O2 orders and repeated oxygen saturation documentation, another resident’s MDS omitted oxygen use despite progress notes and an O2 order, a third resident’s MDS omitted depression despite a citalopram order, and a fourth resident’s MDS coded no ROM impairment even though PT identified quadriplegia with limitations in all extremities.
Incomplete Care Plan for Oxygen Therapy and Behaviors: A resident with continuous O2 orders was observed receiving O2 at 3 L via NC, while the chart showed an updated order for 4 L continuous. The care plan only listed O2 under services/orders and did not include a respiratory or behavior focus, even though an LPN reported the resident had behaviors of removing O2 and adjusting the concentrator and flow rate; the RN MDS Coordinator stated the oxygen focus was not on the care plan and should have been included.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
Missed Weekly Weights for Resident With Significant Weight Loss: A resident with tube feeding, poor PO intake, dysphagia, and a history of significant weight loss had a physician order for weekly weights due to weight change, but multiple weekly weights were not recorded. The RD noted the resident had lost weight when TF was reduced and that family snacks may have contributed to weight gain, while the dietary note documented ongoing supplements, bolus Jevity 1.5, and a 6-month unplanned weight loss of 25.6 lbs.
Failure to Document Ordered Skin Treatments: The facility failed to accurately document ordered skin treatments for a resident with a great toe condition. The MAR and TAR did not show the ordered Epsom salt soaks or triple antibiotic ointment, even though the DON, an LPN, the wound care nurse, and the resident stated the treatments were provided. Facility policy required all medications administered to be documented on the MAR immediately after administration.
The facility failed to post accurate nurse staffing information on a daily basis. Surveyors observed staffing sheets posted with future dates, including postings at the main entrance and nursing station, and one posting showed a census that did not match the Resident Listing Report. The DON, Administration, and Staffing Coordinator acknowledged the staffing information was being prepared and posted ahead of time, and the census on the sheet was incorrect.
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.
Unsafe One-Person Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure safe use of a mechanical lift for 2 of 3 residents reviewed for accidents. During an observation on 6/2/2026 at 8:42 AM, Resident #4 was lying on his bed on top of a Hoyer pad while CNA Staff K stood on the right side of the bed with a mechanical lift; the lift hand bags were observed over the resident, and no other staff member was in the room. Staff K stated that he was weighing Resident #4 and that normally only one person uses the Hoyer lift for weights, although the resident’s care plan documented a Hoyer lift with 2 assist. On 6/4/2026 at 10:15 AM, CNA Staff D was observed using a Hoyer lift alone to obtain Resident #13’s weight, with the resident lifted approximately 12 inches off the mattress in the sling and no other staff present. Staff D stated that he was performing weekly weights and most of the time did the weights using the Hoyer lift by himself. Resident #13’s MDS Section GG coded the resident as dependent, and the facility’s mechanical lift competency checklist stated that two caregivers are present, while the facility policy for using a mechanical lifting device stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The DON and Director of Therapy both stated that a mechanical lift should always be used by two staff members.
Respiratory equipment was not maintained and stored per standards
Penalty
Summary
The facility failed to follow professional standards of practice for oxygen and nebulizer treatments for four residents receiving respiratory services. During observations, Resident #56 was receiving continuous oxygen at 4 liters per minute by nasal cannula, and the tubing was dated 5/22 even though staff stated the tubing should be changed weekly on Thursdays. The DON confirmed oxygen tubing is changed weekly. Resident #56’s physician order dated 4/2/2026 ordered continuous oxygen at 4 liters nasal cannula. Resident #29 was observed with oxygen via nasal cannula connected to an oxygen concentrator with a humidification/water bottle dated 5/17/26, and the same date was observed again the next day. Her orders included continuous oxygen at 2 liters and weekly change of tubing, mask, and/or nasal cannula, but there was no order for humidification related to her oxygen and no MAR/TAR entry for humidification. Staff stated the humidification bottles should be changed weekly and at the same time as the tubing, and the DON stated there should be an order for humidification and that tubing and humidification bottles should be documented on the TAR. Resident #55’s nebulizer setup was observed with inhalation tubing hanging from the machine, with the distal tip touching the floor, and the mouthpiece sitting on the bedside table instead of in a plastic storage container. Resident #88 was observed with an oxygen concentrator running at 4.5 liters per minute, while the physician order was for 2 liters continuous; the oxygen cannula was wrapped around the bedside rail and not stored in a bag. The unit manager stated oxygen supplies should be stored in a dated plastic bag and the mouthpiece should not be left on the bedside table.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis provider for two residents who required dialysis services. One resident was admitted with hemiplegia affecting the left nondominant side and end stage renal disease, with an order for hemodialysis on Tuesday, Thursday, and Saturday. The resident’s hemodialysis communication records for multiple dates showed sections that were not completed and not signed by the nurse, including sections to be completed before transfer and upon return from dialysis. During interview, staff stated the facility communicated with dialysis nurses through a communication book, but the dialysis RN reported difficulty communicating with the facility and stated that the communication book had not been filled out for a long time. A second resident was admitted with multiple rib fractures and chronic kidney disease stage 3, with orders for dialysis on Monday, Wednesday, and Friday and for communication with the dialysis center regarding labs and plan of care. The resident’s dialysis communication records for two dates showed the section to be completed by the facility upon return from dialysis was not completed and not signed by the nurse. The facility policy stated that agreements with the contracted ESRD facility include how information will be exchanged between facilities, but the records and interviews showed that the required dialysis communication documentation was not consistently completed.
Failure to Control Pest Activity and Maintain Sanitary Conditions
Penalty
Summary
The facility failed to maintain a sanitary environment by effectively preventing and controlling pest activity. Live pests were observed in multiple resident rooms and common areas, including a pest next to Resident #79’s bed, two live brown insects in Resident #48’s room, a live insect on the wall behind Resident #48’s bed, a live insect on the wall behind Resident #45’s bed, an elongated light brown insect in front of the business manager’s office, and a small brown pest on Resident #79’s laundry basket. Resident #79, Resident #11, Resident #71, and Resident #104 each reported seeing roaches in their rooms, with Resident #11 and Resident #71 stating the facility had not come in to spray for months. The Administrator confirmed the presence of live pests in the facility. Record review showed repeated pest sightings and unresolved building conditions that could allow pest entry. The pest sighting log for May and June 2026 documented roaches 18 times in two of four hallways. Pest control reports noted German roach activity in every treated room, with an actual count of 100 on 4/10/2026, and repeated recommendations to address debris, gaps around pipes, cracks or damage to walls, and voids in baseboards. Observations also identified loose baseboards behind Resident #96’s bed and in Resident #28’s bathroom, along with a small hole in the wall above the floor in Resident #28’s bathroom. A critical work order for the dietary kitchen noted the need for pest control and holes to be closed, but the status was set to be completed and was never completed. The Director of Plant Operations stated they were not aware of or working on the repair recommendations from pest control.
Inaccurate MDS Assessments for Oxygen Use, Depression, and Range of Motion
Penalty
Summary
The facility failed to ensure resident assessments were completed accurately to reflect resident status for 4 of 13 residents reviewed. Resident #3’s Medicare 5-day MDS dated 5/7/2026 did not document oxygen use in Section O, even though the physician order dated 4/28/2026 directed oxygen 2L via nasal cannula PRN and the resident’s oxygen saturation records showed repeated oxygen use during the look-back period. The MDS Coordinator stated the assessment needed to be corrected because the resident did use oxygen during the look-back period. Resident #15’s Medicare 5-day MDS dated 4/2/2026 also did not document oxygen use in Section O, despite a physician order for O2 at 3L via nasal cannula PRN for respiratory distress and progress notes documenting oxygen use via nasal cannula at 2L and 3L. Resident #56’s modification of admission Medicare 5-day MDS dated 4/9/2026 did not document depression in Section I, although the resident had an order for citalopram 20 mg daily related to depression. Resident #19’s MDS dated 4/15/2026 coded no impairment in range of motion for both upper and lower extremities in Section GG, while the resident was observed in PT receiving services and was identified by the PT as a quadriplegic with spinal cord injury and limitations in range of motion in all extremities.
Incomplete Care Plan for Oxygen Therapy and Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #113’s oxygen therapy and behaviors. The resident had physician orders for continuous oxygen, including an order on 5/4/2026 for oxygen at 3 liters, an order on 5/5/2026 for oxygen at 3 liters via nasal cannula, and an order on 5/22/2026 for oxygen at 4 liters continuous. During observations on 6/1/2026 and 6/2/2026, the resident was lying in bed with oxygen being administered at 3 liters via nasal cannula. Review of the resident’s baseline care plan and summary dated 5/4/2026 listed only “O2” under Other Services/Orders, and the care plan reviewed on 6/3/2026 did not include a focus for respiratory services or behaviors related to oxygen. Staff J, an LPN, stated the resident had oxygen orders and should be on 4 liters, and also stated the resident had behaviors and tended to remove the oxygen and touch the concentrator and flow rate. Staff J confirmed the resident was receiving oxygen at 3 liters per minute. Staff I, the RN MDS Coordinator, stated she had just been informed the resident was on oxygen and had behaviors concerning the oxygen, and acknowledged the oxygen focus was not on the care plan and should have been included.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Missed Weekly Weights for Resident With Significant Weight Loss
Penalty
Summary
The facility failed to obtain and document weekly weights for Resident #13, who had a physician order dated 03/19/2026 to weigh weekly due to a significant weight change. Review of the resident’s weight record showed multiple missed weekly weights, including no recorded weights on 05/29/2026, 05/22/2026, 05/08/2026, 04/13/2026, and 03/30/2026. The resident’s documented weights showed fluctuations, including 176.6 pounds on 05/15/2026, 172.8 pounds on 05/01/2026, 171.2 pounds on 04/27/2026, 171.0 pounds on 04/20/2026, 177.4 pounds on 04/06/2026, 176.2 pounds on 03/23/2026, 176.8 pounds on 03/18/2026, 178.0 pounds on 03/09/2026, and 177.4 pounds on 03/05/2026. Resident #13 was admitted from the hospital with tube feeding and a diet, ate little, and had a history of significant weight loss. The regional RD stated the resident had lost weight when tube feedings were reduced and that family brought in snacks, which she believed contributed to weight gain. The dietary progress note dated 05/07/2026 documented NAS diet, regular texture, thin liquids, health shake supplements twice daily, and bolus Jevity 1.5 tube feeding twice daily, with current body weight of 172.8 pounds on 05/01/2026 and a 6-month weight history showing 198.4 pounds on 11/26/2025, reflecting a 25.6-pound, 12.9% unplanned, undesirable weight loss. The care plan included risk for malnutrition related to significant weight loss and dysphagia, with interventions including weights per facility protocol and as ordered.
Failure to Document Ordered Skin Treatments
Penalty
Summary
The facility failed to accurately document treatments ordered for Resident #112, who had a physician order dated 4/6/2026 for daily Epsom salt soaks for 14 days and application of triple antibiotic ointment to the great toe. Review of the resident’s Medication Administration Record and Treatment Administration Record for April 2026 did not show documentation of either the Epsom salt soaks or the triple antibiotic ointment to the great toe. During interviews, the DON stated the order existed but was not documented and that she could not find it in the treatment records, although staff said they had provided the care. An LPN stated she saw nursing provide the treatment and that the Epsom salt remained in the medication cart, adding that staff wrote the order but forgot to check off the box so it would appear on the MAR. The wound care nurse stated she was doing the treatments daily for Resident #112, and the resident confirmed staff provided the Epsom salt soaks and triple antibiotic ointment. The facility policy stated that the MAR is used to document all medications administered and that administration is documented immediately after it is given.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure accurate nurse staffing information was posted on a daily basis. During observations on 6/1/2026, staffing information dated 6/1/2026 was posted at the main entrance, but the census listed as 103 did not match the Resident Listing Report census of 102. Later that same day, staffing information dated 6/2/2026 was observed posted, and on 6/2/2026 staffing information dated 6/3/2026 was posted at the main entrance. On 6/3/2026, staffing information dated 6/4/2026 was posted at the 100 Hall nursing station near the off-hours facility entrance. During interview, the DON confirmed the staffing information posted was dated 6/4/2026 and stated the scheduler would prepare the staffing information sheet before leaving and corrections would be made the next day. The DON also stated the staffing sheet should not be posted in the front and should be placed behind the current day until the new shift starts. Administration stated the staff coordinator should not post the staffing information the day before and should post the current staffing information for the day. The Staffing Coordinator stated she had been putting the staffing information out before leaving at the end of the day for the following day and did not notice the census was incorrect.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 88 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Garden Of Gainesville | 1.2 mi | ★★★★★ | 0 | 0 |
| Magnolia Ridge Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 7 | 0 |
| Gainesville Health And Rehabilitation | 2.7 mi | ★★★★★ | 4 | 0 |
| Terrace Healthcare & Rehabilitation Center | 2.9 mi | ★★★★★ | 7 | 0 |
| Plaza Health And Rehab | 3.6 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.