Aviata At Palm Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Palm Bay, Florida.
- Location
- 5405 Babcock St Ne, Palm Bay, Florida 32905
- CMS Provider Number
- 105985
- Inspections on file
- 21
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aviata At Palm Bay during CMS and state inspections, most recent first.
A resident was discharged from an LTC facility without receiving the necessary medications as ordered by the physician. Despite a discharge plan indicating a safe transition home, the resident's daughter found that the medications were not sent to the local pharmacy or available at home. The facility staff acknowledged the oversight, citing incomplete discharge planning and holiday timing as contributing factors. The prescriptions were not called into the pharmacy until three days post-discharge.
A resident with multiple medical conditions did not have a required urinalysis and culture performed due to a failure in the facility's specimen collection process. An LPN could not recall collecting the specimen, and the lab confirmed it was never received. The facility's logs were incomplete, and the DON acknowledged the expectation for timely collection and communication, which was not met.
A resident with cognitive impairments and a history of wandering eloped from a facility due to inadequate supervision. Despite being under 1-to-1 supervision, the resident removed a security screw from his window and left the facility unnoticed. Staff failed to conduct regular checks, contributing to the incident. The resident's mother located him nearby after being informed of his disappearance.
The facility failed to complete a PASARR for a resident later diagnosed with major depressive disorder and schizophrenia. Despite significant behavioral issues and new diagnoses, the facility did not update the PASARR as required, leading to conflicting information in the resident's medical records and MDS assessments.
The facility failed to ensure accurate PASARR completion for three residents, leading to missed evaluations for serious mental illnesses. One resident's PASARR did not reflect a bipolar disorder diagnosis, another's did not include anxiety and psychotic disorder diagnoses, and a third's Level II PASARR was delayed. The Social Services Director acknowledged these inaccuracies.
A female resident with a complex medical history, including encephalopathy, cognitive communication deficit, dementia, and mobility issues, exited the facility unsupervised and walked 0.3 miles down a heavily trafficked highway before being found by her daughter. The resident had been assessed as a high elopement risk, but the facility did not implement appropriate preventive measures such as a wander prevention device or increased supervision. Multiple staff members were aware of the resident's exit-seeking behaviors and high elopement risk, yet safety interventions were not timely implemented, resulting in Immediate Jeopardy.
A female resident with a complex medical history, including dementia and mobility issues, eloped from the facility despite being assessed as a high elopement risk. The admitting RN did not implement necessary preventive measures, and the receptionist allowed the resident to exit unsupervised. Nursing staff, including an LPN and Discharge Planner LPN, did not take appropriate elopement precautions despite observing exit-seeking behavior.
The facility failed to ensure an appropriate discharge process for two residents, leading to actual harm. One resident was discharged without a wheelchair and necessary home health services, resulting in a fall and hospital readmission. Another resident was discharged with an abdominal wound and did not receive required wound care services due to insurance issues, leaving her in pain and without assistance.
The facility failed to notify residents or their representatives of discharges in a timely manner and did not submit notices to the State LTC Ombudsman. One resident was informed verbally the day before discharge, another's son felt pressured to take her home, and a third learned of her discharge on the same day. The facility's staff had conflicting understandings of their responsibilities, and the policy requiring written notifications was not followed.
The facility failed to implement policies for thorough monitoring and tracking of discharge notifications, leading to repeated deficiencies. Despite re-education and quality monitoring plans, the Social Services Director did not ensure appropriate notification to the Ombudsman, and the Administrator was unaware of the lapse.
A cognitively intact resident's alimony checks were erroneously received and cashed by the facility without her consent, and the facility deducted an amount owed without obtaining written authorization to manage her personal funds. The checks were deposited into the facility's operating account, and the facility's policy was to cover any outstanding balance before issuing a refund.
Failure to Provide Discharge Medications
Penalty
Summary
The facility failed to ensure that a resident was provided with the necessary discharge medications as ordered by the physician. The resident, a cognitively intact female with multiple medical conditions including cerebrovascular disease, atrial fibrillation, and a history of stroke, was discharged home without her prescribed medications. The discharge plan indicated that the resident would have a safe discharge with medications provided, but upon returning home, the resident's daughter discovered that the medications were neither sent to the local pharmacy nor available at home. The Social Services Director and the Director of Nursing (DON) acknowledged the oversight, noting that the discharge planning process was incomplete due to the departure of the former Unit Manager and the timing of the Christmas holiday, which complicated the situation. The resident's daughter had to retrieve leftover medications from the facility, but only a limited supply of Coumadin was available. The facility's APRN did not call in the prescriptions to the pharmacy until three days after the resident's discharge. Interviews with facility staff and the resident's community pharmacist confirmed the delay in providing the necessary medications. The facility's standards and guidelines for discharge planning were not adequately followed, resulting in the resident being discharged without the required medications, which could have posed a significant risk given her medical history.
Failure to Collect and Submit Laboratory Specimen
Penalty
Summary
The facility failed to ensure a laboratory specimen was obtained and submitted per physician's orders for a resident. The resident, a female with multiple medical conditions including left-side paralysis, cerebrovascular disease, and a urinary tract infection, was supposed to have a urinalysis and culture performed on specific dates. However, the specimen was not collected and submitted as required, leading to a lack of test results. The deficiency occurred when a Licensed Practical Nurse (LPN) took a verbal order for a urinalysis and culture due to the resident's altered mental status but could not recall if the specimen was collected. The Treatment Administration Record indicated that the specimen was marked as uncollected, and the laboratory confirmed that no specimen was received. The Director of Nursing (DON) and other staff were unable to locate the necessary logs to verify the collection and submission of the specimen. The facility's process for handling laboratory specimens involved entering orders into the computer, printing requisitions, collecting specimens, and storing them in the refrigerator for pickup. However, the process was not followed correctly, as evidenced by the missing specimen and incomplete logs. The DON acknowledged the expectation for timely collection and communication of specimen status, but the failure to adhere to these procedures resulted in the deficiency.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with a history of traumatic brain injury, psychosis, and cognitive impairment. The resident, who was moderately cognitively impaired and had a history of wandering and agitation, was supposed to be under 1-to-1 supervision and equipped with an electronic wander alarm device. However, on the night of the incident, the resident managed to remove a security screw from his window and eloped from the facility without being noticed by the staff. The resident's mother was informed of his disappearance and was able to locate him in a nearby parking lot. She expressed concern that the facility staff did not check on her son frequently enough, as he was physically independent. The staff, including a CNA and an RN, admitted to not checking on the resident as often as required, with the CNA last seeing the resident at around 11:00 PM and the RN at 10:00 PM. The facility's guidelines required staff to check on residents at least every two hours, but this was not adhered to in this case. The facility's investigation revealed that the staff failed to conduct regular rounds throughout the night, which contributed to the resident's ability to elope. The resident had been upset due to a failed transfer to an assisted living facility, which may have exacerbated his behaviors. The facility's standards and guidelines for elopement risk were not effectively implemented, as the resident was not identified as being at risk for elopement until after the incident occurred.
Failure to Complete PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to complete a Preadmission Screening And Resident Review (PASARR) for a resident who was later identified with a Mental Illness (MI). The resident was admitted with diagnoses including hypertension, type 2 diabetes, and dementia, and had a Level I PASARR completed in the hospital, which indicated that a Level II PASARR evaluation was not required. However, after the resident was diagnosed with major depressive disorder and schizophrenia, the facility did not repeat the Level I PASARR or refer the resident for a Level II evaluation. This oversight was evident in the medical records and Minimum Data Set (MDS) assessments, which showed conflicting information regarding the resident's mental health status and the completion of PASARR evaluations. The resident's medical records indicated significant behavioral issues, including physical behaviors directed toward others and rejection of care, which were documented in the MDS assessments. Despite these behaviors and the new diagnoses, the facility did not update the PASARR as required. Interviews with the Social Service Director confirmed that a new diagnosis should have triggered a review and possible update of the PASARR. The facility's policy and procedure for PASARR also emphasized the importance of ensuring that residents with serious mental illness or intellectual disability receive appropriate care and services, highlighting the facility's failure to adhere to its own guidelines.
Failure to Ensure Accurate PASARR Completion
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurately completed for three residents. Resident #92 was admitted with diagnoses including bipolar disorder, depressive disorder, dementia, and anxiety. However, the PASARR form did not reflect the serious mental illness (SMI) of bipolar disorder. The Social Services Director confirmed that the Level I PASARR was inaccurate and should have been re-done to include the bipolar disorder diagnosis, which would have determined the need for a Level II PASARR evaluation. The Regional nurse also verified that it was the responsibility of the facility's Social Service Department to ensure the PASARR was accurate and re-assessed if necessary. Resident #21 was admitted with diagnoses including cerebral infarction, anxiety disorder, alcohol abuse, brief psychotic disorder, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment indicated severely impaired cognitive skills, and the medical record revealed behaviors of screaming at staff. The Social Service Director acknowledged that the Level I PASARR submitted did not include the anxiety and psychotic disorder diagnoses, making it inaccurate. Another Level I PASARR should have been submitted with the correct diagnoses. Resident #66 was admitted with diagnoses including major depressive disorder, schizoaffective disorder, and type 2 diabetes. The medical record showed a care plan for antipsychotic therapy and behaviors of refusing insulin, food, and medications. The Social Service Director verified that the Level I PASARR completed triggered a Level II PASARR, which had not been submitted until the day of the survey. The facility's policies and procedures required that all SMI and intellectually disabled residents receive appropriate pre-admission screening, and it was the responsibility of Social Services to coordinate and ensure the screenings were conducted and results obtained prior to admission.
Elopement Incident Involving High-Risk Resident with Cognitive Impairments
Penalty
Summary
The facility failed to protect a vulnerable resident, identified as resident #1, from elopement, leading to a deficiency in ensuring the resident's right to be free from neglect. Resident #1, a [AGE] year old female with a complex medical history including encephalopathy, cognitive communication deficit, dementia, and mobility issues, was admitted to the facility from the hospital with a documented high risk of wandering unsafely without 24-hour supervision. Despite being assessed as a high elopement risk, the facility did not implement appropriate preventive measures to mitigate the risk of elopement. On 12/30/23, resident #1 was allowed to exit the facility unsupervised and walked approximately 0.3 miles down a heavily trafficked highway before being found by her daughter at a nearby pharmacy. The facility was unaware of the elopement until the resident was returned. The failure to provide adequate supervision and implement safety interventions for a resident known to be at high risk for elopement resulted in Immediate Jeopardy, placing not only resident #1 but all residents who wandered at risk of serious harm or injury. The deficiency was further highlighted by the facility's lack of timely implementation of safety precautions, including the failure to use a wander prevention device or increase supervision despite clear indications of the resident's elopement risk. The deficiency in protecting resident #1 from elopement was exacerbated by the facility's failure to initiate appropriate interventions despite multiple staff members acknowledging the resident's exit-seeking behaviors and high elopement risk. The lack of implementation of safety measures, such as a wander prevention device or increased supervision, demonstrated a systemic failure in ensuring the safety and well-being of residents with cognitive impairments and mobility issues.
Elopement Incident Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent elopement for a vulnerable resident, identified as resident #1 in the report. Resident #1, a [AGE] year-old female with a complex medical history including encephalopathy, cognitive communication deficit, dementia, and mobility issues, was admitted to the facility from the hospital with a documented risk of wandering unsafely without 24-hour supervision. Despite being assessed as a high elopement risk upon admission, appropriate safety interventions such as an electronic wander prevention device or increased supervision were not implemented. This failure led to resident #1 eloping from the facility by walking out of the front entrance when the receptionist unlocked the door for her, ultimately reaching a local retail pharmacy where she was found by law enforcement. The report highlighted various missed opportunities to prevent the elopement of resident #1. The admitting Registered Nurse (RN) failed to implement the necessary preventive measures despite identifying the resident as a high elopement risk. The facility's Receptionist allowed resident #1 to exit unsupervised after unlocking the door, believing she was leaving with a group of visitors when, in fact, she was alone. Additionally, the facility's nursing staff, including the Licensed Practical Nurse (LPN) and Discharge Planner LPN, did not implement elopement precautions such as an electronic wander prevention device or increased supervision, despite observing signs of restlessness and exit-seeking behavior in resident #1.
Inadequate Discharge Planning Leads to Harm
Penalty
Summary
The facility failed to ensure an appropriate discharge process for two residents, leading to actual harm. Resident #21, who had multiple medical conditions including type 2 diabetes, a right below-knee amputation, and chronic heart failure, was discharged home without the necessary equipment and services. Despite being non-ambulatory and requiring substantial assistance, she was sent home without a wheelchair and did not receive the ordered home health care services. This resulted in her falling at home, being readmitted to the hospital, and receiving intravenous antibiotic therapy for a urinary tract infection that was not communicated to her before discharge. Resident #29, who had undergone surgery and had chronic conditions such as rheumatoid arthritis and chronic obstructive pulmonary disease, was also discharged without proper coordination of home health services. She was sent home with an abdominal surgical wound and did not receive the necessary wound care services. The home health agency did not accept her insurance, and she was left without the required assistance, leading to her lying on her couch in pain, unable to change her wound dressing due to her blindness. The facility's discharge planning process was inadequate, as evidenced by the lack of communication and coordination with home health agencies and the failure to ensure that residents had the necessary equipment and services before being sent home. The interdisciplinary team did not adequately address the residents' needs, and the discharge planner did not follow up to confirm that services were in place. This resulted in unsafe discharges and actual harm to the residents involved.
Failure to Notify Residents and Ombudsman of Discharges
Penalty
Summary
The facility failed to notify residents or their representatives of a facility-initiated discharge in a timely manner and in writing, and did not submit a copy of the notice to the State Long-Term Care (LTC) Ombudsman for three residents. Resident #21 was verbally informed of her discharge the day before she went home and was not provided with information on how to appeal the decision or the Ombudsman's contact details. She signed a discharge form as she was being wheeled out of the facility without receiving copies of the documents. Resident #28's son was informed that the insurance did not approve her stay and was not given the option to appeal. He felt pressured to take her home due to her weak condition and was unaware of the LTC Ombudsman's services. Resident #29 learned of her discharge on the same day she was sent home, with no written notification provided to her or her representative. The facility's records showed no evidence of notification to the LTC Ombudsman for any of these residents, and the staff were unclear about the processes for non-Medicare residents and the responsibilities for sending notifications. The Social Services Director (SSD) and the Medical Records Coordinator had conflicting understandings of their responsibilities regarding discharge notifications. The SSD believed the Medical Records Coordinator was responsible for sending notifications to the Ombudsman, while the Medical Records Coordinator thought it was the SSD's responsibility. The facility's policy required that residents and their representatives be notified in writing before a transfer or discharge, and a copy of the notice be sent to the Ombudsman. However, this policy was not followed, leading to the deficiencies identified in the report.
Failure to Implement Policies for Discharge Notifications
Penalty
Summary
The facility failed to ensure the implementation of policies for thorough monitoring of previously identified areas of concern and adequately track performance to ensure prior improvement measures for discharge notifications were realized and sustained. The facility was cited at F623, Notice Requirements Before Transfer/Discharge, during the last complaint survey conducted on 6/07/23. The Plan of Correction (POC) included re-education of the Social Services Director (SSD) and quality monitoring of discharges to ensure appropriate notification to the Ombudsman. However, during the current survey, F623 was again identified with no continued oversight of the previous citation. The Administrator stated that she was ultimately responsible for overseeing the operation of the facility and explained that audits and monitoring processes were performed to remain in compliance. Despite this, the SSD was responsible for the Ombudsman notification, and the Administrator was unaware that this was not being done as required. This indicates a failure in the facility's internal monitoring and communication processes, leading to repeated deficiencies in discharge notifications.
Failure to Obtain Written Authorization for Managing Resident's Personal Funds
Penalty
Summary
The facility failed to obtain written authorization to manage personal funds for a resident who was cognitively intact and made all decisions for her care. The resident was admitted with diagnoses including a history of falls, pathological fracture of the right humerus, osteoporosis, and muscle weakness. After her discharge, the facility erroneously received and cashed her alimony checks totaling $1500.00 without her consent. The facility returned the money minus $116.18, which they claimed the resident owed them, but did not obtain her written consent to manage her personal funds or deduct the amount owed. The Business Office Manager (BOM) and her assistant confirmed that the checks were deposited into the facility's operating account and that the facility's policy was to deduct any amount owed before issuing a refund. The BOM acknowledged that the checks were payable to the resident and not the facility, and that they should not have cashed them. The Administrator stated that it was their policy to cover any outstanding balance before processing a refund. The Admission Agreement signed by the resident indicated that the facility would refund any overpayment and that the resident must sign an authorization form for the facility to manage personal funds, which was not done in this case.
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.
