Aviata At Seminole
Inspection history, citations, penalties and survey trends for this long-term care facility in Seminole, Florida.
- Location
- 9393 Park Blvd, Seminole, Florida 33777
- CMS Provider Number
- 105895
- Inspections on file
- 30
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Aviata At Seminole during CMS and state inspections, most recent first.
Several cognitively intact residents were not informed or involved in decisions regarding changes to their medications, including psychotropic and pain medications. Residents only became aware of these changes after experiencing symptoms or upon inquiry, and medical records lacked documentation of resident participation in care planning. Staff interviews confirmed inconsistent communication practices, and facility policies requiring resident notification were not followed.
Multiple environmental deficiencies were observed, including unresolved bio-growth in shower areas and unrepaired fixtures in resident rooms. Staff reported issues verbally, but lack of systematic tracking and documentation led to persistent problems. The facility's reliance on informal communication and absence of cleaning and maintenance logs contributed to the failure to maintain a clean and safe environment.
Surveyors found that staff did not consistently follow infection prevention and control protocols, including failing to use PPE when entering rooms of residents on contact precautions, improper storage of medical equipment and clean linen, and unclear or missing precaution signage. Staff interviews revealed confusion about infection control policies and inconsistent application of procedures.
A resident with multiple medical conditions and prescribed medications was observed using marijuana and returning to the facility smelling of the substance. Despite staff awareness and complaints, the resident's provider and medical director were not notified of the drug use, contrary to facility policy requiring notification of changes in condition. Staff interviews revealed confusion about reporting responsibilities, and the care plan did not address illicit drug use or provider notification.
Surveyors found unsanitary conditions, including biogrowth in resident rooms and common areas, and persistent marijuana odors linked to a resident who smoked outside and returned smelling strongly of marijuana. Staff and administration lacked clear policies and consistent procedures for cleaning, biogrowth removal, and odor management, resulting in unresolved environmental concerns.
Two CNAs repeatedly neglected and verbally mistreated multiple residents, leaving them soiled, failing to provide timely hygiene care, and making demeaning comments. Several residents, all with significant care needs, reported being ignored, not cleaned properly, and spoken to disrespectfully. Staff interviews confirmed that these CNAs avoided care duties, were verbally aggressive, and left residents unattended, resulting in a pattern of neglect and emotional distress.
Two CNAs engaged in neglectful and verbally abusive behavior toward multiple residents, including leaving them in soiled briefs, failing to provide proper hygiene, and making derogatory comments. Several residents, many with significant care needs, reported being ignored or made to feel like a burden, while staff interviews confirmed a pattern of unprofessional conduct and lack of timely care. The issues were known among staff but not effectively addressed by management, resulting in ongoing neglect and mental abuse.
Two residents' grievances were not properly investigated or documented, with one resident's complaint about staff behavior during care not resulting in a thorough investigation or communication of outcomes, and another resident being left in feces for an extended period without timely intervention or proper reporting. The facility failed to follow its grievance policy, including requirements for investigation, documentation, and communication.
A resident was found by a CNA to be covered in feces after reportedly requesting assistance for several hours, indicating a lapse in care. Although the incident was documented internally and discussed with nursing staff, the facility failed to report the allegation of neglect to the required state agencies as mandated by policy and federal regulations.
Two residents experienced deficiencies in the facility's grievance process, including lack of proper investigation, documentation, and communication regarding their complaints. One resident did not receive follow-up after reporting inappropriate staff behavior, while another was left in soiled conditions for an extended period without timely care or proper reporting. Staff interviews revealed confusion about responsibility for grievance resolution, and required documentation was incomplete or missing.
A resident who was totally dependent on staff for toileting was found covered in feces after reportedly being left unassisted for several hours, despite requesting help. The incident was documented by staff and reported internally, but the required notification to state agencies was not made, as acknowledged by the facility's administrator.
Several residents assessed as needing constant supervision while smoking were observed smoking unsupervised in unsafe areas near busy roads and driveways, despite care plans and facility policy requiring supervision. Staff interviews revealed confusion over assessment procedures, inconsistent documentation, and inadequate oversight of smoking materials, resulting in residents smoking without the required supervision.
Multiple residents reported delays in call light response and insufficient assistance with care needs, with staff and LPNs confirming high resident-to-staff ratios and frequent short staffing, especially during certain shifts. Observations showed call lights going unanswered while staff were present, and grievances about slow response times remained unresolved. The facility lacked a formal staffing policy and did not have set expectations for call light response times.
The facility did not consistently ensure that controlled medications were accurately reconciled and verified by two nurses when added to medication carts, as required by policy. Observations showed that narcotics were added for several residents without a second nurse's signature or documentation of medication strength, and a significant number of narcotic records across multiple medication carts lacked proper validation. Staff confirmed that procedures for double verification were not always followed, resulting in incomplete documentation and failure to maintain proper chain of custody for controlled substances.
The facility did not ensure accurate reconciliation and accounting for controlled medications, as narcotics were added to medication carts without required second nurse verification and medication strengths were not documented. Despite staff education on proper procedures, audits revealed a high percentage of records lacking a second nurse's validation, and the QAPI process failed to identify or address these deficiencies.
Multiple residents were observed smoking in unsafe, unsupervised areas near busy roads and parking lots, contrary to facility policy requiring designated, supervised smoking areas. Despite care plans and assessments indicating a need for constant supervision, residents were allowed to sign out on LOA and smoke without oversight. Staff interviews revealed confusion about policy implementation, errors in assessments, and inadequate communication about smoking safety, resulting in a failure to protect residents as outlined in the facility's smoking policy.
A resident with a history of hemiplegia and dementia reported being dropped during a transfer, resulting in bilateral knee fractures and a transfer to a higher level of care. The facility failed to thoroughly investigate the incident, as the CNAs involved were not interviewed, and the adverse incident reporting protocol was not clearly followed. The resident later expired at the hospital.
A facility failed to provide wound care as per physician orders for a resident with multiple health issues, with several instances of undocumented care. Additionally, call lights for four residents were not answered in a timely manner, with delays ranging from eight to sixteen minutes. Interviews revealed that call lights were often answered late, and staff sometimes turned off lights without addressing residents' needs. The facility lacked a specific policy on call light response times, contributing to the deficiency.
A resident with multiple medical conditions, including diabetes, was found with long, discolored fingernails and inconsistent shower documentation. Interviews revealed confusion among staff about nail care responsibilities, with a gap in podiatrist services due to a transition. The DON confirmed missing shower sheets and lack of specific nail care documentation, contributing to the deficiency.
A resident with severe cognitive impairments was observed scooting on the floor and left unattended in the hallway. Additionally, the resident was found isolated and sleeping in the activities room, contrary to her care plan goals for social engagement. Staff interviews confirmed that the resident's condition and placement were not managed according to expected standards.
A resident with severe cognitive impairment and difficulty walking was observed with his feet hanging off the edge of his bed on multiple occasions. Despite complaints and staff awareness, no action was taken to provide a suitable bed, revealing a lack of communication and follow-through among staff.
The facility failed to ensure accurate Level I PASRR documentation for four residents, leading to incomplete records of their mental health diagnoses. The ADON and SSD were unsure about marking certain diagnoses, resulting in inaccuracies.
The facility failed to develop and implement person-centered care plans for two residents, one with communication needs due to a language barrier and another with an active DNR order. Staff inconsistently used translator services and relied on another resident for translation, while the care plan for the resident with a DNR order lacked any mention of their code status.
The facility failed to update the care plan for a resident who was initially on contact isolation for candida auris and antibiotic therapy for sepsis and pneumonia. The resident's status changed to being colonized with candida auris and no longer on antibiotics, but the care plan was not revised to reflect these changes.
A facility failed to ensure a resident fed by enteral means received appropriate treatment per physician orders. The resident did not receive the prescribed volume of Glucerna and hydration flushes, and staff admitted to not knowing how to use or document the enteral feeding pump settings. Training deficiencies were also noted.
The facility failed to monitor side effects for a resident on psychotropic medications after the resident returned from hospitalization. Despite the facility's policy requiring every shift monitoring, the side effects monitoring was not re-initiated, leading to a lapse in monitoring for potential adverse reactions.
The facility failed to follow proper infection control practices during medication administration for two residents. An LPN allowed an eye dropper to touch a resident's eyelids, and another LPN did not wear a gown while handling a PEG tube for a resident on Enhanced Barrier Precautions. The DON attributed these breaches to the inexperience of the nursing staff.
A resident with multiple health issues developed severe pressure ulcers due to the facility's failure to implement timely preventive measures and proper skin assessments. Despite being at high risk, the resident's condition worsened, and appropriate interventions were delayed.
The facility failed to maintain a medication error rate below 5.00%, resulting in an observed error rate of 11.54%. Errors included a missed dose of Telmisartan for a resident, late administration of Jevity 1.2 via PEG tube for another resident, and improper insulin administration technique for a third resident.
Failure to Involve Residents in Medication Changes and Care Planning
Penalty
Summary
The facility failed to ensure that four cognitively intact residents were informed in advance and allowed to participate in changes to their person-centered plan of care, specifically regarding medication adjustments. Multiple residents reported that their medications, including psychotropic and pain medications, were changed or discontinued without prior discussion or notification. Interviews revealed that residents only became aware of these changes after experiencing symptoms or upon inquiry, rather than through proactive communication from staff. Documentation in the medical records did not show evidence that residents were involved in or informed about these medication changes. For example, one resident with a history of major depressive disorder, anxiety, and bipolar disorder was not informed about the gradual dose reduction and discontinuation of several psychotropic medications, including Clonazepam and Seroquel. The resident only learned of the changes after noticing symptoms and speaking to nursing staff. Another resident with severe depression and anxiety experienced a reduction in Clonazepam dosage without prior notification, resulting in emotional distress. Similarly, a resident with chronic pain and anxiety had multiple medication changes, including the discontinuation and re-initiation of pain medications, without being consulted or informed about the reasons for these changes. Staff interviews confirmed that there was no consistent process for documenting or ensuring resident involvement in medication changes. The facility's own policies required notification of residents and their representatives when significant changes to treatment occurred, but these procedures were not followed. The lack of communication and documentation was acknowledged by facility leadership, who noted that the forms used for psychiatry notes did not include a section for resident notification or involvement in care planning.
Failure to Maintain Clean and Safe Environment Due to Inadequate QA and Maintenance Tracking
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe physical environment as required, as evidenced by multiple observations and staff interviews. During a survey, black growth was observed on the floor of a shower room, which a CNA had previously noticed and reported to a nurse, but the issue remained unresolved. The Housekeeping Director confirmed that while the shower room equipment had been pressure washed, there was no documentation or logs to verify when this cleaning occurred. Additionally, the facility lacked a system or log for tracking rooms or items needing cleaning, relying instead on direct verbal reports to the Housekeeping Director. Further deficiencies were identified in the maintenance of resident rooms, including loose sinks, loose toilets, and damaged bed lamination. The Maintenance Director was unaware of some of these issues, despite residents having reported them directly to him. Review of work orders did not show documentation for all reported problems, and the Maintenance Director admitted that he often could not enter work orders immediately when residents reported issues in passing. This lack of timely documentation and follow-up resulted in unresolved maintenance concerns. Interviews with the NHA and Regional President revealed that the facility's process for ensuring environmental cleanliness and maintenance relied heavily on informal communication and random checks, rather than systematic tracking and documentation. Staff were expected to report issues into the facility's maintenance system, and while training on this process had been provided, there were still gaps in execution. As a result, several environmental deficiencies persisted, including unresolved bio-growth in shower areas and unrepaired fixtures in resident rooms.
Inconsistent Infection Control Practices and PPE Use
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices across five of six facility halls. Residents on contact precautions were not consistently identified with appropriate signage, and staff did not always use required personal protective equipment (PPE) when entering rooms of residents on contact precautions. For example, staff were seen entering rooms of residents with C. difficile and other transmissible infections without donning gowns or gloves, and some staff believed PPE was only necessary during close care, contrary to facility policy. Additionally, contact precaution signs were missing or obscured on some doors, and staff were unclear about which residents required precautions. Improper storage of medical and personal care equipment was also noted. Nebulizer and oxygen masks were left uncovered on bedside tables without appropriate storage bags, and an open, unlabeled water bottle with a used washcloth was found on a hallway railing. Linen carts intended for clean linen storage contained inappropriate items such as bottles of cleaner, pens, air freshener, perineal/body wash, and an open can of soda, which staff acknowledged should not be stored with clean linen. Interviews with staff confirmed a lack of understanding and inconsistent application of infection control policies, particularly regarding when to use PPE and how to store equipment and supplies. Staff also reported confusion between contact precautions and enhanced barrier precautions, and acknowledged that education on infection control may not be clear enough. Facility policies reviewed by surveyors outlined requirements for signage, PPE use, and storage practices, but these were not consistently followed in practice.
Failure to Notify Physician of Resident's Illicit Drug Use and Potential Medication Interactions
Penalty
Summary
The facility failed to notify and consult with a resident's physician regarding the resident's known use of illicit drugs, specifically marijuana, despite the potential for medication contraindications. The resident, who had diagnoses including Parkinson's disease, chronic kidney disease, seizures, and cannabis abuse, was observed multiple times smelling of marijuana and admitted to smoking it outside the facility. Staff interviews revealed that while some staff reported the resident's marijuana use to supervisors or administration, none notified the resident's provider or medical director as required by facility policy. Documentation showed that the resident was prescribed several medications, including gabapentin, lacosamide, levetiracetam, and trazodone, all of which could have potential interactions with marijuana. The care plan identified the resident as a smoker and included interventions for unsafe smoking practices, but did not address the use of illicit substances or the need for provider notification. Staff members expressed uncertainty about their responsibilities, with some believing that once a resident signed out on a leave of absence, they were not responsible for actions taken outside the facility, and others assuming that reporting to a supervisor was sufficient. Both the nurse practitioner and medical director confirmed that they had not been informed of the resident's drug use, and stated that they would expect to be notified of such incidents to prevent possible medication interactions. The facility's policy required prompt notification of the physician and resident representative when there is a change in status or condition, but this was not followed in the case of the resident's ongoing marijuana use.
Failure to Maintain Clean, Sanitary Environment and Address Odors
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in multiple areas, as evidenced by the presence of biogrowth and unsanitary conditions in both a common room and two resident rooms. Observations revealed multiple gray and black spots of biogrowth on the back wall and floor of a resident closet, as well as stained floors with brown and black substances. In the Day Room, two ceiling air vents were surrounded by peeling paint with black areas visible underneath, indicating moisture and possible mold. Staff interviews indicated that while deep cleaning was reportedly performed monthly, there was no clear checklist or policy for the removal of biogrowth, and responsibilities for cleaning and reporting were inconsistently understood among housekeeping and maintenance staff. Additionally, the facility did not address persistent odors related to a resident who regularly returned from outside smelling of marijuana. The resident was observed smoking marijuana in the parking lot and later in his room, which had a strong odor of marijuana. Staff, including CNAs and LPNs, reported the smell and concerns to administration, but no effective action was taken. Staff expressed uncertainty about their ability to intervene when a resident returned from a leave of absence smelling of marijuana, and there was no policy provided for the removal of odors. Interviews with facility leadership, including the Director of Maintenance, Nursing Home Administrator, and Director of Nursing, revealed a lack of awareness and oversight regarding both the biogrowth and odor issues. The Director of Maintenance was unaware of the biogrowth in the resident closet and could not explain discrepancies in cleaning records. The Nursing Home Administrator had not recently inspected the affected room and was unaware of any cleaning checklist or policy for biogrowth removal. The Medical Director stated that providers should be notified if a resident's room smelled of marijuana, but this was not consistently done. The facility did not provide policies for the removal of biogrowth or odors when requested.
Neglect and Verbal Mistreatment by CNAs
Penalty
Summary
Multiple residents were subjected to neglect and verbal mistreatment by two certified nursing assistants (CNAs), identified as Staff A and Staff B. Residents reported being left in soiled briefs for extended periods, not being cleaned properly during care, and being spoken to in a disrespectful and demeaning manner. One resident, who was dependent on staff for all activities of daily living due to significant physical and cognitive impairments, described being left saturated with menstrual blood and not being wiped during care. This resident also reported that the CNAs made derogatory comments about her and other residents, including discussing their weight and making negative remarks about their children. Other residents corroborated these accounts, stating that the CNAs were rude, did not provide timely assistance, and made them feel like burdens when they requested help. Additional residents described similar experiences, including being left soiled, not being repositioned or assisted out of bed as requested, and being ignored when call lights were activated. Some residents reported that the CNAs would only change them once per shift, regardless of need, and would talk about other residents and staff in a negative manner while providing care. Staff interviews further supported these claims, with several staff members stating that Staff A and Staff B were often unprofessional, verbally aggressive, and would avoid caring for certain residents. Staff also reported that meal trays were left in front of residents for extended periods and that the CNAs would disappear during critical care times. The facility's own policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, mental anguish, or emotional distress, including not providing timely toileting and hygiene care. The policy also required staff to report any allegations of abuse or neglect immediately. Despite these policies, the behaviors of Staff A and Staff B persisted over time, affecting multiple residents on the same unit. The neglect and verbal mistreatment were corroborated by resident interviews, staff statements, and observations, indicating a pattern of failure to provide adequate care and maintain resident dignity.
Plan Of Correction
F 600 1. Residents #1, 2, 3, 4, 5, 6, 8, and 9 have been assessed by nursing and no adverse effects noted. Psych services offered to residents. Social services continue to offer support services to residents. Activities staff has worked with residents to ensure additional support is provided. There are no adverse effects noted and residents remain safe in the center. Residents interviewed by NHA and all stated that they feel safe and are grateful in the response from administration regarding the situation. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed with any other residents or were abused at any time. Skin assessments were completed for residents with a less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and scenarios. Education provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee. Residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns.
Failure to Protect Residents from Neglect and Mental Abuse by Staff
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to protect residents from neglect and mental abuse by two Certified Nursing Assistants (CNAs), referred to as Staff A and Staff B. Multiple residents reported being left in soiled briefs for extended periods, not being cleaned properly, and being made to feel like a burden when requesting assistance. Residents also described disrespectful and unprofessional behavior from the staff, including name-calling, derogatory comments about residents' weight and abilities, and discussing other residents and staff in a negative manner during care. These actions were corroborated by staff interviews and written statements, which described a pattern of rude, verbally aggressive, and neglectful behavior by Staff A and B, particularly when they worked together. The affected residents had significant care needs, including dependence on staff for toileting, hygiene, and mobility due to conditions such as hemiplegia, aphasia, obesity, and limb amputations. Several residents were cognitively intact and able to articulate their experiences, while others had severe cognitive impairment. The neglect included failure to provide timely and adequate personal care, such as not changing soiled briefs, not cleaning residents properly, and leaving residents unattended in the shower. Some residents reported that their call lights were ignored or turned off without their needs being met, and that they were made to wait for the next shift for care. Staff interviews revealed that the issues with Staff A and B were known among other staff members, who reported the behavior to management and described a hostile work environment. Written statements and interviews indicated that Staff A and B would avoid caring for certain residents, complain openly about their assignments, and disappear during critical care times. Despite these reports, there was a lack of effective follow-up or intervention by facility management prior to the survey, allowing the neglectful and abusive behavior to persist and affect multiple residents on the same unit.
Plan Of Correction
1. Residents #1, 2, 3, 4, 5, 6, 8, and 9 have been assessed by nursing and no adverse effects noted. Psych services offered to residents. Social services continue to offer support services to residents. Activities staff has worked with residents to ensure additional support is provided. There are no adverse effects noted and residents remain safe in the center. Residents interviewed by NHA and all stated that they feel safe and are grateful in the response from administration regarding the situation. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed with any other residents or were abused at any time. Skin assessments were completed for residents with a less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and scenarios. Education provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee.
Deficient Grievance Process and Incomplete Investigation of Resident Complaints
Penalty
Summary
The facility failed to ensure a functioning grievance process for two residents, resulting in deficiencies related to the handling and resolution of grievances. In one instance, a resident verbally reported to the Social Service Assistant (SSA) that two CNAs were having personal conversations while providing care, including discussing their likes and dislikes for residents. The concern was relayed to the Administrator In Training (AIT), who assisted in filling out the grievance form but did not conduct an investigation or interview the resident. The Unit Manager (LPN) became aware of the complaint later and spoke to the resident, but there was no documentation of a thorough investigation. The resident reported that no one had come to talk to her about the concern and that she had not received a response from the facility regarding her grievance. Another incident involved a CNA reporting that a resident was found covered in feces and had been left in that condition for an extended period before being changed. The assigned staff member for the investigation was the same LPN/Unit Manager, who documented that the aide responsible was educated about the importance of prompt care. However, the section of the grievance form indicating whether the incident was reportable to the state agency was left blank, and the "Teachable Moment" document in the aide's personnel file was unsigned and not acknowledged by the Human Resource Director. The NHA confirmed that the resident should have been changed at least every two hours and acknowledged that the incident had the potential to be neglect, but the incident was not reported as required. Both cases demonstrate failures in the facility's grievance process, including lack of proper investigation, incomplete documentation, failure to communicate outcomes to residents, and not following reporting requirements for potential neglect. The facility's grievance policy requires prompt resolution, thorough investigation, and proper documentation, but these requirements were not met in the cases reviewed.
Plan Of Correction
F 585 Resident #1 was interviewed regarding the incident, and upon conclusion of the interview, the resident was satisfied with the outcome of the decision made by administration in relation to the submitted grievance. Reportable incident completed regarding this issue on. Additional services offered to the resident to provide additional support. Nursing assessments were completed to ensure there were no adverse effects to the resident. No adverse effects were noted. 2. Grievance log and grievances reviewed for the previous 3 months by NHA and Social Services Director (SSD). There were no other grievances that were found to be reportable events. Resident interviews were completed for residents with above 10 to ensure that there were no outstanding concerns or allegations that were not addressed. Skin assessments were completed for residents with less than 10. No additional findings at the time of evaluation. 3. Grievances are reviewed five times a week by the IDT to ensure a timely response. Grievance log and grievances will be audited weekly by SSD or designee, and NHA or designee to ensure that grievances are completed timely, and allegations of were addressed. This will be an ongoing practice implemented as part of the facility operations. Room rounds continue to be completed five times a week by IDT to ensure the resident is monitored and has no concerns. Education was completed with staff to review the grievance process. Education was provided by IDT members to staff. IDT was educated by the company VP of Risk Management. The grievance process was reviewed at the resident council meeting with residents. The process was reviewed by the Activities Director. Residents confirmed understanding of the process. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Social Services Director or designee.
Failure to Report Alleged Neglect to Appropriate Agencies
Penalty
Summary
A deficiency was identified when the facility failed to ensure that an allegation of neglect involving a resident was reported to the appropriate agencies as required by federal regulations. The incident involved a resident who was found by a CNA to be covered in feces from the waist down, with some of the feces dried on, indicating the resident had been in that condition for an extended period. The resident reported that he had been asking to be changed all morning and had not been attended to until the afternoon shift began. The CNA who discovered the situation documented the incident and reported it to the nurse and unit manager, and a grievance report was completed. Review of the facility's documentation revealed that a "Teachable Moment" form was created regarding the incident, but it was not properly signed or presented, and the Human Resource Director was unaware of its existence. The section of the grievance report that indicated whether the incident was reportable to the state agency was left unmarked. The facility administrator confirmed that the incident was not reported to the state agency or other required officials, despite acknowledging that the care provided was not appropriate and had the potential to be considered neglect. The facility's policy requires immediate reporting of allegations of neglect to the administrator and appropriate agencies, but this process was not followed in this case. The administrator stated that the standard procedure would involve notifying the clinical team, risk manager, and submitting the incident through the appropriate reporting systems, but confirmed that these steps were not taken for this incident.
Plan Of Correction
1. Resident #9 was assessed by nursing and social services and no adverse effects were noted. Resident remains in the center. Staff B was terminated. Resident #9 interviewed by NHA and resident stated that he felt safe in the center and had no additional concerns at the time of the interview. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed with any other residents or were abused at any time. Skin assessments were completed for residents with a less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and education scenarios provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee.
Failure to Ensure a Functioning Grievance Process
Penalty
Summary
The facility failed to ensure a functioning grievance process for two residents, as required by state statute. For one resident, a grievance was verbally communicated to the Social Service Assistant regarding two CNAs having personal conversations while providing care. The grievance form was completed, and the CNAs were identified and verbally educated. However, there was no documentation indicating whether the resident was satisfied with the resolution, and the resident later stated that no one had spoken to her about the concern or provided a response. Interviews with staff revealed confusion about who was responsible for investigating and resolving the grievance, with some staff unaware of the complaint or not participating in the investigation. Another incident involved a resident who was found covered in feces after reportedly waiting for an extended period before being changed. The CNA assigned to the resident was educated about the importance of prompt care, and a "teachable moment" document was placed in the personnel file. However, the form was not signed by the presenter or recipient, and the section indicating whether the grievance was reportable to the state agency was left blank. The resident was totally dependent on staff for toileting, and the care plan reflected this need. The NHA confirmed that the resident should have been changed at least every two hours and acknowledged that the incident could be considered neglect, but it was not reported. Both cases demonstrate a lack of proper documentation, follow-up, and communication with the residents regarding their grievances. The facility did not ensure that grievances were thoroughly investigated, resolved in a timely manner, or that residents were informed of the outcomes, as required by policy and regulation. The absence of clear documentation and communication contributed to the deficiency cited by surveyors.
Plan Of Correction
Resident #1 was interviewed regarding the incident, and upon conclusion of the interview, the resident was satisfied with the outcome of the decision made by administration in relation to the submitted grievance. Reportable incident completed regarding this issue on . Additional services offered to the resident to provide additional support. Nursing assessments were completed to ensure there were no adverse effects to the resident. No adverse effects were noted. Grievance log and grievances reviewed for the previous 3 months by the NHA and Social Services Director (SSD). There were no other grievances that were found to be reportable events. Resident interviews were completed for residents with above 10 to ensure that there were no outstanding concerns or allegations that were not addressed. Skin assessments were completed for residents with less than 10. No additional findings were noted at the time of evaluation. Grievances are reviewed five times a week by the IDT to ensure a timely response. The grievance log and grievances will be audited weekly by the SSD or designee, and NHA or designee, to ensure that grievances are completed timely and that allegations were addressed. This will be an ongoing practice implemented as part of the facility operations. Room rounds continue to be completed five times a week by the IDT to ensure the resident is monitored and has no concerns. Education was completed with staff to review the grievance process. Education was provided by IDT members to staff, and the IDT was educated by the company VP of Risk Management. The grievance process was reviewed at the resident council meeting with residents. Residents confirmed their understanding of the process. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Social Services Director or designee.
Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
A facility failed to report an allegation of neglect to the appropriate agencies as required by state and federal regulations. The incident involved a resident who was found covered in feces, with evidence indicating he had been left in that condition for several hours. The resident, who was totally dependent on staff for toileting, reported that he had been asking to be changed all morning and had not received assistance until the afternoon shift began. The staff member assigned to the resident during the morning shift had already left the building before the afternoon aide discovered the situation. Documentation in the resident's clinical chart and care plan confirmed his dependence on staff for activities of daily living, including toileting. A "Teachable Moment" form was found in the personnel file of the CNA assigned to the resident, describing the incident and noting that the resident had been left in feces for an extended period. However, the form was unsigned, and the Human Resource Director was unaware of its origin. The afternoon CNA who discovered the resident reported the incident to the nurse and unit manager, and also submitted a written statement and grievance report detailing the neglect. Despite these reports and documentation, the incident was not reported to the state agency as required. The Nursing Home Administrator acknowledged that the care provided was not appropriate and had the potential to be considered neglect, but confirmed that the incident was not reported through the required channels. The process for reporting such allegations was described, but in this case, it was not followed.
Plan Of Correction
1. Resident #9 was assessed by nursing and social services and no adverse effects were noted. Resident remains in the center. Staff B was terminated. Resident #9 interviewed by NHA and resident stated that he felt safe in the center and had no additional concerns at the time of the interview. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed any other residents or were abused at any time. Skin assessments were completed for residents with less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and scenarios. Education provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. Mistreated, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated coordinator. Once an allegation of mistreatment is reported, the Executive Director, as the coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notifications of Law Enforcement if a reasonable suspicion of crime has occurred. A review of Resident #9's clinical chart documented an admission of his diagnosis list included but not limited to Type 2 diabetes. A review of a dated document showed a score of 13, with a comment "Intact response." A review of Resident #9's clinical chart, the Care Plan, documented a focus area: Resident #9 has an ADL (Activity of Daily Living) self-care performance and is at risk for decline. Interventions included: Toilet Use: The resident is totally dependent on staff for toileting. A review of Staff B, Certified Nursing Assistant's... 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee.
Failure to Provide Required Supervision for Residents During Smoking Activities
Penalty
Summary
The facility failed to ensure that residents assessed as needing constant supervision while smoking received adequate supervision. Multiple residents, all identified as smokers with various medical conditions such as COPD, diabetes, muscle weakness, amputations, and cognitive impairments, were observed smoking outside the facility without staff supervision. Some residents were seen smoking on sidewalks adjacent to busy roads and driveways, with traffic moving at high speeds, and in areas not designated as safe smoking locations. Several residents had access to lighters and cigarettes, contrary to facility policy requiring these items to be stored by staff. Record reviews revealed that these residents had care plans and smoking assessments indicating a need for constant supervision while smoking. However, staff interviews and observations confirmed that residents were allowed to sign out on Leave of Absence (LOA) and smoke unsupervised in potentially hazardous areas. The facility's own policies required supervision for residents assessed as needing it, but staff reported confusion and errors in completing smoking assessments, and there was a lack of clear communication regarding safe smoking locations and supervision requirements. Some residents had not signed the required smoking policy agreement, and documentation of LOA times was inconsistent with actual resident whereabouts. Staff interviews further revealed that the facility struggled to keep track of residents' smoking materials and LOA cards, and that supervision during smoking times was inconsistent, sometimes pulling aides away from other resident care duties. The facility's designated smoking policy and procedures were not consistently followed, leading to unsupervised smoking by residents who required supervision according to their assessments and care plans.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews, staff interviews, and direct observations. Several residents reported untimely responses to call lights, with one resident stating she often received incontinence care only once during the first shift and had to wait extended periods for assistance. Another resident described being left in a hallway for two hours after requesting help to return to bed, and others confirmed that staff frequently cited being short-handed as the reason for delays. Staff interviews corroborated these accounts, with CNAs and LPNs reporting high resident-to-staff ratios, feelings of being overwhelmed, and an inability to provide timely care due to insufficient staffing, especially during certain shifts such as 3-11 p.m. Observations by surveyors further supported these concerns. On multiple occasions, call lights were observed to be active for extended periods while staff were present in the area but did not respond promptly. In one instance, a bathroom alarm was sounding while a unit manager sat at the nurse's station and a CNA walked past the room without responding, indicating a lack of immediate action to resident needs. The resident council president and other residents also reported that staff often disappeared from the floor during evening shifts and that there were fewer CNAs than expected, leading to longer wait times for assistance. A review of facility records revealed unresolved grievances related to call light response times, with at least one resident stating her complaint had not been addressed or followed up on. The staffing coordinator confirmed that CNA assignments could reach up to 12 residents per CNA, and nurses could have up to 40 residents, though typically had 25-31. The facility did not have a formal staffing policy, and while call light audits and room rounds were being conducted, there was no established expectation for response times. The combination of high resident-to-staff ratios, lack of prompt response to call lights, and unresolved grievances demonstrates the facility's failure to ensure sufficient staffing to meet resident needs.
Failure to Ensure Accurate Reconciliation and Verification of Controlled Medications
Penalty
Summary
The facility failed to maintain an accurate system for reconciliation and accounting of controlled medications across four out of six sampled medication carts. Observations revealed that narcotics were added to medication carts for multiple residents without the required verification by a second nurse. In several instances, narcotic cards lacked documentation of medication strength, and the necessary second nurse signature was missing on both the narcotic cards and the Shift Change Controlled Substance Inventory Count Sheets. These deficiencies were observed during medication cart checks on multiple hallways, with staff confirming that they had received education on the correct procedures, which included double signatures for receiving and discontinuing narcotics. Further review of narcotic books across all hallways showed a significant proportion of Medication Monitoring / Control Records were not initialed or validated by a second nurse, with non-compliance rates ranging from 36% to 77% depending on the hallway. Staff interviews confirmed that the process for counting and documenting controlled substances was not consistently followed, and that the facility's policy did not explicitly require two nurse initials on individual narcotic Medication Monitoring / Control Records. Despite education and audits, the required verification steps were not reliably performed, leading to incomplete documentation and lack of proper chain of custody for controlled substances. The facility's policies outlined procedures for the acceptance, counting, and disposal of controlled drugs, including the requirement for two nurses to open and reconcile pharmacy deliveries and to count controlled substances at shift change. However, observations and record reviews demonstrated that these procedures were not consistently implemented in practice. The lack of adherence to established protocols resulted in discrepancies in the documentation and verification of controlled medications, as evidenced by missing second nurse signatures and incomplete records.
Failure to Ensure Accurate Controlled Substance Reconciliation and QAPI Oversight
Penalty
Summary
The facility failed to establish and implement an effective Quality Assurance and Performance Improvement Program (QAPI) that ensured accurate reconciliation and accounting for all controlled medications across four out of six sampled medication carts. Observations revealed that narcotics were added to medication carts for multiple residents without the required verification by a second nurse, as evidenced by missing second nurse signatures on narcotic cards and inventory count sheets. Additionally, the strength of each medication was not documented on the narcotic cards, further compromising the accuracy of controlled substance records. Staff interviews confirmed that nurses had received education on proper narcotic management, including the requirement for double signatures when receiving narcotics from the pharmacy and when discontinuing or removing narcotic cards. Despite this, the observed practice did not align with the facility's policy or the education provided, as the necessary second nurse verification was consistently absent. Audits of the narcotic books across multiple hallways showed a significant percentage of Medication Monitoring / Control Records lacking a second nurse's validation, with rates ranging from 36% to 77% depending on the hallway. Further review indicated that the facility's QAPI process did not effectively identify or address these ongoing deficiencies. Although the QAPI plan outlined systematic analysis and interdisciplinary participation, the actual implementation failed to ensure compliance with controlled substance handling procedures. Staff acknowledged that the process for counting and documenting controlled substances was not being followed as required, and that the QAPI process did not detect or resolve these issues prior to surveyor identification.
Failure to Provide Safe, Designated Smoking Areas and Supervision
Penalty
Summary
The facility failed to follow its own smoking policy by not providing a safe, designated smoking area for nine of 27 sampled residents. Observations revealed that multiple residents were smoking on the sidewalk or driveway adjacent to busy roads and parking lots, rather than in a designated, supervised area as required by facility policy. Several residents were seen in potentially hazardous locations, such as crossing multiple lanes of traffic or sitting near high-traffic areas, without staff supervision or the required safety equipment. Some residents were also found in possession of lighters and cigarettes, despite the policy stating that such materials should be stored by the facility. Record reviews showed that many residents had care plans and smoking assessments indicating they required constant supervision while smoking, yet they were allowed to sign out on a Leave of Absence (LOA) and smoke unsupervised in unsafe areas. In some cases, the documentation on the LOA sign-out sheets did not match the observed times residents were outside smoking, indicating a lack of accurate tracking. Additionally, at least one resident had not signed the required Smoking Agreement/Notice of Policy, and staff interviews revealed confusion and inconsistency in the implementation of the smoking policy, including errors in smoking assessments and a lack of communication about safety concerns related to smoking near the road. Interviews with staff and residents highlighted further issues, such as staff being pulled from other duties to supervise smoking breaks, leading to delays in resident care. Some staff were unaware of the specific safety risks associated with residents smoking near busy roads, and there was a lack of clear guidance provided to residents about where they could safely smoke. The facility's failure to enforce its smoking policy and ensure proper supervision and designated smoking areas directly contributed to the observed deficiencies.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was transferred to a higher level of care. The resident, who had a history of hemiplegia, hemiparesis, and dementia, reported to a registered nurse that he was dropped while being transferred from his bed to a wheelchair. The nurse conducted a head-to-toe assessment and notified the nurse practitioner and the Director of Nursing (DON). However, the two CNAs involved in the transfer denied the fall, and the nurse could not identify them by name. The incident was reported, but the DON did not interview the CNAs and relied on the nurse's report. The resident was transferred to the hospital after complaining of pain and was found to have bilateral knee fractures. The facility's policy required adverse incident reporting for events resulting in fractures or requiring a higher level of care, but it is unclear if this was done. The Director of Clinical Services stated that in such cases, a root cause analysis should be conducted, including staff interviews, but this was not mentioned as having been completed. The resident's hospital records indicated significant pain and bilateral knee fractures, with some fractures of indeterminate age. The facility's policy on adverse incident reporting outlines the need for reporting events that result in fractures or require a higher level of care, but the report does not confirm if this was adhered to. The resident ultimately expired at the hospital, and the facility's failure to thoroughly investigate the incident and adhere to reporting protocols constitutes a deficiency.
Deficiencies in Wound Care and Call Light Response
Penalty
Summary
The facility failed to provide treatment and services in accordance with physician orders for a resident with multiple diagnoses, including acute osteomyelitis, chronic ulcer, peripheral vascular disease, and type 2 diabetes mellitus with a foot ulcer. The Medication Administration Record for November 2024 showed multiple instances where wound care was not documented as completed on specified dates. Observations on November 25, 2024, revealed that the resident's dressing was not changed as per the schedule, and the Director of Nursing confirmed that the facility's expectation was for dressings to be dated and initialed by the nurse. The facility's policy required timely documentation of physician orders, which was not adhered to in this case. The facility also failed to ensure that call lights were answered within a timely manner for four residents. During a tour on November 25, 2024, it was observed that call lights were left unanswered for periods ranging from eight to sixteen minutes, despite staff being present in the vicinity. Interviews with residents revealed that call lights were routinely answered late, sometimes taking over thirty minutes, and staff occasionally turned off the lights without addressing the residents' needs. The Unit Manager and other staff confirmed that call lights should be answered promptly, but acknowledged that busy periods could delay responses. Interviews with the Regional President of Operations and the Director of Clinical Services confirmed that call light response times ranging from eight to sixteen minutes were not timely. They noted that staff were trained on the importance of answering call lights promptly, but acknowledged that busy times could lead to delays. The facility did not have a specific policy related to call light response times, which contributed to the deficiency in timely response to residents' needs.
Deficiency in Nail Care and Shower Services
Penalty
Summary
The facility failed to provide adequate nail care and consistent shower services for a resident, leading to a deficiency in the care of activities of daily living. The resident, who has a history of metabolic encephalopathy, chronic kidney disease, and diabetes insipidus, was observed with long, discolored, and uneven fingernails. The resident's family member also reported that the resident appeared unclean during video chats. Despite being scheduled for showers twice a week, there was no documentation of the resident receiving showers in the past 30 days, and the resident's care plan required nail care on bath days. Interviews with facility staff revealed a lack of clarity and responsibility regarding nail care. A Licensed Practical Nurse stated that nail care was the responsibility of social services, while the Social Service Director indicated that CNAs or nurses should cut fingernails, with podiatrist services reserved for toenails, especially for diabetic residents. The transition to a new podiatrist group had caused a gap in services, and the resident was not scheduled for fingernail care by the podiatrist. The Director of Nursing confirmed that there was no specific documentation for nail care and acknowledged the absence of shower sheets for the resident. The DON stated that the resident had received a shower recently but could not specify the date. The facility's shower sheet form included a section for nail care needs, but there was no evidence that this was completed for the resident. The lack of documentation and coordination among staff contributed to the deficiency in providing necessary care for the resident.
Failure to Ensure Dignified Existence for Resident
Penalty
Summary
The facility failed to ensure a dignified existence for one resident, who was observed scooting around on the floor in her room and into the hallway in front of other residents and staff. The resident, who has severe cognitive impairments and a history of falls, was left unattended on the floor for a period of time before staff assisted her. Additionally, the resident was found in the activities room, separated from other residents, sleeping in a reclined chair with a blanket over her whole body, which was not in line with her care plan goals for social and cognitive engagement. Interviews with staff revealed that the resident was care planned to put herself on the floor, but staff did not promptly assist her. The Activities Director admitted to placing the resident in the activities room but did not ensure she was engaged or comfortable. The Director of Nursing and the Nursing Home Administrator both acknowledged that the resident's condition and placement were unacceptable and not in accordance with the expected standards of care. The resident's care plan included interventions to ensure activities were compatible with her physical and mental capabilities, but these were not followed, leading to the deficiency.
Failure to Provide Appropriate Bed for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, specifically regarding the provision of an appropriate bed. Resident #44, who has a history of difficulty walking and severe cognitive impairment, was observed on multiple occasions with his feet hanging off the edge of his bed. Despite the resident's complaints and the staff's awareness of the issue, no action was taken to provide a suitable bed. The resident had been using an air mattress, which was initially provided due to a wound that had since resolved, making the air mattress unnecessary and inappropriate for his current needs. Interviews with staff, including a CNA, the ADON, and the DON, revealed a lack of communication and follow-through regarding the resident's bed size issue. The CNA acknowledged the problem but did not escalate it appropriately. The ADON was unaware of the need to change the mattress, and the DON admitted that the facility did not measure residents for mattress size and relied on staff to report such issues. The Regional Nurse Consultant confirmed that there was no specific policy for mattress sizing, and the standard of care was not met in this case.
Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASRR) for four residents. Resident #43 was admitted with multiple diagnoses including undifferentiated schizophrenia, unspecified dementia, and major depressive disorder. However, the PASRR assessment did not reflect the dementia diagnosis. The Assistant Director of Nursing (ADON) and the Social Services Director (SSD) were responsible for updating PASRRs but were unsure if dementia should be marked, leading to inaccuracies in the PASRR documentation for Resident #43. Resident #68 was admitted with primary and secondary diagnoses of panic disorder, anxiety, insomnia, major depressive disorder, and unspecified psychosis. The PASRR Level I for Resident #68 did not have items checked for mental illness/diagnoses, despite the resident's medical records and psychiatric notes indicating significant mental health issues. The Nursing Home Administrator (NHA) confirmed that the PASRR was incomplete regarding diagnoses. Resident #6 was admitted with a primary diagnosis of end-stage renal disease and secondary diagnoses including bipolar disorder, schizoaffective disorder, and homicidal ideations. The PASRR Level I did not reflect these mental health diagnoses. Similarly, Resident #36 was admitted with diagnoses of bipolar disorder, major depressive disorder, and unspecified dementia with psychotic disturbance, but the PASRR Level I only noted bipolar disorder and major depressive disorder. The ADON confirmed the PASRR was incomplete and did not include all relevant diagnoses.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan to meet the communication needs of a resident who primarily spoke Spanish. Despite the resident's severe cognitive impairment and preference for Spanish, the care plan did not include any focus, goal, or interventions related to communication. Staff often relied on the resident's roommate to translate, which is against the facility's policy, and there was inconsistent use of translator services among staff members. The Director of Nursing acknowledged that using another resident for translation, especially for medical information, was not appropriate, and staff should use the translator services provided by the facility. Additionally, the facility did not develop a care plan related to the code status for another resident who had an active Do Not Resuscitate (DNR) order. The resident was admitted with a primary diagnosis of respiratory failure, and the care plan lacked any mention of the resident's code status. The Minimum Data Set (MDS) Coordinator admitted that a care plan should have been developed for the resident's code status but was unable to explain why it was not done. The facility's policies and procedures require an individualized person-centered plan of care to be established by the interdisciplinary team with the resident and/or their representative. However, the facility failed to adhere to these policies, resulting in deficiencies in communication and care planning for the residents involved.
Failure to Update Care Plan for Resident
Penalty
Summary
The facility failed to review and revise the care plan for one resident out of the sampled thirty-nine residents. Resident #87 was initially admitted with diagnoses including candidiasis and pneumonia. The care plan indicated that the resident had candida auris and was on contact isolation, and later, antibiotic therapy for sepsis and pneumonia. However, the care plan was not updated to reflect the resident's current status of being colonized with candida auris and on enhanced barrier precautions, nor was it updated to show that the resident was no longer on antibiotics for pneumonia or sepsis. The Assistant Director of Nursing (ADON) confirmed that Resident #87 was now colonized with candida auris and on enhanced barrier precautions, and no longer on antibiotics. The MDS Coordinator acknowledged that the care plan should have been updated. The facility's policy requires that the comprehensive plan of care be reviewed, updated, and revised based on changing goals, preferences, and needs of the resident, which was not adhered to in this case.
Failure to Ensure Proper Enteral Feeding and Documentation
Penalty
Summary
The facility failed to ensure that a resident fed by enteral means received appropriate treatment and services per physician orders. Resident #87, who had diagnoses including dysphagia and pneumonia, was observed with an enteral feeding pump set at 65 ml per hour. However, the Medication Administration Record (MAR) indicated that the total volume of Glucerna was not infused to 1200 ml per day as ordered, and the resident did not receive the hydration flushes totaling 800 ml per day. This discrepancy was observed over multiple days, leading to a 10-pound weight gain in 13 days. Staff members, including an LPN and the Unit Manager, admitted to not knowing how to properly use or document the enteral feeding pump settings, and they had not completed the required training on gastrostomy tube (G-Tube) and documentation. The Regional Registered Dietitian confirmed that the enteral feeding pump's total volume was equivalent to 8 days' worth of feeding, indicating that the machine was not being reset or cleared as required. The Assistant Director of Nursing acknowledged that training had been conducted but noted that many new staff members had been hired. The Director of Nursing stated that her expectations were for staff to follow the physician's orders precisely and to seek assistance if needed. The facility's policies and procedures required documentation of medication administration via enteral tube, but this was not followed in Resident #87's case.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure side effects monitoring was in place for a resident receiving psychotropic medications. Resident #8, who was admitted with diagnoses including Schizoaffective Disorder, Bipolar type, Parkinson's Disease, Major Depressive Disorder, and Anxiety Disorder, had several psychotropic medications prescribed. The resident's care plan included specific interventions for monitoring side effects of these medications. However, after the resident was hospitalized and returned to the facility, the side effects monitoring was not re-initiated as required by the facility's policy. The Medication Administration Report (MAR) showed that side effects monitoring was discontinued during the hospitalization and was not resumed upon the resident's return, resulting in a lack of monitoring from the readmission date onwards. The Director of Nursing confirmed that the side effects monitoring was not conducted as per the facility's policy. The facility's policy on Medication Management-Psychotropic Medications mandates that residents receiving psychotropic medications should have their behavior and side effects monitored every shift. Despite this, the facility did not adhere to its policy for Resident #8, leading to a lapse in monitoring for potential adverse reactions to the psychotropic medications. This deficiency was identified through record review, interviews, and policy review, highlighting a failure in the facility's medication management and monitoring processes for residents on psychotropic medication regimens.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to provide proper infection control practices during medication administration for two residents. In one instance, an LPN was observed administering eye drops to a resident, during which the tip of the dropper touched the resident's eyelids. The resident struggled to keep their eyes open, and the LPN continued to administer the drops under the same conditions for both eyes. The dropper was then capped and returned to the medication cart without proper sanitization. In another instance, an LPN was observed checking the placement of a PEG tube and administering enteral feedings to a resident on Enhanced Barrier Precautions. The LPN did not wear a gown during contact with the resident's PEG tube, which is against the facility's policy for Enhanced Barrier Precautions. The Director of Nursing acknowledged the breach of infection control practices and attributed it to the inexperience of the nursing staff. The facility's policy on Enhanced Barrier Precautions requires the use of gowns and gloves during high-contact resident care activities, including device care such as PEG tubes. The policy also mandates that staff be trained prior to caring for residents under these precautions. The observed actions of the LPNs were in direct violation of these established protocols, leading to the identified deficiencies.
Failure to Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper and timely interventions to prevent pressure ulcers for a resident. The resident, who had multiple diagnoses including severe protein-calorie malnutrition, congestive heart failure, and unspecified dementia, was admitted with excoriation on the sacrum and mushy bilateral heels. Despite being at high risk for skin breakdown, as indicated by a Braden Scale score that decreased from 15 to 12 over a two-week period, the facility did not implement adequate preventive measures in a timely manner. The resident's family expressed concerns about the resident's pressure sores and the lack of appropriate bedding, which was only addressed after the sores had developed further. Observations revealed that the resident had a sacral open area and a stage 4 pressure injury on the left lateral malleolus. The resident was found in a low air loss mattress only after the pressure sores had worsened. The wound care provided included cleansing and dressing the wounds, but the resident's indwelling catheter was not secured properly, causing additional skin damage. The facility's documentation showed that the resident's skin condition was not adequately monitored, and preventive measures such as pressure-relieving devices and nutritional support were delayed. Interviews with the Director of Nursing and a review of the facility's policies indicated that the facility did not follow its own protocols for skin assessment and prevention of pressure ulcers. The DON acknowledged the need for better skin assessment and immediate education for staff. The facility's policies required a total body evaluation upon admission and weekly thereafter, but these were not effectively implemented, leading to the resident's deteriorating skin condition and the development of severe pressure ulcers.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5.00%, resulting in an observed error rate of 11.54%. During medication administration, three errors were identified among three residents. For Resident #79, Staff C, LPN, failed to administer Telmisartan 20 mg as prescribed for hypertension. For Resident #22, Staff D, LPN, administered Jevity 1.2 via PEG tube later than the prescribed time, contrary to the physician's order to start at 2:00 p.m. and disconnect at 10:00 a.m. For Resident #6, Staff E, LPN, did not prime the insulin needle before administering Novolog, which is against the manufacturer's instructions for use of the insulin pen. The Director of Nursing was informed of the medication error rate of 11.54%. The facility's policy on administering medications, revised in April 2019, states that medications should be administered safely, timely, and as prescribed. The policy also requires that medication errors be documented, reported, and reviewed by the QAPI committee to inform process changes and additional staff training. Despite these policies, the observed errors indicate a failure to adhere to prescribed medication administration protocols.
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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.
