Aviata At St Cloud
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Cloud, Florida.
- Location
- 4641 Old Canoe Creek Road, Saint Cloud, Florida 34769
- CMS Provider Number
- 105888
- Inspections on file
- 29
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Aviata At St Cloud during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported being touched inappropriately by another cognitively impaired resident. The incident was reported to two LPNs, but neither ensured immediate safety measures or completed required assessments and documentation. Notification to the DON was delayed, and a full investigation was not initiated until the following day, contrary to facility policy.
The facility did not provide a homelike dining experience for residents during breakfast and dinner in the unit day/dining rooms. Meals were served on trays, creating an institutional appearance, with no centerpieces or table linens. Staff interviews revealed a lack of guidance on creating a homelike environment, and the facility's policy did not address this need.
The facility did not provide a homelike dining experience for residents eating breakfast and dinner in unit dayrooms. Observations showed residents eating from trays without table linens or centerpieces, creating an institutional feel. Staff interviews indicated this was a routine practice, and the facility's meal distribution policy lacked guidance on ensuring a homelike environment.
The facility failed to implement proper hand hygiene protocols for 23 residents before meals, as observed in the dining room. Staff, including CNAs, did not offer wipes or other hygiene measures, despite acknowledging the importance of preventing germ spread. The facility's policy emphasized hand hygiene but did not specify offering it to residents before meals. Interviews revealed a lack of consistent practice and awareness among staff, with the Infection Preventionist expressing disappointment over the situation.
During a survey, it was found that an egress door near a resident room on the 100 Hall did not positively latch, violating NFPA 101 standards. The Director of Maintenance acknowledged the issue, which was documented with photographic evidence.
The facility was cited for a repeat deficiency in reporting abuse allegations, as identified in both a December 2024 survey and the current survey. The Administrator did not review actual grievance forms, only logs, and was unable to confirm actions taken to prevent repeat issues. The facility's policies require review of grievances and abuse allegations during QAPI meetings, but insufficient auditing and oversight were noted.
A resident with cognitive impairment filed a grievance about being yelled at by a CNA, but the facility failed to properly investigate or report the incident. The grievance was not discussed in detail during meetings, and the Administrator was unaware of it until the survey. The facility did not adhere to its grievance policy, which requires prompt resolution and communication with the resident.
The facility failed to prevent further abuse and did not timely report allegations of abuse for two residents. One resident, who was cognitively impaired, filed a grievance about verbal abuse by a CNA, which was not reported or investigated. Another resident, who was cognitively intact, reported a CNA raised her hand as if to hit him. The facility's investigation was inadequate, lacking necessary documentation and timely reporting to the State Agency.
A resident dependent on staff for hygiene reported being yelled at by a CNA after needing to be changed. The grievance was documented but not investigated or reported to the State agency. The Social Services Director and Administrator were unaware of the grievance, and the facility's grievance process was not followed.
Two residents reported incidents of neglect involving CNAs, which were not properly reported or investigated by the facility. One resident was yelled at by a CNA for needing to be changed, and another felt threatened when a CNA allegedly raised her hand as if to hit him. The facility failed to report these incidents to the State Agency and did not conduct a thorough investigation, leading to a deficiency in handling allegations of neglect.
A resident with cognitive impairment and speech difficulties was involved in an altercation with an LPN, who allegedly cursed at him after being punched. The incident was not reported until the end of the shift, despite multiple staff witnessing it. Facility policy requires reporting within two hours, which was not followed, leading to a deficiency in abuse reporting procedures.
A facility failed to update a care plan for a resident with severe cognitive impairment and wandering behaviors. Despite significant changes in the resident's behavior, including disorganized thinking and wandering into other residents' rooms, the care plan was not revised after multiple incidents. The facility's policies required care plans to be updated based on changing needs, which was not followed.
The facility failed to maintain complete and accurate medical records for two residents involved in an alleged abuse incident. One resident attempted to pull another out of bed, and although staff intervened, the documentation of the event and immediate care was incomplete. The Social Service Director and RN did not properly document their observations and actions in the electronic medical record system, contrary to facility policy.
The facility failed to ensure a safe smoking environment for residents, with staff not providing adequate supervision or following smoking policies. Residents, including those with cognitive impairments, were observed smoking unsupervised, retaining lighters, and using overflowing ashtrays. Staff were either inside the building or unaware of the facility's smoking policies, leading to unsafe practices.
Two residents experienced deficiencies in IV care at the facility. One resident had a midline IV catheter without a documented dressing change, contrary to facility policy. Another resident with a PICC line had an overdue dressing change, and the green cap on the IV tubing was not replaced. The DON confirmed the lack of adherence to standards for catheter care and the need for staff to follow proper procedures.
The facility failed to administer oxygen therapy as ordered for two residents. One resident received oxygen without a physician's order, and another received a higher flow rate than prescribed. The discrepancies were confirmed by nursing staff, and adjustments were made to comply with physician orders.
A resident with multiple health conditions was found in a lethargic state with suspected illicit drugs. The weekend supervisor nurse confiscated the item but failed to log the incident or initiate an investigation. The facility's policies for incident investigation were not followed, and the suspected drug was improperly disposed of without documentation or a second witness.
A resident with multiple health issues, including diabetes and heart failure, was found with suspected illicit drugs and later admitted to cocaine use. Despite being on Alprazolam and Morphine, the facility did not update the care plan to address potential drug interactions. The staff was unaware of the drug use until a survey, and the Weekend Supervisor lacked training on handling such incidents.
A resident with multiple health issues developed a pressure ulcer that was not present upon admission to an LTC facility. The facility failed to provide timely treatment, resulting in the wound worsening and leading to severe infections and sepsis. The resident required hospitalization and later died on hospice services. The facility's investigation into the neglect was inadequate, with limited staff interviews and poor documentation of care.
A resident with multiple health issues developed a pressure ulcer that was not treated for 10 days, leading to severe infections and sepsis. The facility failed to implement timely interventions and ensure adequate care, resulting in the resident's hospitalization and death. The resident required significant assistance and was at risk for pressure injuries, but the facility did not initiate a care plan for the wound or accurately assess the risk level. Interviews and records revealed inadequate repositioning and catheter care, contributing to the wound's deterioration.
The facility failed to provide dignified meal assistance to residents, as CNAs were observed feeding residents while standing, contrary to policy requiring them to sit at eye level. This was noted with several residents who had cognitive impairments and required assistance with eating. CNAs acknowledged their actions, citing reasons such as difficulty reaching residents comfortably. The facility's policy emphasizes a pleasant meal experience, which was not followed.
The facility failed to maintain accurate ADL documentation for three residents, leading to deficiencies in medical records. A resident with multiple sclerosis and aphasia had inconsistent documentation of eating and meal consumption. Another resident with intact cognition but requiring assistance had inadequate documentation for dressing and meal consumption. A third resident with Alzheimer's and Parkinsonism had missing ADL documentation for an entire shift. CNAs faced challenges with paper documentation, leading to incomplete records, and the facility's management confirmed the inaccuracies.
A facility failed to update care plans for two residents, leading to deficiencies in care. One resident's pressure ulcer progressed from stage II to stage IV without care plan revisions, while another resident's family preferences were not documented, despite being communicated. The facility's policy required individualized and updated care plans, but these were not adequately revised, resulting in unmet care needs.
A resident with multiple diagnoses, including dyskinesia and Alzheimer's, was admitted with a high fall risk. Despite a care plan that included fall prevention measures like fall mats, these were not implemented due to a lack of communication and verification in the facility's system. The resident experienced two falls without injury, highlighting the failure to ensure proper fall interventions were in place.
The facility failed to maintain safe food temperatures during a dinner meal service. The cook did not take food temperatures before serving, and the parmesan baked zucchini liquid was recorded at 109°F, below the safe threshold. Hamburgers were also served at an unsafe temperature of 98°F, as they were not placed in a steam table well. The Interim CDM and Administrator acknowledged these deficiencies.
A resident was observed in a day room wearing a hospital gown that exposed their hip, compromising their dignity. The resident expressed a preference for different clothing and had limited options in their room. The DON and Administrator acknowledged the issue, noting the availability of clothes from the laundry department, yet the resident was seen in the same state the following day.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure timely reporting and thorough investigation of an allegation of sexual abuse involving a cognitively impaired male resident and a female resident with moderate cognitive impairment. The incident occurred when the female resident was awakened in her room by the male resident touching her back, arm, and stomach. She screamed, causing the male resident to leave, and subsequently reported the incident to another resident, who then informed an LPN. The LPN and another nurse were made aware of the allegation, but neither took immediate steps to ensure the safety of the resident or to prevent the alleged perpetrator from accessing other residents. Despite being informed of the incident, the assigned nurse did not perform a skin check on the alleged victim, did not complete an incident report, and only attempted to notify the DON via text message, which was not received until the following morning. The nurse did not escalate the report to the Administrator or follow up when the initial notification failed. The DON and Administrator delayed gathering statements from staff and did not initiate a full investigation, as they believed the event did not rise to the level of harm. The male resident continued to wander the hallways without supervision until the victim's sister insisted on further action. The facility's policies required immediate segregation of the alleged perpetrator, a thorough nursing evaluation, notification of the attending physician, and completion of an incident report upon any allegation of abuse. These procedures were not followed, as the staff failed to promptly report the incident to appropriate authorities, did not conduct required assessments, and did not initiate a comprehensive investigation. The lack of immediate and thorough response resulted in a delay in implementing corrective actions to protect residents.
Lack of Homelike Dining Experience in Unit Day/Dining Rooms
Penalty
Summary
The facility failed to provide a homelike dining experience for residents during breakfast and dinner meals in the day/dining rooms on both nursing units. Observations revealed that meals were served on trays with dishes, drinks, and flatware left on the trays, creating an institutional appearance. There were no centerpieces or table linens on the tables, and residents expressed that the environment felt crowded and less homelike. The facility's main dining room was not open for breakfast or dinner, leaving residents to eat in the unit day/dining rooms or their bedrooms. Interviews with staff, including the Activities Director and Certified Nursing Assistants, indicated a lack of awareness and guidance regarding the removal of meal trays to create a more homelike environment. The facility's policy on meal distribution did not address the need for a homelike dining experience. The Administrator and Regional Vice President of Operations acknowledged the issue and mentioned plans to improve the dining environment, but these actions were not part of the deficiency findings.
Plan Of Correction
1. Ensured trays and lids were removed from the tables during all meals in the day room areas, tablecloths and centerpieces were ordered on. The dining room was opened on for dinner, then scheduled to open the following day for breakfast. 2. Observed all dining areas and corrected all issues found at that time. Daily observation of the day room areas and dining room to ensure that resident meals are served in a homelike environment with tablecloths and centerpieces, as well as the trays being removed under the plate and lids removed from table. 3. Educate all staff on removing trays and lids from table for all meals with an emphasis on meals served in day rooms. Audit of two meals per day to ensure that meals are set properly on table in the dining room and day rooms, without lids on tables, tablecloths and centerpieces in place including cleanliness. The dining room is now scheduled to be opened for breakfast, lunch, and dinner according to facility policy. 4. 5 Random Quality reviews will be completed weekly, including weekends by weekend supervisor or designee. The audits will include homelike environment, such as plates and lids removed from trays for all meals and main dining room open for all meals. Audit will include observation of tablecloths and centerpieces to ensure compliance. 5. NHA/DON will conduct a quality review on mealtimes being set properly and homelike environment components are in place. This will be conducted 5x weekly for 4 weeks, then weekly for 2 months.
Lack of Homelike Dining Experience in Unit Dayrooms
Penalty
Summary
The facility failed to provide a homelike dining experience for residents eating breakfast and dinner in the day/dining rooms on both nursing units. During observations, residents were seen eating their meals from trays, which created an institutional appearance. The tables lacked centerpieces or linens, and meal trays with lids were left on the tables, contributing to a non-homelike environment. Residents expressed that the dining experience was better during lunch when trays were removed, and dishes were placed directly on the tables, with flower centerpieces enhancing the atmosphere. Staff interviews revealed that the practice of leaving dishes on trays during breakfast and dinner in the unit dayrooms was routine, with no specific reason provided for this method. The facility's policy on meal distribution did not address the need for a homelike dining experience. The Activities Director and other staff acknowledged the importance of creating a homelike environment, but there was no directive to remove trays during these meals, indicating a lack of guidance and awareness in maintaining a homelike setting for residents during all meals.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. Ensured trays and lids were removed from the tables during all meals in the day room areas, tablecloths and centerpieces were ordered on. The dining room was opened on for dinner, then scheduled to open the following day for breakfast. 2. Observed all dining areas and corrected all issues found at that time. Daily observation of the day room areas and dining room to ensure that resident meals are served in a homelike environment with tablecloths and centerpieces, as well as the trays being removed under the plate and lids removed from table. 3. Educate all staff on removing trays and lids from table for all meals with an emphasis on meals served in day rooms. Audit of two meals per day to ensure that meals are set properly on table in the dining room and day rooms, without lids on tables, tablecloths and centerpieces in place including cleanliness. The dining room is now scheduled to be opened for breakfast, lunch, and dinner according to facility policy. 4. 5 Random Quality reviews will be completed weekly, including weekends by weekend supervisor or designee. The audits will include homelike environment, such as plates and lids removed from trays for all meals and main dining room open for all meals. Audit will include observation of tablecloths and centerpieces to ensure compliance. 5. NHA/DON will conduct a quality review on mealtimes being set properly and homelike environment components are in place. This will be conducted 5x weekly for 4 weeks, then weekly for 2 months.
Failure to Implement Resident Hand Hygiene Before Meals
Penalty
Summary
The facility failed to implement proper hygiene protocols for residents before meals, which is a critical component of their infection prevention and control program. Observations revealed that 23 residents dining in the main dining room were not offered any means to clean their hands before eating. Staff members, including CNAs, confirmed that the practice of providing wipes or other hygiene measures had ceased over time, despite acknowledging the importance of hand hygiene in preventing the spread of germs. The facility's policy on handwashing and hygiene, dated 2019, emphasized the importance of hand hygiene as a primary means to prevent the spread of infections, yet it did not specify that staff should offer hygiene to residents before meals. Interviews with several CNAs indicated a lack of consistent practice and awareness regarding the importance of offering hand hygiene to residents before meals. CNA D mentioned that the practice of handing out wipes had stopped, while CNA C and CNA B acknowledged that they had not been reminded or instructed to offer hygiene measures to residents. The facility's Infection Preventionist expressed disappointment that staff were not aware of the need to offer hand hygiene, despite previous education efforts. The Preventionist noted that resources such as washcloths, wipes, and gel were available for use, but staff had not been utilizing them to ensure residents' hands were clean before meals.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. On preventionist immediately educated staff on the importance of hygiene for residents before and after meals. On NHA immediately obtained sanitizing wipes and sanitizer, provided them to staff and residents to use at that time and prior to upcoming meals. 2. On NHA observed both units and corrected any issues at that time. Both units were observed, and the deficient practice was corrected immediately. 3. The Director of Nursing/ Preventionist will educate all current nursing and activity staff on proper control practices related to hygiene before and after meals for residents. The Director of Nursing/ Preventionist/ or designee will administer an eating support competency to measure understanding. The Director of Nursing/ Preventionist will educate alert and oriented residents on proper hygiene before and after meals for increased awareness. The Administrator or designee will conduct 5 random quality reviews including weekends by weekend supervisor or designee. The audit will include control practices regarding hygiene for residents before and after meals to ensure compliance. 4. The Administrator or designee will conduct a quality review on proper hygiene prior to meals. This will be conducted 5 times weekly for 4 weeks, then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance improvement Committee monthly until committee determines substantial compliance has been met.
Egress Door Latching Deficiency
Penalty
Summary
The facility was found to have a deficiency related to the maintenance of egress doors, as observed during a survey conducted on April 8th. During the facility tour, it was noted that one of the nine egress doors, specifically near resident room 118 on the 100 Hall, failed to positively latch. This issue was identified after testing the door three times, each time resulting in the latching mechanism not engaging properly. The Director of Maintenance was present during the inspection and acknowledged the deficiency. The failure of the door to latch properly is a violation of the National Fire Protection Association (NFPA) 101 standards, which require that doors in a required means of egress must not be equipped with a latch or lock that requires a tool or key from the egress side unless specific conditions are met. The deficiency was documented with photographic evidence. The report does not mention any specific residents affected by this deficiency or any immediate consequences resulting from the door's failure to latch. However, the presence of the Director of Maintenance during the survey and his concurrence with the findings indicate an awareness of the issue at the facility level.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. The one egress door near resident room 118 on the 100 hall, noted to not positively latch when tested will be repaired to proper function. 2. Additional egress doors will be reviewed for positive latching. 3. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Egress Doors specific to maintaining egress doors to positively latch, and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.
Repeat Deficiency in Reporting Abuse Allegations
Penalty
Summary
The facility failed to implement its policies effectively, particularly in monitoring and tracking performance in previously identified areas of concern. During a complaint survey conducted in December 2024, the facility was cited for F609 due to issues related to the reporting of abuse allegations. In the current survey, the same citation was identified again, indicating a lack of sufficient auditing and oversight to address the previous deficiency. The Administrator admitted to not reviewing the actual grievance forms, only the grievance log presented at the monthly Quality Assurance and Performance Improvement (QAPI) meetings. The facility's policies, including the Complaint/Grievance policy and the Abuse, Neglect, Exploitation & Misappropriation policy, require that grievances and allegations of abuse be reviewed during QAPI meetings. However, the Administrator, who was not in position during the December 2024 survey, could not confirm what actions were taken to prevent repeat deficiencies. The facility's Quality Assurance Performance Improvement Program policy emphasizes the importance of focusing on care outcomes and quality of life, yet the failure to adequately monitor and address previous deficiencies suggests a gap in the implementation of these policies.
Plan Of Correction
1) On QAPI was reviewed by the Regional Vice President of Operations and Regional Director of Clinical Services for the months of and audits were reviewed and updated. (2) A comprehensive review of QAPI plans were conducted by the RVPO and RDCS to ensure all actions and supporting audits were completed and ongoing audits up to date. Any areas of concern were corrected at this time. (3) 1. Education provided by RDCS to the Interdisciplinary team on the importance of QAPI and how to ensure efficient outcomes through monitoring and evaluation according to facility QAPI policy; as well as a comprehensive review of the facility's Quality Assurance Performance Improvement program policy. 2. Education provided by the Executive Director to the IDT on how the facility will monitor the effectiveness of the performance improvement plan related to quality assurance and process improvement. 3. All grievances (grievance forms and log) will be reviewed by ED, SSD and DON daily 5 days a week. 4. Quality reviews will be conducted weekly for performance improvement adherence; if indicated, an Adhoc QAPI will be completed and submitted to monthly QAPI with any findings. (4) A quality review will be completed by the Executive Director or designee of grievances to ensure the policy and process is adhered to, along with a quality review of performance improvement audits each 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Follow Grievance Process for Resident Complaint
Penalty
Summary
The facility failed to ensure staff were knowledgeable of and followed their grievance process for a resident who filed a concern about being yelled at by a CNA. The resident, who was cognitively impaired and dependent on staff for personal hygiene, reported that the CNA yelled at her for needing to be changed again. The grievance was documented but not properly investigated or followed up with the resident, and it was not reported to the State agency as required. The Social Services Director, who was responsible for overseeing grievances, and the Administrator were not aware of the grievance until it was brought to their attention during the survey. The grievance was not discussed in detail during morning meetings, and the Administrator confirmed that it was not investigated as required. The facility's grievance policy, which mandates prompt efforts to resolve complaints and inform residents of progress, was not adhered to in this case.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly. 1) On , Resident #7 reported grievance was submitted to AIRS system by NHA. (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings and placement of grievance forms. 3. All grievances are reviewed by ED, SSD and DON daily; supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director/designee of grievances and reportable incidents, to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to prevent further abuse and did not timely and accurately report allegations of abuse to the State Agency for two residents. Resident #7, who was cognitively impaired and dependent on staff for personal hygiene, filed a grievance about being verbally abused by a CNA. The grievance was not reported to the State Agency, and the facility's Administrator was unaware of the grievance until it was brought to her attention during the survey. The grievance was not investigated as required, and the incident was not included in the facility's Reportable Event Log. Resident #1, who was cognitively intact but required assistance for personal hygiene, reported an incident where a CNA allegedly raised her hand as if to hit him. The incident was reported to the facility's Director of Nursing (DON) and the Weekend Supervisor, but the investigation was inadequate. The facility did not collect witness statements from all involved staff, and the DON did not follow up on the investigation. The facility's report to the State Agency was delayed, and the investigation folder lacked necessary documentation, such as witness statements and progress notes. The facility's policy on abuse, neglect, and exploitation was not followed. The policy required immediate segregation of the suspect from residents, a thorough nursing evaluation, and timely reporting to the State Agency. However, the facility did not perform a head-to-toe assessment on Resident #1, and the investigation was not conducted thoroughly. The facility also failed to provide emotional support and counseling to the residents involved, as outlined in their policy.
Plan Of Correction
1) On Resident #7 reported grievance was submitted to AIRS system by Executive Director (ED). On Resident #1 reported was submitted to AIRS system by the Executive Director (ED). (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. An audit was conducted on all residents with a of 11 or higher for potential reportable events. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff in regards to the grievance and reporting process, postings and placement of grievance forms, reporting events timely to meet 2 hour post allegation window, and 24 hours for events that do not involve or serious bodily injury. 3. All grievances are reviewed by ED, SSD and DON daily, supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. All investigations will be reviewed by RVPO and RDCS for thoroughness, accuracy and timeliness. 5. A quality review is conducted weekly by ED, DON, and SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director or designee of grievances and reportable incidents to ensure a thorough investigation was completed and to ensure the policy and process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Follow Grievance Process for Resident Complaint
Penalty
Summary
The facility failed to ensure that staff were knowledgeable of and followed their grievance process for a resident who had filed a complaint. The resident, who was dependent on staff for toileting hygiene and required substantial assistance for personal hygiene, reported being yelled at by a CNA after needing to be changed for the second time. The grievance was documented in the Resident Grievance Log, but the investigation findings section was left blank, and there was no follow-up or report submitted to the State agency. The Social Services Director, who was responsible for overseeing grievances, stated that grievances were discussed daily during morning meetings, but the Administrator confirmed that the specific grievance was not brought to her attention. The grievance form was handed to the Social Services Director by the Unit Manager, but it was not read or investigated as required. The facility's policy intended to support residents' rights to voice complaints and resolve them promptly, but in this case, the grievance process was not properly followed, and the grievance was not addressed or reported as necessary.
Plan Of Correction
Grievance was submitted to AIRS system by NHA. A comprehensive review of all grievances for the months of [insert months] was conducted by the Regional Vice President of Operations, Executive Director, and Social Services Director to ensure adherence to facility policy. No new issues found. 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings, and placement of grievance forms. 3. All grievances are reviewed by ED, SSD, and DON daily; supervisor calls and reviews grievances with ED, SSD, DON, or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on [insert date]. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. A quality review will be completed by the Executive Director/designee of grievances and reportable incidents to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to prevent and timely report allegations of neglect for two residents. Resident #7, who was dependent on staff for toileting hygiene and needed substantial assistance for personal hygiene, filed a grievance after a CNA yelled at her for needing to be changed. The grievance was not reported to the State Agency, and the Administrator was unaware of it until it was brought to her attention during the survey. The grievance was not investigated as required, and the Social Service Director and Unit Manager were also unaware of the complaint. Resident #1, who had a history of right lower extremity issues and required substantial assistance for hygiene, reported an incident where a CNA allegedly raised her hand as if to hit him. The resident felt threatened and used foul language in response. The incident was reported to the Weekend Supervisor and the DON, but no immediate investigation or skin check was conducted. The DON later determined it was a customer service issue and did not report it as an abuse allegation. Witness statements were not collected from staff present during the incident, and the facility's investigation was incomplete. The facility's policy required immediate reporting of abuse or neglect allegations, segregation of the suspect from residents, and a thorough investigation. However, these procedures were not followed in the cases of residents #1 and #7. The facility failed to document and report the incidents to the State Agency within the required timeframe, and the investigation process was not adequately conducted, leading to a deficiency in handling allegations of neglect.
Plan Of Correction
1) On Resident #7 reported grievance was submitted to AIRS system by NHA. (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings and placement of grievance forms. 3. All grievances are reviewed by ED, SSD and DON daily; supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director/designee of grievances and reportable incidents, to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an alleged verbal abuse incident involving a resident with moderate cognitive impairment and speech impediment. The resident, who had a history of cerebral infarction, anxiety disorder, and depression, was involved in an altercation with an LPN. The LPN was heard yelling at the resident and allegedly cursed at him after he punched her in the abdomen. Despite the incident occurring around 10:00 PM, it was not reported until the end of the shift, over nine hours later. Multiple staff members, including CNAs and an RN, witnessed or were aware of the incident but did not report it immediately, assuming it was the LPN's responsibility. The facility's policy requires that any allegations of abuse be reported within two hours, but this protocol was not followed. The LPN admitted to cursing at the resident and acknowledged that she should have reported the incident immediately, as per her training. The Director of Nursing and other administrative staff were only informed of the incident the following morning. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting of any witnessed or known incidents, which was not adhered to in this case. The failure to report the incident promptly constitutes a deficiency in the facility's adherence to its own policies and procedures regarding abuse reporting.
Failure to Update Care Plan for Resident with Wandering Behaviors
Penalty
Summary
The facility failed to develop, implement, and revise a person-centered comprehensive care plan for a resident with severe cognitive impairment and wandering behaviors. The resident, who was admitted with diagnoses including a wedge compression fracture, Parkinson's Disease, and cognitive communication deficit, exhibited significant changes in behavior during their stay. Initially, the resident did not show any physical or verbal behaviors towards others, but by the time of discharge, they displayed disorganized thinking, wandering behaviors, and other actions such as pacing, rummaging, and disrobing in public. Despite these changes, the care plan was not adequately updated to address the resident's evolving needs. The facility's records revealed that the resident had an electronic wander bracelet ordered after the first incident of wandering into another resident's room. However, after subsequent incidents, including an alleged resident-to-resident abuse where the resident attempted to pull another resident out of bed, the care plan interventions were not revised. The MDS Coordinator and the DON acknowledged that the care plan was not updated after the second and third incidents, despite the expectation for the Interdisciplinary Team to discuss and determine the effectiveness of care plan interventions. The facility's policies required that care plans be reviewed and updated based on the resident's changing needs, which was not adhered to in this case.
Incomplete Documentation of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents involved in a reportable incident of alleged resident-to-resident abuse. The incident occurred when one resident entered another resident's room and attempted to pull her out of bed. Although staff intervened and assessed the residents, the documentation of the event and the immediate care provided was incomplete. Specifically, there was no documentation in the medical records detailing the incident, the assessments conducted, or the notifications made to family and physicians. The Social Service Director and Registered Nurse involved in the incident did not document their observations and actions in the electronic medical record system. The SSD delayed documenting in the system and instead used a typed note on plain paper, while the RN failed to record the assessment of the resident's condition. The Director of Nursing confirmed that the expected protocol was not followed, as staff were required to document any changes in resident condition and incidents before the end of their shift. The facility's policies emphasized the importance of maintaining accurate clinical records to ensure effective communication among healthcare professionals, which was not adhered to in this case.
Unsafe Smoking Practices in LTC Facility
Penalty
Summary
The facility failed to ensure a safe smoking environment for residents, as observed during a survey. Ten residents were reviewed for smoking, and all were found to be in an unsafe smoking environment. Residents were observed smoking on the patio without staff supervision, and some residents, including those with cognitive impairments, were allowed to keep their own lighters and cigarettes. The staff responsible for supervising the smoking activity were either inside the building or unaware of the facility's smoking policies, leading to residents lighting each other's cigarettes and using overflowing ashtrays. Specific residents, such as one with bilateral leg amputations and another who was blind, were observed with lighters and cigarettes in their possession, contrary to the facility's policy. The blind resident required assistance to light her cigarette, which was provided by another resident instead of staff. Additionally, residents with cognitive impairments were not adequately supervised, and their smoking materials were not retrieved by staff after smoking sessions, as required by their care plans. The facility's policies and procedures for supervised smoking were not followed, as staff did not provide direct supervision or ensure the safe handling of smoking materials. The Director of Nursing and Nursing Home Administrator acknowledged the lapses in supervision and policy enforcement, but staff continued to allow residents to smoke unsupervised and retain their lighters. The facility's failure to adhere to its smoking policies and provide adequate supervision posed a risk to resident safety.
Deficiencies in IV Care and Maintenance
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) care and services for two residents, leading to deficiencies in the administration and maintenance of IV therapy. Resident #2 was observed with a midline IV catheter in her right upper arm without a date on the dressing, indicating a lack of adherence to the facility's policy for catheter dressing changes. The resident's medical record showed that the IV catheter was placed on 9/09/24, but there was no documentation of dressing changes within the required 24 hours after insertion or every 5-7 days thereafter. The Director of Nursing (DON) confirmed the absence of documentation and noted that the last dose of IV medication was administered on 9/11/24, seven days prior to the observation. Resident #18, who was readmitted from an acute care hospital with a peripherally inserted central catheter (PICC) line, also experienced deficiencies in IV care. The dressing on his PICC line was dated 9/06/24 and had not been changed by the facility staff, despite being overdue for a change by 9/13/24. The resident expressed concerns about the lack of dressing changes and the green cap on the IV tubing not being replaced. The assigned Registered Nurse (RN) admitted to not changing the dressing due to it not being on her schedule, although she acknowledged it should have been changed every 7 days and as needed. The facility's policy for catheter insertion and care required central venous catheter dressings to be changed at specific intervals to prevent infections. The DON acknowledged that the nurses were expected to follow these standards and that any nurse administering IV medications should have noticed and addressed the outdated dressing. The DON also mentioned the need to verify the frequency of changing the green cap on the IV tubing, which was not being done as required.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy and did not administer oxygen therapy as ordered for two residents. Resident #2 was observed with a nasal cannula connected to an oxygen tank at a flow rate of 3 liters per minute, but there was no physician's order for this oxygen use. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the absence of a physician's order in the resident's medical record. Additionally, the oxygen tank was found to be empty, and the DON acknowledged that an order might have been mistakenly omitted when the resident was readmitted from the hospital. Resident #13 was observed receiving oxygen at 4 liters per minute via nasal cannula, although the physician's order specified a flow rate of 2 liters per minute. The resident's care plan included instructions to administer oxygen per physician orders, and there was no indication that the resident adjusted her own oxygen settings. The assigned LPN confirmed the discrepancy and adjusted the oxygen concentrator to the correct flow rate. The DON stated that nurses should verify oxygen settings during each room visit to ensure compliance with physician orders.
Failure to Investigate Suspected Drug Possession
Penalty
Summary
The facility failed to investigate an incident involving a resident who was found with suspected illicit drugs. The resident, a male with multiple health conditions including diabetes, heart failure, and nicotine dependence, was discovered by a weekend supervisor nurse in a lethargic state on the patio. A small plastic bag containing a suspected illicit drug was found in the resident's cigarette pack. The nurse confiscated the item and informed the physician, who advised holding the resident's narcotics and monitoring his vital signs. However, the incident was not logged, and no investigation was initiated. The facility's policies and procedures for incident investigation were not followed. The weekend supervisor did not report the incident to the on-call supervisor or initiate an incident report. The suspected drug was disposed of by flushing it down the toilet without proper documentation or a second witness. The Director of Nursing and Unit Manager were unaware of the incident until much later, and the facility's incident log showed no record of the event. The weekend supervisor admitted to not receiving training on handling suspected illicit drugs, contributing to the mishandling of the situation.
Failure to Update Care Plan for Drug Interaction Risk
Penalty
Summary
The facility failed to update an individualized care plan for a resident who was at risk for adverse drug interactions due to the use of opioid and antianxiety medications. The resident, a male with multiple diagnoses including diabetes, heart failure, and phantom limb pain syndrome, was found by a nurse in a lethargic state with suspected illicit drugs. Despite the incident and a subsequent report by an APRN documenting the resident's cocaine use, the care plan was not revised to address potential drug interactions with the resident's prescribed medications, Alprazolam and Morphine. The facility's staff, including the Nursing Home Administrator and Director of Nursing, were unaware of the resident's illicit drug use until the survey. The Weekend Supervisor, who discovered the resident with suspected drugs, had not received training on handling such situations and did not initiate an incident report. The facility's policy required the care plan to be updated based on changing needs, but this was not done, leaving the resident without a plan to manage potential adverse interactions between prescribed and illicit drugs.
Neglect in Pressure Injury Care Leads to Resident Harm
Penalty
Summary
The facility neglected to provide appropriate care and services to prevent a pressure injury for a vulnerable and physically impaired resident. The resident, an elderly male with multiple diagnoses including Alzheimer's disease and type 2 diabetes, was admitted with intact skin but later developed a pressure ulcer that was not present upon admission. The resident required moderate to maximum assistance with activities of daily living and was always incontinent of bowel movements. Despite these needs, the facility failed to implement preventative interventions and ensure timely and adequate treatments for the pressure injury. The resident's pressure ulcer was identified by a CNA, but treatment was delayed for 10 days, during which time the wound worsened. The medical record showed that almost half of the wound treatments were not documented as completed. The resident's condition deteriorated, leading to severe wound infections and sepsis, which required hospitalization. The facility's failure to act promptly and effectively resulted in actual harm to the resident, who later died while on hospice services. The facility also failed to conduct a thorough investigation into the neglect after the pressure injury worsened. The investigation was limited, with only the wound nurse and Director of Rehabilitation interviewed, and did not include the assigned nurses or CNAs who provided care to the resident. The facility's documentation and follow-up on the resident's care were inadequate, contributing to the neglect and subsequent harm experienced by the resident.
Removal Plan
- Educate nurses on wound care and documentation expectations.
- Educate the Interdisciplinary Team (IDT) and Unit Managers.
- Conduct random audits.
- Initiate a Performance Improvement Plan (PIP) regarding pressure wounds.
- Provide additional education for CNAs on skin assessment and notification procedures.
- Conduct facility-wide audit to ensure all residents have up-to-date skin assessments and wound dressing changes.
- Revise PIP to include review of physician orders for treatment, care plan review, physical checks of residents, and documentation support.
Failure to Prevent and Treat Pressure Ulcer Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and worsening of pressure injuries for a resident, resulting in actual harm. The resident, an elderly male with multiple diagnoses including Alzheimer's disease and diabetes, was admitted with intact skin but developed a pressure ulcer that was not treated for 10 days after it was identified. This delay in treatment led to the wound worsening, resulting in severe infections and sepsis, ultimately requiring hospitalization and leading to the resident's death on hospice care. The medical record review revealed that the resident required significant assistance with activities of daily living and was incontinent, which increased his risk for pressure injuries. Despite this, the facility did not implement timely preventative interventions or ensure adequate care for the pressure injury. The resident's care plans included goals to prevent skin breakdown and maintain skin integrity, but there was no care plan initiated for the actual pressure wound. The Braden Score assessments inaccurately reflected the resident's risk level, and there was a lack of documentation and follow-up on the pressure wound by the nursing staff. Interviews with staff and family members highlighted the facility's failure to reposition the resident regularly and change his urinary catheter as required. The wound care nurse confirmed that the resident's wound was not discussed in clinical meetings, and there were missing orders in the medical record. The wound physician's notes indicated a significant deterioration of the wound, and the facility's practice of having floor nurses perform wound care instead of the wound nurse contributed to the inadequate treatment. The facility's lack of timely and appropriate interventions led to the resident's severe sepsis and subsequent death.
Failure to Ensure Dignified Meal Assistance for Residents
Penalty
Summary
The facility failed to treat residents requiring assistance with meals in a dignified and respectful manner. Observations revealed that Certified Nursing Assistants (CNAs) were feeding residents while standing, which is against the facility's policy that requires CNAs to sit at eye level with residents during meals. This practice was observed with four residents who had varying degrees of cognitive impairment and required substantial assistance with eating. For instance, one resident with multiple sclerosis and aphasia was fed by a CNA who stood next to her bed, while another resident with Parkinson's disease and diabetes was also fed by a standing CNA. The CNAs involved acknowledged their actions, with one stating that she stood because she was unable to reach the resident comfortably due to her height, and another admitting to standing despite knowing the expectation to sit. The facility's policy emphasizes the importance of making the meal experience pleasant and giving residents complete attention, which was not adhered to in these instances. The Director of Nursing and the Regional Nurse Consultant confirmed that CNAs were expected to sit while feeding residents and that the term 'feeders' should not be used to refer to residents.
Inaccurate ADL Documentation for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for activities of daily living (ADLs) for three residents, leading to deficiencies in documentation. Resident #4, with multiple sclerosis and aphasia, had severely impaired cognition and was totally dependent on staff for ADLs. However, her CNA-ADL Tracking Form showed inconsistent documentation of eating and meal consumption percentages for May and June 2024. Similarly, Resident #14, who had intact cognition but required assistance with lower body dressing and toileting, had inadequate documentation for dressing, personal hygiene, and meal consumption in May 2024. Resident #17, with Alzheimer's disease and Parkinsonism, also had severely impaired cognition and was totally dependent on staff, yet her ADL documentation was missing for the entire 7 AM to 3 PM shift in May 2024, with incomplete meal consumption records for both May and June 2024. Interviews with CNAs revealed challenges in documenting ADLs due to the lack of tablets and the cumbersome paper documentation process, which involved 16 pages per resident. CNAs expressed difficulties with the small font size on the forms, leading to incomplete documentation. The North Wing Unit Manager was unaware of the documentation issues, and the Director of Nursing and Administrator confirmed the inaccuracies in the medical records. Despite previous education efforts, the facility's Regional Nurse Consultant acknowledged the need for diligent micromanagement to address the documentation deficiencies.
Deficiencies in Care Plan Updates for Residents
Penalty
Summary
The facility failed to review or revise the individualized pressure ulcer care plan for a resident who developed a pressure ulcer that progressed from stage II to stage IV over 27 days. The resident, a male with multiple diagnoses including Alzheimer's disease and type 2 diabetes, was admitted with intact skin but was discharged with a stage IV pressure ulcer. The care plan was not updated to reflect the actual pressure injury or to include new interventions, despite the resident's condition worsening. The MDS Coordinator acknowledged that the new wound should have triggered a change in the care plan, but no such update was made. Another resident, a female with multiple sclerosis and aphasia, had a care plan that did not address her personal choices and individual needs as communicated by her family. The resident's family had specific preferences for her care, such as using bottled water and specific positioning, which were not included in the care plan. Despite the family providing detailed instructions and attending care conferences, these preferences were not documented in the care plan, leading to inconsistencies in care delivery. The facility's policy required that care plans be individualized and updated based on changing resident needs and preferences. However, the care plans for both residents were not adequately revised to reflect their current conditions and preferences, resulting in deficiencies in meeting their care needs. The interdisciplinary team failed to ensure that the care plans were oriented toward maintaining the residents' highest practicable well-being.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident who was admitted with a high risk of falls due to multiple diagnoses, including drug-induced subacute dyskinesia, Alzheimer's disease, and Parkinson's disease. Upon admission, the resident was identified as a fall risk, having fallen within the last 30 days, and the family also noted the risk. The care plan included interventions such as keeping the bed in the lowest position and using bilateral fall mats, but these were not effectively implemented. The resident experienced a fall on the day of admission and another fall later, both without injury. The investigation revealed that the fall mats, which were part of the care plan, were not ordered or listed in the CNA care plan/Kardex. The Director of Nursing confirmed that the interventions were not uploaded to the CNA Kardex, and there was no verification process to ensure the care plan interventions were correctly communicated to the CNAs. This oversight contributed to the resident's second fall, as the necessary fall prevention measures were not in place.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to serve food at proper safe temperatures during a dinner meal service. On the specified date, the cook began serving dinner without taking the temperature of the food before service. The first dinner cart was dispatched from the kitchen at 5:30 pm, but the temperatures of the food on the serving line were only taken at 6:02 pm, after the meal service had concluded. The temperature of the parmesan baked zucchini liquid was recorded at 109 degrees Fahrenheit, which was below the safe temperature threshold. The Interim Certified Dietary Manager (CDM) confirmed that the temperature was too low and should have been above 135 degrees Fahrenheit to prevent foodborne illnesses. Additionally, the hamburgers served during the meal were not maintained at a safe temperature. They were placed on a flat half tray across the top of the steam table, rather than in a well, and their temperature was recorded at 98 degrees Fahrenheit at 6:09 pm. The Interim CDM noted that the hamburgers should have been kept in beef broth in a pan to maintain warmth, and all food should be heated to 165 degrees Fahrenheit before leaving the kitchen. The Administrator also acknowledged that the hamburgers should have been placed inside a well on the steam table to achieve a safe temperature.
Resident Dignity Compromised Due to Inadequate Clothing
Penalty
Summary
The facility failed to promote dignity for a resident by not ensuring they were appropriately dressed in a common area. On May 15, 2024, the resident was observed in the day room wearing a yellow hospital gown that exposed their left hip, making them visible to staff and visitors. The resident expressed dissatisfaction with wearing a hospital gown and mentioned having limited clothing in their room, preferring short-sleeved shirts and pants. The Director of Nursing acknowledged the resident's exposure and suggested that if the resident lacked clothing, they could obtain some from the laundry department. An observation of the resident's closet revealed only a sweatshirt and pants. The following day, the Administrator confirmed the expectation that residents should be covered in common areas and noted the availability of donated clothes, yet the resident was again seen wearing a hospital gown.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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