Aviata At Tallahassee
Inspection history, citations, penalties and survey trends for this long-term care facility in Tallahassee, Florida.
- Location
- 3101 Ginger Dr, Tallahassee, Florida 32308
- CMS Provider Number
- 105433
- Inspections on file
- 37
- Latest survey
- September 19, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Aviata At Tallahassee during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean and safe environment for several residents, including cracked bathroom fixtures, stained walls, a persistently dirty refrigerator that a resident could not clean due to physical limitations, unclean personal items for a bedbound resident, and a wheelchair with exposed foam. Staff interviews confirmed that CNAs were responsible for daily cleaning, and facility leadership acknowledged the issues.
A resident was not screened for safe smoking despite being observed smoking and having access to cigarettes, contrary to facility policy requiring a safe smoking assessment for all smokers. The resident's name was only informally added to the smoking list, and no documentation of a smoking screen was found in the medical record.
Two residents were found with various medications, including topical creams and nasal sprays, stored at their bedside over several days without physician orders for self-administration. These medications were not kept in locked compartments as required, and no documentation supported resident self-administration.
A resident's medical records were found to be incomplete and inaccurate, with missing documentation of wound care on multiple days and an incorrect diagnosis of morbid obesity included in the record, as confirmed by the RD.
The facility did not follow infection control protocols in multiple cases, including not posting required contact isolation signage for a resident with MRSA, placing another resident on droplet isolation without a physician order, and improper wound care technique by a CNA who reused a soiled rag during a dressing change until corrected by an RN.
A resident did not receive prescribed MS Contin 75 mg ER for several days due to the facility's failure to timely reorder and administer the medication. Pharmacy records showed no refill requests after the previous supply ended, and the MAR documented missed doses with the medication marked as unavailable. Staff acknowledged the lapse in timely reordering.
A facility failed to obtain consent for a psychotropic medication prescribed to a resident. The resident was taking Mirtazapine and Trazodone for depression, but only Mirtazapine had a signed consent. The facility's policy required consent for psychotropic medications, but the DON incorrectly stated that consent was not needed for antidepressants. The psychiatric nurse practitioner claimed to have discussed the medication's risks and benefits with the resident's representative, but no documentation was found. Additionally, PRN orders for Trazodone lacked proper justification, leading to the deficiency.
The facility's 100 hall lacked a functioning call light system, with residents using handheld bells instead. The Administrator acknowledged the system had been broken for a long time, and there was no call system in the private bathrooms. Parts for repairs had recently arrived.
A resident's DNR status was not updated in the electronic medical record due to miscommunication and procedural lapses. The SSA placed the DNR form in the advance directives book without ensuring a nurse updated the record, leading to CPR being performed when the resident was found unresponsive.
The facility was found deficient in food safety and staff hygiene standards. Observations revealed unsanitary conditions in the kitchen, including improper dish cleaning, inadequate cold storage, and personal items on food prep stations. Staff failed to document food temperatures and did not adhere to hair containment policies. The cook did not wash hands before taking food temperatures and used improper cleaning techniques for the thermometer.
Several residents experienced dignity issues due to laundry service failures and privacy breaches. A resident wore a hospital gown due to unwashed clothes, while two others faced similar clothing issues, with one arriving without personal clothing. Observations revealed unsorted laundry and staffing shortages. Another resident's privacy was compromised during toileting care, and a resident's access to personal belongings was restricted, contradicting her care plan.
The facility was found to have multiple environmental deficiencies, including cluttered and unsanitary conditions in the laundry room, hazardous spills in the main hallway, and maintenance issues in residential areas. These deficiencies were observed during a survey, highlighting the facility's failure to maintain a safe and clean environment for residents.
The facility failed to properly store and label medications across three medication carts. Unidentified tablets, unlabeled medications, and expired items were found, with improper disposal methods used by LPNs. Insulin pens and inhalers lacked necessary labeling and dates, raising concerns about their storage conditions. The DON acknowledged these issues despite previous audits.
The facility failed to provide a palatable and appropriate diet to residents, as evidenced by multiple observations and interviews. A resident with end-stage renal disease did not receive a bagged lunch on dialysis days, contrary to physician orders. Another resident reported the food as cold and unpalatable, leading to stomach upset and diarrhea. A third resident noted meals were often cold and undercooked, with missing condiments. Staff interviews revealed that residents must request condiments, which are not automatically provided.
The facility failed to maintain a sanitary dumpster area, with garbage and medical waste observed on the ground. Broken items and debris were found around the dumpsters, and garbage cans containing linens were improperly stored. The Plant Operations Manager was aware of the issues but did not take corrective actions. Facility policies on garbage disposal were not followed, resulting in the deficiency.
The facility failed to maintain kitchen and pantry equipment in safe operating condition. Issues included leaking pipes, improper dish cleaning, and malfunctioning refrigerators and freezers. The kitchen's dishwasher and refrigerator had significant maintenance problems, and pantry ice machines and refrigerators were not properly maintained. The facility's policies on equipment maintenance were not followed, leading to these deficiencies.
The facility failed to ensure accurate PASARR documentation for three residents. One resident's Level II evaluation was missing despite a diagnosis of dementia and suspected mental illness. Another resident's PASARR did not reflect multiple mental health diagnoses present in the medical record. A third resident's PASARR failed to indicate existing diagnoses of bipolar disorder and schizoaffective disorder. The facility's policy requires accurate PASARR screenings prior to admission.
A facility failed to create a comprehensive care plan for a resident with an anxiety disorder. The resident was observed calling for help and appeared anxious, but only had scheduled Trazodone without PRN medications for anxiety. The care plan lacked interventions for monitoring mood or behavior, despite a psychiatric history of depression and anxiety. A psych consult was ordered for medication management, and a psychiatric note indicated agitation related to wound care.
A facility failed to ensure accurate narcotic counts and consistency with physician orders for a resident. A discrepancy was found between the narcotic count sheet and the actual tablets present. A staff member administered medication without updating the narcotic book, leading to a resident receiving the wrong dosage due to an unawareness of a change in the physician's order.
The facility failed to consistently post nurse staffing information on the 100 and 200 halls. On two consecutive days, the required information was missing. Interviews with the responsible LPNs revealed that one assumed the task was being done by others, while the other cited time constraints, indicating that updates do not always occur at the beginning of shifts.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, and homelike environment in several resident rooms. In one occupied room, the bathroom toilet lid was cracked and the ceiling near the entryway had a brown, rust-like substance between the tiles. Another occupied room had brown stains and scratched paint on the wall. A small refrigerator in a resident's room contained a foul odor, spilled brown liquid, unfinished bottles of soda, and ice cream spilled throughout the freezer compartment; the resident confirmed the refrigerator had not been cleaned for a long time and was unable to clean it herself due to physical limitations. Multiple follow-up observations confirmed the refrigerator remained dirty over several days. A bedbound resident was observed with a pillow and board used to hold a cell phone, both of which had stains and organic particles that remained uncleaned over several days. Another resident's wheelchair had an armrest with exposed foam. During an interview, an LPN stated that CNAs were responsible for wiping surfaces daily and as needed. The facility's Administrator, Maintenance Director, and Housekeeping Account Manager acknowledged these issues during a tour.
Failure to Screen Resident for Safe Smoking Practices
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents by not conducting a safe smoking assessment as required by facility policy. A review of the electronic medical record for the resident revealed no documentation of a safe smoker screening. The DON stated that a smoking screen is performed on every resident upon admission and that residents who smoke are provided with education and added to a smoking list managed by activities staff. However, the DON indicated that the resident in question did not smoke and would only be screened if she chose to start smoking. Contrary to the DON's statement, an activities assistant reported observing the resident smoking and confirmed that the resident had cigarettes stored in a lockbox designated for residents' smoking supplies. Upon review, the resident's name was found handwritten at the bottom of the smoking list, suggesting a lack of formal inclusion and oversight. The facility's policy requires a safe smoking assessment for all patients electing to smoke, but this was not completed or documented for the resident involved.
Failure to Securely Store Medications at Bedside
Penalty
Summary
Facility staff failed to ensure the safe and secure storage of medications for two residents, as required by professional standards. For one resident, multiple medications including medicated body powder, isopropyl alcohol, ointments, creams, and an ophthalmic solution were observed stored at the bedside table over several days, with no physician order for self-administration documented in the medical record. Similarly, another resident was found with allergy relief nasal sprays at their bedside on multiple occasions, also without any orders for self-administration or physician authorization for these medications. These observations were confirmed through direct inspection, review of the electronic medical record, and photographic evidence, indicating that medications were not stored in locked compartments as required.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who was admitted with multiple diagnoses, including villonodular synovitis pigmented, major depressive disorder, quadriplegia, and a documented diagnosis of morbid obesity. During interviews and record reviews, it was found that the resident had a wound on the left forearm requiring daily dressing changes per physician's orders. However, the Treatment Administration Record (TAR) for this wound care was left blank on several dates, indicating a lack of documentation for the required treatment. Additionally, a review of the resident's medical record with the Registered Dietitian revealed an inaccurate diagnosis of morbid obesity, as the resident had never been obese according to the RD, despite the diagnosis being present in the record.
Failure to Follow Infection Control Practices and Physician Orders
Penalty
Summary
The facility failed to follow infection prevention and control practices in several instances. For one resident with a physician order for contact isolation due to MRSA, the required contact isolation signage was not posted on the resident’s door. Instead, signage for Enhanced Barrier Precautions (EBP) was displayed, and staff did not update the signage even after reviewing the physician’s order. The Assistant Director of Nursing decided to maintain EBP signage, citing a perceived low risk of transmission due to antibiotic treatment, without consulting the physician for clarification. Facility policy required that appropriate transmission-based precaution signage be posted when such precautions are ordered. Another resident was placed on droplet isolation for COVID-19, as indicated by signage on the room door, but there was no corresponding physician order for droplet isolation in the medical record. Additionally, during wound care for a third resident, a CNA was observed reusing a soiled rag to clean the skin around a wound, contaminating the soapy water and the wound area, until corrected by an RN. These actions demonstrate lapses in following established infection control protocols and physician orders.
Failure to Timely Refill and Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to administer prescribed pain medication and did not timely refill pain medication for a resident requiring such services. Record review and interviews revealed that the resident did not receive her nightly dose of MS Contin 75 mg ER for several days, as confirmed by her daughter. Pharmacy records indicated that the last refill requests were made on 7/2 and 8/4, with no further requests submitted after the supply ended on 8/31. Despite documentation on the Medication Administration Record indicating the medication was given, staff acknowledged that the medication was not available and was not administered from 9/10 to 9/13. The staff also confirmed that the medication should have been reordered in a more timely manner.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent for one of the psychotropic medications prescribed to a resident. The resident was taking Mirtazapine and Trazodone for depression and mood disorder. While there was a signed consent for Mirtazapine, no consent was found for Trazodone. The psychiatric notes indicated that the medication was started due to an exacerbation of depression, and the provider claimed to have discussed the risks, benefits, and alternatives, but it was unclear with whom these were discussed. The facility's policy required that consent be obtained for psychotropic medications, but the Director of Nursing incorrectly stated that consent was not needed for antidepressants. The psychiatric nurse practitioner recalled explaining the risks and benefits to the resident's representative before initiating Trazodone, but no documentation of consent was found in the resident's record. The facility's policy also required that PRN orders for psychotropic medications be limited to 14 days unless otherwise justified by the prescribing practitioner. However, there was no documentation of such justification for the PRN order of Trazodone. This lack of documentation and adherence to policy led to the deficiency identified during the review.
Inadequate Call Light System in 100 Hall
Penalty
Summary
The facility failed to maintain an adequately equipped call light system for the 100 hall of the building. During an initial tour, it was observed that all residents in the 100 hall were using handheld bells at their bedsides instead of a functioning call light system. The Administrator confirmed that the call light system had been broken for a very long time and that the bells were a temporary measure. Additionally, it was noted that there was no system for calling staff located in the private bathrooms of the residents' rooms. The Administrator mentioned that parts for the call light system had recently arrived, and repairs were expected to occur soon.
Failure to Update DNR Status in Medical Records
Penalty
Summary
The facility failed to maintain accurate and updated medical records for a resident whose code status was changed to Do Not Resuscitate (DNR) by the family. The process was initiated, and the facility assisted in obtaining the necessary doctor's signature on the same day. However, the Social Service Assistant (SSA) placed the completed DNR form in the advance directives book without ensuring that a nurse updated the electronic medical record. Consequently, when the resident was found without respirations, the electronic record still indicated a Full Code status, leading staff to initiate CPR until paramedics pronounced the resident expired. Interviews revealed a breakdown in communication and procedure adherence. The Regional Director of Clinical Services stated that the advance directives book should remain at the nurse's station and that only nurses are authorized to update orders. The LPN on duty when the DNR was received did not update the electronic record, as she had not been requested to do so and had not verified the form. The SSA assumed the nurse would update the record but did not confirm this action. This miscommunication and failure to follow protocol resulted in the resident's DNR status not being reflected in the electronic medical record at the time of the incident.
Deficiencies in Food Safety and Staff Hygiene
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a kitchen tour. The dish cleaning process was inadequate, with food particles found on supposedly clean dishes and a significant buildup of rust and limescale on the dishwasher. The kitchen environment was unsanitary, with water and food debris on the floor, rust on the garbage disposal, and personal items improperly stored on food preparation stations. Additionally, the cold food storage was compromised, with a broken thermometer in the refrigerator and a temperature reading of 60 degrees F, indicating improper cooling. Further observations revealed that staff did not follow proper food handling procedures. Personal drinks and electronic devices were found on food preparation tables, and staff failed to document food temperatures before service. The cook, Staff I, did not wash her hands before donning gloves to take food temperatures and used improper techniques to clean the thermometer between uses. The kitchen manager acknowledged these issues but stated that the staff were nervous due to the surveyor's presence. The facility also failed to enforce proper hair containment and attire policies. Staff members, including the cook and dietary aides, were observed without appropriate hair or beard nets, and the cook had long acrylic nails, which are against facility policy. The facility administrator was also seen in the kitchen without a hair net. These observations indicate a lack of adherence to the facility's policies on staff attire and hygiene, contributing to the overall deficiency in maintaining a sanitary food preparation environment.
Deficiencies in Laundry Services and Resident Privacy
Penalty
Summary
The facility failed to provide a dignified existence for several residents due to issues with laundry services and privacy. Resident #104 was observed wearing a hospital gown because she had no clean clothes, despite having a closet full of dirty laundry. The confusion between housekeeping and nursing staff regarding the responsibility for transporting and laundering personal clothing contributed to this issue. Interviews with staff revealed a lack of clarity on the process, leading to Resident #104's prolonged use of a hospital gown. Residents #65 and #116 also experienced issues with clothing. Resident #65 arrived at the facility without personal clothing and was observed wearing a patient gown throughout the survey period. Despite expressing a desire for clothes, he had not received any. Resident #116 reported having to re-wear pants due to delays in laundry processing, despite filing a grievance about missing clothes. Observations in the laundry room revealed unsorted and improperly stored clothing, with the Laundry Services Supervisor acknowledging staffing shortages and delays in processing resident clothing. Resident #41's dignity was compromised when a CNA left the bathroom door open while providing toileting care, exposing the resident to the hallway. The CNA cited space constraints and the resident's urgency as reasons for not closing the door. Additionally, Resident #120's access to personal belongings was restricted by turning her dresser and armoire to face the wall, limiting her ability to change clothes. This was done to prevent frequent clothing changes, but it contradicted the resident's care plan, which emphasized self-care and dressing independence.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in several areas, including the laundry room, main hallway, and residential areas. During a tour of the laundry services area, it was observed that the soiled laundry processing area was cluttered with linens and pillows stacked to the ceiling, some of which were on the floor. There were also large garbage disposal bins without lids between the washing machines. The Laundry Services Supervisor explained that the items on the shelves were waiting to be discarded and that the facility had been short-staffed, which contributed to the backlog of unsorted and unfolded laundry. In the main hallway, six unidentified large brown/green semi-liquid piles were observed, posing a slipping hazard. Several facility employees and a resident with a cane walked past the piles without alerting staff. The Director of Nursing was informed of the issue and stated that housekeeping would be called to clean up the piles. This incident highlights the facility's failure to promptly address environmental hazards that could endanger residents and staff. Further environmental concerns were noted during a tour, including a fallen windowsill, stained ceiling tiles, dark brown stains on privacy curtains and floors, a heavily soiled armchair, and exposed metal due to heavy wear on walls. Additionally, the shower rooms on the 100 and 200 hallways had issues such as unidentified brown matter under a shower chair and chipping/peeling paint. These observations indicate a lack of maintenance and cleanliness in the facility, compromising the safety and comfort of the residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications across three medication carts, as observed during a survey. In the Split Haven medication cart, unidentified tablets were found in the drawers, and a Levemir insulin pen lacked an open date, raising concerns about its storage conditions. Additionally, Dorzolamide eye drops were found without a pharmacy label or received date. The LPN responsible for this cart disposed of the loose tablets into a sharp's container instead of using the facility's pill buster solution, which was available in the medication storage room. In the 100-hall medication cart, several unidentified tablets and a multi-dose vial of Lidocaine were found without proper labeling or dates. Symbicort inhalers and a ProAir RespiClick inhaler also lacked pharmacy labels and received dates. Insulin pens and vials were found without open dates, which is crucial for determining their storage requirements. The LPN for this cart used the pill buster for disposal when the issues were pointed out. In the 300-hall medication cart, an unidentified tablet was found, and the LPN initially planned to flush it down the toilet, contrary to the facility's policy of using the pill buster solution. Additionally, a Glucose Gel with an expired date was found. The Director of Nursing acknowledged these issues, despite previous audits by the pharmacist.
Deficiencies in Meal Service and Dietary Compliance
Penalty
Summary
The facility failed to provide a palatable and appropriate diet to residents, as evidenced by multiple observations and interviews. Resident #22, who has end-stage renal disease and is dependent on dialysis, reported not receiving a bagged lunch on dialysis days despite physician orders. Observations showed discrepancies between meal tickets and actual food served, such as receiving milk despite a 'no dairy' diet order. The kitchen manager acknowledged the issue, attributing it to staff not reading meal tickets properly and stated that condiments are provided in bulk, leaving it to nursing staff to distribute them. Resident #248 expressed dissatisfaction with the food quality, describing it as often cold and unpalatable, leading her to avoid eating facility meals. She reported experiencing stomach upset and diarrhea after consuming the food. Observations confirmed missing items on her meal tray, such as syrup and margarine, and noted that the milk was warm. Despite her complaints to staff, the issues persisted, and she opted to bring her own food. Resident #135 also reported issues with food quality, noting that meals were frequently cold and sometimes appeared undercooked. She expressed concern for other residents who might not notice these issues. Her meal tray was missing condiments, and the milk was warm, similar to Resident #248's experience. The resident also mentioned experiencing diarrhea, suspecting it might be related to the food. Interviews with staff revealed that residents must request condiments, which are not automatically provided with meals.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the dumpster area in a safe and sanitary manner, as observed during a survey. Upon initial entrance, a moderate amount of garbage and medical waste was found on the ground surrounding two dumpsters. The first dumpster was clean, but the second had an open side access door and was surrounded by broken items, including a plastic cart, a metal cart, and a wooden table. Further observations revealed that the situation remained unchanged, with the top cover of the second dumpster left open. Additional inspections found five garbage cans alongside the building, three of which contained bags of linens from inside the facility, along with more broken items and debris. The Plant Operations Manager was interviewed and admitted awareness of the pallets and broken items behind the dumpsters. He stated that pallets were picked up weekly but could not confirm when they were last collected or if the accumulation was typical for a weekend. He also acknowledged seeing the garbage cans with linens but did not specify where they should be moved or inspect their contents. The facility's policies on garbage disposal and environmental maintenance, dated 2017, were reviewed and indicated that all garbage should be collected and disposed of safely, with the surrounding area kept free of debris. However, these policies were not adhered to, leading to the observed deficiencies.
Deficiencies in Kitchen and Pantry Equipment Maintenance
Penalty
Summary
The facility failed to maintain food service-related equipment in safe operating condition, as observed during a survey. In the kitchen, a significant amount of water was found on the floor due to a leaking sprayer nozzle and a pipe under the sink. Additionally, there was a buildup of food particles on the clean side of the dishwasher, and dishes were not properly cleaned, as they contained water, soap bubbles, and food particles. The Kitchen Manager acknowledged these issues but did not provide a satisfactory explanation for the improper cleaning process. The facility's Administrator was aware of the dishwasher concern but failed to address the leaking pipe under the sink. The walk-in refrigerator and freezer also presented issues, with water on the floor, condensation on containers, a broken inner door handle, and a broken thermometer. The temperature in the refrigerator was found to be 60 degrees F, which is above the required 41 degrees F for perishable foods. The freezer had a significant buildup of ice, and the temperature was 10 degrees F. The Kitchen Manager admitted that the refrigerator had trouble maintaining temperature during warm weather and that these issues had persisted for over a year without resolution from the administration. In the pantry rooms, one ice machine was unplugged, and another was leaking water, causing a wet floor. The refrigerators in these pantries had a large buildup of ice, indicating a lack of maintenance. The interim Plant Operations Manager was unaware of these issues, and no work orders or maintenance logs were provided to address these concerns. The facility's policies on warewashing, food storage, equipment maintenance, and ice machine sanitation were not followed, leading to these deficiencies.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Preadmission Screening and Resident Review (PASARR) for three residents. For Resident #18, a review of the PASARR dated 3/3/17 showed no evidence of a Level II evaluation, despite the resident having a primary diagnosis of dementia and suspected mental illness. The Regional Social Services Director acknowledged the absence of the Level II review, attributing it to a possible oversight during the transition to electronic records. Similarly, the Regional Clinical Director confirmed the inability to locate the Level II PASARR for this resident. Resident #62's PASARR, dated 1/18/23, did not reflect several mental health diagnoses documented in the medical record, including recurrent depressive disorders and schizophreniform disorder. The Regional Director of Social Services agreed that the PASARR was inaccurate and should have been updated. For Resident #126, the PASARR form dated 3/14/24 failed to indicate the resident's diagnoses of bipolar disorder and schizoaffective disorder, despite these being present upon admission and documented in the care plan. The Regional Social Services Director acknowledged the need for correction. The facility's policy requires PASARR screenings to be conducted and results obtained prior to admission, with updates coordinated by Social Services if necessary.
Failure to Develop Comprehensive Care Plan for Anxiety
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with an anxiety disorder. On June 17, 2024, the resident was observed calling out for help and expressing difficulty breathing, appearing anxious. Nursing staff responded by administering oxygen, but the resident continued to exhibit signs of anxiety. Interviews with staff revealed that the resident, who can become agitated, does not have any PRN medications for anxiety, only scheduled Trazodone. The resident's care plan, initiated on May 17, 2024, lacked interventions for monitoring mood, behavior, or anxiety, despite a psychiatric history of depression and anxiety. A psych consult was ordered on May 30, 2024, for medication management, and a psychiatric note from June 6, 2024, indicated the resident's mood was agitated related to wound care, although her appearance was calm.
Inaccurate Narcotic Count and Medication Error
Penalty
Summary
The facility failed to ensure the accuracy of narcotic counts and the consistency of stored narcotics with physician orders for a resident. During a review, it was found that the narcotic count sheet for a resident's Hydrocodone/APAP medication indicated 66 tablets, while only 65 tablets were present in the medication cart. Staff P admitted to administering the medication at noon but did not sign it out in the narcotic book, although it was recorded in the computerized Medication Administration Record (MAR). Further investigation revealed a discrepancy between the physician's order and the medication administered, as the order was for a different dosage of Hydrocodone/APAP. Staff P was unaware of the change in the order, resulting in the resident receiving the incorrect medication dosage.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post nurse staffing information as required. On two consecutive days, staffing information was not posted on the 100 and 200 halls. On the first day, at approximately 9:11 AM, and on the second day, at approximately 10:09 AM, the required staffing information was missing. Interviews with the staff responsible for updating the boards revealed a lack of consistent practice. Staff O, an LPN for the 100 hall, acknowledged her responsibility for updating the board but assumed it was being done by someone else. Staff N, the LPN for the 200 hall, admitted she had not updated the board that day, citing time constraints and indicating that while it is the nurse's responsibility to update the board every shift, it does not always happen at the beginning of the shift.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
