Aviata At The Gardens - Tallahassee
Inspection history, citations, penalties and survey trends for this long-term care facility in Tallahassee, Florida.
- Location
- 1650 Phillips Rd, Tallahassee, Florida 32308
- CMS Provider Number
- 105764
- Inspections on file
- 38
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Aviata At The Gardens - Tallahassee during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide a clean, safe, and homelike environment, with persistent urine odors in hallways, unsanitary conditions for a resident reported by family and hospice aides, ongoing cockroach infestations in resident rooms, and inadequate housekeeping and linen services for another resident. Facility staff acknowledged ongoing issues with pest control and cleaning schedules.
Surveyors found that medication carts contained loose and unidentified tablets, expired insulin pens, and multi-use vials without proper dating. Narcotic medication cards for discharged residents were not promptly removed, and staff were unclear about medication identification and removal procedures. These deficiencies were observed across multiple units and involved both nursing staff and the DON.
Surveyors observed that the kitchen food cart storage area had damaged walls, broken sheetrock, a hole exposing metal grate, a split main door, chipped and dirty door frames, and a dirty, deteriorating floor with missing tiles and an uncovered drain. These issues were confirmed by dietary and maintenance staff, as well as documented evaluations, all indicating that repairs were pending and the area was not maintained in a safe or functional condition.
A resident reported persistent cockroach infestations in her room, with glue pads placed under the AC unit capturing both dead and live roaches on repeated observations. The Maintenance Director acknowledged ongoing pest issues despite recent changes in pest control methods and regular service visits. Pest Sighting Logs documented numerous roach sightings across multiple halls, demonstrating that the facility's pest control program was ineffective.
A resident with multiple chronic conditions was not promptly assessed for new or worsening pressure ulcers following re-admission. Wounds on the heels and right posterior lower leg were not identified during routine skin checks and were only discovered later, leading to hospital transfer where multiple severe wounds were documented. Facility staff interviews revealed delays and lapses in wound identification and assessment.
The facility failed to provide routine medications to a resident in a timely manner and did not maintain accurate controlled substance records. Nurses were observed signing out narcotics for each other and leaving medication count sheets blank, while a resident reported delays and omissions in receiving prescribed pain medication. The DON was unable to account for numerous narcotic cards belonging to discharged residents that remained on medication carts, and staff interviews confirmed improper documentation practices.
A resident was not invited to participate in care plan meetings, as confirmed by both the resident and a review of medical records. Although care plan meetings were held and documented by staff, there was no evidence that the resident was invited or attended, contrary to facility policy requiring advance invitations and documentation.
Persistent strong urine odors were observed in two hallways, with multiple residents reporting inconsistent housekeeping services, especially on weekends. Housekeeping staff confirmed limited coverage and increased workload when short-staffed, while the DON acknowledged no housekeeping presence during certain hours. The housekeeping manager could not provide documentation of daily cleaning, indicating a failure to ensure a clean and comfortable environment.
The facility failed to maintain proper isolation precautions and hand hygiene practices. Two residents requiring Enhanced Barrier Precautions did not receive care with appropriate PPE, as staff did not don isolation gowns during catheter and wound care. Additionally, two nurses failed to perform proper hand hygiene during medication administration, violating infection control policies.
A facility failed to create a comprehensive care plan for a resident, resulting in unmet needs for maintaining physical functioning. The resident reported difficulty with their wheelchair and right-sided weakness, preventing them from getting out of bed. Despite communicating these issues, no action was taken. The Unit Manager was unaware of the resident's needs, and the care plan lacked recommended restorative programs.
A resident with contractures in the left arm, wrist, and hand did not receive necessary equipment and restorative services to prevent further decline in range of motion. Despite recommendations for a Restorative Splint and Brace program, no orders for restorative services were found, and the resident confirmed not receiving splints. A lack of communication between nursing services and therapy contributed to the oversight.
A resident with a urinary catheter did not receive appropriate care, as staff failed to clean the catheter regularly and did not follow proper procedures during care. The resident, with a history of paraplegia and urinary tract infections, had physician orders for catheter care every shift. However, a CNA was unaware of how to perform catheter care, and an observation revealed improper techniques, such as using gloves from a pocket and not using a catheter securement device. The DON acknowledged concerns about staff competencies in catheter care.
The facility failed to maintain accurate medical records and manage medical equipment properly for three residents. A resident had outdated oxygen tubing, another lacked a care plan for oxygen use, and a third had an overdue PICC line dressing change. Documentation inaccurately reflected care activities, and staff interviews revealed a lack of accountability and verification in executing these tasks.
The facility failed to maintain vaccination consent forms for four residents who refused Influenza and Pneumococcal vaccines. The ADON confirmed the absence of these forms, which were supposed to be documented and retained according to facility policy. The missing documentation resulted from the disposal of original forms after scanning.
The facility failed to maintain COVID-19 vaccination consents for three residents who refused the vaccine. The missing consent forms were discovered during a review of the residents' electronic medical records. An interview with the ADON revealed that the facility's process of scanning and disposing of forms may have contributed to the deficiency.
The facility failed to ensure resident safety during smoking times, as staff were not dedicated to supervise smoking, leading to unsupervised smoking by residents, including those with impairments. Residents were observed with lighters and cigarettes, contrary to policy, and a temporary staff member left residents unsupervised. The facility's smoking policy was not followed, with incomplete evaluations and care plans for residents who smoke.
Two residents reported filing grievances about staff behavior and lack of assistance, but the facility failed to address these issues. The grievance logs showed no record of these complaints, and the Regional Director confirmed the previous administrator did not follow up on them. The facility's grievance policy was not adhered to, resulting in unresolved grievances.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for multiple residents. During facility tours on several dates, a strong odor of urine was present throughout multiple hallways, persisting over several days. Interviews with a resident's family member revealed that the resident was found dirty, soaking wet, and in unsanitary conditions, with hospice aides also reporting the resident being found in a mess. The family member attributed the persistent urine odor to staff leaving soiled linens at the foot of beds for extended periods before removal. Another resident reported a cockroach infestation in her room, confirmed by direct observation of glue pads containing multiple roaches and live roaches present. The Maintenance Director acknowledged ongoing pest control efforts but admitted they had not been effective, as evidenced by pest sighting logs documenting numerous recent roach sightings in various halls. Additionally, an observation of a specific room revealed a visibly soiled privacy curtain, dirty pillows without pillowcases, and a resident who reported not receiving linen changes or housekeeping services for a week despite repeated requests. The Housekeeping Director confirmed that the cleaning schedule for the month was not yet posted and described the general cleaning procedures, but did not address the lack of regular cleaning in the affected room. These findings demonstrate a failure to provide a clean and comfortable environment for residents, as required.
Medication Labeling, Storage, and Removal Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's medication management practices. On several medication carts across different units, there were loose tablets and unidentified medications, including medicine cups with unknown substances and tablets without proper labeling or identification. Expired insulin pens were found on the carts, with labels indicating they should have been discarded 28 days after first use, but they remained accessible. Multi-use vials, such as an opened Haldol injection, were present without any indication of the date they were first accessed. Additionally, medication carts contained narcotic medication cards for residents who had been discharged from the facility, some for over a month or two, and these were not promptly removed from the carts. Interviews with nursing staff and the DON revealed that nurses were instructed not to remove empty or discontinued medication cards from the carts due to a previous drug diversion incident. The DON stated she checks and removes narcotics from the carts every other week, but a significant backlog of narcotic cards for discharged residents was still present, particularly on the 600 unit. Despite these issues, recent pharmacy consultant reports did not document any problems with medication carts or controlled substance logs. The observed failures included improper labeling, failure to date multi-use vials, not following expiration instructions, and inadequate storage and removal of controlled substances.
Kitchen Area Not Maintained in Safe and Functional Condition
Penalty
Summary
The facility failed to maintain the kitchen food cart storage area in a safe and functional condition, as evidenced by direct observation of significant physical damage and uncleanliness. The walls in the kitchen storage area were found to have scuffed marks, deep scratches, scrapes, and broken sheetrock, including a fist-sized hole and exposed metal grate. The main door was damaged with split wood, and door frames had chipped paint and were dirty. The floor was dirty, with chipping material exposing concrete, and in the mop area, floor tiles were missing and the floor drain cover was absent. These deficiencies were confirmed through interviews with the Regional Dietary Manager and Maintenance Director, as well as documented evaluations by the Registered Dietician and Regional Dietary Manager, all indicating that the condition of floors and walls was unsatisfactory and repairs were pending.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in resident rooms and throughout multiple halls. One resident reported ongoing issues with cockroaches in her room, leading her family to purchase and place a glue pad under the air conditioner, which was observed to contain several dead and live cockroaches on multiple occasions. The Maintenance Director confirmed that pest control methods had recently changed from spray to dust and that glue strips were placed in resident rooms, but could not explain the continued presence of live roaches. Pest control invoices showed that services were performed twice monthly in resident rooms and monthly in common areas, kitchens, and other facility locations. Pest Sighting Logs documented numerous recent sightings of roaches across several halls, indicating the pest control measures in place were not effective in eliminating the infestation.
Failure to Timely Identify and Assess Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent the worsening of wounds for a resident with multiple comorbidities, including Peripheral Autonomic Neuropathy, COPD, Rheumatoid Disease, AFIB, and Chronic Respiratory Failure. Upon re-admission, the resident was identified as being at risk for pressure ulcers, and initial wound assessments documented two wounds that were subsequently resolved. However, additional wounds on the heels were not identified or assessed until several weeks after re-admission, and a significant wound on the right posterior lower extremity was not detected during weekly skin checks but was later found during wound care rounds. The resident was eventually transferred to an acute care hospital due to altered consciousness and concerns about worsening wounds. Hospital assessments revealed multiple chronic wounds, including unstageable pressure injuries with necrotic tissue and foul odor, as well as areas of tissue loss and discoloration on the sacrum, hips, and lower extremities. Interviews with facility staff indicated that there were lapses in timely wound identification and assessment, and the wound care nurse was unable to explain the delays in recognizing and treating the resident's wounds.
Failure to Ensure Timely Medication Administration and Proper Controlled Substance Documentation
Penalty
Summary
The facility failed to provide routine medications to residents in a timely manner and did not ensure that controlled drug records were properly maintained and signed out by administering staff. During an observation of medication carts, a nurse was seen removing multiple narcotic cards from the narcotic medication drawer, where a loose tablet was also found. The medication count sheet for these narcotics was blank, yet the nurse admitted to signing it out at the instruction of another nurse. Additionally, a resident reported not receiving her prescribed pain medication over a weekend and experiencing a significant delay in receiving her pain pill in the morning. Review of her medication administration record confirmed that she only received Tylenol for pain during the period in question, despite having orders for other pain medications. Further investigation revealed discrepancies in the documentation and administration of controlled substances. The Director of Nursing (DON) acknowledged that a medication prescription label on a narcotic card had been altered, with the original dosage crossed out and a new dosage handwritten above. The DON described a process for removing controlled substances from medication carts after resident discharge, but was unable to account for a large number of medication cards belonging to discharged residents still present on the carts. Interviews with nursing staff revealed that nurses were signing out narcotics for each other, contrary to facility policy and regulations, and that signatures on narcotic count sheets did not always correspond to the nurse who administered the medication. Staff interviews and documentation review indicated a lack of adherence to established protocols for controlled substance handling, including proper documentation and timely removal of discontinued or discharged medications. Despite these issues, pharmacy consultant reports from the previous three months did not identify any problems with medication carts or controlled substance logs during their inspections.
Resident Not Invited to Participate in Care Plan Meetings
Penalty
Summary
A resident reported not having participated in any care plan meetings since admission and stated she had not been invited to attend. Review of the resident's medical record, conducted with the MDS coordinator, confirmed that care plan meetings had occurred on multiple occasions, but there was no documentation indicating the resident's attendance. Meeting forms were signed only by staff members. The MDS coordinator confirmed the resident did not participate in the meetings and was unsure of the reason. Facility policy requires that residents and/or their representatives be invited to care plan conferences, with invitations delivered 7-14 days in advance and a copy placed in the medical record, but there was no evidence this process was followed for the resident in question.
Failure to Maintain Clean and Homelike Environment Due to Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two out of four observed hallways, as evidenced by persistent strong urine-like odors in hallways 100 and 300. During the initial and follow-up tours, surveyors noted these odors, and interviews with residents confirmed that housekeeping services were inconsistent, particularly on weekends. Residents reported that housekeeping staff were not present on weekends, and when they did come, their cleaning was limited to picking up trash rather than mopping or wiping surfaces. One resident noted that housekeeping only came every two to three days, and during an interview, the floor in her room was found to be sticky with a strong urine odor in the bathroom. Staff interviews revealed that housekeepers were sometimes assigned additional hallways when other staff were absent, and one housekeeper stated she did what she could but did not work weekends. The Director of Nursing confirmed that no housekeeping staff were available in the facility during the evening, as they had already left for the day. The Manager of Housekeeping/Laundry stated that the expectation was for daily cleaning of rooms, including sweeping, mopping, and wiping surfaces, but was unable to provide documentation verifying that these tasks were completed daily.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain proper isolation precautions for two residents who required Enhanced Barrier Precautions (EBP). Resident #97, who had a urinary catheter, reported that staff did not clean the catheter regularly. During an observation, two CNAs performed catheter care without donning an isolation gown, despite the presence of orders for catheter care every shift and EBP. Similarly, Resident #67, who had multiple pressure injuries, received wound care from a Licensed Practical Nurse and a Nurse Practitioner who also failed to don an isolation gown, contrary to the facility's EBP policy. Additionally, the facility did not ensure proper handwashing practices during medication administration. Nurse J was observed dispensing medications to Resident #71 without washing her hands or using hand sanitizer, and then proceeded to prepare medications for another resident without sanitizing her hands. Nurse K, while administering an IV antibiotic to Resident #563, used contaminated gloves to handle medication equipment and did not wash or sanitize her hands between residents. These actions were in violation of the facility's infection prevention and control policies.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, resulting in unmet needs for maintaining the resident's highest practicable level of physical functioning. The resident expressed difficulty in maneuvering their wheelchair due to its size and reported right-sided weakness and pain, which prevented them from getting out of bed. Despite the resident's communication of these issues to the staff, no action was taken to address the need for a more suitable wheelchair. The Unit Manager, who was new to the position, was unaware of the resident's equipment needs and could not provide documentation of any refusal by the resident to get out of bed. The resident's medical record included a recommendation for a Restorative Splint and Brace program and a Bed Mobility Program, but these were not incorporated into the care plan. The care plan only referenced the resident's independent wheelchair use without addressing the recommended restorative nursing or splint and brace program for contracture prevention.
Failure to Provide Restorative Services for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary equipment and restorative services to prevent further decline in range of motion for a resident with contractures. The resident, who had contractures in the left arm, wrist, and hand, was observed without supportive devices in the room. Despite having been discharged from therapy with recommendations for a Restorative Splint and Brace program, no orders or tasks for restorative services or application of splints were found in the resident's medical records. The resident confirmed that she had never been offered or received splints for her wrist or legs. The deficiency was further compounded by a lack of communication between nursing services and therapy. The Director of Physical Therapy stated that he had not received any requests for equipment needs for the resident and was unaware of the extent of the resident's contractures. The Licensed Practical Nurse confirmed that equipment needs are provided through PT/OT, but the nurse must inform them if the resident is not receiving therapy. This breakdown in communication and lack of follow-through on therapy recommendations led to the resident's condition potentially deteriorating due to insufficient staffing and oversight.
Deficiency in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident with a urinary catheter, leading to a deficiency. During a facility tour, the resident reported that staff did not clean his catheter regularly. The resident's medical record indicated a history of paraplegia, hematuria, and urinary tract infections, with physician orders for catheter care every shift. However, a Certified Nursing Assistant (CNA) assigned to the resident was unaware of how to perform catheter care, despite having cared for other residents with catheters. An observation of catheter care revealed improper techniques, such as using gloves from a pocket, raising the catheter bag above the bladder level, and failing to use a catheter securement device. The CNA, assisted by another CNA, performed catheter care without following proper procedures. They used the same washcloth area repeatedly, did not initially replace the resident's foreskin, and only did so after the resident's reminder. The Director of Nursing (DON) acknowledged concerns about staff competencies in catheter care, particularly for uncircumcised residents. The facility's policy outlined specific steps for catheter care, including using a catheter securement device, which were not followed during the observed care.
Inaccurate Medical Records and Equipment Management
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in care. Resident #92 was observed receiving oxygen via a nasal cannula with tubing dated from two weeks prior, despite physician orders to change the tubing weekly. The Treatment Administration Record (TAR) inaccurately documented that the tubing was changed recently, contradicting the physical evidence. Resident #5 also had outdated oxygen tubing, and there was no care plan addressing his oxygen use, despite his medical history of chronic respiratory conditions. The TAR similarly showed incorrect documentation of tubing changes. Resident #105 had a peripherally-inserted central catheter (PICC) line with a dressing dated over a week old, contrary to the physician's orders for weekly changes. The Medication Administration Record (MAR) inaccurately indicated a recent dressing change, which was not supported by physical evidence. Interviews with staff revealed a lack of clarity and accountability regarding the documentation and execution of these care tasks, with staff assuming tasks were completed without verification. The Director of Nursing (DON) confirmed that the facility's expectations were not met, as staff failed to accurately document care activities in the residents' medical records. The facility's policies required regular changes and proper labeling of medical equipment, which were not adhered to, resulting in incomplete and inaccurate medical records for the residents involved.
Failure to Maintain Vaccination Consent Forms
Penalty
Summary
The facility failed to ensure vaccination consents were obtained and maintained for four out of five residents reviewed for Influenza and Pneumococcal vaccinations. Specifically, Resident #101, #51, #105, and #96 were missing consent forms for vaccines they had refused. Resident #101 and #105 were missing consent forms for the Pneumococcal vaccine, while Resident #51 was missing a consent form for the Influenza vaccine. Resident #96, who had been readmitted after an extended hospitalization, was also missing a consent form for the Pneumococcal vaccine from his initial admission. The Assistant Director of Nursing (ADON) confirmed the absence of these consent forms after reviewing the records with the Medical Records Department. The facility's policy requires that refusals of vaccines be documented and placed in the resident's medical record. However, the ADON revealed that after documents are scanned into the residents' charts, the original forms are disposed of and not retained, leading to the missing documentation. This oversight indicates a failure to adhere to the facility's vaccination policies and procedures.
Failure to Maintain COVID-19 Vaccination Consents
Penalty
Summary
The facility failed to ensure that vaccination consents were obtained and maintained for three residents who were reviewed for COVID-19 vaccinations. Each of these residents had refused the COVID-19 vaccine, but their medical records were missing the required consent forms indicating their refusal. The absence of these forms was discovered during a review of the residents' electronic medical records and the facility's immunization consent forms. An interview with the Assistant Director of Nursing (ADON) revealed that the facility's process for handling consent forms may have contributed to the deficiency. The ADON explained that after forms are scanned into residents' charts, they are disposed of and not retained. Additionally, it was noted that sometimes documents might get stuck together, potentially leading to the missing consents. The facility's policy requires staff to review the COVID-19 consent with residents or their representatives, obtain a signature for acceptance or declination, and file the consent form in the resident's electronic health record, which was not adhered to in these cases.
Inadequate Supervision and Policy Adherence During Resident Smoking Times
Penalty
Summary
The facility failed to ensure the safety of residents during smoking times, as observed through staff and resident interviews, record reviews, and policy reviews. Staff members, including CNAs, reported that there was no dedicated staff assigned to supervise smoking, leading to residents, including those with impairments, going outside unsupervised. Residents were observed with lighters and cigarettes in their possession, contrary to the facility's smoking policy, which mandates that such items be stored at the nursing station. During observations, several residents were seen waiting at the door to the smoking area with lighters and cigarettes, and some began smoking without supervision. A temporary staff member, unfamiliar with the location of safety aprons and smoking supplies, left residents unsupervised for a brief period. The Assistant Director of Nursing later confirmed that residents should not have lighters and collected them from several residents. Additionally, a resident with impaired vision was not properly evaluated for smoking safety, and her care plan did not initially reflect her smoking habits or need for supervision. The facility's smoking policy, dated 2014, requires evaluations for residents who wish to smoke and mandates supervision for those identified as needing assistance. However, the policy was not followed, as evidenced by the lack of supervision, improper storage of smoking supplies, and incomplete evaluations and care plans for residents who smoke. This oversight led to residents smoking unsupervised and possessing lighters, posing potential safety risks.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly resolve grievances for two residents, as evidenced by interviews and a review of the grievance log and policy. The husband of one resident reported filing two grievances with the previous administrator in July and August 2024, but no action was taken. Another resident reported filing grievances about disrespectful behavior and lack of assistance from two CNAs, but these issues were not addressed, and the same staff continued to work in the resident's hallway. The resident also experienced retaliation when a CNA skipped serving meal trays to her room after she had complained about the CNA's behavior. A review of the grievance logs from March 2024 to the present showed no recorded grievances for the two residents in question, despite their claims of having filed them. The Regional Director confirmed that these grievances were submitted to the previous administrator, who claimed to have followed up on them, but the failure to address these grievances was only discovered after the administrator's departure. The facility's grievance policy outlines a process for handling grievances, including a 14-day timeframe for follow-up, but this process was not followed in these cases.
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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