Coral Bay At Pensacola, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Pensacola, Florida.
- Location
- 600 W Gregory St, Pensacola, Florida 32502
- CMS Provider Number
- 106051
- Inspections on file
- 24
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 32 (9 serious)
Citation history
Health deficiencies cited at Coral Bay At Pensacola, Llc during CMS and state inspections, most recent first.
The facility failed to adequately assess and mitigate the risk posed by a resident with a documented history of aggressive and violent behaviors who was roomed with a cognitively impaired, non-verbal, limited-mobility roommate. Staff had observed the aggressive resident verbally cursing at the vulnerable roommate and described prior incidents of verbal abuse, threats toward other residents, and sufficient physical strength to move others, yet there was no documentation of enhanced supervision or targeted precautions for the vulnerable resident. After the vulnerable resident was found with significant bleeding, lacerations, and later diagnosed intracranial bleeding, facility leadership initially attributed the injuries to bed rails and the resident’s own teeth and did not include the aggressive roommate in the incident investigation, despite the aggressive history and later acknowledgment that the cheek puncture wounds could not have been self-inflicted.
The deficiency concerns the facility’s failure to thoroughly investigate several abuse-related incidents. In one case, a resident sustained facial lacerations and an intracranial hemorrhage, and leadership attributed the injuries to self-inflicted contact with bed siderails without investigating a former roommate known to have aggressive behaviors, despite external concerns about that roommate’s violent history. In another incident, a staff member reported seeing a CNA pull a resident by the wheelchair arm and yell at him, but the facility deemed the allegation unsubstantiated after the reporting employee resigned and conducted no further inquiry. In a third case, a resident reported that an RN threw a clipboard at him, resulting in a hand bruise, yet the facility relied on a reported retraction and the resident’s decision not to press charges to label the allegation unsubstantiated and document “confabulation,” even though the resident later stated he had not retracted the allegation and the only written investigation was a brief statement from the Risk Manager.
Surveyors found that the facility did not ensure accurate, resident-centered assessments and care plans when leadership directed the addition and repeated use of the term "confabulation" in several residents’ care plans and nursing notes without clear clinical rationale. One resident had confabulation added to the care plan after retracting an abuse allegation, another had a grievance about delayed incontinence care characterized as involving "some sort of confabulation," a third had multiple refusals of care documented as confabulation, and a fourth was described as confabulating after requesting to be changed again. The DSS, Administrator, and DON could not provide adequate justification for this pattern of documentation.
Surveyors found that staff documentation did not accurately reflect the actual condition and care needs of three residents. One paraplegic, bed-bound resident was charted as ambulating and transferring independently or with minimal assistance, despite staff confirming he was unable to walk or transfer. Another resident was documented on CNA flow sheets as independent with toileting, transfers, and lower body dressing and as having call light access and fluids at the hospital, while her care plan and staff interview described her as totally dependent with limited movement and needing feeding assistance. A third resident was charted as independent with toilet transfers and having no behaviors, even though nursing notes described episodes of yelling and screaming, the care plan showed total assistance needs and non-ambulatory status, and observation revealed he could not reposition himself in bed; a CNA stated he required total care and that behaviors were reported to nursing and recorded on a behavior flow sheet.
Staff used personal cell phones to photograph and video a resident experiencing pain and behavioral changes, as well as to routinely capture wound images, and then texted these images to the NP for assessment and treatment recommendations. A RN and the Wound Care Nurse reported storing these images on their personal devices and were unaware of any signed consents authorizing this method of communication. The Administrator did not object to the practice for medical purposes but acknowledged she could not ensure confidentiality once images were on staff devices. Facility policy required explicit written consent for imaging, prohibited unauthorized transmission of resident images, and treated photographs as health care records, yet there was no evidence of resident consent, authorization, or secure, encrypted transmission for the use of personal devices.
A resident with cognitive impairment sustained facial puncture wounds from contact with bed side rails, requiring sutures and hospital transfer. Although facility leadership was aware of the incident, it was not reported to authorities until after an APS investigator arrived, well beyond the facility’s policy requirement to report suspected abuse or injury of unknown origin within 2 hours when serious bodily injury is involved. The Risk Manager acknowledged that staff are expected to immediately report suspected abuse and injuries of unknown origin, but provided no reason for the reporting delay, resulting in noncompliance with the facility’s abuse reporting policy.
A dietary aide reported witnessing a staff member verbally and physically mistreat a resident in a wheelchair and then experienced ongoing harassment and retaliatory behavior from nursing and kitchen staff, including threatening comments, refusal to sign meal-tray forms, and aggressive, profane interactions. The aide, described by a coworker as quiet and respectful, ultimately resigned by phone, citing fear for personal safety and difficulty identifying harassing staff because they were not wearing name badges. Leadership, including the Administrator, DON, Risk Manager, Unit Manager, and HR Director, acknowledged awareness of harassment concerns but did not conduct an investigation into the reported retaliation, despite a written policy requiring protection of individuals who report suspected abuse.
A resident with a history of physical aggression was involved in an incident where they struck a nurse. Although staff began 15-minute checks following the event, this enhanced monitoring was not documented in the care plan or as a physician order. Interviews with the DON, social worker, and MDS nurse confirmed the omission of this intervention from the care plan.
A facility failed to assess a resident's capability to self-administer medications before allowing him to do so. The resident was observed performing his own tracheostomy care and had an unsecured tube of mupirocin ointment. Despite the facility's policy requiring an interdisciplinary team assessment and documentation, no such assessment was conducted for this resident.
A resident with a contracted hand and limited range of motion did not receive proper nail care, resulting in excessively long fingernails. The resident's care plan indicated dependency on staff for personal hygiene, but there was no documentation of nail care being performed or refused. The facility's policy required regular nail maintenance to prevent infections, which was not adhered to in this case.
A resident was observed with an undated dressing on the left lower arm over several days, with no order or documentation in the EMR for the skin tear. The wound care nurse confirmed the lack of documentation, and the DON stated that nurses are expected to notify providers of new skin issues and obtain treatment orders, which should be documented in the EMR.
A resident receiving Magnesium Oxide four times daily did not have their magnesium levels monitored as ordered by the physician. Despite an order for a magnesium level check every six months, no monitoring or documented refusal was found in the resident's record. The DON confirmed the oversight, which was contrary to the facility's policy requiring staff to arrange for necessary tests.
The facility failed to properly dispose of garbage and refuse, as observed during inspections of the kitchen and outside garbage bins. Trash was found around the garbage compactor, and a cardboard box bin had a hole, allowing contents to be visible. The Dietary Manager and Administrator acknowledged these issues, which were not in compliance with the facility's policy requiring safe and efficient disposal practices.
A facility failed to implement Transmission-Based Precautions (TBP) for a resident with an ESBL urinary tract infection (UTI). The resident's room lacked TBP signage and isolation setup, confirmed by the unit manager and infection preventionist. The facility's policy requires TBP for transmissible infections, but there was no clear process for monitoring new infections when the infection preventionist was not on site.
Failure to Address Aggressive Roommate Risk and Provide Adequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and precautions for a vulnerable resident when roomed with another resident who had a documented history of aggressive and violent behaviors. Resident #1 was a cognitively impaired, non-verbal, limited-mobility adult who sustained unwitnessed physical injuries on 01/30/2026, including lacerations that required transfer to a higher level of care, suturing, and diagnostic testing that revealed intracranial bleeding. Resident #6, who moved into Resident #1’s room on 12/23/2025, had a clinical record documenting aggressive and violent behaviors such as yelling and physically acting out toward other residents and staff. Despite this, Resident #1’s record contained no documentation of enhanced supervision or other specific precautions related to being roomed with Resident #6. Staff interviews further described a pattern of concerning behavior by Resident #6 that was not fully assessed or incorporated into supervision plans for Resident #1. A hospice CNA reported witnessing Resident #6 verbally cursing at Resident #1 prior to the 01/30/2026 incident. Another CNA, who discovered Resident #1 with significant blood on the bed rail, in her mouth, and on the floor, recalled that Resident #6 had previously become upset when Resident #1 made noise, had threatened another resident who sat in her chair, was often verbally abusive to other residents, and was physically strong enough to move Resident #1, though she had not personally witnessed physical altercations between the two roommates. A RN reported she had requested a room change for Resident #1 after staff notified her of Resident #6’s violent behaviors and that she had multiple attempts to contact the Administrator about this request. The facility’s Risk Manager and Administrator stated that the initial belief was that Resident #1’s injuries were caused by contact with the bed rails and her own teeth, and the Administrator acknowledged that the investigation of the 01/30/2026 incident did not include Resident #6 as a possible source of the injuries, despite Resident #6’s documented aggressive history and the later acknowledgment that the puncture wounds on the outside of Resident #1’s cheek could not have been caused by her teeth.
Failure to Thoroughly Investigate Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple abuse-related incidents involving three residents. For one resident, the facility documented facial gashes after an event that required transfer to a higher level of care, suturing of two right lower facial lacerations, and identification of an intracranial hemorrhage. Facility leadership concluded the resident caused the injuries by striking her teeth on the bed siderails and stated they had no reason to investigate the resident’s former roommate, despite that roommate’s documented history of aggressive behaviors and prior episodes of becoming upset with other residents. Hospice staff had emailed the Administrator requesting the resident be moved due to concerns about the roommate’s history of violent behaviors, and the resident was moved several days after returning from the hospital. In a separate incident, the facility received an allegation of verbal abuse in which a dietary staff member reported witnessing a CNA pull a resident by the arm of his wheelchair and yell at him. The facility’s investigation concluded the allegation was unsubstantiated, citing an inability to obtain adequate information from the reporting staff member after his resignation, even though leadership knew he resigned due to workplace harassment following his report, and no further investigation was conducted. In another case, a resident alleged that an RN became upset and threw a clipboard at him, resulting in a documented bruise on his hand when he blocked the clipboard. Facility leadership stated the allegation was unsubstantiated based on a reported retraction relayed by the ADON and a note that the resident had signed something with the police; the IDT added “confabulation – allegations of staff abuse” to the resident’s record. However, the resident later stated he only declined to press charges and did not retract the allegation. The police report documented that the resident declined to press battery charges and that the Risk Manager questioned why the incident was reported two days after it occurred, and the facility’s investigation consisted only of the Risk Manager’s written statement that the resident declined to press charges, with no additional investigative documentation provided.
Inaccurate and Non–Resident-Centered Use of Confabulation in Care Plans and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident assessments and care plans were documented accurately and in a resident-centered manner for four residents. During interviews, the MDS LPN identified the Director of Social Services (DSS) as the person responsible for entering behavior items on residents’ care plans, and the DSS stated that such directives could come from upper management, including the Administrator, Risk Manager, or DON. When surveyors questioned why a care plan entry for confabulation was added for one resident shortly after that resident made allegations of abuse, the team did not answer, and the DSS deferred responsibility to the Administrator. In a follow-up interview, the Administrator and DON stated that this resident had retracted his statement of abuse and that this was the reason confabulation was added to his care plan. Further review showed that the term confabulation was also used in the documentation of three additional residents without clear clinical rationale provided by facility leadership. For one resident, confabulation was referenced in the summary of an investigation into a grievance in which the resident reported not being changed for 30 minutes after activating the call light, with the investigation summary stating there was “some sort of confabulation.” For another resident, confabulation was used in four nurses’ notes documenting that the resident refused care. For a fourth resident, confabulation was used in a nurse’s note stating that the resident requested to be changed after it had already been done. When asked, the Administrator and DON did not provide further explanation for the frequent use of confabulation in these residents’ charts.
Inaccurate ADL and Behavior Documentation for Dependent, Non-Ambulatory Residents
Penalty
Summary
The deficiency involves inaccurate and inconsistent medical record documentation for three residents, failing to reflect their actual functional status and behaviors. For one resident diagnosed with paraplegia, ADL documentation showed that he ambulated 150 feet independently or with varying levels of assistance and transferred from bed to chair independently or with supervision on multiple dates. However, observations on two consecutive days showed that he was bed bound with no active movement in his lower extremities, and both an LPN and a CNA confirmed he was paralyzed and unable to walk or transfer independently, stating that the documented entries would be impossible. For another resident, CNA flow sheets over a specified period documented independence with toilet and bed transfers, independence with lower body dressing, call light within reach, and fluids provided while at the hospital, while the resident’s care plan indicated total staff assistance. Observation showed this resident lying on her back with limited body movements, and a CNA later stated she required total care, had not been able to turn from side to side for several years, and required assistance with feeding. A third resident’s CNA flow sheets documented independence with toilet transfer and no behaviors, despite nursing notes on multiple dates describing the resident as upset, yelling, and screaming, and a care plan indicating a self-care deficit with total staff assistance for toileting, hygiene, and transfers, and that the resident was non-ambulatory. Observation showed this resident sliding down in bed and unable to reposition without assistance, and a CNA stated he required total care, while also explaining that behaviors were reported to the nurse and documented in a behavior flow sheet.
Unauthorized Use of Personal Cell Phones for Resident Images and Clinical Communication
Penalty
Summary
The facility failed to protect residents' personal privacy and the confidentiality of medical information when staff used personal cell phones to photograph and video residents for clinical communication with the facility’s Nurse Practitioner (NP). Nursing documentation showed that one resident was observed sliding on the floor while yelling and screaming with abdominal pain, and staff contacted the NP for clinical guidance. The NP’s written statement confirmed that staff provided a video of this resident and requested guidance based on the behaviors shown in the recording. During interviews, a RN admitted to taking a video of the resident on her personal cell phone to send to the NP and acknowledged knowing that personal devices were technically not permitted, though she believed the restriction related to posting on social media. The RN also reported that staff take photographs of residents’ skin concerns to send to the NP. The Wound Care Nurse stated that she routinely uses her personal cell phone to take and store pictures of residents’ wounds and sends them via text message to the NP for assessment and treatment recommendations, and both staff members were unaware of any signed consents from residents for this form of communication. The Administrator did not oppose the practice if done for medical purposes but acknowledged she could not ensure confidentiality once images were on personal devices. Review of the facility’s policy on videotaping, photographing, and imaging of residents showed requirements for explicit written consent, prohibition of unauthorized transmission of images, and treatment of photographs as health care records, but there was no evidence of consent, authorization, or secure, encrypted transmission for the use of staff personal devices as practiced.
Failure to Timely Report Suspected Abuse/Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged incident of abuse/neglect within the required 2-hour timeframe. An incident report filed on 02/03/2026 at 4:00 PM documented an event as occurring on 02/03/2026, but further review showed the incident actually occurred on 01/30/2026. The event involved Resident #1, described as a vulnerable adult with cognitive impairment, who was found with her face pressed against the side rails of her bed on 01/30/2026, sustaining puncture wounds to the outside of her cheek that required sutures and a transfer to a local hospital. Although the report indicated the Administrator was notified on 02/03/2026, the Administrator was already aware of the incident that occurred on 01/30/2026. The incident was not reported to the appropriate authorities until after an Adult Protective Services investigator arrived at the facility on 02/03/2026 at 4:00 PM to investigate the allegation. During an interview on 02/09/2026, the facility Risk Manager stated she decided to report the incident after the APS investigator entered the facility and confirmed that her expectation is that any suspected abuse observed by staff must be reported immediately so she can initiate an investigation. She also stated that any injury of unknown origin must be reported within two hours, followed by a five-day report with investigation findings. The facility’s written policy on Abuse, Exploitation or Misappropriation-Reporting and Investigating, last revised 04/2021, requires that suspected abuse, neglect, or injury of unknown source be reported immediately to the administrator and other officials, defining “immediately” as within two hours for allegations involving abuse or resulting in serious bodily injury. The Risk Manager did not provide an explanation for the delay in reporting this incident, resulting in noncompliance with the facility’s policy and regulatory reporting timeframes.
Failure to Protect Abuse Reporter From Retaliation and Harassment
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse-prevention and anti-retaliation policies to protect an employee who reported alleged abuse of a resident. A dietary aide (Staff Q) reported witnessing a staff member pull Resident #4 by the wheelchair arm and tell the resident, “get your ugly *** out here,” and he immediately reported this to a Unit Manager, who then notified the Risk Manager. After making this report, Staff Q stated that staff spoke loudly about him in a threatening manner, made retaliatory remarks, refused to sign meal-tray forms, and used aggressive tones and profanity toward him. He reported ongoing harassment from both kitchen and nursing staff, but had difficulty identifying those involved because staff were not wearing name badges. Staff Q ultimately resigned by phone, stating he feared for his safety and reiterating that he could not positively identify all involved staff due to the lack of visible name badges. Multiple interviews with facility leadership and staff showed that no investigation into the reported harassment and retaliation was conducted, despite the facility’s written policy stating that the administrator ensures the person reporting suspected violations is protected from retaliation or reprisal. The Dietary Manager reported that when Staff Q told her he was resigning due to harassment after reporting abuse, she did not investigate the harassment herself but notified the Administrator and Risk Manager. The 3rd Floor Unit Manager acknowledged hearing that Staff Q resigned due to harassment but stated staff-to-staff harassment was outside her scope and should be handled by HR. The Risk Manager stated she attempted to contact Staff Q twice, was unable to reach him, and then unsubstantiated the abuse allegation without further investigation. The Administrator confirmed awareness that Staff Q reported being harassed but acknowledged that no investigation into the harassment occurred. A former dietary staff member (Staff R) also reported experiencing harassment from nursing and kitchen staff during his employment and stated he had reported it to HR, who told him to speak with his supervisor, who was allegedly involved in the harassment. The HR Director recalled a harassment report from Staff R, acknowledged uncertainty about the timeline, and admitted staff were “bad about wearing badges,” despite repeatedly instructing them to wear them.
Failure to Update Care Plan with Enhanced Monitoring After Aggressive Incident
Penalty
Summary
The facility failed to maintain a complete and comprehensive care plan for a resident with a history of physical aggression, including behaviors such as striking out, hitting, kicking, throwing objects, spitting at staff, and refusing care. On the morning of 5/27/25, staff responded to an incident where the resident was observed hitting a nurse in the dining room. Following the incident, the resident was seen by a Psychiatric APRN, and staff implemented 15-minute checks for the next 48 hours as a monitoring intervention. However, review of the resident's electronic medical record revealed that while the care plan for physical aggression was revised on the same day as the incident, no new interventions were documented, and the enhanced rounding of 15-minute checks was not added to the care plan. Additionally, there was no physician order for the enhanced rounding. Interviews with the DON, social worker, and MDS/care plan nurse confirmed that the care plan update for enhanced rounding was missed, and the intervention was not included in the resident's care plan.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) assessed and determined if a resident was capable of self-administering medications before allowing a resident to do so. This deficiency was identified during an observation of a resident who was performing his own tracheostomy care and had an unsecured tube of mupirocin ointment on the sink. The resident had been declining tracheostomy care from staff and providing his own care on multiple occasions without an assessment to determine his capability to self-administer medications and treatments. The Director of Nursing (DON) acknowledged that the facility has a process to assess residents before allowing them to self-administer medications, but this process was not followed for the resident in question. The facility's policy requires that the IDT assess each resident's cognitive abilities to determine if self-administration is safe and appropriate, and this should be documented in the medical record and care plan. However, no such assessment or documentation was found for the resident, leading to the deficiency.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was dependent on staff for activities of daily living (ADL). During an observation, the Director of Nursing (DON) noted that the resident's fingernails on the right hand were excessively long, with the 5th digit's nail measuring 1.5 cm past the nail bed. The resident's right hand was contracted, making it difficult to measure the 4th digit's nail, which was also noted to be long. The DON confirmed that the nail length was unacceptable given the resident's condition. A review of the resident's records showed that the resident had a functional limitation in the range of motion on one side of the upper extremity and required supervision or assistance for personal hygiene. The care plan indicated the resident was dependent on staff for various personal care tasks, including nail care. However, there was no documentation of nail care being performed or any refusal of such care by the resident. The facility's policy on nail care, revised in February 2018, emphasized the importance of regular cleaning and trimming to prevent infections, but there was no record of compliance with this policy for the resident in question.
Failure to Document and Order Treatment for Skin Tear
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and facility policy for a resident with a non-pressure related skin condition. Observations revealed that the resident had an undated dressing on the left lower arm over several days. The wound care nurse confirmed that the dressing was not dated and that there was no order for the dressing or documentation of the skin tear in the resident's electronic medical record (EMR). The wound was new to the wound care nurse that week, and no order had been obtained for the treatment. The Director of Nursing (DON) confirmed the absence of a documented order in the EMR for the resident's left lower arm/wrist area. The DON stated that it is expected for the nurse to notify the provider of any new skin issues, obtain an order for treatment, and document it in the EMR. Additionally, the resident's representative should be notified. The facility's policy on skin tears and minor breaks in the skin requires obtaining a physician's order, documenting physician notification, and reviewing the resident's care plan and current orders.
Failure to Monitor Magnesium Levels
Penalty
Summary
The facility failed to appropriately monitor the magnesium levels for a resident who was receiving Magnesium Oxide 400 mg by mouth four times a day since September 15, 2023. The physician had ordered a magnesium level to be checked every six months along with other routine labs, as per the order dated July 6, 2023. However, a review of the resident's record revealed that there was no monitoring of the magnesium level or any documented refusal of the test since the order date. An interview with the Director of Nursing confirmed that the magnesium level was not completed, and there were no documented attempts or refusals in the resident's record. The facility's policy, Lab and Diagnostic Test Results-Clinical Protocol, revised in November 2018, states that the physician will identify and order diagnostic and lab testing based on the resident's needs, and the staff will process test requisitions and arrange for tests. Despite this policy, the necessary monitoring was not conducted, leading to a deficiency in the resident's care.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during an inspection of the kitchen and outside garbage collection bins. On the initial tour, trash was found around the garbage compactor, and a cardboard box trash bin was on the ground with a visible hole in the forklift port, allowing cardboard boxes to be seen through it. The Dietary Manager acknowledged the issues, indicating plans to notify the Maintenance Manager about the hole and to clean up the area. A follow-up observation confirmed the ongoing issues, with the Administrator noting the hole in the cardboard box bin and trash scattered on the ground around the bins. The facility's policy, dated October 2019, requires that garbage and refuse be collected and disposed of safely and efficiently, with specific responsibilities assigned to the Dining Services Director and the Director of Maintenance to maintain cleanliness and proper disposal practices.
Failure to Implement Transmission-Based Precautions for ESBL UTI
Penalty
Summary
The facility failed to implement Transmission-Based Precautions (TBP) for a resident diagnosed with an extended-spectrum B-lactamase (ESBL) urinary tract infection (UTI). On September 10, 2024, the room of Resident #8 was observed without TBP signage or any isolation setup, including personal protective equipment (PPE). This was confirmed by the unit manager, Staff K, who acknowledged that residents with ESBL UTI should be on contact precautions, which include TBP signage and isolation setup by the door. The infection preventionist (IP) confirmed that an order for antibiotics was placed on September 6, 2024, and that the resident should have been placed on contact isolation at that time. Further interviews revealed a lack of a clear process for monitoring new infections when the IP is not on site. Staff K was unaware of any such process, and the Director of Nursing (DON) stated that the house supervisor reviews orders on weekends for residents being readmitted from the hospital. However, there was no indication that this process was followed for Resident #8. The facility's policy on Isolation-Initiating Transmission Based Precautions, revised in August 2019, states that such precautions should be initiated when a resident has a laboratory-confirmed infection and is at risk of transmitting it to others, which was not adhered to in this case.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
