Regents Park At Aventura
Inspection history, citations, penalties and survey trends for this long-term care facility in Aventura, Florida.
- Location
- 18905 Ne 25th Ave, Aventura, Florida 33180
- CMS Provider Number
- 105596
- Inspections on file
- 28
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Regents Park At Aventura during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter was left exposed during hygiene care when the privacy curtain did not fully extend, and the roommate entered the room while care was ongoing. The LPN continued care despite being aware of the lack of privacy, citing concern that the resident might refuse care if interrupted. Facility policy requires staff to maintain resident dignity and privacy.
A resident with an indwelling urinary catheter received improper care when an LPN placed the drainage bag and tubing on the bed at bladder level, causing urine backflow. The LPN emptied the bag without cleaning the port, despite physician orders to keep the bag below bladder level. Staff interviews confirmed the correct procedure was not followed, and there was no facility policy on catheter bag positioning.
A resident with COPD and dementia fell and sustained fatal injuries during a mechanical lift transfer when CNAs failed to operate the lift safely. Despite prior training, the lift unexpectedly rose, leading to the resident's fall. The facility's investigation found the lift in working order, and the neglect was deemed unsubstantiated.
A resident fell and sustained fatal injuries during a transfer using a mechanical lift in an LTC facility. CNAs involved failed to ensure the lift's safe operation, leading to the lift rising unexpectedly. Despite training, one CNA may have inadvertently pressed the remote, causing the incident. The resident, with a history of COPD and dementia, required total assistance and was transferred to the hospital, where they later expired.
A resident with chronic health issues and dementia fell from a mechanical lift during a transfer, resulting in fatal injuries. Two CNAs were involved in the transfer when the lift unexpectedly rose, leading one CNA to grab the lift pad, causing the resident to fall. The facility's policies on lift inspections and staff training were not effectively implemented, contributing to the incident.
The facility was cited for failing to provide adequate supervision and interventions to prevent accidents, resulting in repeated falls and injuries to residents. During a recertification survey, a razor was found on a resident's nightstand, indicating a failure to maintain a safe environment free of accident hazards.
The facility failed to adhere to food safety standards, affecting 164 residents. Observations revealed issues such as a leaking ceiling, improper food storage, and unsanitary handling of silverware. Food temperatures were not maintained at regulatory levels, and the kitchen had cleanliness issues, including mold and condensation. These deficiencies indicate a significant risk to resident safety and health.
The facility failed to maintain a safe and clean environment across multiple areas, including the first, second, and third floors, as well as the maintenance and laundry departments. Issues included condensation dripping from air-conditioning vents, unattended hazardous materials, soiled floors, damaged furniture, inadequate privacy curtains, and malfunctioning bathroom fixtures. Additionally, staff failed to document issues in housekeeping and maintenance logbooks, contributing to the deficiencies.
The facility failed to follow the approved menu portion sizes, serving insufficient roast turkey portions during a lunch meal. Observations revealed that the turkey portions were smaller than the required 3 ounces, with a weighed portion measuring only 2.46 ounces. This affected 88 residents on a Regular diet.
The facility failed to maintain resident dignity and provide adequate care, as observed in several instances. A resident reported delayed assistance leading to incontinence issues, while another was left without proper bedding due to staff miscommunication. Additionally, a resident with limited understanding was not assisted with her meal, and staff were overheard using undignified terms for residents needing help with eating.
Two residents experienced a decline in daily living abilities due to inadequate care. One resident, with severe cognitive impairment, was left unsupervised during meals, resulting in poor food and fluid intake and significant weight loss. Another resident's dentures were improperly maintained, with visible residue indicating inadequate cleaning. These deficiencies highlight the facility's failure to provide necessary care to prevent the decline in residents' daily living abilities.
A facility failed to prevent accident hazards by allowing a resident to keep multiple razors in their room, despite a care plan indicating a risk for bleeding due to medication. The resident, with a history of cerebrovascular disease and hemiplegia, was observed with razors in their nightstand, contrary to the facility's policy. Interviews with the resident and staff confirmed the deficiency, highlighting a lapse in supervision and policy enforcement.
A resident with multiple health conditions experienced significant weight loss due to the facility's failure to monitor and document weights as per policy. The resident's weight was not recorded for several weeks, resulting in an 11.4% weight loss over one month without timely nutritional evaluation. The registered dietician acknowledged the oversight in weight monitoring.
The facility failed to secure medications in a medication room and for three residents. An RN left a medication room unlocked, and residents with cognitive impairments or legal blindness had medications at their bedside without being assessed for self-administration. The RN/Unit Manager confirmed that medications should be locked unless residents are assessed for self-administration.
The facility failed to provide food in the correct form for residents requiring pureed and mechanical soft diets. Observations revealed that pureed foods contained lumps, and a resident with cerebral ischemia received meals not compliant with their mechanical soft diet order. The cook lacked training and did not taste test pureed foods, affecting 31 residents with pureed diets and 43 with mechanical soft diets.
The facility failed to implement an effective QAPI program, resulting in repeated deficiencies in Resident Rights, Pharmacy Services, Food and Nutrition Services, and QAPI itself. The Administrator acknowledged issues such as condensation in the kitchen and medication management but lacked documentation and tracking through QAPI to address these problems.
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy for two residents, as isolation gowns were not available at their doors. Additionally, a dietary aide was observed transporting uncovered soiled food trays through the hallway, contrary to facility policy. These lapses were identified during a survey, highlighting deficiencies in infection prevention and control practices.
Failure to Ensure Privacy During Hygiene and Catheter Care
Penalty
Summary
The facility failed to provide adequate privacy during hygiene and catheter care for one resident with an indwelling urinary catheter. During an observation, an LPN performed hygiene care for the resident while the privacy curtain did not fully extend around the bed, leaving the resident exposed. While care was ongoing, the resident's roommate entered the room, further compromising privacy. The LPN acknowledged awareness of the incomplete privacy but continued care to avoid the resident refusing it. The facility's policy requires staff to protect and promote resident rights, including maintaining dignity and privacy during care.
Improper Catheter Care and Drainage Bag Positioning
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. During hygiene and catheter care, an LPN placed the resident's urinary drainage bag and tubing on the bed next to the resident's feet, at the same level as the bladder, resulting in backflow of urine in the tubing. The LPN later lowered the drainage bag and emptied the urine without cleaning the port before or after the procedure. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction and was noted to have severe cognitive impairment. Physician orders specified that the urine collection bag should always be kept below the level of the bladder. Interviews with staff, including the LPN, Infection Control Preventionist, and DON, confirmed that the drainage bag should be kept below the bladder to facilitate urine flow and prevent backflow. The LPN acknowledged that leaving the bag on the bed could cause reflux and that the port should be cleaned with an alcohol pad before and after draining urine. The Infection Control Preventionist and DON both stated that the bag should not touch the floor and must hang by gravity, and that the exit port should be cleaned with soap and water. It was also revealed that there was no facility policy regarding the correct positioning of the indwelling urinary catheter drainage bag.
Neglect During Mechanical Lift Transfer Results in Resident's Death
Penalty
Summary
The facility failed to protect a resident from neglect by its staff during a transfer using a mechanical lift. Certified Nursing Assistants (CNAs), identified as Staff A and Staff B, were involved in the incident where the mechanical lift malfunctioned, causing the resident to fall and sustain fatal injuries. The lift unexpectedly rose, and when Staff B attempted to stabilize the situation by grabbing the lift pad, the resident fell to the floor, resulting in head injuries. The resident was subsequently transferred to the hospital, where they expired approximately four hours later. The resident involved had a history of Chronic Obstructive Pulmonary Disease (COPD) and dementia, requiring total assistance with activities of daily living due to impaired mobility. The resident's care plan included the use of a mechanical lift for transfers. On the day of the incident, the CNAs were performing a routine transfer from the bed to a chair when the lift malfunctioned. Despite having completed training on the use of mechanical lifts, the CNAs were unable to prevent the resident from falling. The facility's mechanical lifts had been inspected for safety and functionality, with the most recent inspections occurring before and after the incident. However, during the transfer, it was reported that Staff A may have inadvertently pressed the remote control, causing the lift to rise unexpectedly. This led to Staff B's attempt to hold the lift pad, which resulted in the resident's fall. The facility's investigation concluded that the neglect was unsubstantiated, and the mechanical lift was found to be in working order after the incident.
Removal Plan
- Competency/training Mechanical Lift operations completed for CNAs Staff A and Staff B
- Medical Equipment Company checked all mechanical lifts to make sure they were functioning properly
- Safe Handling policy for Mechanical lifts were reviewed with DON, ADON, NHA, Unit Managers
- Safe and Proper Handling of Mechanical lifts training/competencies-completed for all nurses and CNAs
- Reviewed interviews for alert residents and family interviews for alert residents about safety and abuse/neglect
- Abuse and Neglect policy reviewed and revised, revisions were implemented in the employee training section
- New Abuse Investigate Protocol checklist was implemented, DON, ADON, NHA, SSD were in-serviced on the new form
- In service on Abuse, Neglect and Exploitation was completed for all staff at the facility
- The sixty residents requiring Mechanical lift for transfers, care plans were reviewed
Failure in Safe Transfer with Mechanical Lift
Penalty
Summary
The facility's Certified Nursing Assistants (CNAs), Staff A and Staff B, failed to ensure the safe transfer of a resident from the bed to a chair using a mechanical lift. During the transfer, the mechanical lift unexpectedly rose, and when Staff B attempted to stabilize the situation by grabbing the lift pad, the resident fell from the lift, sustaining head injuries. The resident was subsequently transferred to the hospital, where they expired approximately four hours later. The facility's policy on safe resident handling and transfers mandates that mechanical lifting equipment be inspected prior to use to ensure functionality. However, the mechanical lift involved in the incident was not effectively inspected or maintained, leading to its malfunction during the transfer. The CNAs involved had completed training on the use of mechanical lifts, but during the incident, Staff A may have inadvertently pressed the remote control, causing the lift to rise unexpectedly. The resident involved had a history of Chronic Obstructive Pulmonary Disease (COPD) and unspecified dementia, requiring total assistance with activities of daily living due to impaired mobility. The resident's care plan included the use of a mechanical lift for transfers. Despite the facility's protocols and training, the incident occurred, resulting in the resident's fall and subsequent death due to blunt force trauma.
Removal Plan
- Lift #846 was inspected and found to be functioning correctly, stored in the maintenance room.
- Competency/training Mechanical Lift operations completed for CNAs Staff A and Staff B.
- Safe and Proper Handling of mechanical lifts training/competencies completed for all nurses and CNAs.
- ADHOC Quality Assurance and Performance Improvement (QAPI) meeting on Mechanical lift transfers completed with the QAPI team.
- Safe Handling policy for mechanical lifts were reviewed with DON, ADON, NHA, Unit Managers, attendees were documented on the QAPI sign in sheet.
- Medical Equipment Company checked all mechanical lifts to make sure they were functioning properly; no areas of concern were reported.
- Monthly Maintenance Mechanical lift logs completed by Maintenance Director.
- Residents' Kardex audited/updated for mechanical lift pad sizes.
- Mechanical sling size assessment for the 60 residents using mechanical lifts were completed by Unit Managers.
- Safe and Proper Handling of Mechanical lifts training/competencies completed for all nurses and CNAs.
Fatal Incident Due to Improper Mechanical Lift Operation
Penalty
Summary
The facility failed to effectively inspect and operate a mechanical lift safely during the transfer of a resident, resulting in a fatal incident. Two CNAs, Staff A and Staff B, were involved in transferring the resident from the bed to a chair using the mechanical lift. During the transfer, the lift unexpectedly continued to rise, and when Staff B attempted to stabilize the situation by grabbing the lift pad, the resident fell from the lift and sustained severe head injuries. The resident was subsequently transferred to a hospital, where they expired approximately four hours after the fall. The resident involved had a history of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and unspecified dementia. The resident was dependent on staff for transfers due to impairments in both upper and lower extremities. The care plan for the resident included the use of a mechanical lift for transfers, which was not executed safely during the incident. The facility's policies required that mechanical lifts be inspected before use and that staff be trained and competent in their operation, but these measures were not effectively implemented in this case. Interviews with staff revealed that the mechanical lift involved in the incident was functioning correctly at the time of the surveyor's inspection. However, the incident report suggested that Staff A may have inadvertently pressed the remote control, causing the lift to rise unexpectedly. This prompted Staff B to grab the lift pad, leading to the resident's fall. The facility's maintenance logs indicated that the lifts were inspected regularly, but the training and competency of the staff in using the lifts were called into question following the incident.
Removal Plan
- Lift #846 inspected and found to be functioning correctly, stored in the maintenance room.
- Competency/training Mechanical Lift operations completed for CNAs Staff A and Staff B.
- Safe and Proper Handling of Mechanical lifts training/competencies completed for all nurses and CNAs.
- ADHOC Quality Assurance and Performance Improvement meeting on Mechanical lift transfers completed with the QAPI team.
- Safe Handling policy for Mechanical lifts reviewed with DON, ADON, NHA, Unit Managers, attendees documented on the QAPI sign in sheet.
- Medical Equipment Company checked all mechanical lifts to ensure they were functioning properly; no areas of concern reported.
- Maintenance Mechanical lift logs completed by Maintenance Director.
- Residents' Kardex audited/updated for mechanical lift pad sizes.
- Mechanical sling size assessment for the 60 residents using mechanical lifts completed by Unit Managers.
Failure to Ensure Resident Safety and Prevent Accident Hazards
Penalty
Summary
The facility was cited for failing to ensure the safety of residents by not providing adequate supervision and interventions to prevent accidents. During a complaint survey ending in December 2023, the facility was found to have failed in preventing repeated falls that resulted in injuries to vulnerable residents. Additionally, during a recertification survey in August 2024, a razor was observed on the nightstand of a resident, indicating a failure to maintain a safe environment free of accident hazards. The facility's survey history revealed that during a recertification conducted in late July to early August 2024, the same deficiency was cited. The facility did not ensure that a resident's room was free of accident hazards, as evidenced by the presence of razors at the bedside. This deficiency was noted for one of the forty sampled residents, highlighting a repeated issue with maintaining a safe environment for residents.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, affecting 164 residents. During an initial kitchen observation, a large section of the ceiling was dripping water onto the floor near food production areas, and staff were walking through the contaminated water. Soiled clothing was found in the dry food storage area, and a commercial package of macaroni salad lacked an expiration date. The food preparation area had a rust-laden electrical box, and soiled dishes were stored in a clean area, posing a risk of cross-contamination. Food utility carts were heavily soiled with black mold, and adaptive eating dishes were stained. The walls and floors of the food production area were dirty, with broken tiles, and a ceiling vent had condensation dripping onto clean equipment. During a second observation, dietary staff handled clean silverware unsanitarily, and hot and cold foods on the tray assembly line were not held at regulatory temperatures. A third observation revealed that raw chicken was thawing in hot water, contrary to regulations, and food temperatures were again not maintained. Condensation from a ceiling vent dripped onto clean carts and dishes, and rodent traps and flying insects were noted in the kitchen. A fourth observation found that food temperatures were still not compliant, and a pan of powdered thickener lacked a date. These deficiencies indicate a lack of adherence to food safety standards, with multiple instances of improper food storage, preparation, and handling. The facility's failure to maintain clean and safe kitchen conditions, as well as to ensure food is stored and served at appropriate temperatures, poses a risk to resident safety and health.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment across multiple areas, including the first, second, and third floors, as well as the maintenance and laundry departments. On the first floor, air-conditioning vents were observed to be covered with condensation and dripping onto the hallway floor. The maintenance department was left unattended with the door open, allowing resident access to hazardous chemicals and sharp tools. On the second floor, various rooms and common areas were found to be in disrepair, with issues such as soiled floors, damaged furniture, and inadequate privacy curtains. Additionally, there were reports of offensive odors, algae-covered windows, and malfunctioning bathroom fixtures. The third floor also exhibited deficiencies, including non-functional paper towel dispensers and privacy curtains that were too short to ensure resident privacy. In the laundry room, a staff member was observed sitting on a clean linen shelf, and the area was cluttered with personal items and food containers. The facility's housekeeping and maintenance logbooks, intended for staff to report issues, were not being utilized effectively, as staff were not documenting problems. These observations were made during a survey conducted over several days, highlighting significant lapses in housekeeping and maintenance services necessary for resident safety and comfort.
Insufficient Portion Sizes of Roast Turkey
Penalty
Summary
The facility was found to have not adhered to the approved menu portion sizes during a lunch meal service. Specifically, the portion size of roast turkey served to residents on a Regular diet was insufficient. During an observation in the main kitchen, it was noted that the turkey portions appeared smaller than required. A review of the facility's approved menu indicated that a minimum of 3 ounces of roast turkey should be served. However, when a portion was weighed by the Food Service Director using a calibrated food scale, it was found to be only 2.46 ounces. This discrepancy potentially affected 88 residents who were on a physician-ordered Regular diet.
Dignity and Care Deficiencies in Resident Assistance
Penalty
Summary
The facility failed to treat residents in a dignified manner, as evidenced by several observations and interviews. Resident #72, who has a self-care deficit and is incontinent, reported that staff sometimes take a long time to respond to calls for assistance, leading to instances where the resident soils himself. The resident mentioned wearing two diapers to prevent urine from going everywhere, indicating a lack of timely incontinence care. Similarly, Resident #136, who is legally blind and incontinent, reported that some staff members have her wear two diapers, which she did not request, suggesting inconsistency in care practices. Resident #154, who is dependent on staff for all activities of daily living, was found in her bed without sheets or a blanket, giving the appearance of being cold. This was observed during a facility tour, and staff interviews revealed a lack of communication and responsibility between CNAs, leading to the resident being left without proper bedding. Staff C and Staff F both acknowledged their roles in the situation, with Staff F leaving the resident without linens, assuming Staff C would return to complete the care. Resident #6, who has a BIMS score indicating she is rarely understood, was observed with an untouched breakfast tray and no staff present to assist her. Staff interviews revealed confusion about who was responsible for assisting the resident with her meal, resulting in inadequate assistance during dining. Additionally, during a breakfast meal observation, staff were overheard referring to residents as "feeders," which was identified as a dignity issue by the surveyor.
Failure to Maintain Residents' Daily Living Abilities
Penalty
Summary
The facility failed to provide necessary care and services to prevent the decline in activities of daily living for two residents. Resident #64, who has severe cognitive impairment and multiple medical diagnoses including Alzheimer's Disease and dysphagia, was observed during a breakfast meal in a nearly lying position, attempting to feed themselves with their hands, resulting in food spillage and inability to consume beverages. The resident received no supervision or assistance from staff during the meal, consuming less than 50% of the meal and none of the fluids. The resident's clinical records indicated a significant weight loss over several months, with a BMI within the health range, but noted a need for assistance with meals and a risk for nutritional issues. Resident #177, also with severe cognitive impairment, was observed with dentures improperly maintained. The top denture was out of the mouth and the bottom denture had a greenish-brown film, indicating inadequate cleaning. Despite the RN/UM's assertion that CNAs clean the dentures, the film was easily removed with a toothbrush, suggesting a lack of proper care. These observations highlight the facility's failure to ensure residents maintain their ability to perform daily activities, such as self-feeding and dental care, without medical justification for the decline.
Failure to Prevent Accident Hazards in Resident's Room
Penalty
Summary
The facility failed to ensure a resident's room was free from accident hazards, specifically regarding the presence of razors at the bedside. This deficiency was identified for one resident who was admitted with diagnoses including unspecified sequelae of cerebrovascular disease and hemiplegia affecting the left nondominant side. The resident's care plan highlighted a risk for bleeding and easy bruising due to their medication regimen, which included Clopidogrel Bisulfate for blood clot prevention. Despite this, observations revealed multiple safety razors in the resident's room, contrary to the facility's policy that prohibits residents from possessing or using sharp objects independently. Interviews with the resident and staff further confirmed the deficiency. The resident admitted to using razors almost every day and showed the surveyor several razors stored in the nightstand. The Director of Nursing and a Licensed Practical Nurse both stated that razors should be disposed of immediately after use in a sharps container, indicating a lapse in adherence to the facility's policy. This oversight in supervision and enforcement of safety protocols led to the presence of potential accident hazards in the resident's environment.
Failure to Monitor Resident's Weight Loss
Penalty
Summary
The facility failed to adequately monitor and identify significant weight loss in a timely manner for a resident, leading to a deficiency in nutritional care. The facility's policy required residents to be weighed within 24 hours of admission and weekly for the first four weeks, with further monitoring if significant weight changes were observed. However, the resident in question, who had multiple diagnoses including cerebral atherosclerosis, type 2 diabetes mellitus, and mild protein-calorie malnutrition, experienced significant weight loss without timely intervention. The resident's weight was not recorded for several weeks, and a significant weight loss of 11.4% was noted over a one-month period without a timely nutritional risk evaluation. The registered dietician acknowledged the oversight in obtaining and recording the resident's weights, despite the facility having a system in place for weight monitoring. The dietician confirmed that the resident had experienced significant weight loss and that some weekly weights were missed. This lapse in monitoring and documentation contributed to the failure to address the resident's nutritional needs promptly, as required by the facility's policy.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure that medications were secured in one of the two medication rooms observed. During an inspection, a Registered Nurse (RN) led a surveyor to an unlocked room containing various over-the-counter medications and an unlocked treatment cart with Hydrocortisone Acetate 1%. Additionally, an adjoining room inside the unlocked medication room was found with its door wide open, containing various creams, ointments, and solutions for wound care. The RN acknowledged that the room should have been locked and admitted to forgetting to lock the cart and the medication room after cleaning. The facility also failed to secure medications for three residents. One resident, with moderate cognitive impairment, was observed with Biotene dry mouth lozenges on their overbed table. The RN confirmed that residents should not have medications at the bedside unless assessed for self-administration, which had not been done for this resident. Another resident, who is legally blind, was found with Emergen C vitamin C gummies, vitamin C lozenges, and Vicks vapor ointment on their overbed table. The LPN and RN/Unit Manager confirmed that the resident had not been assessed for self-administration, and the medications should have been locked. A third resident, with a cognitive response, was observed with Tums, Aspercreme, and other medications in their nightstand drawer, along with several safety razors. The resident stated that they use the Tums for gas and the razors almost every day. The RN/Unit Manager confirmed that residents should not have medications unlocked at the bedside unless assessed for self-administration, which had not been done for this resident.
Failure to Provide Appropriate Diets for Residents
Penalty
Summary
The facility failed to prepare food in a form designed to meet the individual needs of residents, specifically those requiring pureed and mechanical soft diets. During observations, it was noted that pureed foods, such as cilantro rice and eggs, contained lumps and pieces, indicating they were not of the required smooth consistency. The cook admitted to not having specific training on preparing pureed foods and did not taste test the mixtures to ensure they met the necessary consistency. This affected 31 residents with physician-ordered pureed diets, including several sampled residents. Additionally, the facility did not provide the correct mechanical soft diet to 43 residents, including a resident with a principal diagnosis of cerebral ischemia. This resident was observed receiving meals that did not comply with the mechanical soft diet requirements, such as whole pieces of chicken instead of ground meat. The registered dietician confirmed that the meals provided were inappropriate for a mechanical soft diet. These deficiencies highlight a failure in adhering to physician-ordered dietary requirements for residents with specific dietary needs.
Ineffective QAPI Implementation Leads to Repeated Deficiencies
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement Program (QAPI) as evidenced by repeated deficiencies in four federal areas: Resident Rights (F550), Pharmacy Services (F761), Food and Nutrition Services (F812), and Quality Assurance Performance Improvement (F867). The facility's QAPI plan lacked regular review and analysis of data, and there was no effective action taken on available data to make necessary improvements. During a QAPI review, the Administrator acknowledged that while they meet monthly to review past deficiencies, they had not yet started a QAPI for the identified condensation issue in the central kitchen, which was related to the repeated deficiency under Food and Nutrition Services. Additionally, the Administrator mentioned issues related to Resident Rights, specifically staff standing over residents during dining, which was resolved without a QAPI. The Administrator also identified problems with medications at the bedside and residents ordering medications online, but there was no QAPI paperwork available to track and trend these issues. The lack of documentation and tracking indicates a failure to effectively address and monitor these deficiencies through the QAPI process.
Infection Control Lapses in EBP and Food Tray Handling
Penalty
Summary
The facility failed to adhere to its policy on Enhanced Barrier Precautions (EBP) for two residents, as observed by surveyors. Resident #177, who was on EBP due to a wound, did not have isolation gowns available at the door as required by the facility's policy and CDC guidelines. During an interview, the Registered Nurse/Unit Manager acknowledged the absence of gowns and indicated that they were supposed to be next to the door but had run out. Further investigation revealed that additional gowns were stored in an unlocked room at the end of another hallway, contrary to the expectation that they should be readily accessible. Similarly, Resident #69, who was also on EBP, did not have isolation gowns available in the room. Additionally, the facility failed to ensure that food trash and soiled resident food trays were covered during transportation. An observation was made of a dietary aide pushing an uncovered meal tray cart with dirty trays through the hallway. The dietary aide mentioned that the cover was missing, suggesting it might have been discarded. These observations indicate lapses in infection prevention and control practices as per the facility's policies.
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.
