Royal Care Of Avon Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon Park, Florida.
- Location
- 1213 W Stratford Rd, Avon Park, Florida 33825
- CMS Provider Number
- 105812
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Royal Care Of Avon Park during CMS and state inspections, most recent first.
Two residents with known behavioral conflict and one with dementia and mood instability engaged in a verbal altercation in a common area that escalated when one resident kicked the other, causing a fall and shoulder injury, while no staff were present to intervene. Staff had prior knowledge of the aggressive resident’s history of verbal and physical behaviors and the pair’s past roommate conflicts, and behavior monitoring for psychotropic use lacked specific behavior descriptions. The DON later confirmed that key staff statements were not obtained and that staff could not clearly describe the behaviors previously documented, demonstrating a failure to provide adequate supervision and behavior-specific monitoring to prevent resident-to-resident abuse.
A resident developed a Stage 4 pressure ulcer due to the facility's failure to identify and treat a new area of skin impairment. The resident did not receive adequate preventive measures or timely treatment, resulting in an infected ulcer that required hospitalization and a wound vac.
The facility failed to maintain a clean and homelike environment, with surveyors detecting offensive odors in the front lobby, nurses' station, and four resident rooms over several days. The Environmental Services Director acknowledged that their audit process does not include checking for odors, and despite using an IT ticket system for reporting concerns, the issue persisted.
The facility failed to ensure accurate PASARR screenings for multiple residents, missing key diagnoses that could have warranted Level II reviews. Interviews revealed that the process for reviewing and correcting PASARRs was not adequately followed.
The facility failed to provide proper wound care for four residents and did not obtain physician's orders for hand splints for one resident. Observations revealed undated and soiled dressings, improper sterile techniques, and lack of documentation for wound care and refusals, leading to deficiencies in care.
The facility failed to ensure proper storage of drugs and biologicals, with treatment carts left unlocked and a bottle of nasal spray found on a resident's bedside dresser. Staff acknowledged the oversights and secured the carts after being made aware.
The facility failed to maintain food safety standards, including unclean kitchen areas, improper food storage, and inadequate equipment maintenance. Black soil was found on the floors of the walk-in refrigerator and freezer, expired egg salad was stored, and a black substance resembling biogrowth was noted on a wall. Additionally, frozen ground beef was improperly thawed, and a spatula with burnt edges and broken thermometer were found. These deficiencies were confirmed by the facility's dietitian and dietary director.
The facility failed to maintain an effective infection control program, with staff not donning appropriate PPE, not assisting residents with hand hygiene before meals, and not maintaining urinary catheters in a sanitary manner. Additionally, inconsistencies in cleaning medical equipment were observed.
The facility failed to securely affix handrails in the corridors of the West and South units. During tours, multiple handrails were found to be loose and not firmly secured to the wall. Staff and the Director of Environmental Services acknowledged the issue, but discrepancies were found in the inspection process.
The facility failed to maintain dignity and a homelike dining experience for residents in the West dining/common area. Observations revealed that staff did not remove dinnerware from trays when serving residents, and plate covers remained on the tables while residents dined. Interviews indicated a lack of awareness or adherence to the facility's policy on dignity.
A resident with broken, chipped teeth and dental caries was inaccurately documented as having normal dentition in multiple assessments. Despite visible dental issues, no care plan or dental consults were provided, and the resident's medical records consistently marked her dental status as normal.
A resident with Parkinson's Disease and an infection due to an internal knee prosthesis did not receive proper IV medication administration. The IV tubing was not labeled, and a significant amount of vancomycin remained in the bag. Staff could not explain the oversight, and the DON confirmed it was a medication error.
The facility failed to ensure proper respiratory care for residents, including improper storage of equipment, lack of physician's orders, failure to change oxygen tubing weekly, and missing cautionary signage. Staff interviews and observations confirmed these deficiencies.
The facility failed to post complete daily nursing staff information. Observations on 5/9/24 revealed missing details for the 7 p.m. to 7 a.m. shift and the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. A review of the 5/8/24 posting also showed missing CNA and PCA information for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts.
The facility failed to administer antihypertensive medications according to prescribed parameters for a resident with multiple diagnoses, including Type 2 Diabetes Mellitus and essential hypertension. The medications Losartan, Diltiazem, and Spironolactone were given outside of the specified blood pressure limits, as confirmed by the DON.
The facility failed to maintain a medication error rate below 5%, resulting in a 21.43% error rate. An RN crushed extended-release medications and administered them incorrectly to a resident, and administered medications late to another resident. The DON confirmed the errors and policy violations.
A resident with Parkinson's Disease and an infection due to an internal knee prosthesis did not receive the full dose of prescribed vancomycin intravenously. The IV tubing was not labeled, and a significant amount of medication remained in the bag. Staff and the DON confirmed this as a medication error, and the facility's policy was not followed.
A resident with several broken, chipped teeth, and dental caries was not assisted in obtaining routine dental care. Despite being cognitively intact and having obvious dental issues, the resident's MDS assessments did not reflect any dental problems, and there was no care plan addressing the dental status. Interviews revealed that the facility's protocol for dental referrals was not followed, leading to the deficiency.
Failure to Supervise Leading to Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent resident-to-resident abuse, resulting in a physical altercation between two residents. Resident #2, who was cognitively intact with a BIMS score of 15 and had diagnoses including abnormalities of gait and mobility, muscle weakness, and type 2 diabetes, alleged that another resident kicked her, causing a fall and subsequent left shoulder pain. Resident #3, who had severe cognitive impairment with a BIMS score of 6 and diagnoses including unspecified mood disorder, depression, and dementia, had a documented history of verbally and physically threatening staff and other residents, aggressive behavior, and pilfering items. The facility’s care plan for Resident #3 identified behavioral symptoms and cognitive loss/dementia, with approaches including redirection, diversional activities, and, later, 1:1 sitter supervision. Prior to the incident, staff were aware that Resident #3 exhibited verbal aggression and had prior altercations with other residents to the point of needing separation, and that the two involved residents had previously been roommates who did not get along, leading to a room change. Resident #3 was also on Depakote for mood instability, mood swings, and aggression, with behavior monitoring ordered. However, the behavior monitoring documentation for January showed only intervention codes (e.g., giving food, fluids, encouraging rest) without any description of the specific behaviors exhibited, and facility staff, including the MDS coordinators, could not state what behaviors had occurred on those dates despite acknowledging that some type of behavior must have been present. The facility’s abuse policy required identification of residents with behaviors that might lead to conflict, sufficient supervision, and monitoring for changes that could trigger abusive behavior, but the documentation and staff interviews did not demonstrate clear, behavior-specific monitoring or consistent preventive supervision. On the day of the event, the altercation occurred in the east wing atrium/common area near the nurses’ station. Resident #8, another resident, reported witnessing Resident #3 approach Resident #2 in a wheelchair, exchange derogatory names, stand up from their wheelchairs, and then kick Resident #2 in the shin, causing Resident #2 to fall to her left side. Resident #8 stated no staff were present at the time. Staff B, an RN, reported hearing Resident #2 crying and asking for help, then seeing her in her wheelchair and separating the residents, but did not witness the actual kick or fall. The DON’s investigation notes, based on interviews, indicated that Resident #3 admitted to pushing another resident after a verbal altercation, and that Resident #2 and Resident #8 both described Resident #3 kicking Resident #2 and causing her to fall. The facility’s abuse policy required sufficient staffing, supervision, and obtaining signed witness statements, but the DON confirmed that written, signed staff statements were not obtained from key staff present that shift, and staff could not clearly account for supervision at the time of the incident, supporting the finding that the facility failed to provide adequate supervision to prevent resident-to-resident abuse.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to identify and treat a new area of skin impairment for a resident, which resulted in the development of an advanced stage pressure ulcer. The resident, who had multiple health conditions including Type 2 Diabetes Mellitus, muscle weakness, and spinal stenosis, initially had no pressure ulcers upon admission. However, the resident developed an unstageable pressure ulcer on the sacral region, which later progressed to a Stage 4 pressure ulcer. The resident reported that the facility did not provide adequate treatment or preventive measures, such as a special mattress, until the ulcer had significantly worsened and become infected, necessitating hospitalization and the use of a wound vac for treatment. Observations and interviews revealed that the resident was often positioned on his back and did not receive consistent repositioning or the use of heel protectors as outlined in his care plan. The facility's documentation showed gaps in progress notes and skin assessments, with no records indicating the development of the pressure ulcer at a lower stage. The facility's Director of Nursing and Medical Director provided conflicting information about the resident's care and the timeline of the pressure ulcer's development. The Medical Director initially claimed the ulcer was unavoidable due to the resident's debility but later admitted to not being familiar with the resident's case. The facility's policy on pressure ulcer prevention and treatment was not adequately followed, as evidenced by the lack of timely assessments, appropriate interventions, and consistent documentation. The resident's care plan included measures such as turning and repositioning every two hours, using an air mattress, and reporting changes in skin condition to the primary care physician. However, these interventions were not consistently implemented, leading to the resident's pressure ulcer progressing to an advanced stage and causing significant harm.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment, as evidenced by the presence of offensive odors in multiple areas. Upon entering the facility, the survey team detected a smell of old urine in the front lobby. Similar odors were noted in front of the nurses' station and in four resident rooms over the course of several days. Specifically, rooms 103, 107, 109, and 110 were identified as having strong and offensive odors, some of which were not related to urine. These observations were made at various times, indicating a persistent issue with maintaining a clean environment. An interview with the Environmental Services Director revealed that the facility's current audit process does not include checking for offensive odors. The Director mentioned that if an odor is noticed, a deep clean is performed, and that room 110B had recently undergone such a cleaning, including a bed replacement. The facility uses an IT ticket system for reporting environmental concerns, which are then prioritized and addressed by the Environmental Services team. Despite these measures, the persistent odors suggest that the current processes are insufficient to maintain a consistently clean and homelike environment for residents.
Inaccurate PASARR Screenings for Multiple Residents
Penalty
Summary
The facility failed to ensure the Level I Preadmission Screening and Resident Review (PASARR) was accurate for four residents. Resident #15 was admitted with diagnoses including vascular dementia, bipolar disorder, and major depressive disorder, but the PASARR did not reflect these diagnoses, and no Level II PASARR was required. Similarly, Resident #26's PASARR did not include a diagnosis of bipolar disorder, and Resident #28's PASARR missed several qualifying diagnoses such as anxiety, schizoaffective disorder, and PTSD. These inaccuracies were not corrected at the time of admission, which could have warranted a Level II PASARR review. Additionally, Resident #38's PASARR was not updated to reflect a new diagnosis of schizoaffective disorder, which was added after the initial screening. This oversight meant that a Level II PASARR review was not conducted when it should have been. Interviews with the Director of Nursing and the Social Services Director revealed that the facility's process for reviewing and correcting PASARRs was not adequately followed, leading to these deficiencies.
Failure to Provide Proper Wound Care and Follow Physician's Orders
Penalty
Summary
The facility failed to provide wound care and treatment in accordance with professional standards of practice for four residents and did not ensure physician's orders were obtained for the application of splints for one resident. Resident #67 had a wound infection on his right knee that required dressing changes. However, the wound dressing was observed without a documented date, and the facility did not follow the physician's orders for wound care. Resident #328 had a wound on his right middle finger that was supposed to be dressed daily, but the dressing was not applied, and there was no documentation of the resident refusing treatment or removing the dressing himself. The facility's staff failed to document the wound care treatment and any refusals properly, as per the facility's policy. Resident #36 was observed with a soiled and undated dressing on his right shin, which was not changed as per the treatment administration record. The resident had a skin tear that required dressing changes every other day, but the facility did not follow the prescribed wound care protocol. Resident #177 had bilateral below-knee amputations with sutures/staples in the surgical sites. The wound dressing changes were not performed using proper sterile techniques, as the nurse used bare hands to handle gauze and did not clean the scissors between cutting the old and new dressings. This practice was against the facility's policy for dry/clean dressings. Resident #41 was observed wearing bilateral hand splints without a physician's order. The resident's care plan did not include the use of hand splints, and the occupational therapist confirmed that the splints were not part of the care plan. The facility's policy required that care plans be individualized and include all necessary interventions, but this was not done for Resident #41. The lack of proper documentation and adherence to physician's orders and facility policies led to deficiencies in the care provided to these residents.
Improper Storage of Drugs and Biologicals
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals, as evidenced by two specific incidents. On two separate days, a treatment cart was observed unlocked and unattended in the South unit hallway. On the first occasion, a Registered Nurse (RN) admitted to leaving the cart unlocked after receiving items from the pharmacy. On the second occasion, the facility's Infection Preventionist (IP) and Assistant Director of Nursing (ADON) did not notice the unlocked cart and walked away without securing it. Both instances were acknowledged by the staff involved, who subsequently locked the cart after being made aware of the oversight. Additionally, during a medication administration observation, a bottle of nasal spray was found on a resident's bedside dresser. The RN administering the medication was unaware of how the nasal spray got there and speculated it might have been placed by a family member. The Director of Nursing (DON) later confirmed that no residents were allowed to self-administer medications and that all medications should be stored in the facility's medication carts. The facility's policy mandates that all drugs and biologicals be stored securely and that medication carts be locked when not in use.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to maintain food safety standards, which included maintaining clean floors and walls, properly storing ready-to-eat refrigerated Time/Temperature Control for Safety (TCS) food, thawing frozen TCS food correctly, and keeping equipment in good condition. During an initial tour of the kitchen, black soil was observed on the floors of the walk-in refrigerator and freezer. A container of egg salad with an expired use-by date was found in the reach-in refrigerator, and a black substance resembling biogrowth was noted on a wall in the dry storage area. Additionally, a 10-pound log of frozen ground beef was improperly thawed in a prep sink without running water, and a spatula with burnt edges was found hanging above the sink. The same spatula was observed again during a follow-up visit, along with three scoops with rough, uncleanable plastic handles. A broken thermometer was also found in a resident nourishment mini refrigerator. These observations were confirmed through interviews with the facility's dietitian and dietary director, who provided documentation of previous training and performance improvement plans that did not address the identified concerns during the survey. The facility's policies on sanitization and food storage were not adhered to, as evidenced by the unclean kitchen areas and improper food handling practices. The kitchen weekly cleaning schedule indicated that specific staff members were responsible for cleaning the walk-in refrigerator, freezer, and storage room, but these tasks were not adequately performed. The facility's dietitian and dietary director acknowledged the deficiencies and provided documentation of employee training and performance improvement plans, but these measures were insufficient to prevent the identified issues. The failure to maintain food safety standards has the potential to cause foodborne illness for the majority of the facility's residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to develop and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Staff members did not don appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission-based precautions for COVID-19. Specifically, staff were observed entering rooms without eye protection, and some staff donned N95 masks over surgical masks, which compromised the fit and effectiveness of the N95 masks. Additionally, staff did not doff PPE before exiting the rooms, further risking the spread of infection. Interviews with staff revealed a lack of awareness and understanding of the proper PPE protocols, and the facility's Infection Preventionist and Director of Nursing confirmed that the observed practices were not in line with the facility's policies or infection control guidelines. The facility also failed to ensure proper hand hygiene practices for residents before meals. During meal service observations, residents were not assisted with hand hygiene, which is a critical step in preventing the spread of infections. This lapse in protocol was confirmed by the Director of Nursing during an interview. Additionally, the facility did not maintain urinary catheters in a sanitary manner. Observations showed catheter tubing lying on the floor, which poses a significant risk for infection. The care plan for the resident with the urinary catheter explicitly stated that the drainage bag should be kept below the waist and off the floor, but this was not adhered to. Further deficiencies were noted in the cleaning and disinfection of medical equipment. During a medication administration observation, a registered nurse did not clean the stethoscope used for blood pressure measurement, although other equipment was disinfected. This inconsistency in following infection control protocols highlights a broader issue within the facility's infection prevention and control program. The facility's policies, last revised in January 2021, were not being effectively implemented or followed by the staff, leading to multiple instances of non-compliance and increased risk of infection spread among residents and staff.
Failure to Securely Affix Handrails in Corridors
Penalty
Summary
The facility failed to equip corridors with securely affixed handrails on two of its three units, specifically the West and South units. During a tour on the [NAME] unit, a handrail between rooms was observed to be loose and not firmly secured to the wall. Similarly, on the South unit, multiple handrails between rooms were found to be loose and not securely affixed. Staff I, an LPN on the South unit, acknowledged the issue but admitted she had not noticed the loose handrails prior to the survey. The Director of Environmental Services (DES) also confirmed the handrails were loose and stated that inspections are conducted weekly, and maintenance concerns can be documented in the electronic maintenance system. However, the Weekly Hand Rail Checks for the [NAME] unit showed no issues, indicating a discrepancy in the inspection process. The facility's policy on maintenance service, last revised in December 2009, mandates that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. This includes maintaining the building in compliance with federal, state, and local laws, and ensuring the building is free from hazards. Despite this policy, the observations during the tours and the interviews with staff revealed that the handrails were not maintained in a safe condition, leading to the identified deficiency.
Failure to Maintain Dignity and Homelike Dining Experience
Penalty
Summary
The facility failed to maintain dignity and a homelike dining experience for residents in the West dining/common area. Observations on multiple occasions revealed that staff did not remove dinnerware from trays when serving residents. Specifically, during the noon meal service, several residents were served their meals with dinnerware left on the trays, and plate covers remained on the tables while residents dined. This practice was observed with four out of five residents sitting at the dining tables. Additionally, the Director of Nursing (DON) was seen standing over a resident and cutting up food with the dinnerware still on the serving tray. Interviews with staff, including the Assistant Director of Nursing/Risk Manager (ADON/RM) and the Dietary Director, indicated a lack of awareness or adherence to the facility's policy regarding the removal of dinnerware from trays. The DON confirmed that plates should be removed from trays, but the facility's policy was not readily available. The facility's policy on dignity, revised in August 2009, emphasized treating residents with dignity and respect, which includes assisting them in maintaining and enhancing their self-esteem and self-worth. However, the observed practices did not align with this policy, leading to the deficiency.
Inaccurate Dental Status Documentation
Penalty
Summary
The facility failed to accurately reflect a resident's dental status, as observed during multiple instances. Resident #17 was noted to have several broken, chipped teeth, dental caries, and black gums around several teeth. Despite these observations, the resident's Annual Minimum Data Set (MDS) assessments did not document any dental issues, and the resident did not have a care plan addressing her dental status. The resident's weight had gradually decreased over several months, but her meal intake remained high, averaging 76 to 100% in April 2024. The resident's medical records, including social history assessments, speech therapy screens, and nutritional evaluations, consistently marked her dental status as normal, with no referrals necessary for dental issues. Progress notes from healthcare providers also documented normal dentition, with no indication of dental consults or services provided to the resident. The Director of Nursing was informed of the inaccuracies in the resident's MDSs regarding her oral/dental status.
Failure to Properly Administer IV Medication
Penalty
Summary
The facility failed to provide proper administration of intravenous (IV) medication in accordance with professional standards of practice for a resident diagnosed with Parkinson's Disease and an infection due to an internal left knee prosthesis. The resident had a physician's order for vancomycin to be administered intravenously every other day. During an observation, it was noted that the IV tubing was not labeled with the date it was hung, and a significant amount of the medication remained in the IV bag, indicating that the medication was not fully administered. Staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), were unable to explain why the IV tubing was not labeled or why the medication was not fully administered. Further interviews with the Unit Manager (UM) and the Director of Nursing (DON) confirmed that the IV tubing and medication should have been labeled with the date and that the medication should have been fully administered. The DON stated that the medication should run via an IV pump or a manual flow regulator until fully administered and that failure to do so would be considered a medication error. Photographic evidence supported these findings, and the staff acknowledged the oversight but could not provide a reason for the lapse in proper procedure.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for residents, specifically in the areas of equipment storage, obtaining physician's orders, changing oxygen tubing, and posting necessary signage. Resident #54 was observed with an oxygen concentrator and nasal cannula tubing that was not dated or stored in a plastic bag as required. Additionally, there was no physician's order for oxygen therapy for Resident #54 prior to 5/9/2024, despite the resident using oxygen on an as-needed basis. Interviews with staff confirmed that the equipment should have been labeled and stored properly, and a physician's order should have been in place before administering oxygen. Resident #126's oxygen tubing was not changed weekly as per physician's orders, with the tubing dated 4/21/24 still in use on 5/7/24. Furthermore, there were no cautionary and safety signs indicating the use of oxygen posted outside Resident #126's room. The resident's medical records and care plan indicated a need for oxygen therapy due to conditions such as COPD and recent respiratory failure. Interviews with staff and the DON confirmed that the oxygen tubing should be changed weekly and that appropriate signage should be posted. The facility's policies on oxygen administration and storage of respiratory equipment were not followed, leading to these deficiencies. The policies required a physician's order for oxygen administration, proper storage of respiratory equipment in plastic bags, and weekly changes of oxygen tubing. The lack of adherence to these policies was confirmed through staff interviews and observations, highlighting a failure to provide respiratory care in accordance with professional standards.
Incomplete Daily Nursing Staff Information
Penalty
Summary
The facility failed to post daily nursing staff information accurately, as required. On 5/9/24 at 8:13 a.m., the posted staffing information in the front lobby was observed to be incomplete. The posting, dated 5/9/24, indicated a census of 79 residents and listed the staffing for the 7 a.m. to 7 p.m. shift, including 3 Registered Nurses (RN) and 5 Licensed Practical Nurses (LPN), and for the 7 a.m. to 3 p.m. shift, including 9 Certified Nursing Assistants (CNA) and 1 Patient Care Assistant (PCA). However, it did not include the number of licensed staff scheduled for the 7 p.m. to 7 a.m. shift or the number of CNAs or PCAs scheduled for the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts. Additionally, a review of the daily staffing information dated 5/8/24 showed no CNA or PCA information for the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts.
Failure to Administer Antihypertensive Medications per Parameters
Penalty
Summary
The facility failed to provide medications appropriately for one resident out of five sampled, specifically related to antihypertensive medications. The resident, who had diagnoses including Type 2 Diabetes Mellitus with hyperglycemia, unspecified cirrhosis of the liver non-alcoholic, and essential hypertension, was administered Losartan, Diltiazem, and Spironolactone outside of the prescribed parameters. For instance, Losartan was given on two occasions despite the resident's systolic blood pressure being below the threshold. Similarly, Diltiazem was administered when the resident's blood pressure was below the set limit, and Spironolactone was inconsistently administered. The Director of Nursing confirmed that the medications were not administered according to the specified parameters, acknowledging the discrepancy during an interview.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to ensure that the medication error rate was less than 5.00%, resulting in a 21.43% medication error rate. During an observation of medication administration, a registered nurse (RN) administered medications to a resident by crushing extended-release medications, which were listed on the facility's 'DO NOT CRUSH' list. The medications included Metoprolol Succinate Extended-Release and Oxybutynin Extended-Release. Additionally, the RN dispensed a Multi-Vitamin tablet that did not contain minerals, contrary to the resident's Medication Administration Record (MAR). The Director of Nursing (DON) confirmed that these medications should not have been crushed and that the Multi-Vitamin tablet was incorrect. The resident's blood pressure and pulse were also not within the parameters specified for administering Metoprolol Succinate Extended-Release, yet the medication was still given. This incident highlights a significant deviation from the facility's medication administration policies and procedures, which require medications to be administered as prescribed and within pharmacy guidelines. In another instance, the same RN administered medications to a second resident, including Senna, Aspirin, Metformin, and Humulin R. The medications were administered significantly later than the scheduled times, with the Aspirin and Senna given approximately one and a half hours late and the Metformin administered two and a half hours late. The RN also crushed the medications and mixed them with applesauce before administration, despite the resident being able to take the medications whole. The DON was informed of the lateness of the medication administration. The facility's policies on administering oral medications and ensuring timely administration were not followed, leading to these medication errors.
Failure to Ensure Resident is Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident receiving intravenous medication was free from significant medication errors. Resident #54, who was admitted with diagnoses of Parkinson's Disease and an infection due to an internal left knee prosthesis, had a physician's order for vancomycin to be administered intravenously. During an observation, it was noted that the IV tubing was not labeled with the date it was hung, and a significant amount of the medication remained in the IV bag. Staff H, a Registered Nurse and Unit Manager, was unable to explain why the medication was not fully administered or why the IV tubing was not labeled. Photographic evidence was obtained to document the observation. Further interviews with Staff G, another Registered Nurse and Unit Manager, and the Director of Nursing (DON) confirmed that the medication should have been fully administered and the IV tubing should have been labeled. The facility's policy on medication errors defines significant errors as wrong dose or omission, and the failure to fully administer the vancomycin to Resident #54 was acknowledged as a medication error. The progress notes did not document the amount of medication left in the bag, further indicating a lapse in proper medication administration procedures.
Failure to Assist Resident in Obtaining Routine Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care, as evidenced by the condition of the resident's teeth and gums. The resident, who was cognitively intact according to the most recent Annual Minimum Data Set (MDS), was observed with several broken, chipped teeth, and dental caries. Despite these obvious dental issues, the resident's MDS assessments did not reflect any dental problems, and there was no care plan addressing the resident's dental status. The resident had a small gradual weight loss over several months, but her meal intake remained high, averaging 76 to 100% in April 2024. The resident's medical record did not document any referrals for dental consults or services, despite the facility having a dental service that visited monthly. Interviews with the Social Services Director and the Director of Nursing revealed that the facility's protocol for referring residents to dental services involved staff notifying the social worker if a dental problem was observed. However, in this case, the resident's dental issues were not identified or referred for a dental consult. The Social Services Director confirmed that the resident had not been referred to the dentist, and the Director of Nursing could not specify how often the contract dental service visited the facility. The lack of documentation and referral for dental care led to the deficiency identified in the report.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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