Village Place Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Charlotte, Florida.
- Location
- 2370 Harbor Blvd, Port Charlotte, Florida 33952
- CMS Provider Number
- 106072
- Inspections on file
- 21
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Village Place Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and high fall risk experienced a fall that was not documented or assessed by the nurse on duty, and neither the DON nor the physician was notified. The resident later reported pain, but this was not communicated to nursing, and an ordered X-ray was never completed despite being marked as done. The resident's condition declined, and hospital imaging revealed multiple fractures. Staff interviews confirmed failures in communication, documentation, and follow-up, resulting in neglect and Immediate Jeopardy.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall that was not properly documented, reported, or followed up by staff. The facility failed to notify the physician and DON, did not conduct a post-fall assessment or investigation, and did not implement new interventions. The resident's pain and injuries were not recognized until a later hospital transfer, where serious fractures were identified. Staff interviews revealed a lack of awareness and protocol breakdowns, and the facility lacked a system to track fall risks and incidents.
A resident with severe cognitive impairment experienced a fall that was not properly documented or reported by nursing staff. The physician and therapy department were not notified, and required diagnostic X-rays were not completed or tracked. The resident later required hospital transfer, where multiple injuries were discovered. Facility staff interviews revealed a lack of awareness, missing documentation, and no system to identify residents at risk for falls, with inconsistent incident reporting and no nursing supervisor on evening or night shifts.
A resident with severe cognitive impairment and high fall risk experienced a fall that was not documented or reported by nursing staff, with no post-fall assessment or physician notification. The resident's pain complaints were not communicated, and a physician-ordered X-ray was not completed or tracked. Facility administration and nursing leadership were unaware of the incident due to breakdowns in documentation, communication, and oversight, resulting in the resident's emergency hospital transfer with serious injuries and a finding of Immediate Jeopardy.
The facility failed to prevent the misappropriation of controlled medications for four residents when multiple tablets of narcotics and other controlled substances were found missing from medication carts. A nurse left the facility several times during her shift with the medication cart keys, did not follow sign-out procedures, and refused to count medications with the oncoming nurse. The discrepancies were discovered after the nurse abruptly left, but the incident was not reported to the State Agency or fully investigated internally, despite causing distress to affected residents.
The facility failed to promptly review and resolve grievances filed by residents, as evidenced by multiple cases where residents reported unresolved issues such as missing personal items, inadequate supplies, and lack of communication regarding hospital transfers. Despite filing grievances, residents and their families did not receive timely responses or resolutions, highlighting deficiencies in the facility's grievance handling process.
The facility failed to provide scheduled showers and personal hygiene care for several residents, as required by their care plans. Multiple residents reported not receiving showers, and documentation confirmed these omissions. Additionally, some residents were observed with untrimmed nails and without necessary palm protectors, indicating a lack of personal hygiene care.
The facility failed to properly disinfect a multi-resident use glucometer and adhere to standard precautions during medication administration. A nurse did not allow the glucometer to remain wet for the required time after disinfection, and an LPN handled pills with ungloved hands for two residents, contrary to the facility's hand hygiene policy.
A facility failed to provide ordered treatments for three residents, including Geri sleeves and compression stockings for one resident, padded boots for another, and a dermatology consultation for a third resident with a worsening rash. The unavailability of supplies and lack of communication with the physician contributed to these deficiencies.
A resident with severe cognitive impairment lost multiple personal items during their stay, including clothing, a cell phone, dentures, and a C-Pap machine. The facility did not follow its policy on investigating theft or misappropriation, as the inventory form was incomplete upon discharge. The Interim DON confirmed the loss of the cell phone but did not provide a thorough investigation or follow-up with the family, leading to a deficiency in promoting the resident's rights.
A resident with severe cognitive impairment experienced an allergic reaction to a new anxiety medication, resulting in swelling, hives, and thrush. The LTC facility failed to notify the resident's representative about the adverse reaction and changes in the resident's condition, as required by their policy. The Interim DON confirmed the lack of documentation and notification.
The facility failed to involve two residents and their representatives in care plan meetings after completing the comprehensive admission MDS assessment. Despite policy requirements, there was no documentation of care plan meetings being held with the residents or their representatives. The MDS Coordinator and DON confirmed the lack of documentation, indicating non-compliance with the facility's policy.
The facility failed to prevent the development or worsening of pressure ulcers for two residents. One resident, with hemiplegia and an unstageable pressure ulcer, was not repositioned adequately, and the air mattress settings were incorrect. Another resident, with diabetes and a pressure ulcer on the heel, did not receive the ordered padded boots due to supply delays and lack of communication with the physician. These deficiencies highlight lapses in pressure ulcer prevention protocols and timely provision of necessary equipment.
The facility failed to provide necessary care to prevent a decline in range of motion for three residents with limited mobility. One resident was observed without a prescribed hand splint, another without a palm protector, and a third without a rolled washcloth or palm protector, despite occupational therapy recommendations. Care plans lacked necessary interventions, and staff were unaware of or did not follow through with the required care.
Failure to Document, Assess, and Report Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and high fall risk was found on the floor in his room. The licensed nurse on duty failed to document the fall, did not assess the resident for injuries such as fractures, and did not notify the DON or physician. The clinical record lacked evidence of a fall investigation or implementation of interventions to prevent further incidents. The resident's care plan required substantial to maximal assistance with activities of daily living, including transfers, and the resident was not ambulatory due to medical and safety concerns. Following the fall, the physical therapy assistant documented that the resident verbalized right knee and groin/hip pain but did not communicate this change in condition to the nursing department. A unit manager later wrote an order for an X-ray of the right hip, but the X-ray was never performed, and a nurse incorrectly marked it as completed. There was no documentation of the X-ray results, and the resident's pain was not properly evaluated or reported. The resident continued to decline, requiring maximum assistance for mobility, and was eventually transferred to the hospital for altered mental status and abnormal labs. Hospital imaging revealed a comminuted intertrochanteric right femoral fracture and an acute lumbar vertebra fracture. Interviews with facility staff revealed a lack of awareness and communication regarding the fall, the X-ray order, and the resident's change in condition. The DON and unit manager were not notified of the fall, and there was no formal system to track diagnostic orders or ensure follow-up. The physical therapy and nursing documentation systems were not integrated, leading to missed communication about the resident's pain. The facility's policies required assessment, documentation, and reporting of falls and changes in condition, but these processes were not followed, resulting in neglect and a determination of Immediate Jeopardy.
Failure to Document and Respond to Resident Fall Resulting in Serious Injury
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of falls and severe cognitive impairment from avoidable falls and related serious injuries. The resident was admitted with vascular dementia, muscle weakness, and a need for assistance with personal care. Despite being identified as high risk for falls, the facility did not consistently document, report, or follow up on the resident's fall that occurred in the resident's room. There was no evaluation or documentation of the fall in the clinical record, and the physician and DON were not notified for a post-fall assessment. No fall investigation or root cause analysis was conducted, and no corrective actions were implemented to prevent further incidents. The clinical record lacked documentation of the fall, physician notification, post-fall assessment, and individualized interventions to prevent further falls. Although a neurological evaluation was completed, it did not lead to appropriate follow-up, and an X-ray order was entered but not completed or tracked. Therapy staff noted the resident's pain and attempted to notify the physician and Director of Rehab, but there was no documentation that nursing staff were informed. The resident's pain was not adequately documented or managed, and the resident was later transferred to the hospital for altered mental status, where a right femoral fracture and lumbar vertebrae fracture were identified. Interviews with facility staff revealed a lack of awareness and breakdowns in protocol regarding the fall, with the DON and Unit Manager unaware of the incident and the X-ray order. The facility did not have a system in place to identify residents at risk for falls or to ensure that incidents were reported and followed up appropriately. The incident was not included in the facility's fall report, and the attending physician was not notified of the fall or the resident's pain. The failure to document and respond to the fall resulted in a delay in identifying serious injuries.
Failure to Ensure Nursing Staff Competency and Oversight After Resident Fall
Penalty
Summary
Nursing staff failed to ensure appropriate assessment, documentation, and follow-up after a resident experienced a fall. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was found on the floor in their room. The nursing staff did not document the fall, notify the physician, or report the incident to the next shift or therapy department, as required by facility policy. There was also no documentation of individualized interventions to prevent further falls or of a thorough evaluation of the incident. Further review revealed that a physician's order for diagnostic X-rays was entered, but the X-rays were never completed, and the results were not documented. Nursing staff incorrectly indicated on the treatment administration record that the X-rays had been done. There was no system in place to track diagnostic orders to ensure completion and communication of results. Additionally, the therapy department was not notified of the fall, and there was a lack of documentation regarding the resident's subsequent pain and decline in mobility. The resident was later transferred to the hospital, where a right femoral fracture and lumbar vertebrae fracture were identified, along with new onset hematuria and a Foley catheter placement without a documented physician order. Interviews with facility staff, including the DON and medical director, confirmed a lack of awareness of the fall, missing documentation, and absence of a system to identify residents at risk for falls. The facility did not have a nursing supervisor for evening or night shifts, and incident reporting was inconsistent. The resident's fall was not included in the facility's incident report log, and staff failed to follow established protocols for post-fall assessment, documentation, and communication.
Failure to Prevent Neglect and Maintain Oversight Resulting in Immediate Jeopardy
Penalty
Summary
Facility administration failed to utilize its resources effectively and maintain oversight to prevent the neglect of a resident with severe cognitive impairment who was dependent on staff for activities of daily living. The resident was admitted with a known fall risk, as documented in the admission and fall risk evaluations, and sustained a fall that was not documented in the clinical record. There was no post-fall assessment, no physician notification, and no individualized interventions implemented to prevent further falls. The administration was unaware of the incident, and the nursing staff did not follow established protocols for incident documentation and follow-up. Further review revealed that a physician's order for a right hip and knee X-ray was entered, but the X-ray was never completed, and the results were not documented. Nursing staff placed a check mark on the treatment administration record indicating the X-ray was done, but interviews confirmed it was not. There was no formal system in place to track diagnostic orders or ensure completion and communication of results. Additionally, the resident's complaints of pain were not communicated to the nursing department, and there was no documentation of follow-up or notification to the physician regarding these complaints. Interviews with staff, including the DON, unit manager, and LPN, confirmed a lack of awareness and breakdowns in communication and documentation processes. The DON acknowledged gaps in the incident reporting and order review systems, and there was no supervisor coverage during certain shifts. The administrator was also unaware of the incident and could not find pertinent information in the clinical record. These failures resulted in the resident being emergently transferred to the hospital, where significant injuries were identified, and led to a determination of Immediate Jeopardy due to the likelihood of serious harm or injury.
Failure to Prevent and Report Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to implement effective processes to prevent the misappropriation of residents' controlled medications for four residents. According to facility policy, nursing staff are required to count controlled medications at the end of each shift, with both the oncoming and outgoing nurses present, and to document and report any discrepancies to the Director of Nursing Services. However, review of medication logs and pharmacy packages revealed that multiple tablets of controlled substances, including Hydrocodone/Acetaminophen, Oxycodone/Acetaminophen, Oxycodone, and Chlordiazepoxide, were unaccounted for across four residents. Photographic evidence was obtained to document the discrepancies between the inventory logs and the actual medication counts. Interviews with the DON and Administrator revealed that the missing medications were discovered after a nurse, who was assigned to the medication cart, left the facility several times during her shift with the medication cart keys and did not follow proper sign-out procedures. The nurse also refused to count the controlled medications with the oncoming nurse and left the facility abruptly, after which the discrepancies were discovered. The DON reported the incident to the local police and the Board of Nursing but did not conduct an internal investigation or report the misappropriation to the State Agency, based on advice from the Regional Nurse Consultant, who believed that replacing the medications for the residents was sufficient. Residents affected by the missing medications were informed by the facility that some of their medications had been taken, which caused distress and concern for their safety. One resident reported feeling unsafe and not receiving follow-up information about the outcome of the incident. The facility's failure to follow its own policies and regulatory requirements resulted in the misappropriation of resident property and a lack of appropriate reporting and investigation.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances filed by residents were promptly reviewed and investigated, as evidenced by the experiences of five residents. Resident #41, who had intact cognition, reported missing clothes from the facility laundry and filed a grievance on 5/6/24. Despite the administrator's acknowledgment of the grievance, there was no documentation of efforts to resolve the issue or keep the resident informed. The resident was promised reimbursement for the missing clothes, which had not been fulfilled by the time of the survey. Resident #36, also with intact cognition, expressed dissatisfaction with the facility's failure to provide Pull-Ups instead of incontinent briefs, which she found embarrassing. She filed a grievance on 3/28/24, but there was no documentation of any action taken to address her request. Similarly, Resident #37, who had been requesting XXL Pull-Ups since March 2024, found no resolution to her grievance, as the facility's supply room lacked the necessary size, and her grievance was not documented or addressed. Resident #272's spouse filed a grievance after not being informed of her husband's transfer to the hospital. The grievance was not properly investigated, and there was no follow-up communication with the spouse. Additionally, Resident #422's family reported missing personal items, including a cell phone, dentures, and parts of a C-Pap machine, upon discharge. The facility failed to document the inventory of personal effects at discharge, and the social worker did not return calls regarding the missing items, indicating a lack of proper grievance handling and resolution.
Failure to Provide Scheduled Showers and Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for seven residents who were unable to perform activities of daily living independently. The facility's policy required that residents receive assistance with personal hygiene, including showers, as per their care plans. However, multiple residents reported not receiving scheduled showers, and documentation confirmed that these showers were not provided as scheduled. For instance, Resident #6, who required moderate assistance, did not receive any scheduled showers between May 21 and June 18, 2024, despite being scheduled for showers twice a week. Resident #32, who was dependent on staff for bathing, also reported not receiving scheduled showers, and her family filed a grievance regarding this issue. Documentation showed that she only received three showers between May 20 and June 17, 2024. Similarly, Resident #47, who required moderate assistance, reported receiving only one shower instead of the scheduled two per week, and CNA documentation confirmed this lack of care. Resident #53, who required maximum assistance, did not receive any of her scheduled showers between May 22 and June 15, 2024. Additionally, Resident #21, who was incontinent and required showers twice a week, received only two showers out of a possible 13 since her admission. There was no documentation of her refusing showers or any interventions taken to encourage her to take them. Furthermore, Resident #15 and Resident #40 were observed with untrimmed nails and without necessary palm protectors, indicating a lack of personal hygiene care. The Director of Nursing confirmed these deficiencies, acknowledging that the facility staff did not follow the required procedures for documenting and providing personal hygiene care.
Infection Control Deficiencies in Glucometer Disinfection and Medication Administration
Penalty
Summary
The facility failed to ensure proper disinfection of a multi-resident use glucometer and adherence to standard precautions during medication administration. Observations revealed that a registered nurse did not allow the glucometer to remain visibly wet for the required time after wiping it with a disinfectant, as per the manufacturer's guidelines and facility policy. The nurse admitted to not knowing how long the device remained wet, and the unit manager confirmed the need for the glucometer to stay wet for one to two minutes. Additionally, during medication administration, a licensed practical nurse was observed handling pills with ungloved hands for two residents. The nurse confirmed this was her usual practice, which contradicts the facility's hand hygiene policy that emphasizes hand hygiene as a primary means to prevent infection spread. These actions indicate a failure to follow established infection control protocols, potentially compromising resident safety.
Failure to Provide Ordered Treatments and Consultations
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for three residents. Resident #6, who had diagnoses including hemiplegia and hemiparesis, was not provided with Geri sleeves and compression stockings as ordered by the physician. Despite the physician's orders, the Geri sleeves were not applied due to unavailability, and the compression stockings were also not applied for the same reason. The nursing staff did not notify the physician about the unavailability of these items, and the resident continued to experience bruising and swelling. Resident #47, who had a pressure ulcer on the right heel, was not provided with padded boots as ordered by the physician to prevent further pressure wounds. The resident's family member reported that the boots were never seen in the room, and the nursing staff confirmed that the boots were not available and had been ordered. The physician was not informed about the unavailability of the padded boots, and the resident remained at risk for pressure wounds. Resident #423 was admitted with a full-body rash that worsened over time. Despite the resident's spouse requesting a dermatology consultation multiple times, no such consultation was conducted. The rash was documented inconsistently in the resident's records, and there was no care plan addressing the rash. The medical director later suggested that the rash might be an allergic reaction, but no definitive diagnosis was made, and the resident continued to suffer from the rash.
Failure to Safeguard Resident's Personal Possessions
Penalty
Summary
The facility failed to uphold the rights of a resident to retain and use personal possessions, as evidenced by the loss of multiple personal items during the resident's stay. The resident, who had severe cognitive impairment due to dementia and other medical conditions, was admitted with several personal belongings, including clothing, a cell phone, dentures, and a C-Pap machine. Upon discharge, the resident's family discovered that most of these items were missing, with only a dress and one bra remaining. The family reported the missing items to the facility staff, but the facility did not adequately address the issue or communicate effectively with the family. The facility's policy on investigating incidents of theft and misappropriation of resident property was not followed, as evidenced by the lack of a completed inventory form upon discharge. The Interim Director of Nursing confirmed the loss of the cell phone and speculated that it might have been lost during a hospital visit. However, there was no evidence of a thorough investigation or follow-up with the family regarding the missing items. The facility's failure to safeguard the resident's personal possessions and communicate with the family constitutes a deficiency in promoting the resident's rights to retain and use personal possessions.
Failure to Notify Resident's Representative of Allergic Reaction
Penalty
Summary
The facility failed to notify the resident's representative of changes in condition for a resident who experienced an allergic reaction to a medication. The facility's policy requires prompt notification of the resident, their attending physician, and representative in the event of changes in the resident's medical or mental condition. However, in this case, the resident's representative was not informed about the allergic reaction, the change in medication, or the resident's worsening condition, which included swelling of the face and eyes, hives, and thrush in the mouth. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and diabetes, was administered a new medication for anxiety, Buspirone, which led to an allergic reaction. Despite the adverse reaction and the resident's deteriorating condition, the facility did not notify the resident's family. The resident's daughter only became aware of the situation when she visited and found her mother in poor physical condition. The Interim Director of Nursing acknowledged the lack of documentation and notification to the resident's representative regarding the allergic reaction and subsequent medical issues.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to provide evidence of conducting care plan conferences with residents and/or their representatives after completing the comprehensive admission Minimum Data Set (MDS) assessment. This deficiency was identified for two residents, Resident #13 and Resident #54, out of four residents reviewed. The facility's policy requires the development of an individualized comprehensive care plan within seven days of the MDS assessment, with the involvement of the resident and their family or representative. However, the facility did not adhere to this policy, as there was no documentation of care plan meetings being held with the residents or their representatives. Resident #21 and her granddaughter expressed concerns about not being included in a care plan meeting since her admission. Despite requests, there was no documentation indicating that Resident #21 or her family attended the Interdisciplinary Team (IDT) meeting. The MDS assessment for Resident #21 was completed, but the facility failed to document the involvement of the resident or her family in the care planning process. Similarly, Resident #13 reported not having met with the IDT to discuss his care plan since his admission. The facility did not document any invitation or encouragement for Resident #13 or his representative to participate in the care planning process. The MDS Coordinator and the Director of Nursing (DON) confirmed the lack of documentation regarding the involvement of residents and their families in the care plan meetings. The facility's policy mandates that the nursing department is responsible for inviting residents and their families to these meetings. However, the review of medical records for Residents #21 and #13 revealed no evidence of such invitations or encouragement, indicating a failure to comply with the facility's Care Planning - Interdisciplinary Team policy.
Failure to Prevent Pressure Ulcers in Two Residents
Penalty
Summary
The facility failed to prevent the development or worsening of pressure ulcers for two residents, identified as Resident #40 and Resident #47. Resident #40, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, had an unstageable pressure ulcer upon admission. Despite the care plan and recommendations for repositioning and pressure reduction, observations revealed that Resident #40 was often left on her back without proper repositioning or offloading of pressure from her heels. The air mattress settings were not adjusted according to her weight, and staff interviews confirmed a lack of adherence to repositioning protocols, contributing to the worsening of her condition. Resident #47, admitted with type 2 diabetes, peripheral vascular disease, and a pressure ulcer on the right heel, was also at risk for pressure wounds. The resident required substantial assistance with bed mobility and had a physician's order for padded boots to offload pressure from the heels. However, observations and interviews revealed that the padded boots were not provided due to delays in ordering and a lack of communication with the physician. The facility did not have a policy for following physician orders, and the necessary supplies were not available in a timely manner, leading to inadequate pressure ulcer prevention for Resident #47. The report highlights significant lapses in the facility's adherence to pressure ulcer prevention protocols and the timely provision of necessary equipment. Staff interviews and observations indicated a lack of proper repositioning and pressure offloading for both residents, contributing to the development and worsening of pressure ulcers. The facility's failure to follow through with physician orders and ensure the availability of essential supplies further exacerbated the situation, resulting in deficiencies in the care provided to these residents.
Failure to Prevent Decline in Range of Motion for Residents
Penalty
Summary
The facility failed to provide adequate care and services to prevent a decline in range of motion for three residents with limited mobility. Resident #14, who had hemiplegia and hemiparesis following a stroke, was observed multiple times without a prescribed hand splint, despite recommendations from occupational therapy to use it to maintain proper alignment and protect skin integrity. The care plan for Resident #14 did not include any interventions for range of motion or hand splint care, and the Director of Nursing (DON) acknowledged that nurses should inquire if care is not being provided. Resident #15, also affected by hemiplegia and hemiparesis, was observed without a palm protector on several occasions, despite occupational therapy recommendations for its use to prevent further decline. The resident's care plan lacked interventions to prevent a decrease in range of motion or worsening contractures. Interviews revealed that staff were unaware of the need for a palm protector, and the DON confirmed the absence of an order for its use, despite the occupational therapy notes indicating its necessity. Resident #40, with similar diagnoses, was observed without a rolled washcloth or palm protector, which were recommended by occupational therapy to maintain finger and elbow extension. The care plan only listed therapy interventions, with no nursing or CNA interventions. Staff interviews confirmed the lack of consistent application of the recommended devices, and the DON and Director of Rehabilitation acknowledged the need for written orders to ensure staff compliance with therapy recommendations.
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.
