Vivo Healthcare West Orange
Inspection history, citations, penalties and survey trends for this long-term care facility in Ocoee, Florida.
- Location
- 1556 Maguire Rd, Ocoee, Florida 34761
- CMS Provider Number
- 105706
- Inspections on file
- 29
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at Vivo Healthcare West Orange during CMS and state inspections, most recent first.
A resident with multiple comorbidities and moderate cognitive impairment had a physician DNR order and hospital documentation indicating DNR status, and staff confirmed his DNR wishes with his health care proxy at admission. However, the Florida DNRO form in the record was signed only by a physician and lacked the resident/proxy signature, and staff did not document verification calls or complete the form. When the resident was later found unresponsive, an RN confirmed DNR status in the EMR, but EMS deemed the DNRO form invalid due to missing signatures and initiated CPR until the resident was pronounced deceased, resulting in the resident’s DNR wishes not being honored.
A resident with multiple comorbidities and documented DNR status in the EMR was admitted with a Florida DNRO form that was signed only by a hospital physician and lacked the resident’s or proxy’s signature. Facility staff, including the SSD and nursing leadership, recognized prior to the event that the DNRO was incomplete but did not obtain a valid, signed form. When the resident was later found unresponsive, an RN verified the DNR status in the EMR but still called EMS, then provided EMS with a printed copy of the incomplete DNRO on goldenrod paper. EMS determined the DNRO was invalid and initiated CPR per protocol, ultimately pronouncing the resident deceased after unsuccessful resuscitation, resulting in CPR being performed contrary to the resident’s expressed DNR wishes.
Three residents were found to have inaccurate MDS assessments, with two documented as receiving dialysis they never had and one listed as using a mechanical ventilator when only tracheostomy care was provided. The MDS Coordinator confirmed the errors after reviewing medical records and care plans, but could not explain why the assessments were coded incorrectly.
A resident with a history of falls was found to have a cracked and split bedside fall mat that exposed the interior layer, which could not be properly cleaned. Despite staff acknowledging the mat's poor condition and confirming that it had not been replaced or reported for replacement, the damaged mat remained in use.
The facility failed to re-admit two residents after hospitalization, citing behavioral and insurance issues. One resident remained in the hospital for over two months, while the other stayed for two weeks until alternate SNF placement was found. The facility's actions were inconsistent with its policy and federal regulations, causing significant disruption to the residents' care and well-being.
The facility failed to ensure effective communication and oversight of changes to the plan of care, resulting in the administration of an excessive dose of insulin to a resident. This led to the resident becoming unresponsive due to critically low blood glucose levels and requiring transfer to a higher level of care.
The facility failed to maintain a clean and homelike environment for several residents. One resident's room was found in an unacceptable condition upon admission, and multiple residents reported a severe roach problem. The facility's pest sighting log confirmed ongoing issues, and the facility's policy on Resident Rights was not upheld.
A resident with severe pain due to a recent surgical amputation did not receive timely and effective pain management upon admission. Despite having a care plan, the resident received pain medication only once in 16 hours, and there were discrepancies in the documentation and administration of the medication. The facility's policies for pain management and pharmacy services were not followed, leading to unmanaged pain and discomfort for the resident.
A resident with type 2 diabetes was hospitalized after being found unresponsive with a critically low blood glucose level. Despite the hospitalization, the medical record inaccurately documented that the resident's blood glucose levels were checked and medications were administered two days later. The DON confirmed the documentation was inaccurate and against facility policy.
Failure to Ensure Valid DNRO Resulted in Unwanted CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) wishes by not ensuring those wishes were completely and accurately documented to promote continuity of care between providers. The resident, an older male admitted with stroke, type 2 diabetes, essential hypertension, HIV, unspecified dementia, heart failure, coronary artery disease, renal insufficiency, and non-Alzheimer’s dementia, had a physician order for DNR in the electronic medical record (EMR). His Minimum Data Set assessment showed moderate cognitive impairment, and his care plan included impaired cognitive process with an intervention to communicate with the resident and family regarding his needs. The hospital transfer documentation (3008 form) indicated the resident was DNR, and a Florida Do Not Resuscitate Order (DNRO) form signed by the hospital physician was present in the EMR. On the night of admission, the LPN Supervisor reported that the resident was confused, so she and another nurse contacted the resident’s daughter by phone for consent to treat and to confirm his DNR status. They confirmed with the daughter that the resident’s wish was to be DNR and signed the facility’s Advance Directives Discussion Document, but they did not sign off on the Florida DNRO form. The Social Services Director (SSD) later reviewed the admission packet and noted that the Florida DNRO form was signed only by a physician and lacked any other signature. The SSD stated that she, the former DON, and the former ADON called the resident’s daughter to verify his wish not to have CPR, and confirmed that the two nurses on the call were RNs. However, the SSD could not explain why the nurses did not document this conversation, did not sign the Florida DNRO form until the resident or proxy could sign, and did not obtain the necessary signature by another means. On the morning of the resident’s death, the assigned RN reported that a CNA notified her that the resident was unresponsive at approximately 5:45 AM. The RN assessed the resident, found no blood pressure, pulse, or respirations, and confirmed in the EMR that the resident’s code status was DNR. She then called EMS and, upon their arrival, provided them with a printed copy of the Florida DNRO form, which she located on goldenrod-colored paper in the front office. EMS personnel observed that the form contained only the physician’s signature and lacked the resident’s or authorized representative’s signature, and informed the RN that the form was invalid. EMS then initiated CPR and continued until they discontinued efforts and pronounced the resident deceased. The resident’s daughter later confirmed she was his health care proxy, stated she had informed facility staff at admission that he was DNR, and was later told by facility staff that EMS performed CPR because the Florida DNRO form was not signed. The facility’s own policies required complete, accurate, and timely documentation of residents’ treatment choices and advance directives, but the necessary signatures and documentation for a valid Florida DNRO were not obtained or made available, leading to the failure to honor the resident’s DNR wishes.
Removal Plan
- Notify the attending physician, Medical Director, Administrator, interim DON and resident representative of the incident and initiate an investigation.
- Conduct an immediate 100% audit of all current residents' code status and care plan; verify the presence of a valid Florida DNRO form for each applicable resident in the EMR; confirm the form contains the physician and resident/proxy signatures, signature dates, and legal proxy authority; and contact attending physicians and legally authorized representatives to complete any missing or incomplete Florida DNRO form documentation.
- Print the Florida DNRO form for each applicable resident and place it in Emergency Response Binders.
- Place Emergency Response Binders on each unit, in the rehabilitation (therapy) room, and in social services.
- Initiate advanced directives audits weekly for three months to ensure the Florida DNRO form is complete and valid.
- Implement a revised admission/readmission process that includes Resident Rights and Advance Directive education upon admission, completion of an Advance Directives Discussion Document, and validation of advance directives by Social Services/designee.
- Provide education to licensed nurses, the Social Services Director, and the Admissions Coordinator on the location of goldenrod (yellow) paper for printing Florida DNRO forms.
- Provide education to licensed nurses, the Admissions Coordinator, and the SSD on documentation in the medical record to ensure each resident's medical record contains complete, accurate, and timely documentation.
- Educate the SSD on ensuring accuracy of advance directives and the Florida DNRO form.
- Implement a Florida DNRO form admission and readmission checklist to ensure verification of required signatures, confirmation of proxy authority, proper form completion, and physical availability of the Florida DNRO form.
- Hold an Ad Hoc QAPI committee meeting.
- Complete a 100% chart audit of advanced directives including code status, DNR orders, and Florida DNRO forms.
- Educate all licensed nurses on Resident Rights related to Advanced Directives, verification of advance directives, DNR orders, Florida DNRO forms and requirements, and complete and accurate documentation in the EMR.
- Require completion of a post-test following education to ensure understanding.
- Continue education for new employees.
- Hold Ad Hoc and monthly QAPI meetings with the Administrator, Director of Nursing, Medical Director, and administrative staff.
- Review and revise education, audits, and post-tests as indicated.
- Conduct staff interviews representing all shifts to assess knowledge of advanced directives, verification of code status, completion of the Florida DNRO form, and location of Emergency Response Binders.
Invalid DNRO Led to CPR Against Resident’s Stated DNR Wishes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s Do Not Resuscitate (DNR) wishes were honored due to an invalid Florida Do Not Resuscitate Order (DNRO) form being provided to Emergency Medical Services (EMS). The resident, an elderly male with a history of stroke, type 2 diabetes, heart failure, HIV, coronary artery disease, renal insufficiency, and non-Alzheimer’s dementia, was admitted with a documented DNR order in the electronic medical record (EMR). A hospital transfer form indicated he was alert but disoriented, required a surrogate for decision making, and was a DNR. The EMR contained a Florida DNRO form dated and signed only by the hospital physician, with no signatures from the resident or an authorized representative, and no power of attorney, health care surrogate, or proxy documents were scanned into the EMR. On the morning of the incident, a CNA found the resident unresponsive at approximately 5:45 AM and notified the assigned RN. The RN assessed the resident, was unable to obtain a blood pressure, pulse, or respirations, and left the room to verify the code status in the EMR, which confirmed the resident was a DNR. Despite this, the RN called EMS and documented that she could not obtain vital signs. She later stated she thought she saw the resident take small breaths and called EMS based on a prior company policy, but could not explain the discrepancy between her observation and her documentation that respirations were absent. When EMS arrived, the RN showed them the DNR order in the EMR, and EMS requested a physical copy of the Florida DNRO form. The RN was unable to locate a paper DNRO form and instead printed the scanned hospital DNRO onto goldenrod paper. EMS determined the form was invalid because it lacked the signature of the resident or his authorized representative and therefore initiated CPR. EMS performed three rounds of CPR before discontinuing efforts and pronouncing the resident deceased at 6:40 AM. Interviews with the resident’s daughter confirmed she was his health care proxy, that she had informed facility staff of his wish to be a DNR, and that she was later told EMS performed CPR because the Florida DNRO form had not been signed. The Social Services Director and facility leadership acknowledged that staff had recognized the hospital DNRO form was incomplete prior to the event but failed to ensure a valid, signed Florida DNRO form was obtained and available, resulting in EMS performing CPR contrary to the resident’s documented DNR status. The facility’s policies for CPR and documentation required adherence to residents’ advance directives and accurate, complete documentation in the medical record. Staff interviews and the facility’s internal investigation confirmed that although the DNR order was present in the EMR and the need for a surrogate and DNR status had been identified, the Florida DNRO form remained incomplete and unsigned by the resident or his proxy at the time of the emergency. During the emergency response, the absence of a valid DNRO form led EMS to determine that CPR must be initiated. This sequence of actions and inactions—failure to complete and validate the DNRO form, lack of proper documentation of the proxy’s authorization on the DNRO, and reliance on an invalid hospital DNRO—resulted in the resident receiving CPR against his stated wishes.
Removal Plan
- Initiated an internal investigation including resident record review and staff interviews; notified the Department of Children and Families, the Florida Agency for Health Care Administration, and local law enforcement; validated notification of the attending physician/medical director and the resident’s responsible party regarding the event.
- Conducted a 100% audit of all current residents’ code status and care plans; verified the presence of a valid Florida DNRO form for each applicable resident in the EMR.
- Conducted code blue drills across all shifts.
- Implemented Emergency Response Binders containing the Florida DNRO form for applicable residents, a facility Florida DNRO verification checklist, and a code status reference guide for staff; placed binders at each nurses’ station, the rehabilitation department, and the social services office.
- Provided education to licensed nurses, the Social Services Director, and the Admissions Coordinator on the location of goldenrod (yellow) paper for printing Florida DNRO forms.
- Educated staff that CPR must be initiated by EMS unless a valid Florida DNRO form is physically available.
- Established designated locations for goldenrod (yellow) paper for Florida DNRO forms to prevent delays.
- Held an Ad Hoc QAPI committee meeting to review education and audits.
- Completed a 100% chart audit of advance directives including code status, DNR orders, and Florida DNRO forms.
- Educated all licensed nurses on Resident Rights regarding Advance Directives; verification of code status and advance directives; DNR orders; Florida DNRO forms and requirements; CPR policy and EMS response requirements; communication of code status; location of goldenrod (yellow) paper for printing Florida DNRO forms; and complete and accurate documentation in the EMR; administered a post-test to ensure understanding.
- Trained all licensed nurses and had them complete post-tests; continued education to include new employees.
- Conducted Code Blue Drills with licensed nurses; scheduled remaining staff to complete a code blue drill upon return from leave.
- Held Ad Hoc QAPI meetings and a Monthly QAPI meeting with Administrator, Director of Nursing, Medical Director, and administrative staff to review and revise education, audits, code blue drills, and post-tests as indicated.
- Conducted staff interviews across all shifts to validate knowledge of advance directives, code status verification, Florida DNRO form completion, and location of Emergency Response Binders; validated education, audits, and code blue drill participation through interviews and review of attendance sheets and post-tests.
Inaccurate MDS Assessments for Special Treatments and Procedures
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, resulting in incorrect documentation of special treatments, procedures, and programs. For one resident with epilepsy and tracheostomy status, the MDS assessment inaccurately indicated that she received dialysis, which she confirmed she had never received. Another resident with a history of a nontraumatic brain bleed and tracheostomy was documented as using an invasive mechanical ventilator, but direct observation and staff verification confirmed that only tracheostomy care was provided, with no ventilator in use. A third resident with bladder inflammation was also incorrectly documented as receiving dialysis, which he denied ever having received. The MDS Coordinator reviewed the medical records and care plans for all three residents and verified that the MDS assessments were coded incorrectly. The Coordinator was unable to explain the reason for the inaccuracies, noting that another MDS staff member, who was responsible for the assessments, was not available to provide clarification. The facility's policy requires that all assessments accurately reflect the resident's status at the time of assessment and that each staff member certifies the accuracy of their portion of the assessment.
Failure to Replace Damaged Bedside Fall Mat
Penalty
Summary
The facility failed to maintain a sanitary environment by not replacing a cracked and split bedside fall mat for a resident with a history of falls, abnormal posture, and lack of coordination. The resident's care plan identified a risk for falls and included the use of fall mats as an intervention. During multiple observations, the fall mat at the resident's bedside was found to be cracked and split along its entire length, exposing the interior layer of the mat. Interviews with facility staff confirmed that the mat was in disrepair and could not be properly cleaned. The Director of Maintenance stated that nursing staff were responsible for replacing damaged fall mats, but no replacement had been obtained from central supply, nor had a service request been entered into the maintenance system. The unit manager acknowledged the mat's poor condition and confirmed it was an older version that had not been replaced.
Failure to Re-Admit Residents After Hospitalization
Penalty
Summary
The facility failed to re-admit two residents who were transferred to a higher level of care for treatment of acute conditions. Resident #3, who had multiple psychiatric and medical diagnoses, was sent to the hospital for altered mental status and verbal aggression. Despite being medically cleared for discharge, the facility refused to re-admit him, citing his aggressive behavior. This resulted in the resident remaining in the hospital for over two months while alternate SNF placement was sought, causing significant disruption to his care and well-being. The facility's staff, including the Social Services Director and the Director of Nursing, provided conflicting statements regarding the decision not to re-admit the resident, and the facility's Outside Marketer/Care Liaison incorrectly stated that the resident was ambulatory and a danger to others, despite documentation showing he was bedbound for years. Resident #2, who had end-stage kidney disease, diabetes, and other complex medical conditions, was transferred to the hospital for acute metabolic encephalopathy due to hypoglycemia. After being medically cleared for discharge, the facility refused to re-admit him, citing insurance issues and the need for the family to complete a Medicaid application. This led to the resident remaining in the hospital for approximately two weeks until another SNF could be found. The facility's Business Office Manager and the VP of Census Development provided inconsistent explanations for the refusal, with the VP of Census Development stating that the facility did not refuse re-admission, despite evidence to the contrary from the hospital's case management notes and the insurance company's records. The facility's policy and procedure for transfer and discharge indicate that residents should be permitted to return to the facility upon discharge from an acute care setting unless specific conditions are met, such as the resident's needs cannot be met, or the resident poses a danger to others. However, in both cases, the facility failed to adhere to its policy, resulting in extended hospital stays and significant disruption to the residents' care and well-being. The facility's actions were inconsistent with the stated policy and federal regulations, leading to actual harm for the residents involved.
Failure to Ensure Effective Communication and Oversight of Insulin Orders
Penalty
Summary
The facility failed to ensure effective communication, collaboration, and oversight of changes to the plan of care by members of the interdisciplinary team (IDT) for a resident. This failure resulted in the administration of an excessive dose of insulin, rendering the resident unresponsive due to a critically low blood glucose level, and necessitating transfer to a higher level of care for treatment. The resident, who had a history of type 2 diabetes with long-term insulin use, end-stage kidney disease with hemodialysis, and other complex medical conditions, was admitted to the facility and had a care plan for diabetes management that included monitoring blood glucose levels and administering insulin as ordered. However, discrepancies in medication orders and lack of proper review led to the administration of both Detemir and Levemir insulin, resulting in a total of 42 units in 24 hours, which was more than double the intended dosage. The medical record review revealed that the resident received a one-time dose of Detemir 22 units and an additional dose of Detemir 20 units on the same day, followed by another dose of Levemir 22 units at bedtime. This excessive insulin administration caused the resident's blood glucose level to drop to 25 mg/dL, leading to unresponsiveness. Despite the nurse's attempts to increase the blood glucose level with Glucagon, the resident remained unresponsive and was eventually transferred to the hospital. The hospital records confirmed the resident's critically low blood glucose level and the diagnosis of acute metabolic encephalopathy due to hypoglycemia. Interviews with the Director of Nursing (DON), the Advanced Practice Registered Nurse (APRN), and the attending physician revealed a lack of awareness and communication regarding the changes in insulin orders. The DON acknowledged that the IDT review process did not involve pulling up residents' charts to identify discrepancies or contraindications in medication orders. The APRN confirmed that she would not have ordered an additional dose of insulin without proper review and clarification. The attending physician expressed concern over the incident and the outcome. The facility's failure to thoroughly review and communicate medication orders led to the administration of an excessive dose of insulin, resulting in actual harm to the resident.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to promote a clean, comfortable, and homelike environment for several residents. Resident #6 was admitted with type 2 diabetes and a skin infection, and her room was found to be in an unacceptable condition. The room had stained sheets, dried urine stains under the toilet seat, and a used plastic container on the toilet lid. Despite the granddaughter's complaints, it took two hours for staff to remove the container, and the granddaughter had to change the sheets herself. The Admissions Concierge and Housekeeper D acknowledged the room should have undergone a deep clean, but it did not meet the required standards. Resident #5, who was cognitively intact and admitted with a right hip fracture and a history of falls, reported a roach problem in her room and the common areas. She had seen roaches during the day and night and even used her trash can to squash one. The facility's pest sighting log confirmed roach issues in multiple rooms and hallways. Resident #5 had to store a can of roach spray in her bedside commode to feel safe. Resident #7, admitted with type 2 diabetes and heart disease, also reported a severe roach problem in her room. During an interview, a large roach was observed running across the room. Resident #7 and her roommate, Resident #9, confirmed that roaches were a persistent issue, with Resident #9 stating she had a roach in her bed the previous night. The facility's policy on Resident Rights emphasized the right to a safe, clean, and comfortable environment, which was not upheld in these cases.
Failure to Ensure Timely and Effective Pain Management
Penalty
Summary
The facility failed to ensure timely and effective pain management for a resident who was admitted with severe pain due to a recent surgical amputation and other medical conditions. Despite having a care plan in place that included administering pain medication as ordered and monitoring pain characteristics, the resident did not receive adequate pain relief. The resident's granddaughter reported that the resident was in severe pain upon admission and did not receive the prescribed Tramadol in a timely manner. The granddaughter's account was corroborated by the resident, who confirmed that she experienced severe pain and received pain medication only once in the 16 hours following her admission. The Licensed Practical Nurse (LPN) assigned to the resident during the evening shift confirmed that she did not have access to the medication dispensing machine and relied on another nurse to retrieve the medication. However, there was no documentation to support that the medication was administered as claimed. The Medication Administration Record (MAR) and the medication dispensing machine's transaction records showed discrepancies, indicating that the Tramadol was not removed or administered as reported. The Director of Nursing (DON) and the pharmacy's records further confirmed that there was no transaction for the medication on the night of the resident's admission. The facility's policies for pain management and pharmacy services were not followed, as evidenced by the lack of proper documentation and timely administration of pain medication. The resident's pain levels were inaccurately recorded, and the nursing staff failed to conduct thorough pain assessments and provide consistent pain relief. The DON acknowledged the discrepancies and the absence of documentation, which contributed to the resident's unmanaged pain and discomfort during her initial hours at the facility.
Inaccurate Medical Record Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure the medical record accurately reflected the status of and services provided for a resident who was hospitalized. The resident, who had type 2 diabetes with long-term insulin use, was found unresponsive with a critically low blood glucose level and was sent to the hospital. Despite the resident being hospitalized, the medical record inaccurately documented that the resident's blood glucose levels were checked and medications were administered two days after the hospitalization. This discrepancy was confirmed by the Director of Nursing (DON) upon review of the medical record. The facility's policy and procedure for documentation in the medical record, revised in November 2023, required that each resident's medical record contain an accurate representation of the actual experiences of the resident through complete, accurate, and timely documentation. The policy explicitly stated that false information should not be documented. However, the assigned nurse documented services and medications for the resident who was not present in the facility, leading to inaccurate medical records. The DON validated this inaccurate documentation and stated that her expectation was for nurses to document the actual care provided and medications administered.
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.
