Abbey Delray South
Inspection history, citations, penalties and survey trends for this long-term care facility in Delray Beach, Florida.
- Location
- 1717 Homewood Blvd, Delray Beach, Florida 33445
- CMS Provider Number
- 105411
- Inspections on file
- 20
- Latest survey
- February 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Abbey Delray South during CMS and state inspections, most recent first.
The facility failed to maintain food safety and sanitary conditions, with staff not using facial hair restraints and improper food storage in the kitchen. A resident's perishable food was left unrefrigerated, contrary to facility policy. The resident, with cognitive communication deficit and Parkinsonism, had food items brought by relatives left on their overbed table without refrigeration.
The facility failed to maintain an effective system for timely MDS assessments, affecting all residents. The MDS Coordinator identified the issue and initiated a PIP, but assessments remained consistently late due to high turnover and workload in the Social Services Department. The Administrator was not fully aware of the PIP's progress, and communication among staff was insufficient, contributing to the ongoing deficiency.
The facility failed to maintain effective infection control, as staff did not adhere to Enhanced Barrier Precautions (EBP) for three residents. A CNA did not wear a gown for wound care, a resident lacked EBP orders for a pressure ulcer, and an LPN administered medications without proper PPE. Staff misunderstandings and documentation oversights contributed to these deficiencies.
The facility failed to implement fall prevention measures for two residents, leading to deficiencies in care. One resident, with a hip fracture and dementia, did not receive a post-fall assessment, and fall mats were inconsistently placed. Another resident, with severe cognitive impairment, had their bed left in a high position without staff presence, and personal items were out of reach. Staff interviews revealed misunderstandings of fall risk status, and the DON acknowledged the lapses in protocol adherence.
A resident with Dementia, Osteoporosis, and Hemiplegia was not provided with necessary dining assistance despite a physician's order and care plan indicating the need for such support. Observations showed the resident eating without staff help, leading to a reported weight loss. The resident expressed needing more help during meals, while a CNA believed minimal assistance was sufficient.
The facility failed to obtain a physician order and initiate a care plan for a resident with a urinary catheter, and did not secure the catheter for another resident, despite physician orders. The first resident had a urinary catheter without documented orders or a care plan, and staff were unclear about responsibilities. The second resident, with severe cognitive impairment and recurrent UTIs, had a catheter that was not secured as required, with staff acknowledging the absence of a leg strap.
A resident with cerebral infarction and dementia experienced significant weight loss due to the facility's failure to provide the recommended Ensure high-protein supplements. Instead, the resident received Ensure original, which did not meet the caloric and protein requirements. Staff interviews revealed issues with ordering and stocking the correct supplement, leading to the deficiency in meeting the resident's nutritional needs.
A resident with COPD and other health issues was observed using oxygen therapy without a physician's order, contrary to facility policy. The care plan mentioned oxygen use, but no formal order was documented, and the oxygen tubing lacked a date tag. The resident confirmed the oxygen was helpful, highlighting a deficiency in care management.
A facility failed to limit a resident's PRN psychotropic medication to 14 days, as required by regulations. The resident, diagnosed with bipolar disorder and major depressive disorder, had a physician's order for Lorazepam for 30 days, which was not addressed by the Consultant Pharmacist during a review. Interviews revealed that the facility did not adhere to its policy of reviewing PRN psychotropic medications exceeding 14 days with the prescribing physician.
The facility failed to monitor behaviors and side effects for two residents on psychotropic medications. One resident on Rexulti for bipolar disorder had no documented monitoring of side effects, while another on Escitalopram for depression lacked documented monitoring of depression symptoms. Staff interviews revealed inconsistencies in documentation and awareness of monitoring procedures.
A resident was found with unsecured medications at the bedside, contrary to facility policy requiring locked storage. The resident, with a history of myocardial infarction and tongue neoplasm, had not been evaluated for self-administration. Staff confirmed the policy breach, and the CNA removed the medication.
A resident with a history of tongue cancer and on nectar thickened liquids was found with regular ice water at their bedside, contrary to physician orders. The care plan lacked documentation for nutrition or hydration, and staff interviews revealed inconsistencies in providing thickened liquids. A nurse acknowledged the error and removed the water, while the Speech Therapist confirmed the resident's liquid consistency needs.
The facility failed to provide a homelike environment by not having pull cords on overbed lights for two residents. Observations confirmed the absence of pull cords in rooms 22-B and 28-B, which was acknowledged by the Maintenance Supervisor. The supervisor stated that each light should have a pull cord for residents to operate the lights independently.
A resident with multiple diagnoses, including arthritis and MRSA infection, experienced a deficiency in medication administration due to the facility's failure to process a physician's order for an increased dosage of Percocet. The MAR inaccurately reflected the administration of the higher dosage without a valid order, as staff did not follow through to ensure the prescription was received. The DON acknowledged the error after reviewing the records.
Food Safety and Storage Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitary conditions during two visits to the central kitchen. Observations revealed that staff members, including a dietary aide and a chef, did not wear facial hair restraints while in the food production area. Additionally, garbage bins in the food production area were uncovered and contained food debris. The walk-in refrigerator contained improperly labeled and stored food items, including raw fish, cooked shrimp, and raw ground meat with bloody drainage. Unlabeled and undated raw meat, as well as exposed raw chicken and pork, were also noted. The walk-in freezer had condensation above the food, with food boxes exposed. In the satellite kitchen, a dietary aide was observed wearing long earrings and handling prepared foods without changing gloves after using a sanitation bucket. The facility also failed to store a resident's food at the appropriate temperature. A resident with cognitive communication deficit and Parkinsonism had perishable food items brought by relatives left on their overbed table without being refrigerated. The food items, including cut-up mango, egg salad, and fish, were not labeled according to facility policy and had been left unrefrigerated over the weekend. A registered nurse acknowledged that the food should have been refrigerated and was likely no longer safe for consumption.
Deficiency in Timely MDS Assessments Due to Ineffective System
Penalty
Summary
The facility failed to maintain an effective system for obtaining and utilizing feedback from the Minimum Data Set (MDS) Department, which resulted in untimely completion of MDS assessments. This deficiency had the potential to affect all 70 residents in the facility. The facility's Quality Assurance and Performance Improvement (QAPI) program plan indicated that the Administrator, along with the QAPI Committee, was responsible for coordinating care and services, including the timely completion of MDS assessments. However, the facility's Performance Improvement Project (PIP) for late MDS assessments, initiated by the MDS Coordinator, showed that assessments were consistently late, with percentages ranging from 47.62% to 78% over several weeks. Interviews revealed that the MDS Coordinator identified the issue of late assessments in December 2024 and notified the Administrator, Director of Nursing (DON), and Regional MDS Director. Despite this, the problem persisted, and the Administrator was not fully aware of the PIP's effectiveness or its details. The Social Services Department was identified as a significant contributor to the delays due to high turnover and a high volume of admissions and discharges, compounded by having only one full-time social worker. The Administrator acknowledged the issue but was uncertain about the PIP's progress and had not reviewed it thoroughly. The QAPI Committee meetings included discussions about the late MDS assessments, but there was a lack of clear communication and coordination among the staff. The MDS Coordinator had initiated the PIP independently, and not all relevant staff members were informed or involved in the process. The Social Service Director confirmed that the issue had been ongoing for several weeks and was mentioned in QAPI meetings, but without detailed discussion. This lack of effective communication and coordination contributed to the continued deficiency in timely MDS assessments.
Infection Control Deficiencies in PPE Use and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) for three residents. For Resident #545, a CNA did not wear a gown while assisting with wound care and changing briefs, despite the presence of an EBP sign and orders requiring gown and glove use for high-contact care. The CNA admitted to not checking the EBP sign and was reminded by the RN, who confirmed that staff received training on EBP. Resident #501 did not have an EBP order or care plan related to a right heel pressure ulcer, despite the need for such precautions. A CNA incorrectly believed that gowns were only necessary for highly contagious diseases, indicating a lack of understanding of EBP requirements. This oversight in documentation and staff education contributed to the deficiency. For Resident #38, an LPN administered medications and assisted with a transfer without wearing a gown, despite EBP orders and signs indicating the need for gown and glove use during high-contact care. The LPN was unsure about the requirements and sought clarification from the surveyor. The DON, acting as the Infection Preventionist, acknowledged the need for PPE during direct contact activities, especially when transferring residents.
Failure to Implement Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to adhere to the care plan interventions designed to prevent falls for two residents, leading to deficiencies in their care. Resident #69, who was readmitted to the facility with a right hip fracture, dementia, and general anxiety, experienced a fall that was not followed by a post-fall assessment as required. Observations revealed inconsistencies in the implementation of fall prevention measures, such as the absence of a floor mat on one side of the bed, despite the care plan's directive for mats on both sides. Interviews with staff highlighted a lack of awareness and adherence to the care plan, with the Director of Nursing acknowledging the oversight. Resident #64, admitted with severe cognitive impairment and a high fall risk score, also experienced lapses in fall prevention measures. Observations showed that the resident's bed was left in a high position without staff presence, and personal belongings and call lights were not within reach. Despite the care plan's instructions, a floor mat was not consistently placed on the floor, and staff interviews revealed a misunderstanding of the resident's fall risk status. The Director of Nursing confirmed the discrepancies and acknowledged that the fall prevention protocol was not properly followed. The facility's policies on comprehensive care planning and fall prevention were not effectively implemented, resulting in a failure to meet the residents' needs. The lack of post-fall assessments, incorrect implementation of care plan interventions, and staff's misunderstanding of residents' fall risks contributed to the deficiencies observed. These actions and inactions highlight the need for improved adherence to care plans and staff training to ensure resident safety and compliance with established protocols.
Failure to Provide Dining Assistance
Penalty
Summary
The facility failed to provide necessary assistance during dining for a resident who was reviewed for nutrition. The resident, who was admitted with diagnoses of Dementia, Osteoporosis, and Hemiplegia, was found to have a Brief Interview of Mental Status (BIMS) score indicating cognitive intactness. Despite a physician's order for careful oral assisted feeding by hand with every meal, observations revealed that the resident was eating meals without staff assistance. The resident reported eating as much as she could and noted weight loss, although she was unsure of the amount. A nutrition dietary progress note indicated a 9.6% weight loss over three months, with meal intake varying between 25% and 75%. The care plan identified the resident as being at nutritional and dehydration risk, requiring staff to provide necessary meal assistance. However, during interviews, the resident expressed needing more help during meals, contrary to the statement from a Certified Nursing Assistant who believed the resident could eat independently with minimal assistance. This discrepancy between the care plan, physician's orders, and staff actions contributed to the deficiency in providing adequate dining assistance to the resident.
Deficiencies in Urinary Catheter Management for Two Residents
Penalty
Summary
The facility failed to acquire a physician order for a urinary catheter and did not initiate a urinary catheter care plan for Resident #502. The resident was admitted with diagnoses including malignant neoplasm of the cervix, acute cystitis, and a urinary tract infection. Despite the presence of a urinary catheter, there were no physician orders or care plans documented for the catheter's care and maintenance. Observations revealed that the resident had a urinary bag strapped to her leg, and staff interviews indicated a lack of clarity regarding who was responsible for emptying the urinary bag. Additionally, the admission registered nurse admitted to only recently placing the order for the urinary catheter, despite the resident having had it for an unspecified duration. For Resident #69, the facility failed to keep the urinary catheter anchored, as required by the physician's orders. The resident, who was severely cognitively impaired, had a diagnosis of neurogenic bladder and recurrent UTIs. Despite orders to secure the catheter to the leg to prevent tension, there was no documentation of this being done from the beginning of February to February 19th. Observations confirmed that the catheter was not secured during care, and staff interviews revealed that they were aware of the need for a leg strap but acknowledged that the resident did not have one. The Director of Nursing confirmed that anchoring the catheter is best practice.
Nutritional Needs Not Met for Resident
Penalty
Summary
The facility failed to meet the nutritional needs of a resident, identified as Resident #47, who was admitted with diagnoses of cerebral infarction and dementia. The resident experienced significant weight loss, dropping from 180.2 pounds to 155.0 pounds over several months. Despite a recommendation for Ensure high-protein supplements twice a day to meet the resident's nutritional needs, the facility provided Ensure original, which did not meet the caloric and protein requirements. The resident's intake was only meeting 65% to 75% of his estimated nutritional needs, as documented in the facility's records. Interviews with staff revealed a lack of proper ordering and stocking of the required Ensure high-protein supplement. The Registered Dietitian and other staff members acknowledged the absence of the high-protein supplement in the facility's inventory and the failure to provide the correct nutritional support. Staff members were unsure of when the high-protein supplement was last available, and the resident was consistently given the wrong type of Ensure, which contributed to the deficiency in meeting the resident's nutritional needs.
Lack of Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration for a resident, leading to a deficiency in providing safe and appropriate respiratory care. The resident, who was admitted with diagnoses including a displaced intertrochanteric fracture of the right femur, COPD, and chronic systolic congestive heart failure, was observed using oxygen without a corresponding physician's order. The facility's policy on oxygen administration, revised in October 2010, requires verification of a physician's order for oxygen use, which was not adhered to in this case. Observations revealed that the resident was using a nasal cannula connected to a portable oxygen tank set at 2 liters per minute, yet there was no physician's order documented for this oxygen therapy. The care plan for the resident included interventions related to COPD, such as monitoring for respiratory issues and administering bronchodilators, but it also mentioned oxygen therapy without a documented order. Additionally, the oxygen tubing lacked a date tag, indicating a lapse in proper equipment management. The resident confirmed that the oxygen was beneficial, but the absence of a formal order represents a significant oversight in care management.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications on a PRN basis, specifically for a resident diagnosed with bipolar disorder and major depressive disorder. The resident, who was cognitively intact with a BIMS score of 15, had a physician's order for Lorazepam 0.5 milligrams to be administered every 8 hours as needed for anxiety, with a duration of 30 days. This order exceeded the regulatory limit of 14 days for PRN psychotropic medications. Despite a pharmacy review conducted five days after the order was placed, the Consultant Pharmacist did not identify any irregularities or address the extended duration of the PRN medication. Interviews with the Director of Nursing (DON) and the Consultant Pharmacist revealed a lack of adherence to the facility's policy, which requires the nurse and pharmacist to contact the prescribing physician to discuss the necessity of any psychotropic medication that has been PRN for more than 14 days. The DON acknowledged the findings, indicating a lapse in the facility's protocol to ensure that psychotropic medications are not administered unnecessarily or beyond the regulatory timeframe without proper justification and physician review.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to adequately monitor behaviors and side effects for two residents on psychotropic medications, leading to deficiencies in care. Resident #17, who was admitted with bipolar disorder and major depressive disorder, was prescribed Rexulti, an antipsychotic medication. However, there were no documented orders to monitor the medication's side effects or behaviors, and the Medication Administration Record (MAR) for February 2025 lacked documentation of such monitoring. Despite the care plan's directive to monitor and document for side effects and effectiveness, staff interviews revealed a lack of awareness and documentation regarding the antipsychotic medication. Resident #501, admitted with multiple diagnoses including anxiety disorder, was prescribed Escitalopram for depression. The physician's orders included monitoring for signs and symptoms of depression using numerical codes, but the MAR did not reflect this monitoring. Additionally, there was no care plan addressing the resident's depression. Interviews with staff indicated a general understanding of behavior monitoring procedures, but inconsistencies in documentation and uncertainty about monitoring side effects were evident. The deficiencies highlight a failure in the facility's processes for monitoring psychotropic medication effects and behaviors, as evidenced by the lack of documentation and staff awareness. This oversight could potentially impact the residents' well-being, as monitoring is crucial for identifying adverse reactions and ensuring the effectiveness of the prescribed medications.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure medications were secured at the bedside for one resident. The facility's policy requires that all medications and biologicals be stored in locked compartments and that only authorized personnel have access to them. Additionally, the policy on self-administration of medications mandates an evaluation of the resident's cognitive and physical abilities to determine if self-administration is safe and appropriate. However, there was no documentation of such an evaluation for the resident involved. The resident, who had a history of acute myocardial infarction and malignant neoplasm of the tongue, was observed with a clear plastic bag containing ChapStick and Nystatin ointment on the nightstand and overbed table. The resident mistakenly identified the Nystatin ointment as denture adhesive. Staff interviews confirmed that medications should not be at the bedside, and the resident had not been evaluated for self-administration of medications. The CNA removed the medication and gave it to the Director of Nursing.
Failure to Provide Appropriate Hydration for Resident on Thickened Liquids
Penalty
Summary
The facility failed to provide water consistent with the needs of a resident on thickened liquids, leading to a deficiency. Resident #645, who was admitted with diagnoses including Acute Myocardial Infarction and a history of tongue cancer, was observed with a full 20-ounce Styrofoam cup of regular ice water at their bedside, despite having a physician's order for nectar thickened liquids. The resident's care plan lacked documentation for nutrition or hydration, and there was no record of a Brief Interview of Mental Status being completed. During an observation, a Registered Nurse acknowledged the resident should not have regular water and removed it. The Speech Therapist confirmed the resident was on nectar thickened liquids and could use a straw due to tongue issues. Interviews with staff revealed inconsistencies in how water was provided to residents on thickened liquids, with reliance on verbal communication from nurses. The Certified Nursing Assistant stated that water is provided once or twice a shift, but there was no clear protocol for ensuring residents on thickened liquids received the appropriate consistency.
Missing Pull Cords on Overbed Lights
Penalty
Summary
The facility failed to ensure a homelike environment by not having pull cords attached to overbed lights for two out of seventy occupied beds. Observations were made on multiple occasions in room 22-B, where the overbed light located on the wall above the head of the bed had no pull cord attached. This was confirmed during a side-by-side observation with the Maintenance Supervisor, who acknowledged the missing pull cords in rooms 22-B and 28-B. The Maintenance Supervisor stated that each overbed light should have a pull cord long enough for each resident to be able to turn the light on and off themselves.
Failure to Process Physician's Order for Pain Medication
Penalty
Summary
The facility failed to process a physician's order in a timely manner for a resident, leading to a deficiency in medication administration. The resident, who was admitted with multiple diagnoses including arthritis, muscle wasting, and MRSA infection, had a physician's order for Oxycodone with Acetaminophen to be administered as needed for pain. However, there was a discrepancy in the medication administration record (MAR) and the controlled substance utilization record, indicating that the resident was documented as receiving a higher dosage of Percocet without a corresponding physician's order. The issue arose when the resident's orthopedic surgeon was supposed to provide a prescription for an increased dosage of Percocet, but the facility did not receive or document this order in a timely manner. Staff A, a registered nurse, attempted to contact the orthopedic surgeon's office to obtain the prescription but did not follow through to ensure it was received. As a result, the MAR inaccurately reflected that the resident was administered the higher dosage of Percocet, despite the absence of a valid physician's order. Further investigation revealed that other nursing staff members also signed off on the MAR for the increased dosage without verifying the existence of a physician's order. The Director of Nursing acknowledged the error after reviewing the records, confirming that the medication was signed off as administered without proper authorization. This lack of documentation and verification led to the deficiency in medication administration for the resident.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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