Advanced Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearwater, Florida.
- Location
- 401 Fairwood Ave, Clearwater, Florida 33759
- CMS Provider Number
- 105478
- Inspections on file
- 21
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Advanced Care Center during CMS and state inspections, most recent first.
Surveyors found multiple rooms with environmental deficiencies such as missing paint, oxidized bed frames, broken side rails, detached baseboards, and unfinished repairs. These issues were not reported through the facility's work order system, and the maintenance director was unaware of them prior to the inspection. The facility's process for identifying and addressing environmental concerns was not effectively followed, resulting in a failure to provide a safe, clean, and homelike environment for residents.
Two residents with diabetes were admitted without timely physician orders for insulin or blood glucose monitoring, despite hospital discharge instructions indicating ongoing insulin therapy. Facility staff did not reconcile hospital medication lists with a provider upon admission, resulting in delayed insulin administration and blood glucose checks. Staff interviews revealed confusion over discharge paperwork and inconsistent use of admission protocols.
Two residents with diabetes did not receive their prescribed insulin upon admission due to incomplete medication reconciliation and lack of provider review. Nursing staff relied on confusing hospital discharge paperwork and did not consistently verify medication needs with a provider, resulting in delayed insulin administration and elevated blood glucose levels.
A resident with multiple medical conditions and a high risk for falls developed significant bruising that was not promptly identified, investigated, or reported by staff. Despite protocols for skin checks and incident reporting, staff failed to document or communicate the presence of new bruises, and nursing administration was unaware of the injury until it was pointed out during a survey. This resulted in a deficiency for not investigating and reporting suspected abuse, neglect, or injuries of unknown origin as required by facility policy.
A resident with complex medical conditions, including bladder dysfunction and chronic kidney disease, was not provided a urology consult after a failed voiding trial, despite verbal orders from the ARNP. Miscommunication between the ARNP, DON, and nursing staff, along with the absence of a facility policy on care consultation and referral, led to the omission of the required specialist evaluation.
The facility failed to update PASRR Level II evaluations for several residents with new mental health diagnoses. Despite having conditions like schizoaffective disorder and dementia, the necessary evaluations were not completed, as required by regulations. The Social Services Director acknowledged the oversight, which affected the care planning and assessment process.
The facility failed to complete the PASRR for three residents with mental disorders or intellectual disabilities. A resident with major depressive disorder and Alzheimer's disease had a blank PASRR, another with multiple mental health diagnoses had no indication of mental illness on their PASRR, and a third resident's PASRR only marked schizophrenia, omitting other diagnoses. The Social Services Director acknowledged the PASRRs were not updated upon acquiring new diagnoses, contrary to facility policy.
The facility failed to maintain resident rooms in a safe and sanitary manner in Zones 3, 6, and 8. Observations included stained and damaged walls, dirty toilets, and unclean bed frames. A resident expressed dissatisfaction with her room's condition. The Regional EVS Director acknowledged cleaning lapses, and the Director of Maintenance noted that repairs were delayed and not documented in the work orders system.
A resident with severe cognitive impairment was discharged without receiving a 30-day advance notice, as required by the facility's policy. The notice was given on the day of discharge, lacking documentation of prior notification to the resident or their emergency contact. The discharge was facility-initiated due to capacity issues and behavioral incidents, but there was no evidence of attempts to meet the resident's needs or justification for the transfer.
The facility failed to accurately code the MDS Assessments for two residents with Serious Mental Illness, as indicated by their PASRR Level II Determination Summary Reports. Despite having diagnoses such as major depressive disorder and generalized anxiety disorder, the MDS Assessments inaccurately reflected no serious mental illness. The MDS Coordinator and DON confirmed the inaccuracies and noted the absence of a specific policy for MDS completion.
A resident with chronic edema and DVT was not consistently monitored or documented, leading to a deficiency in care. Despite the presence of edema, the care plan was not updated in a timely manner, and staff interviews revealed a lack of consistent documentation. Facility policies on documentation and monitoring were not followed, resulting in inadequate care for the resident.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
Surveyors identified multiple environmental deficiencies in fourteen resident rooms during a facility tour, including missing paint on walls, oxidized and stained bed frames, broken side rails, detached edging on bedside tables, holes in walls, missing or detached baseboards, unfinished work under sinks, toilets lacking sealant, and inappropriate storage of toilet paper. Additional concerns included air mattress cords improperly placed and plugged into televisions, and black marks or missing boards from walls. These issues were directly observed and documented by surveyors during their inspection. Interviews with the Director of Maintenance (DOM) and the Nursing Home Administrator (NHA) revealed that these environmental concerns had not been reported through the facility's work order system, and the DOM was unaware of the issues prior to the survey. The NHA stated that department heads are expected to identify and report such concerns during daily rounds, and that staff are trained to report environmental issues. However, the specific deficiencies observed by surveyors had not been communicated or addressed through the established reporting and maintenance processes, resulting in the failure to maintain a safe, clean, and homelike environment as outlined in the facility's policy.
Failure to Obtain and Implement Physician Orders for Immediate Care Upon Admission
Penalty
Summary
The facility failed to ensure that two residents received physician orders for their immediate care and necessary services upon admission. Both residents were admitted with a history of diabetes mellitus and required insulin therapy, as indicated by their hospital discharge documentation and medication reconciliation. However, upon admission, there was no documentation that the facility staff reviewed or reconciled the discharge medication list with a provider, nor were appropriate insulin orders entered in a timely manner. In both cases, the residents did not receive their prescribed insulin until several days after admission, and blood glucose monitoring was also delayed. For the first resident, the hospital discharge records indicated ongoing insulin therapy, but the facility did not initiate insulin orders or blood glucose checks upon admission. The resident and their representative reported concerns to the nursing staff about the lack of insulin administration, and a grievance was filed. The facility's records showed that insulin was not administered until two days after admission, and long-acting insulin was not started until four days after admission. The resident's blood glucose was not checked until two days post-admission, at which point it was elevated. The second resident was also admitted with a diagnosis of diabetes and a hospital discharge summary indicating insulin therapy. However, the facility did not enter insulin orders or perform blood glucose checks until two days after admission. The resident's representative informed the admitting nurse about the need for insulin, but the orders were not entered, and the first blood glucose check revealed a significantly elevated level. Interviews with staff revealed confusion regarding the hospital discharge paperwork and a lack of communication with the provider to verify or clarify medication orders. The facility lacked a policy on medication reconciliation or diabetes management, and staff did not consistently follow the admission checklist to ensure proper medication review and provider notification.
Failure to Administer Prescribed Insulin Upon Admission Due to Inadequate Medication Reconciliation
Penalty
Summary
Two residents were admitted to the facility and did not receive their necessary prescribed insulin medications upon admission. In the first case, the resident and their representative reported concerns that insulin was not administered as ordered, with the resident only receiving half of the normal dose after repeated requests. The resident's hospital discharge paperwork included orders to stop insulin, which led the admitting nurse to withhold the medication despite the resident's statements and a filed grievance. There was no documentation that the discharge medication list was reviewed or reconciled with a provider upon admission, and blood glucose monitoring was not initiated until two days after admission, at which point the resident's blood glucose was elevated. In the second case, another resident with a history of diabetes was admitted without clear documentation of insulin orders in the hospital paperwork, though the discharge summary indicated the resident was on insulin. The resident's representative informed the admitting nurse of the need for insulin, but the resident went a day or more without receiving it. Blood glucose checks were not performed until two days after admission, revealing significantly elevated levels. Insulin orders were not entered until two days post-admission, and there was no evidence that the medication reconciliation was reviewed with a provider at the time of admission. Interviews with nursing staff and facility leadership revealed inconsistent practices regarding medication reconciliation and provider notification upon admission. The Director of Nursing confirmed that there was no documentation of provider review for the admission medications and acknowledged that nurses were expected to call the provider before entering orders. The facility lacked policies on medication reconciliation, diabetes management, or a standardized admission process, and the use of the admission checklist was inconsistent among staff. These actions and inactions resulted in residents not receiving necessary prescribed medications in a timely manner.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who had multiple medical conditions, including osteoarthritis, epilepsy, and anemia, and was at high risk for falls and skin impairment. Documentation showed that the resident had a fall, after which darker bruises were observed on her upper thighs, described as appearing to be from prior falls. However, subsequent skin checks and daily skilled notes did not document any new or existing bruises, and staff interviews revealed inconsistent awareness and reporting of the bruising. The resident was also noted to have additional bruising and skin tears on her forearm, which she attributed to a bracelet, and a significant bruise on her upper left hip that had been present for 10-14 days, but this was not documented or reported to nursing administration until brought to their attention during the survey. Interviews with staff, including LPNs and CNAs, indicated that while there were protocols for assessing and documenting falls and skin changes, these were not consistently followed. Staff were unaware of recent falls or new bruising, and weekly skin checks were not reliably performed or documented. The DON and RNC confirmed that the expected weekly skin sweeps were not being completed, and the nursing administration team was unaware of the new bruising on the resident's hip until it was pointed out during the survey. The facility's own policies required prompt notification and investigation of injuries of unknown source, as well as thorough documentation and communication with physicians and resident representatives, but these procedures were not followed in this case. The lack of timely investigation and reporting of the resident's bruising, as well as the failure to perform and document regular skin checks, resulted in a deficiency related to the facility's responsibility to identify, investigate, and report suspected abuse, neglect, or injuries of unknown origin. The facility's policies on change in condition and abuse prevention were not adhered to, leading to a delay in recognizing and addressing potential harm to the resident.
Failure to Provide Urology Consultation Following Failed Voiding Trial
Penalty
Summary
A deficiency occurred when the facility failed to ensure a urology consultation was provided for a resident with multiple complex diagnoses, including Type 2 Diabetes Mellitus with hyperglycemia, neuromuscular dysfunction of the bladder, infection and inflammatory reaction due to an indwelling urethral catheter, and chronic kidney disease. Upon admission, there was a verbal order to consult urology for urinary retention, and the ARNP documented in progress notes that a voiding trial should be initiated, with instructions to consult urology if the trial failed. Despite these instructions, the voiding trial was either not performed as ordered or, when eventually conducted and failed, the required urology consult was not arranged. Interviews with facility staff revealed miscommunication and lack of follow-through regarding the urology consult order. The DON acknowledged that the ARNP had requested a voiding trial and a urology consult if the trial failed, but stated that the ARNP did not enter the consult order into the system. The ARNP, however, reported that she verbally instructed both the DON and the Unit Manager on multiple occasions to consult urology after the failed voiding trial. The facility did not have a policy or procedure in place regarding care consultation and referral, contributing to the failure to secure the necessary specialist evaluation for the resident.
Failure to Update PASRR Level II Evaluations for Residents with New Diagnoses
Penalty
Summary
The facility failed to complete the Pre-Admission Screening and Resident Review (PASRR) Level II evaluations for residents with new qualifying mental health diagnoses. This deficiency was identified for five residents out of ten sampled. The PASRR Level II evaluations were not updated to reflect new diagnoses, which is a requirement under state and federal regulations. The facility's policy mandates that all residents receive a PASRR evaluation, and any significant changes in a resident's mental health status should prompt a Level II review. Resident #1 had multiple mental health diagnoses, including schizoaffective disorder and unspecified dementia, but the PASRR Level II was not updated to include these new diagnoses. Similarly, Resident #3 and Resident #98 had diagnoses of generalized anxiety disorder and unspecified dementia, yet their PASRR Level I evaluations incorrectly indicated that a Level II evaluation was not required. Resident #46 and Resident #38, both with serious mental illness, also lacked updated PASRR Level II evaluations after acquiring new diagnoses. The Social Services Director acknowledged that the PASRRs were not updated upon acquiring new diagnoses and that Level II PASRRs should have been completed. The facility's policy emphasizes the importance of incorporating PASRR recommendations into resident assessments and care planning, but this was not adhered to in these cases. The failure to update PASRR evaluations upon significant changes in residents' mental health status led to the identified deficiency.
Failure to Complete PASRR for Residents with Mental Disorders
Penalty
Summary
The facility failed to complete the Pre-Admission Screening and Resident Reviews (PASRR) for three residents with mental disorders or intellectual disabilities. Resident #36 was admitted with newly acquired diagnoses of major depressive disorder and Alzheimer's disease, but their Level I PASRR was left blank, and the qualifying diagnoses were not checked. Resident #102 was admitted with multiple mental health diagnoses, including bipolar disorder and major depressive disorder, yet their PASRR Level I Screen did not indicate any mental illness. Resident #53 was admitted with major depressive disorder and generalized anxiety disorder, but their PASRR Level I Screen only marked schizophrenia, leaving out the other diagnoses. The Social Services Director (SSD) acknowledged that the PASRRs were not updated upon acquiring new diagnoses. The facility's policy requires coordination with the PASRR program to incorporate recommendations into a resident's assessment and care planning. However, the policy was not followed, as evidenced by the lack of updated PASRRs for residents with newly identified mental health conditions. The SSD stated that after admission, she reviews the resident's PASRR and diagnoses with the nursing leadership team to determine if a Level II PASRR evaluation is required, but this process was not effectively implemented in these cases.
Failure to Maintain Safe and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain resident rooms in a safe, sanitary, and homelike manner in three zones, specifically Zones 3, 6, and 8. During a tour of Zone 6/8, several issues were observed, including stained and damaged walls, dirty and uncaulked toilets, and unclean bed frames. A resident expressed dissatisfaction with the condition of her room, noting a large stain on the ceiling and a crumbling wall behind her bed. The Regional Environmental Services (EVS) Director acknowledged that the rooms should have been cleaned, especially during terminal cleaning, and noted that the deep cleaning schedule was not followed as room [ROOM NUMBER] had not been deep cleaned since October. In Zone 3, environmental concerns were identified in multiple rooms, including holes, chipped paint, and damaged baseboards. The toilet base caulking in one room was stained with a brown substance. Staff F from housekeeping stated that he would report uncleanable or damaged items to maintenance, but the Director of Maintenance (DOM) confirmed that the rooms with concerns were not documented in the work orders management system. The DOM was aware of the damaged walls and baseboards and mentioned that repairs were scheduled but delayed due to the facility's census. The facility's maintenance policy, revised in December 2009, outlines the responsibilities of the maintenance department to keep the building in good repair and free from hazards. However, the observations and interviews indicate that the policy was not effectively implemented, as evidenced by the lack of documentation in the work orders system and the failure to address the identified environmental concerns in a timely manner.
Failure to Provide Timely Discharge Notice
Penalty
Summary
The facility failed to provide a written Notice of Transfer and/or Discharge Notice to a resident, identified as Resident #94, who was part of a group of three residents reviewed for the transfer/discharge process. The deficiency was identified when it was found that Resident #94 did not receive a 30-day advance notice of discharge, as required by the facility's policy. The notice was only given on the day of discharge, and there was no documentation indicating that the resident or their emergency contact had been informed in advance. Additionally, the notice lacked the name or signature of the person receiving it. Resident #94, who was admitted to the facility with severe cognitive impairment and diagnosed with dementia, was involved in incidents that led to the decision for discharge. The resident's medical records indicated a history of impaired cognition, memory, and judgment, with a BIMS score of 6/15 and a SLUM exam score of 10/30. Despite these cognitive deficits, the facility did not document any attempts to meet the resident's needs or provide evidence of the services available at the new facility that were not available at the current one. Interviews with facility staff, including the Psychiatric Physician Assistant and the Director of Nursing, revealed that the discharge was facility-initiated due to capacity issues and behavioral incidents involving Resident #94. The resident's emergency contact was not notified of the transfer, and there was no evidence of a 30-day discharge notification. The facility's policy requires that residents and their representatives receive written notice at least 30 days prior to a transfer or discharge, except in specific circumstances, none of which were documented in this case.
Inaccurate MDS Coding for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) Assessment was accurately coded for two residents, leading to a deficiency in the accuracy of assessments. Resident #46 was admitted with diagnoses including adjustment disorder with depressed mood, generalized anxiety disorder, schizoaffective disorder, and major depressive disorder. Despite a Florida Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report indicating that Resident #46 met the definition of Serious Mental Illness, the MDS Assessment inaccurately reflected that the resident did not have a serious mental illness or related condition. Similarly, Resident #38, who was admitted with diagnoses such as major depressive disorder, generalized anxiety disorder, and dementia, also had a PASRR Level II Determination Summary Report confirming a Serious Mental Illness. However, the MDS Assessment for Resident #38 was inaccurately coded, indicating no serious mental illness or related condition. Interviews with the MDS Coordinator and the Director of Nursing revealed that the facility lacked a specific policy and procedure for MDS Assessment completion, relying solely on regulations, which contributed to the inaccuracies in the assessments.
Inadequate Monitoring and Documentation of Chronic Edema
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with chronic edema, as evidenced by inconsistent monitoring and documentation of the resident's condition. The resident, who was observed with swelling in both lower legs, had a diagnosis of deep vein thrombosis (DVT) confirmed by an ultrasound. Despite the presence of edema, the facility's records did not consistently reflect this condition, and the care plan was not updated in a timely manner to address the resident's needs. Interviews with staff revealed a lack of consistent documentation and monitoring of the resident's edema. The Director of Nursing (DON) and other nursing staff acknowledged that the resident's condition was not adequately documented, and there was a failure to establish a baseline for monitoring the edema. The resident's care plan was only revised after the deficiency was identified, indicating a delay in recognizing and addressing the resident's chronic condition. The facility's policies on charting and documentation, as well as changes in a resident's condition, were not followed. The policies required documentation of changes in the resident's condition and progress toward care plan goals, but these were not consistently adhered to. The lack of documentation and monitoring led to a deficiency in providing care according to professional standards and the resident's needs.
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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