Alexander "sandy" Nininger State Veterans Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Pembroke Pines, Florida.
- Location
- 8401 W Cypress Dr, Pembroke Pines, Florida 33025
- CMS Provider Number
- 106038
- Inspections on file
- 18
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Alexander "sandy" Nininger State Veterans Nursing during CMS and state inspections, most recent first.
A resident with a history of adrenalectomy, bipolar disorder, dementia, and hypertension experienced significant weight loss, which the facility failed to address in a timely manner. The dietitian did not attend risk meetings consistently or communicate the weight loss to the resident's practitioner or nursing staff. Despite monitoring the resident's weight, the facility did not implement effective nutritional interventions, leading to a deficiency in maintaining the resident's nutritional health.
The facility did not provide fresh fruit to residents as per the menu, affecting eight residents who reported receiving fresh fruit only once or twice a week instead of daily. The diet technician confirmed the availability of bananas and other fruits but could not explain the discrepancy. Residents involved had various medical conditions and were mostly cognitively intact.
The facility failed to provide palatable and appetizing meals to several residents, as evidenced by consistent complaints about the food's taste and appearance. Despite varying cognitive impairments, residents reported that meals were bland, unappetizing, and inconsistent with their requests. A test tray confirmed the lack of seasoning and color variation, while the Food Service Director attributed the blandness to dietary restrictions, though the issue persisted across different diets.
The facility failed to provide the correct pureed diet consistency for several residents, serving meals that were lumpy and contained solid particles. This inconsistency was observed during multiple meal services, affecting residents with conditions like dysphagia and Parkinson's. The Food Service Director acknowledged the issue, and the Speech Language Pathologist confirmed that the pureed food should be smooth, as per facility policy.
The facility failed to maintain food safety and sanitation standards, affecting 106 residents. Observations revealed improper food storage, unclean kitchen equipment, and unsafe food temperatures. Nourishment rooms also had unsanitary conditions, with unclear cleaning responsibilities among staff.
A resident with Quadriplegia expressed a desire to be out of bed by 10:00 AM, as per their care plan, but was consistently left in bed until after 12:00 PM. Despite communicating this preference to staff, the resident was told the schedule was based on staff convenience. A CNA confirmed the resident's request but lacked the authority to change it. The DON was informed of these findings.
A resident with severe cognitive impairment lost his hearing aids, and despite his daughter's report to staff, the facility failed to investigate or update them. Staff interviews revealed a lack of awareness and communication, and the Licensed Social Worker only initiated an investigation after being informed by the surveyor.
The facility failed to provide timely assistance to residents, leading to prolonged waits for toileting help. A resident with quadriplegia was left in a fetal position for two hours without receiving a needed suppository. Another resident with cerebral infarction and diabetes reported frequent delays in receiving toileting assistance, sometimes waiting up to one and a half hours. A third resident with hemiplegia and spinal stenosis experienced a half-hour wait for help while on the toilet. Staff interviews suggested potential staffing inadequacies.
A resident with limited ROM did not receive a left hand splint as ordered by the physician. Despite multiple observations showing the resident with a contracture and no splint, staff interviews revealed a lack of awareness and documentation regarding the splint order. The Restorative team was responsible for applying the splint, but there was no record of its application in the electronic system.
A facility failed to provide adequate supervision during a Hoyer lift transfer, as a CNA used the lift without a second staff member, contrary to policy. Additionally, an oxygen tank was improperly stored beside a resident's bed, against facility policy. The resident required continuous oxygen therapy due to respiratory issues. Staff interviews revealed inconsistent practices in oxygen tank storage.
The facility failed to accurately reconcile controlled substances for two residents. One resident's Alprazolam administration was not documented in the controlled drug record, while another resident's Oxycodone administration was not recorded in the MAR. Staff interviews revealed lapses in following documentation protocols.
The facility failed to secure treatment and medication carts and did not dispose of expired medications. An unlocked treatment cart was observed in the Delta unit, and an LPN left a medication cart unattended during a resident altercation. Expired medications were found in a medication cart, despite regular checks by staff.
The facility failed to implement CDC guidelines for Enhanced Barrier Precautions for two residents with wounds. One resident lacked EBP guidelines in their care plan, and observations showed missing PPE and signposts. CNAs assisted the resident without gowns due to urgency and lack of PPE. Another resident also lacked EBP guidelines, with no signpost or PPE readily available. Staff relied on verbal reports for EBP adherence, indicating a failure in infection prevention and control.
The facility failed to maintain functional emergency call devices in two bathrooms on the Alpha Unit, with pull cords wrapped around grab bars and dragging on the floor. Staff interviews confirmed the cords should not be wrapped, and the DON acknowledged the absence of a policy on call devices.
The facility failed to follow physician's orders for wound treatment for two residents. One resident's dressing was not changed as required, and another resident had a skin tear dressing without a physician order. Both discrepancies were confirmed by staff and documented inaccurately.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss in a timely manner for a resident, leading to a deficiency in providing adequate nutritional care. The resident, who had a history of right adrenalectomy, bipolar disorder, dementia, and hypertension, experienced multiple significant weight losses over a period of time. Despite these changes, the facility did not implement effective nutritional interventions or communicate effectively among the multidisciplinary team to address the resident's nutritional needs. The facility's policies required the dietitian to work closely with the interdisciplinary team to assess and address nutritional issues. However, the dietitian did not consistently attend risk meetings or communicate significant weight loss to the resident's practitioner or nursing staff. The resident's weight was monitored, but the dietitian's recommendations were not timely or sufficient to prevent further weight loss. The resident's nutritional supplements were reduced based on meal consumption, but this decision did not consider the ongoing weight loss. Interviews with staff revealed a lack of awareness and communication regarding the resident's severe weight loss. The nurse practitioner was not informed of the significant weight loss until it was visibly noticeable, and the dietitian did not contact the practitioner or nursing staff about the resident's condition. The facility's director of nursing and other staff members were aware of the weight loss but did not take appropriate action to address it. This lack of communication and timely intervention contributed to the deficiency in maintaining the resident's nutritional health.
Failure to Provide Fresh Fruit as Per Menu
Penalty
Summary
The facility failed to adhere to its own menu guidelines by not providing fresh fruit to residents as specified. Observations and interviews with eight residents revealed that they were not receiving fresh fruit daily as indicated on their meal tickets. Residents reported receiving fresh fruit, specifically bananas, only once or twice a week, contrary to the menu that promised fresh fruit for breakfast daily. This discrepancy was noted during breakfast observations in the main dining room and in residents' rooms. The residents involved in this deficiency were cognitively intact, as indicated by their Brief Interview of Mental Status (BIMS) scores of 15, except for one resident who was rarely or never understood. The facility's diet technician confirmed the weekly delivery of bananas and the substitution of other fresh fruits but could not explain why fresh fruit was not provided to all residents on the observed date. This failure to follow the menu affected residents with various diagnoses, including Hypokalemia, Hemiplegia, Depression, Dysphagia, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Type 2 Diabetes, Hypertension, Parkinson's, and Anxiety Disorder.
Facility Fails to Provide Palatable and Appetizing Meals
Penalty
Summary
The facility failed to provide palatable, appetizing, and flavorful food to eight residents, as observed through interviews and record reviews. Residents expressed dissatisfaction with the quality and taste of the food, describing it as bland, unappetizing, and inconsistent with their requests. For instance, one resident complained about the inconsistency in receiving eggs cooked to their preference, while another mentioned that meals were incomplete and did not match the menu. Additionally, a test tray revealed that the food lacked seasoning, color variation, and was served in an unappealing manner. Several residents, despite having varying levels of cognitive impairment, consistently reported that the food was not flavorful and did not meet their expectations. One resident with severe cognitive impairment stated that the food was horrible, while another with no cognitive impairment mentioned that the staff reacted negatively when complaints about the food were made. The residents' medical conditions, such as chronic kidney disease, amyotrophic lateral sclerosis, and diabetes, were noted, but the primary concern was the lack of appetizing and flavorful meals. The Food Service Director acknowledged that many residents were on a No Added Salt diet, which contributed to the bland taste of the food. However, the test tray was conducted on a Regular diet, indicating that the issue was not solely related to dietary restrictions. The deficiency in providing palatable meals was evident across multiple residents, regardless of their dietary needs or cognitive status, highlighting a systemic issue in the facility's food service operations.
Failure to Provide Correct Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct diet consistency for nine residents who were prescribed a pureed consistency diet. Observations revealed that meals served to these residents were not smooth and contained lumps or solid particles, which is inconsistent with the requirements for a pureed diet. This issue was observed during multiple meal services, where residents were served pureed entrees that appeared lumpy and contained small pieces that required chewing. The Food Service Director acknowledged the inconsistency after a surveyor's observation and tasting of the meals. The facility's policy on pureed food consistency, which requires a smooth texture without solid particles, was not adhered to. Specific residents affected included those with conditions such as dysphagia and Parkinson's, who require a pureed diet to prevent complications with chewing or swallowing. For instance, one resident with Parkinson's and dysphagia was served a meal with visible pieces of corn, and another resident with dysphagia was served lumpy pureed corn. The Speech Language Pathologist confirmed that the pureed food should have a smooth consistency and expressed concern over the presence of solid particles in the meals served. The facility's failure to provide the correct diet consistency had the potential to affect 14 residents prescribed the pureed diet.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitary conditions, impacting 106 of 112 residents. During an initial kitchen tour, several deficiencies were noted, including the presence of personal food stored improperly in the walk-in refrigerator, debris on the floor of the Arctic walk-in freezer, and unclean equipment such as a metal backsplash with black and brown streaks, a clear plastic bin with dried residue, frying pans with burned debris, a large stock pot with black debris, and a meat slicer with rusty and brown residue. These observations indicate a lack of proper cleaning and maintenance of kitchen equipment and storage areas. Further issues were identified during a follow-up tour, where food temperatures were found to be above the safe standard of 41°F, with chocolate pudding at 48°F and puree Black Forest Cake at 54°F. Additionally, the nourishment rooms had unsanitary conditions, including brown residue on refrigerator shelves and door handles, and a microwave with brown residue on its interior surfaces. The refrigerator in the Delta Yellow nourishment room was also above the safe temperature at 44°F. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities, contributing to the unsanitary conditions observed.
Failure to Honor Resident's Bedtime Preference
Penalty
Summary
The facility failed to honor a resident's choice regarding their preferred scheduled bedtime, as outlined in their care plan and interest assessments. The resident, who was admitted with Quadriplegia, C1-C4 incomplete, and had a BIMS score indicating no cognitive impairment, expressed that it was very important for them to choose their bedtime. Despite this, observations showed the resident was still in bed undressed late in the morning on multiple occasions. The resident expressed a desire to be out of bed by 10:00 AM, but was consistently left in bed until after 12:00 PM. The resident communicated this preference to the staff, but was told that the schedule was based on what was best for the nursing staff. A CNA confirmed the resident's request but stated she did not have the authority to change the schedule. The Director of Nursing was informed of these findings.
Failure to Address Grievance Regarding Lost Hearing Aids
Penalty
Summary
The facility failed to address a grievance regarding the loss of hearing aids for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including Traumatic Subdural Hemorrhage and Major Depressive Disorder, reported losing his hearing aids two weeks prior to the survey. Despite the resident's daughter reporting the loss to both laundry and nursing staff, no action was taken to investigate or resolve the issue, and the resident was not updated on the status of his hearing aids. Interviews with staff revealed a lack of awareness and communication regarding the resident's grievance. A Certified Nursing Assistant (CNA) and a Charge Licensed Practical Nurse (LPN) were unaware of the resident's loss of hearing aids. The Licensed Social Worker (LSW) explained the facility's process for reporting lost items, which involves completing a Care and Concern form and initiating an investigation. However, no such form was completed for the resident's hearing aids, indicating a breakdown in the reporting process. The resident's daughter expressed concern about her father's difficulty in communicating due to the loss of his hearing aids. Despite her efforts to report the issue, she received no updates from the facility staff. The LSW acknowledged the reporting failure and initiated the investigation only after being informed by the surveyor. This deficiency highlights the facility's failure to adhere to its grievance policy and promptly address resident concerns.
Failure to Provide Timely Assistance to Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for three residents. Resident #114, who has quadriplegia, was left in a fetal position on his bed for two hours waiting for a suppository that was never administered. This incident was discovered by a CNA who found the resident sweating and with a racing heart, and subsequently assisted him to the bathroom. Resident #34, who has a history of cerebral infarction and diabetes, reported during a resident council meeting that he frequently waits too long for toileting assistance, sometimes up to one and a half hours, despite using the call bell and contacting the front desk for help. Resident #104, who has hemiplegia and spinal stenosis, also reported waiting for half an hour for assistance while on the toilet. A CNA informed him that she could not assist because she was assigned to a different section. Interviews with staff revealed that each CNA was responsible for seven residents, and while they believed they could manage with love and cooperation, there was an implication of insufficient staffing to meet residents' needs promptly. These incidents highlight a failure to provide timely and adequate care, as required by professional standards.
Failure to Apply Left Hand Splint as Ordered
Penalty
Summary
The facility failed to provide a left hand splint as per the physician's order for a resident with limited range of motion. The resident, who was readmitted with diagnoses of hypertension and muscle weakness, had an order dated 11/30/23 to apply a left hand splint and left elbow protector for 8 hours during AM hours. Observations on multiple occasions revealed that the resident was in bed with a contracture on the left hand and no splint in place. The resident confirmed that the splint had not been applied, and staff interviews indicated a lack of awareness and documentation regarding the splint order. Interviews with the facility's Rehab Director, Registered Nurse, and Restorative Certified Nursing Assistant revealed a breakdown in communication and responsibility for ensuring the splint was applied. The Restorative team was responsible for overseeing the placement of splints, but there was no documentation in the electronic system for the resident's splint application. The Restorative CNA was unaware of the order for the left hand splint, and the Registered Nurse confirmed that no documentation was present for the splint's application in the last 14 days. The Director of Nursing was informed of these findings.
Inadequate Supervision and Oxygen Tank Storage Deficiencies
Penalty
Summary
The facility failed to provide adequate supervision during a Hoyer lift transfer for a resident, which was observed when a Certified Nursing Assistant (CNA) used the mechanical lift to lower the resident into bed without the assistance of another staff member, contrary to the facility's policy. The policy requires at least two people to assist during mechanical lift transfers. The CNA acknowledged the difficulty in finding additional staff to assist during busy times, such as breakfast, which led to the unsupervised transfer. This deficiency had the potential to affect 50 residents who used Hoyer lifts in the facility. Additionally, the facility failed to ensure that an oxygen tank was properly secured for another resident. Observations revealed that an additional oxygen tank was standing next to an empty holder beside the resident's bed, contrary to the facility's policy that requires all portable oxygen tanks not in use to be secured and stored in the designated oxygen storage room. Interviews with staff members indicated a lack of consistent practice regarding the storage of oxygen tanks, with some staff stating that extra tanks should not be kept at the bedside and should be returned to the oxygen room when empty. The resident involved in the oxygen tank deficiency had a history of respiratory issues, including COPD and acute respiratory failure, and required continuous oxygen therapy. Despite the facility's policy and the resident's care plan, the unsecured oxygen tank posed a potential hazard. The inconsistency in staff practices regarding the storage of oxygen tanks highlights a gap in adherence to the facility's safety protocols.
Controlled Substance Reconciliation Failures
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substance medications for two residents. For one resident, there was a discrepancy in the documentation of Alprazolam administration. The resident's controlled drug record sheet did not reflect the removal of a tablet on a specific date, although the electronic Medication Administration Record (eMAR) indicated it was administered. The Licensed Practical Nurse (LPN) involved acknowledged the oversight, stating she missed documenting the removal in the controlled drug record. The Director of Nursing expressed confusion over the inconsistency between the eMAR and the controlled drug binder. For another resident, there was a failure to document the administration of Oxycodone in the Medication Administration Record (MAR), despite it being signed out on the Controlled Drug Record. The Registered Nurse (RN) confirmed the correct count of the medication, but the administration was not recorded in the MAR. Interviews with nursing staff, including the Director of Nursing, revealed that the protocol requires documentation in both the Controlled Drug Record and the MAR, which was not followed in this instance.
Medication and Treatment Cart Security and Expired Medications
Penalty
Summary
The facility failed to ensure the security of treatment and medication carts, as well as the proper disposal of expired medications. During an initial tour, a treatment cart in the Delta unit was found unlocked and unattended, containing treatment medications labeled with residents' names and a pair of scissors. This cart remained unlocked for an extended period, despite multiple staff members and residents passing by. Additionally, during a medication administration observation, an LPN left a medication cart unlocked and unattended for approximately seven minutes while addressing a potential altercation between two residents. The dispensed medication for a resident was left on top of the cart during this time. Furthermore, a review of medication storage revealed expired over-the-counter medications in a medication cart in the Delta Yellow unit. The expired medications included an antacid and a cough syrup, both past their expiration dates. Staff E, a Senior LPN, expressed surprise at finding expired medications, despite regular checks by the pharmacist and unit nurse supervisor. The Delta Unit Nurse Supervisor confirmed that random checks are conducted, and floor nurses are responsible for checking expiration dates before administering medications.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to implement CDC guidelines for Enhanced Barrier Precautions for two residents with wounds. Resident #61, who was readmitted with multiple diagnoses including wounds on the right and left heels, did not have Enhanced Barrier Precautions (EBP) guidelines included in their care plan. Observations revealed the absence of EBP signposts on the resident's door and a lack of personal protective equipment (PPE) such as gowns and gloves on the metal shelf. During an incident, two CNAs assisted the resident with toileting without wearing gowns, citing the absence of gowns on the shelf and urgency as reasons. Interviews with staff revealed a lack of clarity on who was responsible for replenishing PPE and the omission of EBP guidelines in the care plan. Similarly, Resident #101, admitted with end-stage renal disease and sacral pressure ulcers, also lacked EBP guidelines in their care plan. Observations showed no EBP signpost or PPE shelf on the resident's door. A wound care RN had to request a PPE gown before entering the resident's room, indicating a lack of readily available PPE. Interviews with staff highlighted that the wound care RN had placed the PPE cart, but there was no EBP signpost, and staff relied on verbal reports to know when EBP guidelines should be followed. These deficiencies indicate a failure to adhere to CDC recommendations for infection prevention and control in the care of residents with wounds.
Deficiency in Emergency Call Device Functionality
Penalty
Summary
The facility failed to ensure that the emergency call devices in the bathrooms of the Alpha Unit were functioning properly. Observations revealed that in two of the twelve bathrooms, the emergency call device pull cords were wrapped around the grab bars, rendering them non-functional. Photographic evidence was obtained to document these findings. Interviews with staff members, including CNAs and RNs, confirmed that the pull cords should not be wrapped around the grab bars, indicating a lack of adherence to proper protocol. Further investigation revealed that the facility did not have a policy in place regarding the proper use and maintenance of emergency call devices. The Director of Nursing confirmed the absence of such a policy during an interview. The Registered Nurse Supervisor acknowledged the issue during a side-by-side observation with the surveyor and attempted to rectify the situation by unwrapping the cords, which were found to be excessively long and dragging on the floor. This deficiency highlights a gap in the facility's procedures for ensuring resident safety in bathroom areas.
Failure to Follow Physician's Orders for Wound Treatment
Penalty
Summary
The facility failed to follow the physician's orders for wound treatment for two residents. Resident #4, who had diagnoses including Non-Traumatic Intracerebral Hemorrhage, Encephalopathy, Unsteadiness on Feet, Diabetes Mellitus, and an Unspecified Open Wound on the Lower Leg, was supposed to have his left lower leg dressing changed every other day as per physician's orders. However, observations revealed that the dressing was dated 04/18/24, indicating it had not been changed as required. The Wound Care Nurse and a Registered Nurse confirmed the discrepancy, and the Treatment Administration Record falsely documented that the dressing had been changed on 04/20/24 and 04/22/24. Resident #5, who had diagnoses including Atrial Fibrillation, Diabetes Mellitus, Venous Insufficiency, Cellulitis of the Left Toe, Localized Swelling, Acute Osteomyelitis, and an Open Wound of the Left Foot, had a skin tear on the left shin with a Xeroform gauze dressing. However, there was no physician order for this treatment. The Wound Care Nurse was unaware of the skin tear, and the Director of Nursing confirmed the absence of a physician order for the dressing. An RN later stated that an order for the skin tear was obtained on the day of the surveyor's observation.
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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