Ambassador Healthcare At College Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Myers, Florida.
- Location
- 13755 Golf Club Pkwy, Fort Myers, Florida 33919
- CMS Provider Number
- 105387
- Inspections on file
- 25
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 3 (2 serious)
Citation history
Health deficiencies cited at Ambassador Healthcare At College Park during CMS and state inspections, most recent first.
A cognitively impaired, frail resident with cancer, severe malnutrition, and documented moderate cognitive deficits repeatedly exhibited confusion, poor safety awareness, and treatment‑interfering behaviors such as pulling out IV/PICC lines. Despite therapy and psychiatric evaluations showing moderate cognitive impairment and a formal determination that the resident lacked decision‑making capacity, the facility’s elopement risk assessment classified the resident as not at risk, and the care plan was not updated to address elopement. On one morning, the front desk was left unattended and the front door remained accessible; the resident walked out unnoticed, crossed a road, and traveled about half a mile to a nearby college dorm, where staff found the resident disoriented, unsteady, and shaking and called EMS. Facility staff did not realize the resident was gone until contacted by campus security, did not document the elopement in the clinical record, and did not promptly reassess elopement risk, leading to an Immediate Jeopardy citation under F689 for failure to prevent accidents and provide adequate supervision.
Facility administration failed to ensure effective oversight and processes to prevent unsafe wandering and elopement when a cognitively impaired, confused, and frail resident with documented treatment-interfering behaviors and an incapacity determination walked past an unattended front desk, exited through an unlocked front door, and traveled off premises without staff knowledge. Despite prior documentation of moderate cognitive-communication deficits, fluctuating confusion, and dementia-level testing, the resident had been assessed as not at risk for elopement and was not reassessed. After the resident was found offsite and sent to the ER, leadership declined to classify the event as an elopement, did not document the incident or preventive measures in the clinical record, and a nurse reported being instructed not to document, contrary to the facility’s own elopement and documentation policies, resulting in an Immediate Jeopardy finding under F835.
A resident with moderately impaired cognition eloped from the facility without staff knowledge, was found at a nearby college dorm confused and unsteady, and was transported by EMS to a local ER, yet these events were not documented in the clinical record. Facility policy required specific, objective, and timely nurse’s notes with signatures and credentials, but staff reported being told not to chart the incident, and the only related BIMS assessment form on the date of return lacked a signature and credentials. This resulted in an incomplete and inaccurate medical record that did not reflect the resident’s elopement, ER visit, or subsequent assessment.
A resident with severe cognitive impairment and dependence for ADLs required two-person assistance for bed mobility, as specified in the care plan and Kardex. A CNA, unaware of this requirement and lacking Kardex training, provided care alone, resulting in the resident falling from bed and sustaining a forehead injury that required hospital treatment. Facility leadership confirmed this was neglect due to failure to follow the care plan.
A resident with severe cognitive impairment and mobility deficits fell from bed and sustained a forehead laceration requiring sutures when a CNA, unaware of the two-person assist requirement, provided care alone. The CNA had not been trained on the Kardex system, and the incident was substantiated as neglect by the DON and LNHA.
Two residents requiring assistance with meals were left with trays out of reach, delaying their dining assistance. Staff interviews revealed that CNAs delivered all trays before returning to assist, contrary to facility protocol. The RN and Unit Manager confirmed the need for immediate setup for residents needing help.
Failure to Supervise Cognitively Impaired Resident Resulting in Unnoticed Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment to prevent unsafe wandering and elopement for a cognitively impaired resident. The resident was admitted with diagnoses including esophageal cancer, severe protein‑calorie malnutrition, adult failure to thrive, and a history of immunosuppression therapy. Therapy and clinical evaluations shortly after admission documented moderate cognitive impairment, decreased insight, poor judgment, and decreased safety awareness. A Speech Language Pathology evaluation showed moderate cognitive‑communication deficits with impaired short‑term memory, problem solving, and executive functioning, and a SLUMS score indicating moderate cognitive impairment. The admission MDS BIMS score also indicated moderate cognitive impairment, and the care plan identified cognitive loss/dementia and fall risk. Multiple nursing and provider notes over the following weeks documented intermittent and worsening confusion, treatment‑interfering behaviors such as repeatedly pulling out IV/PICC lines, disorientation, and statements reflecting confusion. Despite this documentation, the facility’s Elopement Risk Evaluation completed on 11/6/25 concluded the resident was not at risk for elopement. The Unit Manager who completed the tool answered “No” to questions about cognitive impairment, poor decision‑making, exit‑seeking behaviors, wandering oblivious to safety, and history of elopement, while acknowledging the resident was independently mobile and able to exit the facility. On 11/19/25, a psychiatric APRN formally evaluated the resident for capacity at the request of the primary physician and documented that the resident lacked capacity to make decisions related to healthcare or long‑term placement, was significantly disoriented, and could benefit from a guardian or POA. Another APRN note the same day described significant disorientation and fluctuating mental status, with risk of delirium and unsafe behaviors. Nonetheless, the facility did not update the elopement risk assessment or care plan to reflect this change in condition and did not implement elopement‑specific interventions. On the day of the incident, staff notes and the facility’s own timeline show that the resident was last seen at the nursing station around mid‑morning, when he denied needing anything. The front desk receptionist left the front desk unattended to go to the kitchen, and the front door, which could be opened without staff intervention, was left accessible. Around that time, EMS exited the building with another resident, and the facility asserts the doors closed and locked, but the receptionist later stated that a visitor likely opened the front door, allowing the cognitively impaired resident to leave unnoticed. The resident walked out the front door, crossed a two‑lane road, and traveled approximately half a mile over uneven terrain and near multiple water retention ponds to a nearby college dormitory. College staff found him in the dorm, describing him as confused, disoriented, unsteady, shaking, disheveled, and unsure of where he was. EMS documentation noted he did not remember where he was supposed to be and believed he was in a different city. The facility did not become aware that the resident had left until contacted by campus security after EMS had been called, and there was no documentation in the clinical record that the resident had exited the facility without staff knowledge or supervision. Interviews with the Unit Manager indicated she was told not to document the incident and that no elopement re‑evaluation or care plan update was completed afterward. The facility’s failure to recognize and act on the resident’s documented cognitive impairment and lack of capacity, to accurately assess elopement risk, to maintain supervision at the front entrance, and to document the elopement led to the determination of Immediate Jeopardy under F689. The resident’s family member reported being very upset that they were not notified of the incident until 24 hours later and expressed concern about what could have happened while the resident was unsupervised outside the facility. The Administrator and DON acknowledged in interviews that the resident left the facility without staff knowledge and supervision, but the Administrator repeatedly resisted characterizing the event as an elopement, instead describing it as the resident going for a walk and forgetting to sign out. The Administrator also stated that she would allow residents she considered cognitively impaired but without a formal incapacity statement to leave unsupervised and was unaware of the psychiatric APRN’s documented incapacity determination at the time. The DON confirmed that she did not direct staff to make a late entry documenting the incident and did not order a new elopement risk assessment, stating she believed the resident was alert and oriented and that a new evaluation was only done when a resident newly expressed a desire to leave and “did not make sense.” These actions and inactions, in the context of extensive documentation of confusion and impaired safety awareness, contributed directly to the unsafe elopement and the cited deficiency for failure to prevent accidents and provide adequate supervision.
Removal Plan
- Resident #900 no longer resides at the facility and was successfully discharged home as planned.
- Resident #900 was immediately placed on 1:1 staff observation.
- A licensed nurse performed a complete skin inspection for Resident #900 with no new skin concerns identified.
- Resident #900’s cognitive status was re-evaluated using the BIMS assessment.
- The Administrator/Designee re-educated all staff on Missing Resident Drill and Elopement policy, emphasizing responding to door alarms, using the elopement binder, performing a resident headcount, and Administrator/DON notification.
- The Administrator modified the receptionist process for residents exiting the facility and added it to new hire education, including use of a binder with blue (requires supervision) and white (safe for unsupervised LOA) sheets, clinical team determination of supervision, and resident sign-in/sign-out for each LOA; front door opened by remote or keypad.
- The contracted vendor removed the automatic open option on the front double doors so doors remain locked with access by staff remote or keypad entry/exit only.
- The facility extended receptionist hours to 7:00 a.m.–9:00 p.m., 7 days/week.
- The front desk coverage process was updated to establish coverage when the receptionist is on break/steps away and to define the process for 9:00 p.m.–7:00 a.m. for assisting residents with LOA and/or visitors entering/exiting.
- Residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk by the DON/Designee.
- The Administrator confirmed the LOA process is included in the new admission packet.
- The DON/Designee completed a new elopement risk assessment on all current residents in the electronic medical record system.
- The receptionist on duty for the event was re-educated on ensuring residents exiting the facility were approved by clinical staff prior to exit and on the binder/blue-white sheet LOA process and door access process.
- The DON/Designee re-educated all employees on F689 (including CMS definition of elopement), the updated facility elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident exiting (binder/blue-white sheets, clinical team determination, sign-in/sign-out, remote/keypad door access).
- All licensed nurses were educated on communicating physician changes to a resident’s capacity and notifying the DON and/or Administrator at the time of determination to ensure timely re-evaluation of elopement risk.
- An ad hoc QA meeting was held with the facility Medical Director in attendance via phone.
Failure of Administrative Oversight Leads to Undetected Elopement of Cognitively Impaired Resident
Penalty
Summary
Facility administration failed to provide effective oversight and implement processes to ensure resident safety related to unsafe wandering and elopement. A cognitively impaired, ambulatory, and confused resident with poor safety awareness exited the building through an unlocked front door after walking past an unattended front desk. The resident crossed a two-lane road and walked approximately half a mile over uneven terrain and near water ponds to a nearby college dormitory. Facility staff were unaware the resident had left until they were notified by college campus security about the resident’s transfer to a local emergency room via EMS. The resident had multiple documented indicators of cognitive impairment and safety risk prior to the incident. The admission MDS showed moderately impaired cognition with a BIMS score of 12 and a need for partial to moderate assistance with ambulation and activities of daily living. Speech therapy documented moderate cognitive-communication deficits with problems in short-term memory, problem solving, and executive functioning. Nursing and provider notes described intermittent confusion, pulling out IV lines, statements indicating disorientation, and treatment-interfering behaviors requiring close supervision and safety monitoring. A psychiatric APRN documented that the resident lacked capacity to make healthcare and long-term placement decisions, was unable to understand the consequences of not receiving care, and recommended a guardian or POA. Despite this, the admission elopement assessment scored the resident as not at risk for elopement, there were no subsequent elopement reassessments, and the care plan, while noting impaired cognition, did not translate into effective elopement risk management. After the resident left the facility unsupervised, the administration did not consider the event an elopement and did not document the incident or any measures to prevent further unsafe wandering in the clinical record. The Administrator characterized the event as the resident going out for a walk and failing to sign out, and stated the resident was cognitively intact based on a BIMS score obtained upon return, despite prior documentation of incapacity and dementia-level SLUMS scoring. The DON expressed a desire not to label the event as an elopement and acknowledged there was no documentation in the record about the incident, stating she did not want to enter a late note because the Administrator conducted the investigation. A Unit Manager LPN reported being told not to document anything and that the Administrator and DON would handle it. The facility had an elopement prevention policy defining elopement for incapacitated residents and requiring an elopement risk assessment, monitoring device, and care plan when such a resident wanders into an unsafe area or leaves the building, but these processes were not implemented for this resident. The lack of adequate supervision, failure to recognize and classify the event as an elopement, failure to reassess elopement risk, and failure to document the incident and related interventions led to a determination of Immediate Jeopardy under F835.
Removal Plan
- Resident #900 was successfully discharged home as planned.
- The Administrator/Designee completed staff re-education on Missing Resident Drill and Elopement with all staff members, emphasizing responding to door alarms, using the elopement binder, performing a resident headcount, and Administrator and DON notification.
- The Administrator/Designee completed Missing Resident Drills at varying times with staff members participating collectively from each department.
- The Administrator modified the receptionist process for residents exiting the facility and added this to education for newly hired staff, including use of a newly created binder with blue (supervision required) or white (safe for unsupervised LOA) sheets for each resident, requiring residents to sign in/out for LOA each time they leave, and opening the front door by remote or keypad.
- The facility’s contracted vendor removed the automatic open option on the front double doors so doors remain locked with access by staff remote or keypad entry/exit only.
- The facility extended receptionist hours and updated the front desk coverage process for breaks/step-away coverage and for after-hours coverage for LOA/visitors.
- The Chief Nursing Officer re-educated the Administrator and Director of Nursing on the CMS definition of elopement, their roles to ensure resident safety, and the expectation to complete a risk management report for elopement events.
- The facility changed its elopement policy to reflect CMS’s definition of elopement.
- The interdisciplinary team was re-educated on reporting and documenting resident incidents in the clinical record, the alleged deficient practice outlined on the immediate jeopardy template, and federal regulation F835, emphasizing adherence to medical record documentation policies and procedures.
- Residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk.
- The receptionist on duty for the event was re-educated on ensuring residents exiting the facility were approved by clinical staff prior to allowing exit and on use of the LOA binder/blue-white sheets, sign in/out requirement, and door access by remote/keypad.
- The Director of Nursing/Designee completed new elopement risk assessments on all current residents in the EMR.
- All licensed nurses were educated on communicating physician determinations/changes in resident capacity to notify the DON and/or Administrator timely to ensure prompt re-evaluation of elopement risk.
- Staff were re-educated on the CMS definition of elopement, the updated elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident exits (including binder/blue-white sheets, clinical team determination of supervision for LOAs, sign in/out requirement, and door access by remote/keypad).
- An ADHOC QAPI meeting was held with the medical director participating by phone, and the QAPI committee approved the recommendations.
- QA meetings included review of the new receptionist process for residents exiting the facility.
Failure to Accurately Document Resident Elopement and ER Visit in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who eloped from the facility and was sent to the emergency room. Facility policy required that nurse’s notes be written by licensed/qualified nursing personnel, address the resident’s condition, be specific and objective, and be signed with the writer’s name and credentials, with frequency of entries based on resident need and changes in condition. The resident was admitted in early November and had an admission MDS showing a BIMS score of 12, indicating moderately impaired cognition. Nursing progress notes documented the resident’s level of consciousness and orientation on the evening of one date, with the next note two days later, but there was no documentation in the clinical record of the resident’s elopement, emergency room visit, or return to the facility. Interviews and external records confirmed that on a late November morning the resident exited the facility without staff knowledge or supervision, walked to a nearby state college dormitory, and was found there confused, disoriented, unsteady, and shaking. Campus personnel contacted EMS, which transported the resident to a local emergency room, with EMS records documenting times of response, departure, and transfer. The DON and Administrator verified the elopement and lack of documentation in the clinical record, and a unit manager stated she had been told not to document anything about the incident in the record, believing the DON and Administrator would handle it. The Administrator reported that a BIMS test was administered upon the resident’s return, but the provided BIMS form was unsigned and lacked the writer’s credentials, further contributing to the incomplete and noncompliant documentation of the resident’s medical record.
Failure to Follow Care Plan Results in Resident Injury Due to Neglect
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan and safety precautions for a resident with Alzheimer's Disease, anxiety disorder, and major depressive disorder, who had severely impaired cognition and was dependent on staff for activities of daily living (ADLs). The resident required substantial or maximum assistance of two staff members for bed mobility, as documented in both the care plan and the electronic Kardex system. Despite these requirements, a Certified Nursing Assistant (CNA) provided care alone, rolled the resident toward her, and the resident fell out of bed, sustaining a forehead injury that required hospital transfer and sutures. Interviews revealed that the CNA was unaware of the two-person assist requirement and had not been trained on the Kardex system during orientation. The CNA reported having provided solo care to the resident multiple times previously. The Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) confirmed that the CNA did not follow the resident's plan of care, and both identified this as neglect. The facility's investigation substantiated that the failure to follow the care plan and lack of staff training directly led to the resident's fall and injury.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, severe cognitive impairment, and significant ADL self-care deficits experienced a fall with injury during care. The resident's care plan and Kardex specified the need for substantial or maximum assistance of two staff members for bed mobility due to weakness and impaired balance. However, a CNA provided care alone, rolled the resident toward herself, and the resident fell out of bed, sustaining a forehead laceration that required hospital transfer and sutures. Staff interviews revealed that the CNA was unaware of the resident's two-person assist requirement and had not received training on the Kardex system during orientation. The DON and LNHA confirmed that the CNA did not follow the resident's plan of care, and the incident was substantiated as neglect. The facility's policy required that residents unable to perform ADLs independently receive necessary services, but this was not followed in this case, resulting in an avoidable accident and injury.
Failure to Provide Timely Dining Assistance
Penalty
Summary
The facility failed to provide timely assistance with dining for two residents who required help with their meals. Resident #2, diagnosed with Parkinson's Disease, was observed lying in bed with a breakfast tray placed out of reach on an over-the-bed table. The resident required partial to moderate assistance with eating, but the tray was not set up, and the resident was not awakened to eat. Similarly, Resident #3, who had a diagnosis of malignant neoplasm, was also observed with a breakfast tray out of reach. This resident required setup or cleanup assistance with eating, but the tray was left on the table without being set up, and the resident was not positioned to eat. Interviews with staff revealed that the Certified Nursing Assistant (CNA) responsible for delivering meal trays left them out of reach until all trays were delivered, delaying assistance for residents needing help. The Registered Nurse (RN) and Unit Manager confirmed that residents requiring assistance should have their trays delivered last and set up immediately. However, this protocol was not followed, leading to the deficiency. The Director of Nursing and Regional Nurse Consultant reiterated that trays should not be left without setting up and waking the resident, as outlined in the facility's care instructions.
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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