Apopka Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Apopka, Florida.
- Location
- 2001 Alston Bay Blvd, Apopka, Florida 32703
- CMS Provider Number
- 106144
- Inspections on file
- 21
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Apopka Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and a court determination of total incapacity had documented upper dentures and a court-appointed legal guardian whose contact information was on file. The resident’s record indicated use of dentures or partials, yet the resident was later observed in the dining room without dentures, and staff believed the dentures had been missing for several weeks. The legal guardian reported not being informed that the dentures were missing, and the ED acknowledged the guardian was not notified because dentures often go missing and later reappear, despite a facility policy requiring notification of the resident’s representative when an incapacitated resident experiences changes requiring decisions.
The facility failed to notify the Ombudsman of a resident's transfer/discharge to the hospital. The resident, with multiple complex medical conditions, was hospitalized and readmitted, but the required notice was not found in records or submitted to the Ombudsman. The SSD acknowledged the missing documentation, and the facility could not provide a transmission log for February discharges, affecting fifteen residents.
The facility failed to ensure accurate medical records and proper splint application for two residents. One resident's splint was not consistently applied as per physician's orders, and there was confusion among staff about the task. Another resident's EMR contained progress notes for a different resident, indicating a lack of systematic organization and oversight.
A facility failed to ensure an effective discharge planning process for a resident with multiple diagnoses, leading to a delay in necessary care and services post-discharge. The resident was discharged without required Home Health Care (HHC) services and medical equipment, forcing the resident's son to arrange for these services himself. Facility staff acknowledged the communication breakdown and lack of proper follow-up.
The facility failed to promote the right to self-administer medication for two residents. One resident with moderate cognitive impairment was using Biofreeze without a physician's order or assessment, while another cognitively intact resident was using eye drops without proper authorization. The facility did not follow its policy on assessing residents' ability to self-administer medications.
A resident with multiple health conditions had a care plan indicating a preference for showers on specific days and times, but the facility scheduled her showers on different days and times, leading to her refusal of care. Staff confirmed the discrepancy, and the facility's policy on resident rights was not followed.
A facility failed to honor a resident's DNRO due to a discrepancy in records and lack of communication between hospice and facility staff. The resident was incorrectly listed as a full code, risking unwanted CPR for six weeks.
A facility failed to complete a significant change in status assessment (SCSA) within the required 14-day timeframe for a resident receiving Hospice services. The oversight was due to a lack of communication between Social Services, MDS, and nursing staff, resulting in non-compliance with CMS guidelines.
A facility failed to develop a comprehensive person-centered care plan for a resident receiving Hospice services due to a lack of communication between Social Services, MDS, and nursing staff. The resident's medical record lacked a care plan for Hospice or end-of-life care despite having a Hospice Medicare Election form and certification of terminal illness.
The facility failed to provide adequate ADL assistance for two residents, resulting in poor personal hygiene and unkempt appearances. One resident had long, unkempt fingernails and greasy hair, while another had long facial hair and reported not receiving razors despite requests. The facility's policies and care plans were not consistently followed.
The facility failed to apply a right-hand resting splint per physician order for a resident with hemiplegia and hemiparesis following a stroke. Observations revealed the splint was not applied, and staff interviews indicated a lack of training and responsibility in applying the splint after the resident was discharged from therapy.
A resident with multiple diagnoses, including a non-healing wound, had a midline IV with a bloody gauze pad under the transparent dressing that was not changed for four days. LPNs responsible for the resident's care failed to inspect and change the dressing as required, posing an infection risk. The facility's policies for IV site care were not followed, contributing to the deficiency.
Failure to Notify Legal Guardian of Missing Dentures for Incapacitated Resident
Penalty
Summary
The facility failed to notify a court-appointed legal guardian of a significant change involving missing dentures for a resident who had been determined totally incapacitated. The resident was admitted with dementia with behavioral disturbances, and a court determination dated 10/26/23 documented the resident’s total incapacity related to dementia and lack of awareness. On 8/8/24, a legal guardian of person and property was appointed, and the guardian’s name, phone number, and email address were documented in the admission record. The resident’s inventory list dated 7/29/24 showed that the resident had upper dentures, and a monthly summary progress note on 1/19/26 indicated the resident wore dentures or partials. On 1/27/25 at 12:24 PM, the resident was observed in the dining room for lunch without dentures in place. During a phone interview on 1/28/26 at 3:40 PM, the legal guardian reported being unaware that the dentures were missing and stated the facility had never notified her of this issue. On 1/29/26 at 10:05 AM, the Executive Director stated that staff believed the dentures had been missing for approximately three weeks and acknowledged that the guardian had not been notified because dentures often go missing for a few weeks before turning up again. Review of the facility’s “Notification of Changes” policy showed that when a resident is deemed incapacitated, the resident’s representative is to be notified so that they can make necessary decisions, which did not occur in this case.
Failure to Notify Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The facility failed to ensure a copy of the notice for transfer/discharge to the hospital was sent to a representative of the Office of the State Long-Term Care Ombudsman for one resident. The resident, who had multiple complex medical conditions including metabolic encephalopathy, hemiplegia/hemiparesis following a stroke, and acute and chronic respiratory failure, was hospitalized and readmitted to the facility. However, the required Nursing Home Transfer and Discharge Notice for the resident could not be found in the clinical records or the Social Services Director's (SSD) binder, and there was no evidence that the notice was submitted to the Ombudsman as required. The SSD, who was recently hired, acknowledged the missing documentation and explained that she was informed all documents would be scanned into the facility's electronic medical record. Despite providing a Nursing Home Transfer and Discharge Notice dated for the resident, there was no documentation to indicate it was submitted to the Ombudsman's office. Additionally, the facility could not provide a transmission log for February discharges, and a review revealed that fifteen residents were discharged to the hospital during that period without proper notification to the Ombudsman. The facility also failed to provide a corresponding policy or procedure regarding the notification of discharges.
Deficiencies in Medical Record Accuracy and Splint Application
Penalty
Summary
The facility failed to ensure medical records were accurate regarding the application of a splint for a resident with hemiplegia and hemiparesis following a stroke. The physician's order required the splint to be applied to the resident's right wrist following morning care and removed before bedtime, with monitoring of skin integrity. However, observations revealed the splint was not applied on multiple occasions, and there was ambiguity in the Treatment Administration Record (TAR) about whether the task being signed off was the application of the splint or the monitoring of skin integrity. Interviews with staff indicated confusion and lack of training regarding the application of the splint, leading to inconsistent care and documentation for the resident. The facility also failed to maintain accurate and systematically organized medical records for another resident. The resident's Electronic Medical Record (EMR) contained twenty progress notes that belonged to a different resident. This error was acknowledged by the Regional Director of Clinical Services and the Executive Director, who noted that the Health Information Coordinator was on leave and that the discrepancy had been reported to the facility's Corporate office. The Executive Director admitted to not knowing who was responsible for reviewing the residents' EMRs to ensure accuracy. These deficiencies highlight significant lapses in the facility's adherence to professional standards for maintaining accurate medical records and ensuring proper care for residents. The issues with the splint application and the misfiled progress notes indicate a need for better training, clearer documentation practices, and more rigorous oversight of medical records to prevent such errors from occurring in the future.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to ensure an effective discharge planning process for a resident, leading to a delay in necessary care and services post-discharge. The resident, who had multiple diagnoses including a left hip fracture, stroke, and brain cancer, was discharged home without the required Home Health Care (HHC) services. Despite having a care plan that included arranging community resources and medical equipment, the resident was discharged without a walker and necessary wound care supplies. The resident's son had to arrange for HHC services and purchase a walker himself after discovering that the initially referred HHC agency was not in-network with their insurance. The medical record indicated that the resident required assistance with activities of daily living and had a wound that needed daily dressing changes. The facility's Social Services Director (SSD) failed to ensure that the HHC services and medical equipment were arranged before discharge. The SSD relied on an outside HHC agency to make arrangements, but there was no follow-up to confirm that these services were in place. The resident's son reported the issues to the facility, but the necessary services were not provided until three days after the discharge. Interviews with facility staff confirmed that the discharge planning process was not adequately managed. The Business Office Manager and the Administrator acknowledged the communication breakdown and the lack of proper documentation and follow-up by the SSD. The facility's policy required the Social Services staff to oversee discharge arrangements and ensure a safe transition, which was not adhered to in this case. The failure to provide the necessary care and services as ordered by the physician led to a significant lapse in the resident's post-discharge care.
Failure to Promote Right to Self-Administer Medication
Penalty
Summary
The facility failed to promote the right to self-administer medication for two residents. Resident #87, who had moderate cognitive impairment and was using Biofreeze for pain relief, was found to have the medication at his bedside without a physician's order or an assessment for safe self-administration. The Unit Manager and the assigned nurse were unaware of the medication's presence and confirmed that no proper documentation or assessment had been completed for the resident to self-administer the medication safely. Similarly, Resident #161, who was cognitively intact and managing her own eye drops since admission, was found with both prescription and non-prescription eye drops at her bedside. The resident had been using these medications without a physician's order or an assessment to verify her capability to self-administer them safely. The Unit Manager confirmed that the facility's policy and procedures for self-administration of medications were not followed, as there was no documentation or assessment for the resident's ability to self-administer the medications. The facility's policy on self-administration of medications requires an assessment of the resident's mental and physical abilities, comprehension of medication labels, and understanding of the purpose, dosage, and administration times. However, in both cases, the facility did not implement these procedures, resulting in residents having medications at their bedside without proper authorization or assessment, thereby failing to ensure the safe self-administration of medications.
Failure to Honor Resident's Preferred Shower Schedule
Penalty
Summary
The facility failed to honor a resident's right to choose their preferred shower days and times. Resident #21, who has diagnoses including hemiplegia, morbid obesity, heart failure, and type 2 diabetes, was admitted to the facility and had a care plan indicating a preference for showers on Monday, Wednesday, and Friday during the day shift. Despite this, the resident's bathing task report showed she was scheduled for showers on Tuesday and Friday during the 3-11 PM shift. The resident expressed her preference to staff, but her requests were not accommodated, leading to her refusal of showers on several occasions. Interviews with the resident, CNAs, and the Licensed Practical Nurse Unit Manager confirmed the discrepancy between the resident's care plan and the actual shower schedule. The Assistant Director of Nursing also verified that the resident's scheduled shower days did not align with her preferences. The facility's Resident Rights policy emphasizes the importance of honoring resident choices, but in this case, the facility did not adhere to the resident's preferred shower schedule, thus failing to support her self-determination and choice.
Failure to Honor Resident's DNRO
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate Order (DNRO) for a resident who was under hospice care. The resident, who had multiple serious health conditions including cerebral infarction, acute kidney failure, and idiopathic pulmonary fibrosis, had a DNRO signed by both herself and the hospice physician. However, the facility's records and care plan incorrectly listed her as a full code, meaning that in the event of cardiac or respiratory arrest, CPR would be initiated. This discrepancy was not identified until a surveyor brought it to the facility's attention, despite the DNRO being present in the hospice notebook at the nurses' station. The issue was compounded by a lack of communication between the hospice staff and the facility staff. The hospice nurse who admitted the resident did not document any communication with the facility staff regarding the change in code status. As a result, the facility staff, including the usual day nurse for the resident, were unaware of the DNRO and would have initiated CPR based on the incorrect full code status in the facility's records. This failure persisted for six weeks, during which the resident's wishes for a DNRO were not honored, posing a significant risk to her autonomy and end-of-life care preferences.
Failure to Complete Significant Change in Status Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) within the required timeframe of 14 days for a resident who was receiving Hospice services. The resident, who had multiple diagnoses including cerebral infarction, acute kidney failure, idiopathic pulmonary fibrosis, acute respiratory failure, repeated falls, weakness, anxiety, depression, and dysphagia, was admitted and readmitted to the facility. Despite the resident signing the Medicare Election Statement for Hospice services and having a physician order for Hospice services, the facility did not complete the SCSA within the required 14-day period. The most recent Minimum Data Set (MDS) assessment was conducted on 1/23/24, and no SCSA was found in the resident's medical record after the Hospice election date of 2/15/24. The Registered Nurse MDS Coordinator confirmed that the SCSA had not been initiated due to a lack of communication between Social Services, MDS, and nursing staff. The usual process of updating care plans, Advanced Directives, and initiating the SCSA during morning or clinical meetings was not followed. The MDS Coordinator acknowledged that the SCSA was out of compliance and was only brought to their attention by the surveyor. According to the CMS Resident Assessment Instrument Manual, an SCSA is required when a terminally ill resident enrolls in a hospice program, and it must be performed within 14 days to ensure a coordinated plan of care between the hospice and the nursing home.
Failure to Develop Comprehensive End-of-Life Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for end-of-life care for a resident who was receiving Hospice services. The resident, who had multiple diagnoses including idiopathic pulmonary fibrosis, stroke, and acute kidney failure, was admitted and readmitted to the facility. Despite having an intact cognitive status and requiring partial to moderate assistance with activities of daily living, the resident's medical record lacked a care plan for Hospice or end-of-life care, even though a Hospice Medicare Election form and certification of terminal illness were present. The deficiency was acknowledged by the Registered Nurse MDS Coordinator, who cited a lack of communication between Social Services, MDS, and nursing staff as the reason for the oversight. The usual process of updating care plans and advanced directives during morning or clinical meetings was not followed, resulting in the failure to initiate a significant change in status assessment and a comprehensive care plan for the resident when she began receiving Hospice services.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, specifically in the areas of bathing, skin care, and shaving. Resident #134, who has Parkinson's disease and is cognitively intact, was observed with long, unkempt fingernails, greasy hair, and unshaven facial hair. The resident reported receiving infrequent bed baths and showers, and the Unit Manager confirmed that the resident's fingernails were excessively long and that his feet showed signs of inadequate hygiene. The resident's care plan indicated he should receive three bed baths or showers weekly, but records showed inconsistencies in this care being provided. Resident #87, who has moderate cognitive impairment and multiple diagnoses including congestive heart failure and type 2 diabetes, was observed with an unkempt appearance and long facial hair. The resident reported asking for razors for three days without receiving any and stated that staff had not offered to shave him recently. The Unit Manager confirmed the resident's need for shaving and noted that the resident's care plan required substantial assistance with bathing and personal hygiene tasks. The shower schedule indicated the resident should have showers twice weekly, but there was no documentation of refusal of ADL care. The facility's policy and procedure for ADL care and assistance, as well as the CNA job description, require staff to assist residents with bathing, grooming, and maintaining personal hygiene according to their care plans. However, the observations and interviews revealed that the facility did not consistently provide the necessary care, leading to deficiencies in the residents' personal hygiene and overall well-being.
Failure to Apply Right-Hand Resting Splint Per Physician Order
Penalty
Summary
The facility failed to ensure that a right-hand resting splint was applied per physician order and the resident's plan of care for a resident with hemiplegia and hemiparesis following a stroke. The resident, who had functional limitations in range of motion to one side of his upper and lower extremities, had a physician's order to apply the splint following morning care and remove it before bedtime. However, observations on multiple occasions revealed that the splint was not applied, and the resident confirmed that no one had applied it. The splint was consistently found on the resident's bedside table instead of being worn by the resident. Interviews with staff, including an LPN and a CNA, revealed that the splint had not been applied for several days, and the CNA admitted he was not trained to don/doff the splint. The Rehabilitation Director stated that once the resident was discharged from therapy, nursing staff were responsible for applying the splint. However, the Director of Nursing and Assistant DON acknowledged that the expectation was for nurses to follow physician orders and sign off on the Treatment Administration Record (TAR) to indicate the splint was applied and skin integrity monitored. Despite this, there were inconsistencies in the application and monitoring of the splint, as evidenced by the LPN's admission that she signed off on the TAR without applying the splint.
Failure to Properly Monitor and Change IV Dressing
Penalty
Summary
The facility failed to provide care and services for an intravenous (IV) access site according to professional standards of practice to prevent infection for a resident. Resident #18, who had multiple diagnoses including ischemic cardiomyopathy, type 2 diabetes, and dementia, was receiving Ertapenem via a midline IV for a non-healing right heel wound with osteomyelitis. The resident's care plan included instructions for IV therapy, which required nurses to change the IV dressing and monitor the catheter insertion site every shift for signs of infection and other complications. However, observations revealed that the resident had a bloody, folded gauze pad under the transparent dressing, which had not been changed for four days, posing an infection risk. Licensed Practical Nurse (LPN) M and LPN N, who were responsible for the resident's care, failed to inspect and change the dressing as required. LPN M admitted she had not assessed the IV site during her shift, and LPN N confirmed she had not checked the dressing since the start of her shift, planning to do so only when administering the IV medication. The dressing was dated 3/30/24, and there were no initials to indicate which nurse performed the IV site care. The gauze under the dressing was saturated with blood and yellow-colored fluid, indicating a lack of proper monitoring and timely intervention. The facility's Unit Manager and Regional Director of Clinical Operations acknowledged the issue, noting that the dressing should have been changed more frequently due to the bleeding. The facility's policy and procedure for IV site care required transparent dressings to be changed weekly and gauze dressings to be changed every two days. The failure to adhere to these protocols and the lack of documentation regarding the bleeding and use of gauze contributed to the deficiency, placing the resident at risk for infection.
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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