Avante At Boca Raton, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Boca Raton, Florida.
- Location
- 1130 Nw 15th Street, Boca Raton, Florida 33486
- CMS Provider Number
- 105521
- Inspections on file
- 28
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Avante At Boca Raton, Inc. during CMS and state inspections, most recent first.
Two residents did not receive appropriate care: one missed multiple doses of a critical IV antibiotic due to a medication entry error during admission, resulting in a hospital transfer, while another, on antiplatelet therapy, experienced a significant nosebleed with insufficient monitoring and documentation, ultimately requiring hospitalization.
A facility failed to conduct a thorough investigation into a neglect allegation involving wound care for a resident with multiple medical conditions, including an unstageable pressure ulcer and an indwelling catheter. The investigation did not include staff interviews or a review of wound care records, and lacked documentation explaining the circumstances of the wounds or measures to prevent recurrence.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures were not consistently implemented to avoid the development of new ulcers. Surveyors found that established protocols for pressure ulcer management and prevention were not followed, resulting in deficiencies in resident care.
A resident admitted with an indwelling Foley catheter did not have physician orders entered for routine catheter care every shift, and there was no documentation that such care was provided. Nursing staff confirmed the omission, and facility leadership acknowledged that the resident was not receiving appropriate catheter care as required by policy.
A resident with limited mobility and cognitive impairment did not receive a physician-ordered gynecological procedure due to the facility's failure to schedule and communicate about the order. Nursing staff were unaware of the order, and the resident's family was not informed or updated about the status of the procedure, resulting in a significant delay.
A resident with significant cognitive and physical impairments did not receive a physician-ordered procedure due to the facility's failure to schedule and communicate about the order. Nursing staff were unaware of the order, and the resident's family was not kept informed, resulting in a delay of necessary care.
The facility was found deficient in maintaining a clean and homelike environment. Observations included brown and rust-colored stains in the second-floor shower room, gaps and black markings in the first-floor shower room, cracked floor tiles, peeling paint and rust on a bed rail, black stains on privacy curtains, and a blanket with holes. Photographic evidence was obtained.
The facility was found deficient in maintaining a clean and homelike environment. Surveyors observed brown and rust-colored stains in the shower rooms, gaps and black markings on floors and walls, cracked floor tiles, a bed rail with peeling paint, stained privacy curtains, and a blanket with holes. These issues indicate a failure to provide a safe, clean, and comfortable environment for residents.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Deficiencies included soiled and rust-covered equipment, broken floor tiles, expired yogurt, inadequate chemical levels in cleaning areas, and various other sanitation issues. Numerous requests for maintenance had been made but were not addressed.
The facility failed to ensure an adequate food supply for 111 residents, leading to significant shortages in various food items and multiple resident complaints. The Certified Dietary Manager was suspended, and the Corporate Food Service Director took over temporarily. Two residents were not provided meals or snacks before dialysis, and physician-ordered dietary supplements were unavailable for at least one resident. Residents reported ongoing issues with the approved menu, food quality, and availability of snacks, which were not resolved by the administration.
The facility failed to maintain a sanitary and comfortable environment for residents, with multiple rooms and common areas found to have issues such as dust-laden A/C filters, damaged walls, mold build-up, and heavily soiled floors. The Corporate Maintenance Director confirmed that staff are not effectively using the computerized system to report these issues.
The facility failed to provide two residents with nourishing, palatable, well-balanced meals or snacks for their dialysis appointments. Despite multiple requests, the residents did not receive appropriate nutrition, and facility staff could not confirm if meals were being provided as required.
The facility failed to follow its approved menu, affecting 111 residents. Shortages of 2% milk, skim milk, and orange juice were noted, and several menu items were not prepared or substituted properly. The Certified Dietary Manager cited budget restraints and lack of communication with the Administrator as contributing factors. Interviews with residents revealed additional issues with menu adherence and snack provision.
The facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance, potentially affecting 111 residents. Foods were fully cooked and held for hours before meal service, compromising their quality.
The facility failed to provide food preferences and options of similar nutritive value to potentially 111 residents. Observations and interviews revealed that many items listed on the Alternate Menu Ticket were not available, and residents reported issues such as failure to follow the approved menu and provide between-meal snacks.
The facility failed to provide suitable, nourishing snacks to potentially 111 residents who wanted to eat at non-scheduled times or outside of scheduled meal service times. Many items listed on the Resident Snack Menu were unavailable, and there was no documentation of the times when scheduled snacks were to be provided to residents with specific nutritional care plans. Interviews with staff and residents revealed issues such as failure to follow the approved menu, provide an alternate menu, and offer between-meal snacks.
The facility failed to provide adequate fingernail grooming for two residents, leading to deficiencies in personal hygiene and care. One resident with severe cognitive impairment had elongated nails with black matter, while another resident with hemiplegia had elongated and jagged nails. Staff interviews revealed inconsistencies in nail care responsibilities and a lack of proper documentation.
A resident with malnutrition and other medical conditions experienced significant weight loss, which was not adequately addressed by the facility. Despite recommendations for nutritional supplements, the necessary orders were not placed, and the resident did not receive the required nutritional support, leading to further health deterioration and the development of a pressure ulcer.
The facility failed to ensure that dialysis communication forms were completely and accurately documented for a resident with End Stage Renal Disease. A review found that 24 out of 25 forms were missing required information in various sections, impacting the monitoring and care of the resident before and after dialysis treatments. The deficiency was confirmed by the Director of Nursing.
The facility failed to provide a resident with physician-ordered Nectar Thick liquids, serving non-thickened fluids that exceeded the prescribed fluid restriction. The Registered Diet Technician confirmed the oversight.
A facility failed to provide a physician-ordered therapeutic diet for a resident with chronic kidney disease and dependence on dialysis. The resident was served 660 ml of non-thickened fluids during breakfast, exceeding the prescribed fluid restriction and not adhering to the nectar consistency order. The facility's Registered Diet Technician confirmed the oversight.
Failure to Provide Timely Medication and Adequate Monitoring for Two Residents
Penalty
Summary
The facility failed to provide necessary care and services for two residents. For one resident, an error occurred during the admission process when the Admissions Director entered the dosage of an IV antibiotic incorrectly into the pharmacy system, using milligrams instead of grams. This mistake prevented the pharmacy system from flagging the medication as expensive, delaying the identification of the need for special compounding and shipment. As a result, the resident missed five doses of the antibiotic between admission and transfer back to the hospital, where treatment was continued. For another resident, documentation and monitoring were inadequate during an episode of epistaxis (nosebleed). The resident, who was on antiplatelet medications (Ticagrelor and Aspirin), experienced a nosebleed late in the evening. The nurse instructed the resident on first aid and notified the DON and physician, but did not document ongoing observations throughout the night. Certified Nursing Assistants reported significant bleeding, requiring multiple changes of towels, clothing, and cleaning of the resident's environment. The resident became lethargic and was later transferred to the hospital with low blood pressure. The lack of thorough monitoring and documentation contributed to the deficiency in care.
Failure to Thoroughly Investigate Neglect Allegation Related to Wound Care
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect related to wound care for a resident with multiple medical conditions, including a wedge compression fracture, diabetes, bacteremia, and a history of falls. The resident had an indwelling catheter and an unstageable pressure ulcer, and was discharged to the hospital after experiencing profuse bleeding. The facility's investigation into the neglect allegation included a review of the resident's diagnosis, a skin check evaluation, a previous hospitalization, and interviews with other residents regarding neglect. However, the investigation did not include interviews with staff directly involved in the resident's care, nor did it review records related to the resident's wounds or the care provided for those wounds. Additionally, the investigation lacked documentation explaining the circumstances surrounding the resident's wounds and did not identify procedures to prevent similar occurrences in the future. When questioned, the Administrator stated that a thorough investigation had been conducted, but was unable to provide information regarding the resident's wounds or the connection to the neglect allegation. The only staff interview conducted was with a nurse supervisor present during the resident's transfer to the hospital, and there was no evidence of a comprehensive review of wound care practices or staff actions related to the incident.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents. The report highlights lapses in following established protocols for pressure ulcer prevention and care, contributing to the occurrence and worsening of pressure ulcers among residents.
Failure to Enter and Provide Routine Indwelling Catheter Care
Penalty
Summary
The facility failed to enter and implement physician orders for indwelling catheter care for a resident who was admitted with an indwelling Foley catheter. The resident, who had diagnoses including a lumbar vertebra fracture, type 2 diabetes mellitus, bacteremia, and overactive bladder, was admitted with a Foley catheter in place. Although there were orders for changing the catheter as needed and for irrigation in case of blockage, there was no order entered for routine catheter care every shift and as needed. Review of the Certified Nursing Assistant (CNA) documentation also showed no evidence that catheter care was performed during the resident's stay. Interviews with nursing staff revealed that the admitting nurse and others involved in entering orders did not ensure that the required catheter care order was entered into the system. The Director of Nursing and Administrator confirmed that the resident did not have orders for routine Foley catheter care and was not receiving the appropriate care for the indwelling catheter as required by facility policy. The deficiency was identified through record review and staff interviews, which confirmed the lack of both orders and documentation of catheter care for the resident.
Failure to Schedule and Perform Physician-Ordered GYN Procedure
Penalty
Summary
The facility failed to ensure that a physician-ordered gynecological consult and related procedure were scheduled and performed for a resident with significant medical needs. The resident, who was admitted with multiple diagnoses including limited mobility and cognitive impairment, had a history of fungal rashes in the perineal area that were previously treated and resolved. Despite a physician's order for a gynecological consult and a specific procedure, there was no evidence in the medical record that the order was carried out, and nursing staff were unaware of the order. Interviews with nursing staff confirmed they had not seen or received the order, nor had they observed any ongoing issues in the affected area during their care of the resident. The resident's family member reported not being informed by the facility about the fungal issues or the need for the gynecological procedure, only learning about it during an external gynecologist visit. The family member stated that he had been waiting for almost a month for the facility to schedule the procedure and had not received any updates despite repeated inquiries. The facility administrator acknowledged the delay and lack of communication, citing the procedure's special nature as a reason for the scheduling delay, but provided no timeline or further information to the family.
Plan Of Correction
F684 Quality of Care A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On was scheduled for at 4pm for Resident #1. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Director of Nursing/designee completed an audit of physician order to ensure any outsource diagnostic testing has been ordered. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of nursing/designee to complete education with the nurses to ensure any outsource diagnostic testing has been submitted to the coordinator. b. On education provided to the coordinator to ensure are scheduled timely for outsource diagnostics and transportation if needed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of nursing/designee will complete audit of residents who have outsource diagnostic testing scheduled in a timely manner and transportation if needed, compliance with federal regulation F684 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined. F 684
Failure to Schedule and Perform Physician-Ordered Procedure
Penalty
Summary
The facility failed to ensure that a physician-ordered procedure was scheduled and performed for one resident. The resident, who had significant cognitive impairment and required substantial to maximal assistance with hygiene and toileting, had a history of fungal rashes that were treated and resolved. A physician order for a gynecological consult and a specific procedure was documented, but there was no evidence that the procedure was scheduled or completed. Interviews with nursing staff revealed they were unaware of the order, and there was no documentation indicating the procedure had been arranged. The resident's family member reported not being informed about the resident's condition or the scheduling of the ordered procedure, despite repeated inquiries to the facility's administrator. The administrator acknowledged the delay, attributing it to the special nature of the procedure and the need for additional coordination, but was unable to provide a scheduled date. This lack of follow-through resulted in the resident not receiving timely, physician-ordered care as required by regulation.
Plan Of Correction
N201 Right To Adequate and Appropriate Health Care A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On [date] was scheduled for [procedure] for Resident #1 at 4pm. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On [date], the Director of Nursing/designee completed an audit of physician orders to ensure any outsource diagnostic testing has been ordered. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of Nursing/designee to complete education with the nurses to ensure any outsource diagnostic testing has been submitted to the coordinator. b. On education provided to the coordinator to ensure [specific actions] are scheduled timely for outsource diagnostics and transportation if needed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee will complete an audit of residents who have outsource diagnostic testing scheduled in a timely manner and transportation if needed, compliance with federal regulation N201 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Deficiencies in Facility's Physical Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. The shower room on the second floor had brown-colored matter on the floor, rust-colored stains on the wall above the grab bar, and black stains on the shower walls. Additionally, the paint on the floor was peeling in several areas. The first-floor shower room had gaps between the floor and walls, and both the floors and walls had black markings. The floor tiles on the south wing of the second floor were cracked in several places. Furthermore, a bed rail was observed with peeling paint and rust-colored staining, privacy curtains had black stains, and a blanket was found with holes. Photographic evidence was obtained to support these findings.
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 it is required. **Physical Environment** A) What corrective action will be accomplished for those residents found to have been affected by this practice? a. On __, the second floor shower room was cleaned of brown colored matter. On the wall above the grab bar, as well as, the grab bar was removed of rust colored stains. On __, the black stains on the shower room walls were removed. On __, epoxy flooring project started by Custom Group, Inc., with an estimated completion date of __, to address the peeling paint on the floor of the shower stall. b. On __, epoxy flooring project started by Custom Group Inc., with an estimated completion date of __, to address the floor gaps and black markings in the first floor shower room stalls. On __, the black stains on the shower room walls were removed. c. On __, VCT material for floor tile repairs throughout the building were ordered. Commencement of work to be completed within 30 days of __ by Holiday Carpet Service. d. On __, the bed rails in __ were replaced. e. On __, privacy curtains in __ were replaced. f. On __, the blanket in __ was immediately replaced. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On __, audit completed of the second floor shower room to ensure that it was clean, rust-free, and free of black stains on the walls. b. On __, audit completed of the first floor shower room to ensure that it was clean, rust-free, and free of black stains on the walls. c. On __, audit completed of floor tiles to identify cracks in floor tiles in need of repair. d. On __, audit completed of bed rails to ensure none had peeling paint with rust colored stains. e. On __, audit completed of privacy curtains to ensure curtains are free from stains. f. On __, audit completed of resident blankets to ensure blankets are in good condition. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By __, the ED/designee educated the environmental services supervisor and maintenance director on ensuring that the facility shower room stalls, floors, and walls are maintained in good, clean condition. b. By __, the ED/designee educated the maintenance director on ensuring that cracks in floor tiles are repaired within a timely manner. c. By __, the ED/designee educated staff on identifying and timely reporting environmental concerns in TELS. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. ED/designee to randomly audit shower rooms to ensure that they are clean and in good repair. b. ED/designee to randomly audit 6 resident rooms to ensure resident bed rails are rust-free, bedding is free of holes, and privacy curtains are in good, clean condition. c. ED/designee to randomly audit floor tiles to ensure tiles are in good condition. d. Audits will be conducted weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, homelike environment for its residents, as evidenced by several deficiencies observed during the survey. On the second floor, the shower room had brown-colored matter on the floor of the shower stall, rust-colored stains on the grab bars, and black stains on the walls. Additionally, the paint on the floor was peeling in several locations. The first-floor shower room also exhibited gaps between the floor and walls, along with black markings on both the floors and walls. Furthermore, the floor tiles on the south wing of the second floor were found to have noticeable cracks. Additional deficiencies included a bed rail with peeling paint and rust-colored staining, privacy curtains with black stains, and a blanket with holes. These observations indicate a failure to maintain a sanitary, orderly, and comfortable interior, as required by the regulations. The facility did not ensure that the environment was safe, clean, and homelike, which is a fundamental right of the residents.
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 it is required. **Physical Environment** A) What corrective action will be accomplished for those residents found to have been affected by this practice? a. On __, the second floor shower room was cleaned of brown colored matter. On __, the wall above the grab bar, as well as, the grab bar was removed of rust colored stains. On __, the black stains on the shower room walls were removed. On __, epoxy flooring project started by Custom Group, Inc., with an estimated completion date of __, to address the peeling paint on the floor of the shower stall. b. On __, epoxy flooring project started by Custom Group Inc., with an estimated completion date of __, to address the floor gaps and black markings in the first floor shower room stalls. On __, the black stains on the shower room walls were removed. c. On __, VCT material for floor tile repairs throughout the building were ordered. Commencement of work to be completed within 30 days of __ by Holiday Carpet Service. d. On __, the bed rails in __ were replaced. e. On __, privacy curtains in __ were replaced. f. On __, the blanket in __ was immediately replaced. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On __, audit completed of the second floor shower room to ensure that it was clean, rust-free, and of black stains on the walls. b. On __, audit completed of the first floor shower room to ensure that it was clean, rust-free, and of black stains on the walls. c. On __, audit completed of floor tiles to identify cracks in floor tiles in need of repair. d. On __, audit completed of bed rails to ensure none had peeling paint with rust colored stains. e. On __, audit completed of privacy curtains to ensure curtains are free from stains. f. On __, audit completed of resident blankets to ensure blankets are in good condition. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By __, the ED/designee educated the environmental services supervisor and maintenance director on ensuring that the facility shower room stalls, floors, and walls are maintained in good, clean condition. b. By __, the ED/designee educated the maintenance director on ensuring that cracks in floor tiles are repaired within a timely manner. c. By __, the ED/designee educated staff on identifying, and timely reporting environmental concerns in TELS. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. ED/designee to randomly audit shower rooms to ensure that they are clean and in good repair. b. ED/designee to randomly audit 6 resident rooms to ensure resident bed rails are rust-free, bedding is of holes and privacy curtains are in good, clean condition. c. ED/designee to randomly audit floor tiles to ensure tiles are in good condition. d. Audits will be conducted weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen/food service sanitation tour, several deficiencies were noted, including a soiled and rust-covered exhaust hood system, heavily soiled ceiling-mounted commercial light fixtures, broken and missing floor tiles, and a walk-in refrigerator with a dust and black mold-covered internal fan cover. Additionally, the walk-in freezer door was rust-laden and ajar, and expired yogurt was found in the walk-in refrigerator. The Trauleson reach-in refrigerator had soiled and rusted internal food storing shelves, and the chemical levels in the 3-compartment sink and cleaning rag buckets did not meet regulatory requirements. The dish machine hood system was also rust-laden and had a build-up of a black mold type substance. The Certified Dietary Manager (CDM) stated that numerous requests had been made to maintenance over the past three months to address these issues, but no action had been taken. During a follow-up kitchen/food service sanitation tour, additional deficiencies were observed, including a full and overflowing trash container in the food preparation/serving area, a heavily soiled oven back splash with a large build-up of black carbon matter, and a coffee cart located in the chemical room. A wall-mounted fire sprinkler was rusted and draining on the dish room wall, and soiled cleaning rags were left unattended on clean preparation and serving surfaces. The floor of the pantry room had large areas of peeling paint. These observations were made in the presence of the Corporate Food Service Director, and photographic evidence was obtained during both tours.
Inadequate Food Supply and Nutritional Deficiencies
Penalty
Summary
The facility failed to ensure an adequate food supply necessary to meet the nutritional needs of 111 out of 120 residents. During an initial kitchen/food service tour, it was observed that there was a significant shortage of various food supplies, including frozen foods, dairy products, canned foods, fresh fruits and vegetables, juices, and daily pantry items. The Certified Dietary Manager (CDM) mentioned that she was under monthly food budget restrictions and that numerous requests for emergency food orders were not approved by the new Administrator, leading to the shortages. The CDM was later suspended for failing to perform her duties, and the Corporate Food Service Director (CFSD) took over the oversight of the kitchen operations temporarily. Despite an emergency food delivery, numerous items were still not in supply, and residents continued to experience food shortages and lack of menu alternatives, leading to multiple complaints about the quality and availability of food. Additionally, it was noted that two residents were not provided meals or nutritious snacks before their dialysis appointments, leaving them hungry during their treatments. The survey also revealed that the facility failed to provide physician-ordered thickened liquids and dietary supplements for at least one resident, further highlighting the inadequacies in food supply management. Interviews with residents indicated ongoing issues with the approved menu not being followed, running out of foods regularly, lack of meal substitutions, poor food quality, and unavailability of between-meal snacks. These issues were repeatedly voiced to the administration without resolution.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for multiple resident rooms and common areas. During the survey, it was observed that 12 of 27 resident rooms on the first floor and 11 of 31 rooms on the second floor had various issues such as dust-laden A/C filters, damaged walls, loose or missing fixtures, and mold build-up. Additionally, the second-floor dining room was found to have heavily soiled floors, walls with large scuff marks, and live bugs present. These deficiencies were confirmed during an environment tour with the Corporate Maintenance Director and the Administrator. The Corporate Maintenance Director acknowledged that staff have access to a computerized system to report maintenance and housekeeping issues but stated that staff are not utilizing the system effectively. Specific issues noted included loose bathroom fixtures, damaged ceiling tiles, rusted bed rails, and heavily stained bathroom floors. The dining room also had an oxygen concentrator with a dust-laden filter and a serving table that was heavily soiled and worn. These findings indicate a significant lapse in maintaining a clean and safe environment for the residents.
Failure to Provide Nourishing Meals for Dialysis Patients
Penalty
Summary
The facility failed to provide two residents, who regularly attend dialysis appointments, with a nourishing, palatable, well-balanced meal or snack. Resident #60, who has been residing in the facility for three years and attends dialysis three times a week, reported not receiving a breakfast meal or snack before leaving for dialysis. Additionally, when a bagged snack was provided, it contained only a package of crackers and a warm, undrinkable House Shake. The resident's clinical records confirmed his dependence on dialysis and the absence of documented interventions for providing meals before or during dialysis appointments. Interviews with the facility's Registered Dietetic Technician and Corporate Food Service Director could not confirm if meals were being provided as required. Similarly, Resident #23, who also attends dialysis three times a week, reported not receiving a nourishing bagged lunch or snack for the past year. Despite multiple requests, the issue remained unresolved. The resident's clinical records indicated no cognitive impairment and independent eating ability, yet there was no confirmation from the facility staff regarding the provision of meals or snacks for dialysis appointments. The facility's failure to ensure these residents received appropriate nutrition during their dialysis appointments constitutes a significant deficiency in care.
Failure to Follow Approved Menu and Provide Adequate Food Supplies
Penalty
Summary
The facility failed to follow its approved menu, which potentially affected 111 residents. During a review of the facility's menu for the week of 04/28/24, it was noted that 2% milk and skim milk were supposed to be served to various diets, but only whole milk was available due to a lack of supply for the past two days. Additionally, there was no supply of orange juice for the past seven days. The Certified Dietary Manager (CDM) confirmed these shortages and stated that an emergency order for whole milk was placed, but no such order was made for orange juice. During the lunch meal observation on 04/29/24, it was found that rolls, pureed rolls, and blueberry shortbread were not available, and substitutions were not properly planned or communicated. The Breakfast/Lunch Cook was unaware of certain menu items that needed to be prepared, indicating a lack of communication and planning. For the dinner meal on 04/29/24, it was observed that several items, including potato salad, pureed potato salad, cinnamon applesauce, baked potatoes, and noodles, were either not purchased or not prepared. The Dinner Cook confirmed the unavailability of these items and the lack of planned substitutions. The CDM mentioned that food purchasing was under budget restraints and that she needed emergency permission from the Administrator to place orders. However, the Administrator stated that the CDM had not notified her of the need for emergency food orders in the past seven days. Interviews with 15 residents revealed issues such as failure to follow the approved menu, lack of alternate menu options, and failure to provide between-meal snacks, further highlighting the deficiencies in the facility's food service management.
Improper Food Preparation and Holding
Penalty
Summary
The facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance, potentially affecting 111 residents. During an initial kitchen/food service observation, it was noted that approximately 11 pans of food were covered with aluminum foil and left on the stove top without heat being applied. The breakfast/lunch cook stated that these pans contained lunch foods that were fully cooked and would remain on the stove top or in the steam table for the next three hours until the lunch tray line began. The cook was unaware that prolonged cooking and holding of foods could compromise their nutritive value, taste, flavor, and appearance. The Certified Dietary Manager (CDM) was also interviewed and stated she was unaware that foods were being completely cooked and held hours prior to meal service. She confirmed that foods are required to be prepared as close to meal time as possible and that the early cooking was done for convenience. The deficiency potentially affected 111 residents on various diets, including regular, mechanically altered, and therapeutic diets.
Failure to Provide Food Preferences and Options
Penalty
Summary
The facility failed to provide food preferences and options of similar nutritive value to potentially 111 residents. During an observation of the lunch meal, it was noted that the approved menu items were being served without any alternate hot entree, hot starch food, or hot vegetable prepared and available. Staff A mentioned that baked chicken, which is supposed to be always available, had not been available for over 7 days. The Certified Dietary Manager (CDM) confirmed that the facility was under budget restraints and had not ordered many foods without emergency permission from the Administrator. The Administrator stated that the CDM had not notified her of the need for an emergency food order in the past 7 days. The facility's Alternate Menu Ticket listed several items that were supposed to be always available, but many were not. For example, baked boneless chicken, tuna salad sandwich, and fresh fruit had not been available for several days. Additionally, residents reported issues such as failure to follow the approved menu, failure to provide an alternate menu, and failure to provide between-meal snacks. Interviews with 15 sampled residents revealed these food issues, indicating a significant deficiency in the facility's food service management.
Failure to Provide Suitable and Nourishing Snacks
Penalty
Summary
The facility failed to provide suitable, nourishing snacks to potentially 111 residents who wanted to eat at non-scheduled times or outside of scheduled meal service times. During an initial food service tour, it was noted that the facility had low levels of food supplies, including frozen, canned, dairy, and daily pantry foods. The Resident Snack Menu listed various items that were supposed to be always available, but many of these items, such as puddings, gelatins, cookies, and crackers, were not available for at least the last seven days. Additionally, there was no documentation of the times when scheduled snacks were to be provided to residents with specific nutritional care plans, and the facility could not verify if these snacks were being prepared and served as required. Interviews with the Certified Dietary Manager, Registered Dietetic Technician, and Corporate Food Service Director revealed that they were unaware of the availability and distribution of scheduled snacks. Furthermore, individual interviews with 15 residents indicated issues such as failure to follow the approved menu, failure to provide an alternate menu, failure to provide food substitutions, and failure to provide between-meal snacks. These deficiencies affected residents with specific nutritional needs, including those with diabetes, underweight conditions, and those undergoing dialysis.
Failure to Provide Adequate Fingernail Grooming
Penalty
Summary
The facility failed to provide adequate fingernail grooming for two residents, leading to deficiencies in personal hygiene and care. Resident #26, who has severe cognitive impairment and multiple health issues, was observed with elongated fingernails and black matter underneath them. Despite the resident's statement that he did not refuse care, no staff had offered to clean his nails. Interviews with CNAs and the DON revealed inconsistencies in the responsibility and scheduling for nail care, with some staff unaware of the procedures and others incorrectly stating that a CNA was assigned weekly for this task. The DON admitted to scheduling a CNA for nail care only when multiple residents needed it, and there was no documentation of the resident refusing care or any attempts to address his nail hygiene issues. Resident #43, who has no cognitive impairment but suffers from left-sided hemiplegia and other health conditions, also had elongated and jagged fingernails. The resident reported asking for nail care but stated that only one person usually performed it. Observations confirmed the resident's nails were in poor condition, and he mentioned that his left hand's spasms caused his hand to get into his soiled brief, leading to potential hygiene issues. Interviews with staff revealed a lack of clarity on who was responsible for nail care, with some staff unaware of the procedures and others incorrectly stating that a CNA was scheduled for this task. The DON was not aware of any refusals of care and admitted there was no documentation of the resident refusing nail grooming. The report highlights a systemic issue in the facility's approach to nail care, with inconsistencies in staff responsibilities and a lack of proper documentation and follow-up. Both residents' conditions and the observations made during the survey indicate a failure to provide necessary grooming services, as required by the facility's policies and the residents' care plans.
Failure to Address Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to address a significant weight loss in a timely manner for a resident admitted with malnutrition and other medical conditions. The resident experienced a notable weight loss from 182.8 lbs to 162.6 lbs over a short period, which was documented but not adequately addressed. Despite the Diet Tech's assessment and recommendation for a Medpass protein supplement twice a day, the order was not placed, and the resident did not receive the necessary nutritional support. Additionally, the resident's lunch tray was observed without the prescribed Health Shake or frozen nutritional treat, further indicating a lapse in nutritional care. The resident was readmitted to the facility with a urinary tract infection and continued to show signs of malnutrition and weight loss. The Diet Tech acknowledged the significant weight loss and the development of a pressure ulcer on the resident's sacrum. Despite recognizing the need for additional nutritional support, the necessary orders were not implemented promptly, leading to further deterioration in the resident's condition. The failure to provide adequate nutrition and hydration contributed to the resident's declining health and the development of a pressure ulcer.
Failure to Properly Document Dialysis Communication Forms
Penalty
Summary
The facility failed to ensure that dialysis communication forms were completely and accurately documented for a resident requiring dialysis services. During the review of the clinical record of a resident with End Stage Renal Disease, it was found that 24 out of 25 dialysis communication forms from February 6, 2024, through April 30, 2024, were improperly documented. The forms, which are divided into three sections to be completed by the facility and the dialysis center, were missing required information in various sections. Specifically, Section #1, which includes pre-dialysis information such as medications administered, vital signs, and examination of the shunt site, was incomplete on multiple dates. Section #2, to be completed by the dialysis center, and Section #3, to be completed by the facility upon the resident's return, were also found to be lacking necessary documentation on several occasions. The deficiency was confirmed during a review with the Director of Nursing, who acknowledged that numerous required sections of the forms were not being documented by both facility nursing staff and dialysis center staff. This lack of proper documentation could potentially impact the monitoring and care of the resident before and after dialysis treatments. The resident involved had been admitted to the facility originally in 2017 and re-admitted in December 2023, with a diagnosis of End Stage Renal Disease and current physician's orders for dialysis three times a week. The failure to document critical information on the dialysis communication forms indicates a significant lapse in the facility's protocol for ensuring safe and appropriate dialysis care for the resident.
Failure to Provide Physician-Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide liquids in a Nectar Thick form for a resident with physician-ordered thickened liquids. During the review of the clinical record of a resident with diagnoses including Chronic Kidney Disease Stage 4, Acute Kidney Failure, Type 2 Diabetes, Protein-Calorie Malnutrition, Dysphagia, and Dependence on Dialysis, it was noted that the resident had a physician order for a Renal Diet, Mechanical Soft Meat, and Nectar Consistency liquids. However, during the observation of the breakfast meal, the resident was served non-thickened coffee, cranberry juice, and milk, totaling 660 ml of non-thickened fluids, which exceeded the breakfast fluid restriction of 180 ml. The surveyor discussed the fluid restriction and nectar thickened liquids with the facility's Registered Diet Technician (DTR), who confirmed that the physician-ordered fluid restriction and thickened liquids were not followed for the breakfast meal. The DTR acknowledged that the resident was served an additional 480 ml of fluids over the breakfast allotment and that the tray liquids were not thickened to the physician's orders for Nectar Thick Liquids.
Failure to Adhere to Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to provide a physician-ordered therapeutic diet for a resident with chronic kidney disease and dependence on dialysis. The resident was prescribed a fluid restriction of 1500 ml per day, with specific allocations for dietary and nursing fluids. However, during a breakfast meal observation, the resident was served a total of 660 ml of non-thickened fluids, which exceeded the prescribed breakfast fluid allotment of 180 ml. Additionally, the fluids were not thickened to the physician's order of nectar consistency. The deficiency was confirmed through interviews and record reviews. The facility's Registered Diet Technician acknowledged that the fluid restriction and thickened liquid orders were not followed. The resident's meal tray included 6 ounces of non-thickened coffee, 8 ounces of non-thickened cranberry juice, and 8 ounces of milk, totaling 660 ml of fluids, which was 480 ml over the prescribed breakfast fluid limit. This failure to adhere to the physician's orders for fluid restriction and thickened liquids constitutes a significant deficiency in the resident's care.
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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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