Avante At Lake Worth, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Worth, Florida.
- Location
- 2501 N A St, Lake Worth, Florida 33460
- CMS Provider Number
- 105372
- Inspections on file
- 30
- Latest survey
- October 7, 2025
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Avante At Lake Worth, Inc. during CMS and state inspections, most recent first.
A resident with significant mobility limitations and ongoing skin wounds was not provided an air mattress, despite repeated requests from the resident, her family, and her insurance case manager. Facility staff cited protocol requiring a stage 2 or greater pressure wound or a physician order, but did not obtain or provide the necessary documentation to secure the air mattress, resulting in the resident's continued lack of access to this support surface.
Three residents with indwelling urinary catheters did not receive or have documentation of required catheter care as per their care plans and physician orders. One resident reported dissatisfaction and lack of trust in staff, while another had no catheter care interventions documented for an extended period. A third resident had incorrect orders for catheter care, which were only corrected during the survey. Staff interviews revealed lack of training and confusion about documentation, and the DON was unable to provide evidence of care or explain the lapses.
A resident with diabetes and on both long-acting and short-acting insulin had physician orders requiring blood glucose checks and insulin administration at 11:30 AM. On days when the resident left for dialysis, the 11:30 AM insulin dose and required monitoring were missed, as documented in the MAR. The DON was unaware if the physician knew about the missed doses, and the physician believed the orders should have been clarified to account for the resident's dialysis schedule. Staff confirmed that missed doses occurred and that order clarification had not taken place.
Surveyors identified multiple deficiencies in kitchen sanitation and food storage, including unclean cooking equipment, improper dishwasher temperatures, debris on dish crates, residue on sheet pans and hoods, and unsanitary conditions in the walk-in refrigerator and freezer. These issues had the potential to affect 103 residents on oral diets.
A resident with no cognitive impairment was observed self-administering a prescribed antifungal cream, despite staff documentation indicating they applied it every shift. The facility's policy requires an interdisciplinary team assessment and documentation for self-administration of medication, but no such assessment was found in the resident's record.
A resident who was fully dependent on staff for bathing and had significant medical needs received only two showers over five weeks, despite repeated requests and discomfort with bed baths. Staff interviews and review of the shower log revealed that documentation was not maintained, and the facility was unable to provide records of showers given, resulting in a failure to honor the resident's preferences and care plan.
A resident with severe cognitive impairment was found with scratches on her nose, but staff did not document the injury, complete a change in condition assessment, or notify the family and physician as required. Interviews revealed that staff were aware of the injury but failed to follow facility policy for documentation and communication.
A resident with severe cognitive impairment received PRN Lorazepam for anxiety without a discontinue date, and pharmacy recommendations to taper or discontinue the medication, or provide a specific diagnosis and rationale, were not addressed or signed by the physician. The DON confirmed the medication was psychotropic and stated the recommendations were not followed due to the family's refusal of psychiatric consultation.
A resident with a tracheostomy and intact cognition reported being struck by a remote control and privacy curtain thrown by his roommate, but the facility failed to document the incident, obtain statements from those involved, or conduct a thorough investigation as required by policy. The incident was not promptly reported to authorities, and the resident expressed ongoing distress about the event and the facility's response.
The facility did not fully complete or accurately document PASRR Level 1 screenings for two residents and failed to complete a required PASRR Level 2 for another, despite significant mental health diagnoses and cognitive impairments. Staff interviews revealed that incomplete documentation and lack of timely follow-up were due to staffing shortages and workflow issues.
Staff failed to administer medications and topical treatments according to physician orders and facility policy, with medications given late and inaccurately documented, and topical treatments either not applied or self-applied by residents despite staff documentation stating otherwise. Staff interviews and observations revealed confusion about medication administration times, treatment responsibilities, and proper documentation.
A resident who smoked was not reassessed for safe smoking practices after a significant change in condition, and quarterly smoking assessments were not completed as required by facility policy. The care plan specified regular reassessment, but only two assessments were documented, with the most recent overdue, despite the resident continuing to smoke under staff supervision.
A resident with severe malnutrition and multiple wounds was not provided with meals consistent with prescribed diet orders, including repeated serving of unwanted sandwiches and incorrect food textures, and did not receive weekly weight monitoring as required. The resident experienced significant weight loss, and nutrition assessments and care planning were delayed, with dietary staff unaware of the missed monitoring.
A resident dependent on enteral feeding did not receive the prescribed amount of nutrition due to inconsistent administration and lack of monitoring by nursing staff. The resident experienced significant weight loss, and required weekly weights were not recorded. Staff were unaware of the total volume to be administered and did not utilize the pump's monitoring features, resulting in the resident receiving only about 61% of the ordered nutrition over three days.
The facility failed to provide safe and appropriate respiratory care by not maintaining required tracheostomy equipment at the bedside, not obtaining physician orders for oxygen therapy for two residents, and not following prescribed oxygen flow rates for three residents. Staff were unable to locate necessary equipment and did not adhere to professional standards or physician directives, resulting in improper respiratory care for several residents.
A resident receiving hemodialysis did not have complete and accurate dialysis communication records maintained, as required by facility policy. Multiple dialysis communication sheets were found to be incomplete or missing key information, and there were no corresponding progress notes for several dialysis dates. Staff interviews confirmed inconsistencies in the documentation process for the resident's dialysis care.
The facility did not ensure discontinued controlled medications were removed from medication carts and failed to maintain consistent documentation between narcotic sheets and MARs for three residents with cognitive impairment. Controlled medications were administered after discontinuation orders, and staff could not account for discrepancies in signatures or times of administration.
Surveyors found that a medication cart was left unlocked and unattended by an RN, and that medications were left unsecured at the bedsides of two residents. One resident self-administered a prescribed cream, while another had creams at the bedside but was not receiving them as ordered. The DON and Unit Manager confirmed these medications should have been secured according to facility policy.
Surveyors found that staff failed to accurately document who administered medications and provided wound care for two residents. Medications were given late but recorded as on time by a nurse who did not administer them, and wound care was documented as performed by a nurse when it was actually done by a CNA. Required assessments and progress notes were also missing, resulting in falsified and incomplete records.
Staff failed to follow EBP guidelines and infection control protocols, including not using gowns during high-contact care for a resident with sacral wounds, not performing hand hygiene, and not properly disinfecting or storing glucometers after blood glucose monitoring. Unused lancets and glucose strip containers were also improperly returned to the medication cart after being brought into a resident's room, contrary to infection control standards.
The facility failed to provide a clean and comfortable environment for three residents, with issues including roach infestations, dirt residue, and ceiling damage. Despite pest control efforts, residents reported ongoing problems, and staff acknowledged ineffective cleaning due to broken equipment. The Director of Maintenance and Housekeeping confirmed the need for repairs and cleaning, and the Administrator was made aware of the concerns.
The facility failed to maintain a clean and comfortable environment for three residents, with issues including pest infestations, dirt accumulation, and room damage. Residents and their representatives reported dissatisfaction with cleanliness, and the Director of Maintenance acknowledged broken cleaning equipment and ineffective cleaning methods. The Administrator was made aware of these concerns.
The facility failed to provide necessary respiratory care for residents with tracheostomies, as evidenced by a lack of documented trach care and suctioning for multiple residents. A resident reported performing his own trach care, while staff interviews revealed confusion about care responsibilities. Additionally, extra trach tubes were not available at the bedside for two residents, indicating a deficiency in preparedness and adherence to physician orders.
The facility failed to implement its infection prevention and control program effectively, particularly in the use of PPE during tracheostomy care for residents on Enhanced Barrier Precautions (EBP). Observations showed that PPE, such as gowns, was not readily available, and staff inconsistently wore masks and gowns. A resident with a tracheostomy reported performing his own trach care, and staff were unaware of EBP status. Another resident's trach suctioning was performed by an LPN with a mask worn improperly. These issues highlight deficiencies in EBP and PPE usage.
A resident with a history of serious medical conditions did not receive adequate tube feeding and hydration due to an incorrect feeding schedule in the physician's orders. Observations showed the feeding pump was on hold error alert, and staff interviews confirmed the error in the schedule, leading to insufficient nutrition and hydration.
A facility failed to maintain complete medical records for a resident with respiratory issues, lacking documentation such as CPR sheets, transfer forms, and contact information for the resident's representative. The care plan inaccurately included a feeding tube, and the administrator acknowledged these deficiencies.
Failure to Honor Resident Preference for Air Mattress
Penalty
Summary
The facility failed to honor a resident's preference for an air mattress, despite ongoing requests from the resident, her daughter, and her insurance case manager. The resident, who had a history of hemiplegia, obesity, anxiety, generalized weakness, and was at high risk for skin breakdown, was readmitted to the facility and required maximum assistance for mobility. Her care plan identified a potential for skin integrity impairment due to limited mobility and incontinence, and she was being treated for nonhealing moisture-associated skin damage to both ischial areas. Despite these factors and her expressed desire for an air mattress, she was not provided one upon readmission, and her previous air mattress was not located. Interviews revealed that the resident had been requesting an air mattress for over a year, believing it would help prevent further deterioration of her wounds. Her insurance case manager and the insurance company supervisor both stated that they had attempted to facilitate the provision of an air mattress, but were unable to obtain the necessary physician order or clinical documentation from the facility. The case manager reported repeated communication with facility staff, including the social worker and nursing staff, but was told that they did not handle prescriptions and did not provide the required order for insurance submission. Facility staff, including the DON and Regional Nurse, stated that facility protocol required a stage 2 or greater pressure wound for an air mattress to be provided, unless a physician specifically ordered it. The Regional Nurse acknowledged that the resident had previously had an air mattress and that a physician order could override the protocol, but was unsure why the resident did not currently have one. The administrator and wound care nurse were also involved in discussions but did not facilitate the necessary order or documentation, resulting in the resident's continued lack of access to an air mattress despite her ongoing wounds and requests.
Failure to Provide and Document Catheter Care for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to provide appropriate catheter care and services for three residents with indwelling urinary catheters. For one resident with paraplegia and neurogenic bladder, the care plan and physician orders required catheter care every shift and as needed, but there was no documentation that this care was ever performed. The resident expressed dissatisfaction with the care, stating she often had to care for her own catheter due to lack of trust in staff. Staff interviews revealed that some nurses were inexperienced or untrained in catheter care, and there was confusion about how to document care or refusals. Another resident with a history of femur fracture and neurogenic bladder had a urinary catheter but did not have any catheter care interventions documented from admission until the time of the survey. Orders for catheter care and enhanced barrier precautions were only entered on the day of the survey, and the Director of Nursing (DON) could not explain what care had been provided prior to that date. The resident confirmed having the catheter for several weeks, but there was no evidence of appropriate care or documentation during that period. A third resident with a suprapubic catheter following bladder removal for cancer also lacked appropriate catheter care orders until the day of the survey. Previous orders were for an indwelling catheter, which the resident did not have, and these were only corrected during the survey. The DON acknowledged that orders and documentation for catheter care had been missed for all three residents and was unable to provide evidence of care or explain the process failures that led to the deficiencies.
Failure to Administer Insulin and Monitor Blood Glucose per Physician Orders
Penalty
Summary
A deficiency was identified when the facility failed to follow physician's orders for the monitoring and administration of insulin for one resident. The resident, who had diagnoses including diabetes and was dependent on insulin, had physician orders for both long-acting and short-acting insulin, with specific instructions to check blood glucose prior to the administration of the 11:30 AM dose of short-acting insulin. The Medication Administration Record (MAR) showed that the 11:30 AM dose and the required blood glucose monitoring were missed on five out of fourteen occasions when the resident was out of the facility for dialysis. Interviews with the Director of Nursing (DON) revealed that the resident routinely left the facility three times a week for dialysis, departing by 10:00 AM and returning around 3:00 PM. The DON was not aware if the physician knew that the resident was missing the 11:30 AM insulin dose and associated blood glucose checks on those days. The DON acknowledged that the nurse documented the missed doses and monitoring but had not clarified the order with the prescribing physician to address the resident's regular absence during the scheduled administration time. The resident's primary physician confirmed awareness of the resident's dialysis schedule and insulin regimen but believed that blood glucose should be checked more frequently and that the missed doses were likely due to an oversight in order clarification. The physician stated he was under the impression that the resident would receive the insulin and monitoring upon return from dialysis. Staff interviews indicated that missed doses were considered as such and that clarifying the order with the physician would be the best course of action, but this had not been done.
Plan Of Correction
F684 Quality of Care What corrective action(s) will be accomplished for those residents found to have been affected by this practice? On medication review completed with NP. How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? On , Director of Nursing/designee completed an audit of all resident residents receiving to ensure supplemental orders are in place. On , Director of Nursing/designee completed an audit of all resident receiving to ensure a medication review has been completed. What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? By the Director of Nursing/ designee completed education with the licensed nursing staff regarding supplemental for monitoring, what to do if a medication is scheduled while a resident is at . How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? Director of Nursing/designee to complete random audit to ensure resident receiving have supplemental orders, weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Director of Nursing/designee to complete random audit to ensure a medication review has been conducted for resident receiving 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 a time substantial compliance has been determined. The practice will not recur; what quality measures will be put into place? Director of Nursing/designee to complete random audit to ensure resident receiving have supplemental orders, weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Director of Nursing/designee to complete random audit to ensure a medication review has been conducted for resident receiving 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 a time substantial compliance has been determined.
Deficient Food Storage and Kitchen Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, preparation, and cleanliness. The backsplash of the Vulcan stove top was covered with dark black residue, and the Vulcan double oven had dried white crusty sediment and thick black residue beneath the hinge. The Dean fryer had light brown flaky sediment along the upper rim, despite not being used since the previous day's dinner meal. The dishwasher's rinse cycle temperature was measured at 114°F, below the required 120°F, and the plastic crates used for dishes had a thick, white, flaky debris that could be scraped off. Additionally, a stack of sheet pans was found with black residue, and the hood over the cooking area had brown and white residue. The floor under the shelves in the walk-in refrigerator contained various food items and debris, including milk, creamers, lettuce, deli meat, yogurt, and both dried white and brown residue. Further inspection revealed a build-up of ice near the entrance to the walk-in freezer, attributed to air leakage at the doorway, with a temperature reading of 0°F and foods frozen solid. There was also a buildup of ice on the floor and an unsealed open space along the inside door. The walk-in refrigerator was noted to have a loose gasket. Both the Dietary Manager and the Regional Certified Dietary Manager confirmed these findings, and photographic evidence was obtained. These deficiencies had the potential to affect 103 residents on oral diets.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication as required by its policy. The policy states that each resident should be offered the opportunity to self-administer medications during routine assessment by the interdisciplinary team, and the results should be documented in the medical record. However, for one resident who was admitted to the facility and had a BIMS score of 15, indicating no cognitive impairment, there was no documentation of an assessment for self-administration of medication in the medical record. During an interview, the resident stated that they applied their own prescribed antifungal cream to their feet and that nurses had not applied it. Observation confirmed the presence of the ointment at the bedside, and photographic evidence was obtained. Despite this, the Treatment Administration Record showed that staff documented administration of the cream every shift, and there was a physician's order for staff to apply the medication. No interdisciplinary team assessment for self-administration was found in the record.
Failure to Accommodate Resident Shower Preferences and Maintain Shower Documentation
Penalty
Summary
The facility failed to accommodate a resident's preference for showers, as evidenced by the experience of a resident with central cord syndrome, quadriplegia, neuromuscular dysfunction of the bladder, and major depressive disorder. This resident, who was cognitively intact and fully dependent on staff for bathing, reported receiving only two showers over a five-week period despite repeatedly requesting assistance and expressing discomfort with bed baths. The resident specifically noted feeling unclean and uncomfortable, particularly around the neck area where a cervical collar was worn. Interviews with CNAs and review of facility documentation revealed that the shower log, intended to track when residents received showers, was not maintained or updated. Staff were unable to provide documentation of showers given to the resident, and multiple requests by surveyors for the shower log went unfulfilled. The facility's policy required that residents receive necessary care and services according to their care plan and preferences, but the lack of documentation and failure to honor the resident's requests for showers demonstrated noncompliance with this policy.
Failure to Document and Notify Change in Resident Condition
Penalty
Summary
The facility failed to identify and document a change in condition for one resident who was observed with scratches on her nose. Despite the presence of dried blood and scabs, there was no documentation in the medical record regarding the new skin condition, nor was there a change in condition evaluation completed. Staff interviews revealed that neither the Certified Nursing Assistant nor the LPN on duty knew how the scratches occurred, and the skin assessment completed did not mention the new injuries. The Unit Manager acknowledged awareness of the scratches and claimed to have notified the family and physician, but admitted that no documentation of these notifications or the incident itself was made in the resident's record. Further investigation showed that the behavior of the resident scratching herself was not care planned, and there were no progress notes or assessments related to the incident. The resident had severe cognitive impairment, as indicated by a low Brief Interview for Mental Status score. Interviews with the resident's family confirmed that they were not informed about the scratches, nor were they aware of any habitual scratching behavior. Staff described a process for reporting and documenting new injuries, but this process was not followed in this case, resulting in a lack of required notifications and documentation.
Failure to Address PRN Psychotropic Medication Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a PRN (as needed) psychotropic medication, Lorazepam, prescribed for a resident with severe cognitive impairment, was addressed in a timely manner. The resident had a BIMS score of 03, indicating severe cognitive impairment, and was admitted with an order for Lorazepam 0.5 mg every four hours as needed for anxiety, without a discontinue date. The medication was administered as documented in the April and May Medication Administration Records. Pharmacy consultation reports in both April and May recommended that the Lorazepam be tapered and discontinued, or that a specific diagnosis and rationale for use be documented, since the medication had been prescribed for more than 14 days. These recommendations were not addressed or signed by the physician. Interviews with the Consultant Pharmacist confirmed that recommendations to add a stop date and review the necessity of the medication were made but not acted upon. The DON acknowledged that Lorazepam is a psychotropic medication and stated that the physician typically reviews pharmacy consults monthly, but the recommendations were not signed because the family did not want the resident to be seen by a psychiatric doctor. The DON also indicated that the order likely originated from the hospital and that the lack of follow-through on the pharmacy's recommendations was due to the family's wishes regarding psychiatric consultation.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported being struck by a television remote control thrown by his roommate, as well as being hit by a privacy curtain. The resident, who had a tracheostomy and was cognitively intact, communicated the incident to the nurse manager and expressed a desire for police involvement. Despite this, there was no documentation of the incident in the resident's medical record, and the facility did not obtain statements from either the resident or his roommate at the time of the incident. The initial response from staff included a witness statement from a registered nurse who did not observe the incident but concluded it was accidental after speaking with both residents. The administrator was aware of the incident but did not conduct a thorough investigation or collect direct statements from those involved. The facility's policy required immediate reporting and a detailed investigation of alleged abuse, but these procedures were not followed in this case. The delay in reporting the incident to authorities and the lack of proper documentation and investigation were evident. The administrator only reported the incident to the state agency and law enforcement several days after it occurred, and only after being prompted by the surveyor. The resident continued to express distress about the incident and the facility's handling of his concerns.
Failure to Complete and Accurately Document PASRR Screenings
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) Level 1 was fully and accurately completed for two residents, and did not complete a required PASRR Level 2 for one resident. For one resident with diagnoses including metabolic encephalopathy, alcohol-induced dementia, psychosis, and major depressive disorder, the PASRR Level 1 screening was found incomplete, missing pages 2 and 4, and there was no evidence of a Level 2 PASRR in the medical record despite the resident's significant mental health diagnoses and impaired cognitive function. The Director of Social Services acknowledged the incomplete documentation and the lack of a Level 2 PASRR, citing staffing issues and personal absence as reasons for the oversight. Another resident with a history of dementia, major depressive disorder, and schizophrenia had a PASRR Level 1 that indicated a Level 2 PASRR should have been requested due to a diagnosis of serious mental illness. The care plan and progress notes documented ongoing cognitive impairment, behavioral disturbances, and the use of antipsychotic and antidepressant medications. However, there was no evidence that a Level 2 PASRR was completed as required. The social worker admitted to being behind on PASRR documentation and stated that many residents were admitted without properly completed PASRR forms. A third resident with severe cognitive impairment and diagnoses including bipolar disorder, dementia, and anxiety had a PASRR Level 1 that was not accurately filled out, failing to indicate the resident's mental illness diagnosis and instead listing dementia as the primary diagnosis. The care plan reflected the resident's confusion and need for assistance with activities of daily living. The social worker again acknowledged the backlog and the need to review and correct PASRR documentation for residents who may require a Level 2 PASRR.
Failure to Administer Medications and Treatments as Ordered and Documented
Penalty
Summary
Facility staff failed to administer medications and treatments according to physician orders, facility policy, and residents' preferences and goals. During medication pass observations, it was found that medications scheduled for administration at 9:00 AM were instead given after 12:00 PM to a resident with severe cognitive impairment, and the administration times were inaccurately documented as 9:00 AM in the Medication Administration Record (MAR). Staff involved admitted to not knowing how to document the correct administration time. In another case, a resident with good mental cognition received medications significantly later than scheduled, and the MAR was again inaccurately completed to reflect the scheduled, not actual, administration time. Staff acknowledged that the medications were late but believed it was acceptable within a certain window. Additionally, the facility failed to follow physician orders for topical treatments. One resident with no cognitive impairment had antifungal cream prescribed to be applied twice daily to the feet, but the resident reported that nurses were not applying the cream and that he was unable to do it himself. The cream was found at the bedside, not on the medication cart as required, and staff had documented in the record that the treatment was provided, contrary to the resident's statements and physical evidence. Another resident, also with no cognitive impairment, had a similar order for antifungal cream to be applied every shift, but reported self-application and denied nurse involvement, despite staff documentation indicating otherwise. Staff had difficulty locating the cream and could not confirm its application when questioned. A further deficiency was identified in the care of a resident with impaired skin integrity and multiple comorbidities, including diabetes and hemiplegia. The care plan required specific wound care treatments, including the application of silver sulfadiazine cream twice daily. Observations revealed that the cream was being applied by a CNA using a tongue depressor from a cup, and staff interviews indicated confusion about who was responsible for the application and the frequency. The wound care nurse and other staff provided inconsistent information regarding the treatment schedule and responsibility, and the documentation did not align with the actual care provided.
Failure to Complete Required Smoking Reassessments After Change in Condition
Penalty
Summary
The facility failed to follow its Safe Smoking policy by not conducting required smoking reassessments for a resident who smoked. According to the facility's policy, residents who smoke must be reassessed annually and after any significant change in condition. Record review showed that the resident, who had a diagnosis including Generalized Anxiety Disorder and a Brief Interview of Mental Status score indicating cognitive response, experienced a significant change in condition. However, no smoking reassessment was performed after this change, and the facility also failed to complete quarterly smoking assessments as outlined in the resident's care plan. Observations confirmed that the resident continued to smoke on the designated patio under staff supervision, with staff controlling access to cigarettes and lighters. Interviews with the resident and the DON confirmed that only two smoking assessments had been completed since admission, and the most recent quarterly assessment was overdue. The care plan specifically required smoking assessments on admission, quarterly, and after significant changes in condition, but these were not completed as required.
Failure to Provide Adequate Nutrition and Diet Consistency
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with significant medical needs, including malignant neoplasm of the larynx, severe protein-calorie malnutrition, muscle wasting, and multiple pressure ulcers. The resident expressed concern about ongoing weight loss, reporting a decrease from 180 pounds to approximately 130 pounds, and was observed to have severe muscle wasting. Despite a diet order specifying a mechanical soft diet with pureed meat, whole milk, and soft sandwiches, the resident was repeatedly served food items that did not comply with these requirements, such as ground meat instead of pureed, well-done toast instead of soft bread, and 2% milk instead of whole milk. The resident also reported receiving the same type of sandwich (PB&J) multiple times daily, which he did not want, and requests for alternative options like a tuna sandwich were not fulfilled. Observations revealed that the resident frequently did not eat the meals provided, with uneaten food and sandwiches remaining on the tray for extended periods, sometimes attracting insects. The dietary staff acknowledged that the meals served did not match the prescribed diet order. Additionally, the resident's weight was not monitored according to professional standards or the facility's own policy, which required weekly weights for the first four weeks after admission. Only one weight was recorded at admission, and a significant weight loss of 7.8 lbs (6.1%) over 20 days was identified only after the surveyor requested a current weight. The nutrition assessment for the resident was not completed within the expected timeframe, being signed 19 days after admission, and there was no documented nutrition care plan in the medical record. The dietary team was unaware of the lack of weekly weights and could not explain why they were not performed. Interventions to address the resident's weight loss were delayed due to the absence of timely monitoring and assessment, despite the resident's high risk status and ongoing nutritional decline.
Failure to Provide Prescribed Enteral Nutrition and Monitor Weight
Penalty
Summary
The facility failed to provide appropriate enteral feeding care for a resident who was dependent on tube feeding due to dysphagia and other medical conditions. The resident was admitted with a low body mass index (BMI) and was noted to be underweight and cachectic. Despite professional standards and facility policy requiring regular weight monitoring, there were no weekly weights recorded after admission, and the resident experienced significant weight loss over a short period. The physician's order for enteral feeding specified a rate of 80 ml/hr for 20 hours daily, but did not clearly state the total daily volume. Observations revealed inconsistencies in the administration of the feeding formula, with the pump being inactive during scheduled feeding times and less formula being administered than prescribed. Over a three-day period, the resident received only 61.2% of the ordered nutrition, with no documentation explaining the missed feedings. Interviews with nursing staff indicated a lack of awareness regarding the total volume to be administered and unfamiliarity with the pump's monitoring features. The failure to administer the prescribed amount of enteral nutrition and to monitor the resident's weight as required led to inadequate nutritional support, as evidenced by ongoing weight loss and insufficient intake documented during the survey.
Failure to Provide Safe and Appropriate Respiratory Care and Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for multiple residents. For one resident with a tracheostomy, required tracheostomy care was not provided according to physician orders and facility policy. Observations revealed the absence of a tracheostomy obturator at the bedside over several days, and staff were unable to locate or demonstrate where the obturator was kept. Additionally, staff referenced practices not included in the facility's tracheostomy care policy, such as daily tracheostomy tube changes by a respiratory therapist. The facility also failed to obtain physician orders for oxygen therapy for two residents who were observed receiving oxygen via concentrator and nasal cannula at various flow rates. Despite ongoing administration of oxygen, there were no corresponding physician orders in the medical records until after surveyor intervention. Staff interviews confirmed the lack of orders and acknowledged the necessity of having them to guide care. Furthermore, the facility did not follow physician orders for oxygen therapy for three residents. Observations showed that oxygen was administered at flow rates higher than prescribed, and in one case, the oxygen concentrator was set to zero before being corrected. Staff acknowledged these discrepancies during interviews and made adjustments to the oxygen settings only after surveyor involvement. These failures were documented with photographic evidence and were consistent across multiple residents with varying degrees of cognitive impairment and complex respiratory needs.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate dialysis communication records for a resident who required hemodialysis. Review of the facility's policy indicated that nurses are responsible for educating residents and families about dialysis risks and for ensuring regular communication between the facility and the dialysis center, especially when there are changes in the resident's condition. For the resident in question, record review showed multiple deficiencies in the documentation of Dialysis Communication Sheets (DCS) over several dates, including incomplete forms, missing resident and dialysis center names, and undated records. Additionally, there were no corresponding progress notes in the resident's clinical record for the dates when dialysis was provided. The resident had a history of end stage renal disease and was dependent on renal dialysis, with a scheduled regimen of dialysis three times per week. Interviews with staff confirmed that the process involved sending a communication form with the resident to the dialysis center, which was to be completed and returned, with vital signs entered into the electronic medical record and the form filed in a dialysis book. However, the review found that this process was not consistently followed, resulting in incomplete documentation and lack of required communication records for the resident's dialysis care.
Failure to Remove Discontinued Controlled Medications and Inconsistent Documentation
Penalty
Summary
The facility failed to ensure proper management of controlled medications for three residents, resulting in discontinued medications remaining on medication carts and inconsistencies in medication administration documentation. For one resident with severe cognitive impairment, Lorazepam was administered multiple times after the physician had ordered it discontinued, and the medication remained accessible on the cart. Documentation on the narcotic sheet and medication administration record (MAR) did not consistently match, with missing times and unexplained signatures. The Director of Nursing acknowledged responsibility for ensuring discontinued medications are removed but confirmed that the process was not followed. Another resident with impaired cognition received Lorazepam after the discontinuation date, with narcotic sheets showing administration and removal from the medication card, but no corresponding documentation on the MAR. Staff interviewed were unable to identify who signed for the medication. A third resident with cognitive impairment received Oxycodone-Acetaminophen, but the administration times recorded on the MAR and narcotic sheet did not match, and staff could not clarify the discrepancies in signatures. These findings were based on observation, interview, and record review.
Failure to Secure Medications and Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly secured and stored according to professional standards and facility policy. During a medication pass observation, a registered nurse left a medication cart unlocked and unattended while searching for a resident's medication in a storage room. The medication cart was accessible and unsecured during this time, as confirmed by the Director of Nursing, who was able to open the drawers in the nurse's absence. The nurse later returned and was informed of the unsecured cart. Additionally, medications were found unsecured at the bedsides of two residents. One resident, with no cognitive impairment, had a tube of prescribed antifungal cream on the bedside table, which the resident reported self-administering. Another resident, also with no cognitive impairment, had two tubes of cream in a zip lock bag on the bedside table, and stated that they were not applying the medication themselves nor receiving it from staff. In both cases, the Unit Manager confirmed that the medications should have been stored on the medication cart, not at the bedside.
Failure to Accurately Document Medication Administration and Wound Care
Penalty
Summary
The facility failed to accurately document medication administration and wound care for two residents, resulting in deficiencies related to falsification and improper record-keeping. For one resident with diagnoses including metabolic encephalopathy and intractable epilepsy, a medication pass observation revealed that medications scheduled for 9:00 AM were administered after 11:00 AM. Despite this, the Medication Administration Record (MAR) reflected that the medications were given at the scheduled time and were documented with the initials of a nurse who did not actually administer the medications. Interviews with nursing staff and management confirmed inconsistencies in documentation, with staff unable to clarify whose initials were used and who actually provided the care. Another resident with impaired skin integrity and a history of diabetes, obesity, and hemiplegia was found to have incomplete and inaccurate documentation regarding wound care. The care plan required regular application of Silvadene cream to the resident's buttocks and ischium area. Observations and interviews revealed that a Certified Nursing Assistant (CNA) applied the cream, although the order specified that a licensed nurse should perform this task. The Wound Care Nurse and other staff provided conflicting accounts of who applied the treatment, and the MAR indicated that the Wound Care Nurse had signed for treatments she did not perform. Additionally, required skin assessments and progress notes were missing from the resident's record for the relevant dates. These deficiencies were identified through policy review, record review, direct observation, and staff and resident interviews. The facility's failure to ensure accurate and truthful documentation of care provided, as well as to maintain complete medical records in accordance with professional standards, led to findings of falsified documentation and improper record-keeping for both medication administration and wound care.
Failure to Follow Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precaution (EBP) guidelines and infection control protocols for multiple residents. For one resident with sacral wounds and orders for EBP and MDRO precautions, staff did not include EBP interventions in the care plan. During observed care activities, occupational therapy staff wore gloves but did not don gowns as required for high-contact care, such as assisting with activities of daily living and wound care. Staff also failed to perform hand hygiene before entering and after leaving the resident's room, and there was confusion among staff regarding which residents required EBP, with one staff member incorrectly associating EBP only with residents who have a PEG tube. In another instance, a resident with diabetes underwent blood glucose monitoring by an LPN who did not perform hand hygiene before or after the procedure, did not clean the resident's finger before pricking, and failed to properly disinfect and store the glucometer according to manufacturer instructions. The LPN used disinfectant wipes but did not allow the required drying time before returning the glucometer to the medication cart and did not store it in a bag. The same gloves were used to handle multiple items, including the medication cart and disinfectant container, without changing gloves or performing hand hygiene between tasks. Additionally, during glucose monitoring for another resident, an RN brought unused lancets and a glucose strip container into a resident's room with EBP signage and then returned these items to the medication cart, contrary to infection control protocols. The DON confirmed that unused lancets and glucose strip containers should not be brought back into the medication cart after being in a resident's room. These observations indicate multiple failures to follow established infection prevention and control procedures, including proper use of PPE, hand hygiene, and equipment disinfection and storage.
Facility Fails to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for three residents, as evidenced by observations and interviews. Resident #2 reported frequent sightings of roaches in her room, despite pest control efforts, and heavy dirt residue was observed on the floors. Staff A acknowledged the pest control company's ineffectiveness. Resident #3's representative expressed dissatisfaction with the room's cleanliness, pointing out dried splashes and dirt accumulation. Photographic evidence supported these observations. Resident #4's room had ceiling damage and dirt debris, with the Director of Maintenance and Housekeeping confirming the need for repairs and cleaning. The Director of Maintenance and Housekeeping admitted that their cleaning machines had been broken for over a month, leading to ineffective cleaning methods. During an environmental tour, the Director agreed that Resident #3's room required cleaning and repainting, and Resident #4's room needed attention. The facility's Administrator was informed of the cleanliness and pest concerns, acknowledging the issues raised by residents and their families.
Plan Of Correction
Safe/Clean/Comfortable/Homelike Environment A) What corrective action will be accomplished for those residents found to have been affected by this practice? a. On , Resident #2s room was treated for roaches. On heavy dirt residue was removed from the edges and corners of floors in the room and bathroom. b. On Resident #3s room was repainted, deep cleaned, curtains replaced, walls were wiped down and bathroom door was cleaned. Dirt accumulation along edges and corner of floors removed. c. On Resident #4s ceiling was repaired. Resident #4s curtain was replaced. Heavy dirt debris on the floor corner and edges were cleaned. 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. By audit completed in all resident rooms to ensure concerns with pest control were addressed. b. By deep cleaning schedule audit completed to address residents rooms and bathrooms, floors, floor edges/corners, walls in need of repainting, or repairs. Repairs to be completed as indicated on deep cleaning calendar. c. By audit completed to ensure cubical curtains do not have stains or dry splashed feed in residents rooms. d. On ,audit completed to identify ceiling damage, holes, and/or curtain tracks in need of repair. 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 resident rooms are treated appropriately for roaches. Rooms and bathroom walls, floors-edges/corners of floors, and curtains are repaired/maintained in good, clean condition. b. 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 resident rooms to ensure that there are no concerns with pest control. b. ED/designee to randomly audit 6 resident rooms and bathrooms to ensure that they are clean and in good repair, paint touch-ups are made timely, curtains are devoid of holes/stains, and floors and corners are clean. c. ED/designee to randomly audit ceiling damage and holes around curtain tracks to ensure ceiling is 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 Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for three residents, as evidenced by observations and interviews. Resident #2 reported seeing roaches frequently in her room, despite pest control efforts, and noted heavy dirt residue on the floors. Staff A confirmed the pest control company was ineffective. Resident #3's representative expressed dissatisfaction with the room's cleanliness, pointing out dried splashes on walls, doors, and curtains, along with dirt accumulation. Resident #4's room had heavy ceiling damage and dirt debris, with the Director of Maintenance acknowledging the need for repairs and cleaning. The Director of Maintenance and Housekeeping services admitted that their cleaning machines had been broken for over a month, leading to ineffective cleaning methods. During an environmental tour, the Director agreed that Resident #3's room required cleaning and repainting, and Resident #4's room needed attention. The Administrator was informed of the cleanliness and pest concerns, acknowledging the issues raised by residents and their families.
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. Safe/Clean/Comfortable/Homelike Environment A) What corrective action will be accomplished for those residents found to have been affected by this practice? a. On Resident #2s room was treated for roaches. On heavy dirt residue was removed from the edges and corners of floors in the room and bathroom. b. On Resident #3s room was repainted, deep cleaned, curtains replaced, walls were wiped down and bathroom door was cleaned. Dirt accumulation along edges and corner of floors removed. c. On Resident #4s ceiling was repaired. Resident #4s curtain was replaced. Heavy dirt debris on the floor corner and edges were cleaned. 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. By, audit completed in all resident rooms to ensure concerns with pest control were addressed. b. By, deep cleaning schedule audit completed to address residents rooms and bathrooms, floors, floor edges/corners, walls in need of repainting, or repairs. Repairs to be completed as indicated on deep cleaning calendar. c. By audit completed to ensure cubical curtains do not have stains or dry splashed feed in residents rooms. d. On, audit completed to identify ceiling damage, holes, and/or curtain tracks in need of repair. 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 resident rooms are treated appropriately for roaches. Rooms and bathroom walls, floors-edges/corners of floors, and curtains are repaired/maintained in good, clean condition. b. 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 resident rooms to ensure that there are no concerns with pest control. b. ED/designee to randomly audit 6 resident rooms and bathrooms to ensure that they are clean and in good repair, paint touch-ups are made timely, curtains are devoid of holes/stains, and floors and corners are clean. c. ED/designee to randomly audit ceiling damage and holes around curtain tracks to ensure ceiling is 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.
Deficiency in Respiratory Care for Residents with Tracheostomies
Penalty
Summary
The facility failed to provide necessary respiratory care, including tracheostomy care, for three out of five sampled residents with tracheostomies. Resident #3, who has chronic respiratory failure and a tracheostomy, reported that he performs his own trach care once a day, despite physician orders for care twice daily and as needed. The facility's records from January 1 to January 2, 2025, showed no documentation of trach care or suctioning for Resident #3. Additionally, staff interviews revealed a lack of clarity regarding responsibility for trach care, with a registered nurse indicating that respiratory care is typically handled by respiratory therapists. Resident #2, who has a tracheostomy and severe cognitive impairment, also did not receive documented trach care as ordered. The treatment administration records and nurse progress notes from January 1 to January 2, 2025, lacked any documentation of trach care being performed. This indicates a failure to adhere to the physician's orders for trach care twice daily and as needed. Furthermore, the facility failed to ensure that extra trach tubes were available at the bedside for Residents #4 and #5. Staff interviews confirmed that extra trach tubes were not present at the bedside, and there was uncertainty about the appropriate size of trach tubes needed for each resident. This lack of preparedness and documentation highlights a significant deficiency in the facility's ability to provide adequate respiratory care for residents with tracheostomies.
Deficiencies in PPE Usage and EBP Implementation
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically in the use of Personal Protective Equipment (PPE) during tracheostomy care for residents on Enhanced Barrier Precautions (EBP). Observations revealed that PPE, such as gowns, was not readily available in the units, and staff did not consistently wear masks or gowns when providing care. For instance, during a tour, it was noted that no gowns were available in the caddies across three units, and there was no EBP signage on the door of a resident with a tracheostomy and PEG tube. Resident #3, who has chronic respiratory failure and a tracheostomy, reported that staff did not provide trach care, and he performed it himself. He noted that while staff always wore gloves, they inconsistently wore masks and never wore gowns during PEG tube care. A registered nurse was unaware of the EBP status of Resident #3 and indicated that gowns were not available in the designated storage areas. The Assistant Director of Nursing confirmed the absence of gowns in the expected locations. Resident #5, who has a tracheostomy and other complex medical conditions, was observed receiving trach suctioning from an LPN who wore a surgical mask below her nose, compromising its effectiveness. The LPN acknowledged the mask slipped and should have been adjusted. The resident's wife expressed concerns about the comfort level of nurses performing respiratory care, as the facility had recently shifted this responsibility from respiratory therapists to nurses. These observations and interviews highlight deficiencies in the facility's implementation of EBP and PPE usage during tracheostomy care.
Failure to Ensure Proper Tube Feeding Schedule
Penalty
Summary
The facility failed to ensure sufficient fluid intake and tube feeding for a resident who was dependent on enteral feeding. The resident, who had a history of nontraumatic subarachnoid hemorrhage, osteomyelitis of the vertebra, and sacral and sacrococcygeal region, was observed with a tube feeding pump that was not functioning correctly. The physician's orders indicated that the tube feeding should be administered from 10:00 AM to 2:00 PM, but this was acknowledged as incorrect by the dietetic technician, who stated the correct schedule should be from 2:00 PM to 10:00 AM. This error in the feeding schedule led to the resident not receiving the prescribed amount of nutrition and hydration. Observations on the day of the survey revealed that the resident's feeding pump was on hold error alert for an extended period, indicating a disruption in the delivery of the prescribed nutrition and fluids. Interviews with the registered nurse and dietetic technician confirmed the discrepancy in the tube feeding schedule and acknowledged the error in the physician's orders. Despite the technician's claim of periodically checking the pumps, the resident did not receive the necessary tube feeding and water flushes as prescribed, resulting in a failure to maintain proper hydration and nutrition for the resident.
Incomplete Medical Records and Lack of Resident Contact Information
Penalty
Summary
The facility failed to maintain a complete and organized medical record for a resident who was admitted with acute and chronic respiratory failure, dependence on a respiratory ventilator, and muscular dystrophy. The resident was supposed to be on a ventilator at night and use oxygen during the day. However, the medical record lacked crucial documentation, including CPR sheets, a transfer form to the hospital, and details of the hospital to which the resident was transferred. Additionally, there was no documentation of the resident's weight, diet order, or nutritional assessment, and the care plan inaccurately included a feeding tube, which the resident did not have. The deficiency was further compounded by the absence of contact information for the resident's representative on the face sheet, which led to a lack of notification during the resident's hospitalization. The administrator acknowledged that the contacts from hospital records were not transferred to the facility records, and the responsible staff member had been let go. The administrator also confirmed the missing code blue sheets and the lack of a clear timeline regarding the resident's transfer to the hospital.
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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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