Beach Breeze Rehab And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Palm Beach, Florida.
- Location
- 1626 Davis Rd, West Palm Beach, Florida 33406
- CMS Provider Number
- 105492
- Inspections on file
- 20
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Beach Breeze Rehab And Care Center during CMS and state inspections, most recent first.
Surveyors identified improper sanitation practices in the kitchen, including dirty equipment and expired food items, as well as unsafe food storage temperatures in nourishment room refrigerators. The Food Service Director and Registered Dietitian confirmed these issues, which had the potential to affect all residents on oral diets.
Several residents were not treated with dignity and respect, including instances where a CNA was rude and accusatory, a resident was left without a gown after a colostomy incident, and staff were described as moody and disrespectful. Financial discussions were held publicly in the dining room, compromising resident privacy. During meals, a resident with cognitive impairment was physically stopped from eating with her hands, and another resident ate from others' plates before being served, with inconsistent staff response.
Persistent urine and stale odors were noted throughout multiple rooms and common areas, with additional maintenance issues such as oxidized faucets, broken cabinet doors, and a dirty air conditioner. The Housekeeping Manager could not provide documentation of deep cleaning or quality assurance completion, and acknowledged the need for more thorough cleaning after confirming the odors during a tour.
Insufficient staffing in the memory support unit resulted in multiple incidents where residents with severe cognitive impairment consumed food or beverages from other residents' plates or cups without staff intervention. Staff and resident interviews confirmed that the unit was often chaotic, especially on weekends, and that the available CNAs and activities staff were unable to adequately supervise all residents during meal times.
A resident with limited English proficiency and a history of stroke, dementia, and other conditions relied on a sign created by family to communicate preferences and needs. The sign was removed from the resident's room by an unknown individual, causing distress to the resident and spouse, and staff were unable to explain its removal. The facility failed to honor the resident's choice and did not support effective communication as outlined in the care plan.
A resident with no cognitive impairment reported receiving a cash disbursement from the business office without being provided a receipt or signing for the funds, contrary to facility policy. Staff claimed the resident signed the required forms, but could not explain the absence of witness signatures. Review of the documentation revealed signature discrepancies, and the resident denied signing the withdrawal receipt, indicating a failure to properly document and secure the resident's personal funds.
The facility did not provide a resident with her original documents upon request, despite having them available, and failed to ensure another resident received mail as required by policy. Both residents were cognitively intact, and staff interviews revealed inconsistencies in the mail distribution process.
A resident with moderate cognitive impairment and multiple health conditions, who smoked occasionally and required supervision, did not have a care plan addressing smoking despite facility policy and a completed assessment. Staff confirmed the resident smoked with supervision, but no care plan was present in the health record.
The facility failed to ensure that a resident with limited English proficiency and physical impairments had effective means to communicate with staff, as a communication board was inaccessible and translation support was inconsistent. Additionally, another resident managing her own colostomy experienced frequent delays in receiving necessary ostomy supplies, leading to improvised care and discomfort. Staff interviews revealed confusion over responsibilities for providing ostomy care, despite supplies being available.
A resident with dementia and a history of trauma expressed dissatisfaction with the activities provided, stating they were boring and not aligned with her interests, such as playing the piano. Despite repeated requests and staff awareness of her preferences, a policy change prevented her from leaving the memory support unit to access the piano, resulting in unmet psychosocial needs.
A resident with a terminal diagnosis and cognitive impairment was admitted to Hospice with a DNR order, but the facility's EMR and care plan listed the resident as full code. Staff were unaware of the DNR order in the Hospice paperwork, and there was no documentation of communication with Hospice or the resident's representative regarding code status, resulting in contradictory records.
A resident with severe cognitive impairment and a known fall risk experienced a fall that was witnessed by a roommate, but the incident was not reported or documented by staff. Despite the roommate informing staff and administration, there was no record of the fall in the resident's medical records or fall risk assessments, and staff interviews confirmed a lack of awareness and reporting of the event.
A resident dependent on tube feeding did not receive the prescribed amount of Jevity 1.5 via G-tube, as staff failed to initiate and maintain the feeding according to physician orders. Observations and staff interviews confirmed that the enteral nutrition was not started in the morning and was not supplemented to meet the required daily volume, resulting in the resident not receiving the full ordered nutrition.
A resident with COPD did not receive required respiratory assessments before and after nebulizer treatment, and was not provided a mouth rinse after inhaler use, as ordered. An LPN failed to check lung sounds, respirations, or oxygen levels during medication administration, and documented assessments that were not performed. The DON confirmed these assessments should have been completed as per orders.
A resident with no cognitive impairment and on a regular diet did not receive the required protein portion with their dinner, despite the meal ticket specifying chicken as the entree. The omission was not addressed at the time, and the Food Service Manager could not explain why the protein was missing, attributing it to an oversight.
The facility did not maintain an accurate and current Facility Assessment, repeatedly providing outdated documents that listed former staff and referenced expired COVID-19 guidance. Despite multiple attempts during the survey, the assessment continued to contain inaccuracies regarding the governing body and operational details, failing to meet regulatory requirements for annual review and updates.
Sanitation and Food Storage Deficiencies in Food Service Areas
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies during a tour of the facility's main kitchen and nourishment rooms. In the kitchen, several pieces of equipment, including two ovens, a steamer, and a meat slicer, were found with brown residue and debris, indicating inadequate cleaning. Additionally, a stack of sheet pans used for preparing chicken and fish was heavily soiled. The walk-in refrigerator contained expired food items, including butter, Swiss cheese, and a container of Mighty Shake, all past their expiration dates. In the nourishment rooms, the East wing refrigerator was found to be operating at temperatures significantly above the required 41°F, with readings of 58°F and 54°F on separate occasions. This refrigerator contained milk and other labeled food items. The thermometer's accuracy was questioned, but the temperature remained too high to ensure food safety. The Food Service Director and Registered Dietitian acknowledged these findings during the survey.
Failure to Honor Resident Dignity and Privacy During Care and Dining
Penalty
Summary
Multiple residents were not treated with dignity and respect by staff, as evidenced by direct resident interviews and observations. One cognitively intact resident reported that a CNA was consistently rude, accused her of lying, and failed to provide a clean gown after a colostomy bag incident, resulting in the resident sleeping without clothes. The same resident also reported that her food was discarded without being asked if she was finished. Another cognitively intact resident described staff as rude and unhelpful, becoming visibly upset during the interview. An anonymous resident, also alert and oriented, reported that CNAs were moody, arrogant, and disrespectful on both shifts, but declined to name staff due to fear of retaliation. The Social Service Director confirmed that such behavior did not reflect dignified treatment. A resident's financial matters were discussed in public areas, compromising privacy and dignity. The Business Office Manager delivered cash and discussed social security payments with a resident in the dining room, in the presence of other residents and staff. The resident requested documentation and privacy, but the Business Office Manager responded loudly and dismissively, refusing to move the conversation to a private setting. Another resident confirmed overhearing the loud financial discussion, stating it should have been conducted privately. The Business Office Manager admitted that forms were signed in the dining room, not in a private area. During meal observations, residents with cognitive impairments were not supported in a manner that preserved their dignity. One resident, who had severe cognitive impairment and a history of eating with her hands, was physically stopped by a CNA from eating with her hands, causing her to yell out. The CNA then attempted to encourage utensil use, despite the resident's established preference. In another instance, a resident with severe cognitive impairment ate from the plates of two other residents before being served her own meal. One of the affected residents appeared agitated and was provided a new meal, while the other was not. Staff acknowledged that such incidents occurred and that they typically provided a new tray when food was taken from another resident's plate.
Failure to Maintain Clean, Odor-Free, and Well-Maintained Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment on one of its units, as evidenced by persistent and pervasive odors, particularly urine and stale smells, throughout multiple rooms and common areas during the survey week. Observations documented strong and unpleasant odors in several resident rooms, bathrooms, and hallways over consecutive days. The Housekeeping Manager reported that deep cleaning was scheduled for each room at least monthly and that daily quality assurance rounds were conducted, but was unable to provide documentation or logs confirming the completion of these tasks. During a tour, the Housekeeping Manager acknowledged the odors and suggested that the floors might be the source, indicating a need for more thorough cleaning. Additional maintenance concerns were identified, including an oxidized faucet in a resident bathroom, a corroded faucet and broken cabinet doors in the dining room, and a visibly dirty window air conditioner with a black substance present. Photographic evidence of these issues was obtained and shared with the Regional Nurse Consultant, who agreed with the concerns. No specific residents' medical histories or conditions were detailed in relation to the deficiency, but the observations were made in both occupied and unoccupied rooms.
Insufficient Staffing Led to Unsupervised Resident Interactions During Meals
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents in the memory support unit, resulting in multiple incidents where residents consumed food or beverages from other residents' plates or cups without intervention. Observations revealed that one resident with severe cognitive impairment and a history of Alzheimer's Disease, dementia, and dysphagia repeatedly took and drank from other residents' cups in the dining area when no staff were present. Staff were only alerted to these incidents by the surveyor, after which the contaminated cups were discarded. Another resident with severe cognitive impairment was observed eating food from the plates of two other residents before being served her own meal, causing visible agitation in one of the affected residents. Only one of the affected residents received a replacement meal, while the other did not. Interviews with staff indicated that the unit was typically staffed with three or four CNAs for 32 residents, and staff reported difficulty supervising all residents, especially when providing care in individual rooms. Staff from the activities department were noted to assist with supervision, but only one activities staff member was present at a time, making it challenging to monitor both dining rooms simultaneously. Staff consistently reported that more personnel were needed to adequately supervise and assist residents, particularly those with behavioral issues or cognitive impairments. A resident interview described the environment on weekends as chaotic due to insufficient staffing, further corroborating the observations and staff statements. The lack of adequate supervision directly contributed to the incidents where residents consumed food or beverages from others' plates or cups, and to the overall disorder in the unit, affecting the quality of care for all residents in the memory support unit.
Failure to Support Resident Communication Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not supporting the resident's choice to have a sign displaying personal preferences, dislikes, and family contact information posted in the resident's room. The resident, who was Spanish-speaking and assessed as cognitively intact with a BIMS score of 13, relied on the sign for communication due to a language barrier and limited English proficiency. The sign, created by the resident's family, was observed over the resident's bed but was later removed by an unknown individual. The resident and his spouse, both with limited English skills, expressed distress over the removal, stating that the sign was essential for communicating needs to staff. Interviews with facility staff, including the Social Services Director, DON, and Administrator, revealed that none of them knew who removed the sign or why it was taken down. The resident reported that the sign was not removed by direct care staff, but could not identify the person responsible. The care plan for the resident included interventions to address communication barriers, such as providing a translator and evaluating alternative communication methods, but did not address the removal of the sign. The lack of communication and failure to support the resident's expressed preference led to the deficiency.
Failure to Provide Proper Receipts and Documentation for Resident Personal Funds
Penalty
Summary
The facility failed to properly manage and document a resident's personal funds in accordance with its own policy, which requires that residents receive and sign a receipt for any cash or check disbursements, with a copy provided to both the resident and facility records. A resident with no cognitive impairment reported receiving $100 in cash from the Business Office Manager without being given a receipt to sign or a copy for his records. The resident stated he did not understand the reason for the cash disbursement and did not recall signing any documentation for the transaction. When questioned, the Business Office Manager and Marketing Manager both claimed the resident had signed the required forms, but could not explain why they did not sign as witnesses, as required by policy. Upon review, the Administrator noted discrepancies in the signatures on the withdrawal receipt and other documents, agreeing that one of the signatures did not match the resident's usual signature. The resident also denied signing the withdrawal receipt and stated that the signature on the document was not his. The facility's failure to ensure proper documentation and witness signatures during the disbursement of personal funds resulted in a lack of compliance with established policy and created confusion regarding the handling of the resident's finances.
Failure to Provide Original Documents and Deliver Mail to Residents
Penalty
Summary
The facility failed to provide a resident with her original documents upon request and failed to deliver mail to another resident as required by policy. In the first instance, a resident with no cognitive impairment requested her original documents from the Office Manager, expressing concerns that the provided copies were incomplete and altered. Despite the resident's request, the Business Office Manager only provided a copy, stating that the resident should have received the originals from the Department of Children and Families (DCF), and did not directly address the resident's request for the originals, even though original forms were available in the office. In the second instance, another resident, also with no cognitive impairment, reported not receiving any mail and was unaware of the mail distribution process. Interviews with staff revealed that mail addressed to residents is sorted by the receptionist and distributed by the activities staff. However, the process for determining whether mail addressed to both the resident and the facility should go directly to the resident or to the business office was inconsistently described, potentially leading to residents not receiving their mail as intended.
Failure to Develop and Implement Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's smoking needs, despite policy requirements that any smoking-related privileges, restrictions, and concerns be documented in the care plan. The resident in question was moderately cognitively impaired, required assistance with mobility and transfers, and had multiple diagnoses including cancer, chronic lung disease, malnutrition, and muscle weakness. A smoking evaluation indicated the resident required supervision and assistance to light or extinguish cigarettes. Record review revealed that no care plan for smoking was present in the resident's electronic health record, even though the resident reported smoking occasionally and staff confirmed that the resident smoked under supervision. The absence of a care plan was acknowledged by the Regional MDS Coordinator, who noted that an assessment had been completed but a care plan was not generated as required.
Failure to Provide Communication Supports and Ostomy Supplies
Penalty
Summary
The facility failed to provide appropriate means for a resident with communication barriers to effectively communicate with staff. One resident, who was Spanish-speaking and had limited use of his right arm and hand due to multiple medical conditions including stroke and muscle weakness, was unable to access a communication board that was placed on the right side of his bed, out of his reach due to raised bed rails. The resident's care plan identified a potential communication problem and included interventions such as providing a translator and evaluating alternate communication methods, but these were not effectively implemented. Interviews revealed that while some staff and therapists spoke Spanish, there was no assurance that communication needs were met when Spanish-speaking staff were not present, and the resident expressed frustration over the removal of a sign created by his family that helped communicate his needs. Another deficiency involved the facility's failure to ensure a resident with a colostomy had timely and consistent access to necessary ostomy supplies to independently maintain her ostomy care. The resident, who was cognitively intact and managed her own colostomy, reported frequent delays in receiving replacement ostomy bags, sometimes resorting to using zip-loc bags overnight when supplies were not provided. She also reported skin irritation due to these delays. Interviews with staff revealed confusion regarding responsibility for providing colostomy care and supplies, with nurses and CNAs each indicating the other was responsible. The central supply coordinator confirmed that supplies were available and accessible to nursing staff, indicating the issue was not due to a supply shortage. Both deficiencies were substantiated through interviews, observations, and record reviews, demonstrating that the facility did not ensure residents maintained their ability to perform activities of daily living, such as communication and ostomy care, due to failures in providing necessary supports and supplies as outlined in their care plans.
Failure to Provide Resident-Centered Activities in Memory Support Unit
Penalty
Summary
The facility failed to provide activities that met the interests and psychosocial needs of a resident with a history of dementia, mood disturbance, anxiety, and trauma. The resident, who had moderate cognitive impairment and was dependent on staff for emotional, intellectual, physical, and social needs, expressed dissatisfaction with the activities offered, describing them as boring and not aligned with her interests. She specifically stated a preference for crossword puzzles and music, and repeatedly requested access to a piano, reflecting her background as a former piano teacher. Despite these expressed preferences, the resident was observed participating in activities she found unengaging, such as watching TV and folding washcloths, and was often seen asleep in common areas. Staff interviews confirmed that the resident previously enjoyed playing the piano when she was in the general population, but a recent corporate policy change restricted residents in the memory support unit from leaving the unit, preventing her from accessing the piano located outside the locked area. Staff acknowledged the resident's interest in the piano but stated they were not permitted to escort her outside the unit. The resident's daughter also confirmed that her mother frequently requested to play the piano during visits. These actions and inactions resulted in the facility not providing activities tailored to the resident's interests, thereby failing to promote her psychosocial well-being.
Failure to Collaborate with Hospice on Code Status Documentation
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper collaboration with Hospice services regarding a resident's code status, resulting in contradictory documentation. The resident, who was cognitively impaired and had a terminal diagnosis, was admitted to Hospice services with a documented DNR (Do Not Resuscitate) order in the Hospice paperwork. However, the facility's electronic medical record (EMR) and care plan listed the resident as a full code, and current orders reflected this status as well. Discontinued orders and Hospice documentation indicated a DNR status, but this was not consistently reflected in the facility's records. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's correct code status. The RN relied on the EMR banner for code status information and was unaware of the DNR order in the Hospice paperwork. The Unit Manager and DON were also unaware that the DNR order had been provided by Hospice and could not recall or explain changes made to the code status in the EMR. There was no documentation of communication with the Hospice provider or the resident's representative regarding the code status, and staff could not provide a clear process for updating code status upon changes in care, such as admission to Hospice.
Failure to Report and Document Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to implement proper protocol following a resident fall. Record review showed that a resident with severe cognitive impairment and a history of impaired mobility and generalized weakness was not reported as having fallen, despite a care plan identifying fall risk. The resident's roommate reported witnessing the fall and stated that it took staff some time to respond, and that she informed both staff and administration about the incident. However, there was no documentation of the fall in the resident's records, and the fall risk assessment did not reflect any recent falls. Interviews with staff, including the nurse on duty and the DON, revealed that they were unaware of the fall and had not received any reports about it. The DON confirmed that staff are required to report falls in writing, but no such report was found. The lack of documentation and follow-up after the fall indicates that the facility did not ensure adequate supervision or accident reporting as required by protocol.
Failure to Administer Ordered Enteral Nutrition via G-Tube
Penalty
Summary
The facility failed to provide enteral nutrition as ordered for one resident who was dependent on tube feeding for nutritional support. The resident, who had multiple diagnoses including cancer, dementia, and was assessed as rarely or never understood, had physician orders for Jevity 1.5 to be administered via G-tube at 60 ml/hr for a total of 1200 ml over 20 hours daily. Observations revealed that the tube feeding was not initiated in the morning as ordered, with no supplement present in the resident's room during multiple checks. Staff interviews confirmed that the tube feeding was routinely stopped after the 1200 ml was infused, and not restarted until the next scheduled session, rather than running continuously for the prescribed 20 hours. Further review showed that the resident did not receive the full volume of enteral nutrition as ordered, as the feeding was not started until the afternoon and was not supplemented to meet the total daily requirement. Staff acknowledged that the feeding was paused for ADL care but did not adjust the schedule to ensure the resident received the full prescribed amount. These actions resulted in the resident not receiving nutrition via enteral method as ordered, constituting a failure to follow physician orders and provide appropriate care for a resident with a feeding tube.
Failure to Perform Required Respiratory Assessments During Medication Administration
Penalty
Summary
A deficiency occurred when a resident with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) did not receive appropriate respiratory assessments as required by physician orders during medication administration. The resident, who was cognitively intact, had active orders for Albuterol nebulizer treatments and Symbicort inhaler, with specific instructions to check lung sounds, pulse, and respirations before and after nebulizer administration, as well as to rinse and spit after inhaler use. During a medication pass observation, the LPN administered oral medications, the inhaler, and the nebulizer treatment but failed to check lung sounds or assess respirations before or after the nebulizer treatment. Additionally, the resident was not provided water to rinse and spit after the inhaler, as required by the order. When interviewed, the LPN acknowledged that she should have performed the respiratory assessments and checked oxygen levels but forgot due to nervousness. Documentation in the record indicated that the LPN had charted the assessments despite not performing them. The DON confirmed that the expected practice was to assess lung sounds, oxygenation, and respirations before and after respiratory treatments and agreed that the LPN did not follow the required procedures for this resident.
Failure to Provide Complete Meal per Resident's Dietary Needs
Penalty
Summary
A deficiency occurred when a resident did not receive all the food items listed on their meal ticket, specifically the protein portion, during a dinner service. The resident, who was cognitively intact with a BIMS score of 13 and on a regular diet per physician order, received a tray containing mashed potatoes, green peas, and sliced bread, but no protein. The resident reported this to staff and requested an alternative (a peanut butter and jelly sandwich), but did not receive it. The Food Service Manager was unable to provide a clear reason for the omission and confirmed that the meal ticket indicated the resident should have received chicken as the protein. Further investigation revealed that the resident had a known dislike for beef due to difficulty digesting it, but did not have a dislike for pork and typically received fish as a substitute when needed. The Food Service Manager acknowledged familiarity with the resident's dietary preferences but could not explain why the protein was omitted from the meal. The omission was attributed to being overlooked, as confirmed by review of the meal ticket and staff interviews.
Failure to Maintain Accurate and Timely Facility Assessment
Penalty
Summary
The facility failed to review and update its Facility Assessment accurately and in a timely manner, as required by regulations. During the annual recertification survey, the Administrator provided a copy of the Facility Assessment that was outdated, listing former staff members—including the Administrator, DON, Medical Director, Medical Records staff, Social Services Director, and MDS Coordinator—who were no longer employed at the facility. The assessment also contained outdated information regarding the COVID-19 pandemic, referencing the federal Public Health Emergency that had already ended. When the surveyor pointed out these inaccuracies, the Administrator attempted to provide updated versions of the Facility Assessment. However, subsequent versions continued to include outdated information, such as references to the pandemic and incorrect documentation of the governing body and staff involved in the assessment. The Administrator acknowledged missing several areas that required updating and recognized the need for further revisions during the survey process. Throughout the survey, the facility was unable to present a current and accurate Facility Assessment that reflected the present staff, governing body, and relevant operational information. The repeated provision of outdated and inaccurate documents demonstrated a failure to conduct and document a comprehensive, up-to-date facility-wide assessment as required for both day-to-day operations and emergency preparedness.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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