Brookdale Palmer Ranch Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Sarasota, Florida.
- Location
- 5111 Palmer Ranch Parkway, Sarasota, Florida 34238
- CMS Provider Number
- 106022
- Inspections on file
- 20
- Latest survey
- July 21, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Brookdale Palmer Ranch Snf during CMS and state inspections, most recent first.
An LPN administered Melatonin and Benadryl without provider orders to multiple residents, resulting in observed changes such as increased confusion, drowsiness, and behavioral alterations. Staff and resident interviews, along with medication records, confirmed the unauthorized use of these medications, which violated facility policy and residents' rights to be free from abuse.
A nurse administered Melatonin and Benadryl to several residents without physician orders, using these medications to induce sleep during the night shift. This led to changes in resident behavior, including increased confusion and drowsiness, and was reported by staff and residents. The facility's investigation confirmed that the medications were not ordered for the affected residents and that the actions violated residents' rights to be free from chemical restraints and abuse.
Two residents with cognitive impairments were inadequately supervised, leading to one elopement and another being at risk. One resident, initially not deemed an elopement risk, eloped after becoming ambulatory. Another resident was identified as an elopement risk but was not provided with a wanderguard or updated care plan. Clerical errors and lack of timely reassessment contributed to these deficiencies.
The facility failed to provide timely physician-ordered medications for two newly admitted residents, leading to significant care deficiencies. A resident did not receive Tramadol for pain management post-surgery due to procedural lapses, resulting in severe pain and hospital transfer. Another resident with COPD missed doses of Cefepime IV due to unavailability in the facility's stock, causing a delay in treatment. Staff interviews revealed a lack of clarity in medication access procedures during off-hours.
A resident admitted after knee replacement surgery did not receive prescribed Tramadol for pain management due to the facility's failure to reconcile hospital discharge orders and notify the pharmacy. The MAR lacked documentation of the medication, leading to severe pain and a transfer to the emergency room. Staff interviews revealed issues with medication access and order processing.
A facility failed to maintain accurate medical records and ensure proper medication administration for two residents. One resident, admitted for post-surgery care, was discharged with uncontrolled pain due to incomplete documentation and lack of access to medication machines. Another resident, admitted with severe respiratory conditions, did not receive timely IV antibiotics, with records lacking verification of administration. Staff interviews revealed systemic issues with documentation and access to necessary resources, contributing to these deficiencies.
Unauthorized Administration of Sleep Aids and Antihistamines by LPN
Penalty
Summary
A deficiency was identified when a facility failed to protect residents' rights to be free from abuse by allowing an LPN to willfully administer unauthorized over-the-counter medications, specifically Melatonin and Benadryl, to multiple residents during the night shift. The facility's policy prohibits the use of chemical restraints or medications for staff convenience or discipline without a provider order. Despite this, the LPN was found to have given these medications to residents without physician orders, as confirmed by medication counts, staff statements, and resident interviews. Several residents exhibited changes in behavior and cognition that coincided with the nights the LPN worked. For example, one resident became significantly more confused, another was excessively drowsy and unable to walk, and others displayed increased aggression or changes in activity participation. Staff and residents reported these changes, and documentation confirmed that the medications administered were not ordered for these individuals. The facility's investigation substantiated the allegations, with multiple staff overhearing the LPN discuss giving these medications and observing the resulting behavioral changes in residents. The affected residents had various diagnoses, including dementia, anxiety, insomnia, and a history of falls. Some were cognitively intact, while others had severe cognitive impairment. The unauthorized administration of medications was not isolated to a single resident but involved at least five individuals, with the exact number undetermined. The DON confirmed that both Melatonin and Benadryl were stock medications and that the LPN administered them without proper orders, violating residents' rights and facility policy.
Plan Of Correction
I have enclosed the Plan of Correction for the above-referenced facility in response to the Statement of Deficiencies. While this document is being submitted as confirmation of the facility's ongoing efforts to comply with all statutory and regulatory requirements, it should not be construed as an admission or agreement with the findings and conclusions in the Statement of Deficiencies. F: 600 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? On 7/9/25, Nurse A was suspended pending investigation related to the administration of Melatonin and Benadryl. Nurse A resigned on 7/15/25. Resident 999 was evaluated by a licensed nurse on 7/11/25, and notified the Healthcare Provider (HCP), and the resident's representative of the medication error. No new orders were obtained. Resident 900 was reviewed on 7/11/25 by the Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the med error. No new orders were obtained. Resident 850 was reviewed on 7/11/25 by the Director of Clinical Services and/or Assistant Director of Clinical Services for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the Director of Clinical Services and/or Assistant Director of Clinical Services for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the Director of Clinical Services and/or Assistant Director of Clinical Services for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. On 7/15/25, current residents with a BIMS of 12 or higher were interviewed by Social Services or designee regarding medications and if they were offered sleep medications. No further residents were identified. Between 7/10/25 and 7/15/25, eight (8) family members were interviewed by the Executive Director or designee for any concerns in care, medications, or changes in their loved one. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? On 7/18/25, the Assistant Director of Clinical Services provided re-education to licensed nurses on Melatonin and Benadryl administration, 7 rights of medication administration, physician notification on missed/refused medication, PRN medication administration, abuse, and neglect. On 7/8/25, Melatonin was counted by the DCS or designee. Upon further staff interviews, on 7/9/25, daily Melatonin counts expanded to all nurse carts, and daily Benadryl counts were added. On 7/28/25, the DCS or designee changed the Melatonin and Benadryl from stock bottles to individual bubble cards filled through the pharmacy. Social Services and/or designee will review the Behavior Report in Daily Stand Up to assist with identification of new changes in residents' behaviors that may require an additional review. How will the facility monitor its performance to make sure that solutions are sustained? To assist with compliance, the DCS or designee has audited the count for melatonin, daily beginning on 7/8/25. The DCS or designee has audited daily the count for Benadryl beginning on 7/9/25. Daily audits continued through 7/27/25 with no discrepancies noted. Audits will be conducted twice a week for two weeks, then weekly for a combined total of 12 weeks. Social Services or designee will conduct two resident interviews weekly with residents BIMS 12 or higher for 12 weeks. The Assistant Director of Clinical Services or designee will conduct one medication pass observation per week for 12 weeks. The DCS or designee will review findings of the audits monthly in the Quality Assurance Performance Improvement (QAPI) Meeting for 3 months. Discipline Responsible: The Director of Clinical Services or designee will be responsible for compliance.
Unauthorized Administration of Chemical Restraints
Penalty
Summary
A deficiency occurred when a nurse administered over-the-counter medications, specifically Melatonin and Benadryl, to multiple residents without physician orders and for non-medical reasons, such as to induce sleep during the night shift. The facility's policy clearly states that residents have the right to be free from chemical restraints imposed for discipline or staff convenience, and that any use of such medications must be authorized in writing by a physician for a specific and limited period or in an emergency, with proper documentation and immediate physician consultation for chemical restraints. However, the investigation revealed that the nurse gave these medications to residents without proper authorization, and the medications were not ordered for those residents at the time of administration. The incident was brought to light when staff members reported unusual resident behaviors, such as increased confusion, excessive drowsiness, decreased participation in activities, and changes in mood or behavior that correlated with the nights the nurse in question worked. Statements from staff and residents indicated that some residents received medications they were not supposed to get, and in some cases, residents could recall being given something to help them sleep. The facility's investigation found that bottles of Melatonin were placed in medication carts and that a significant number of pills were unaccounted for. The nurse involved denied giving sleep aids but later admitted to administering Melatonin and Benadryl to residents without current orders. Clinical record reviews confirmed that the affected residents did not have active orders for the medications administered. Several residents experienced notable changes in their cognitive and physical status, such as increased confusion, inability to walk, and behavioral changes. The Director of Nursing verified that the allegations of abuse were substantiated, and it was unclear how many residents received unauthorized medications. The facility's failure to ensure that medications were only administered as ordered by a physician and not for staff convenience resulted in a violation of residents' rights to be free from chemical restraints and abuse.
Plan Of Correction
N: 0204 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? On 7/9/25, Nurse A was suspended pending investigation related to the administration of Melatonin and Benadryl. Nurse A resigned on 7/15/25. Resident 999 was evaluated by a licensed nurse on 7/11/25, and notified the Healthcare Provider (HCP), and the resident's representative of the medication error. No new orders were obtained. Resident 900 was reviewed on 7/11/25 by the Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the med error. No new orders were obtained. Resident 850 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. Resident 850 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. On 7/15/25, current residents with a BIMS of 12 or higher were interviewed by Social Services regarding medications and if they were offered sleep medications. No further residents were identified. Between 7/10/25 and 7/15/25, eight (8) family members were interviewed by the Executive Director or designee for any concerns in care, medications, or changes in their loved ones. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? On 7/18/25, the Assistant Director of Clinical Services provided re-education to licensed nurses on Melatonin and Benadryl administration, 7 rights of medication administration, physician notification on missed/refused medication, PRN medication administration, abuse, and neglect. On 7/8/25, Melatonin was counted by the DCS or designee. Upon further staff interviews, on 7/9/25, daily Melatonin counts expanded to all nurse carts, and daily Benadryl counts were added. On 7/28/25, the DCS or designee changed the Melatonin and Benadryl from stock bottles to individual bubble cards filled through the pharmacy. Social Services and/or designee will review the Behavior Report in Daily Stand Up to assist with identification of new changes in residents' behaviors that may require an additional review. How will the facility monitor its performance to make sure that solutions are sustained? To assist with compliance, the DCS or designee has audited the count for Melatonin, daily beginning on 7/8/25. The DCS or designee has audited daily the count for Benadryl beginning on 7/9/25. Daily audits continued through 7/27/25 with no discrepancies noted. Audits are conducted twice a week for two weeks, then weekly for a total of 12 weeks. Social Services or designee will conduct two resident interviews weekly with residents BIMS 12 or higher for 12 weeks. The Assistant Director of Clinical Services or designee will conduct one medication pass observation per week for 12 weeks. The DCS or designee will review findings of the audits monthly in the Quality Assurance Performance Improvement (QAPI) Meeting for 3 months. Discipline Responsible: The Director of Clinical Services or designee will be responsible for compliance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to prevent neglect through inadequate assessments and supervision, leading to the elopement of two residents. Resident #5, who was admitted with severe cognitive impairment and multiple health conditions, was not initially deemed an elopement risk due to his inability to ambulate. However, his condition improved, and he became ambulatory, which was not reassessed in a timely manner. Consequently, Resident #5 eloped from the facility and was found outside, confused and with an abrasion, after passerby's reported his presence. Resident #6, admitted with severe cognitive impairment and a history of repeated falls, was identified as an elopement risk in a quarterly assessment. Despite this, no care plan was updated, and no wanderguard was provided to mitigate the risk. The resident was observed moving independently in a wheelchair, yet the necessary precautions were not implemented. The ADON admitted to a clerical error in the elopement risk assessment, which contributed to the oversight. The facility's failure to reassess and implement appropriate elopement prevention measures for both residents highlights a significant deficiency in their supervision and risk management processes. The lack of timely updates to care plans and the failure to equip residents with necessary safety devices contributed to the potential risk of harm.
Medication Management Deficiencies for Newly Admitted Residents
Penalty
Summary
The facility failed to ensure timely acquisition of physician-ordered medications for newly admitted residents, leading to significant deficiencies in care. Resident #1, admitted after knee replacement surgery, did not receive the prescribed Tramadol for pain management due to a lack of reconciliation of discharge orders with the attending physician and failure to notify the designated pharmacy. The resident experienced severe pain, rated 10/10, and was transferred back to the hospital for uncontrolled pain. The facility's emergency medication kit contained Tramadol, but the medication was not accessed due to procedural lapses, including the absence of a hard script and electronic prior authorization. Resident #2, admitted with a diagnosis of COPD and an acute lower respiratory infection, was prescribed Cefepime IV, which was not administered as scheduled. The medication was not available in the facility's Omnicell, and the first dose was delayed until the afternoon of the following day. The facility did not stock Cefepime, and the resident had to wait for the medication to be delivered, resulting in missed doses. The DON confirmed the delay in receiving the medication but did not comment on the missed doses due to not being employed at the time. Interviews with staff revealed a lack of clarity and training regarding the process for obtaining medications during off-hours. Staff members were unsure of how to access the medication machine or contact the pharmacy for unavailable medications. The consulting pharmacist and regional clinical services director confirmed the absence of necessary orders in the EHR, which contributed to the failure to administer the prescribed medications. These deficiencies highlight significant gaps in the facility's medication management processes, impacting resident care.
Failure in Pain Management for Post-Surgery Resident
Penalty
Summary
The facility failed to provide appropriate pain management services for a resident who was admitted following joint replacement surgery. The resident, who had a right knee replacement and was diagnosed with heart failure, cardiomyopathy, and type 2 diabetes, was discharged from the hospital with orders for Tramadol to manage pain. However, the facility did not reconcile the hospital discharge orders with the attending physician, nor did they notify the designated pharmacy of the new admission. As a result, the resident's Medication Administration Record (MAR) did not include the prescribed Tramadol, leading to the resident experiencing severe pain and requesting to be transferred to the emergency room. Interviews with staff revealed a lack of understanding and access to the medication dispensing process. A Licensed Practical Nurse (LPN) working the overnight shift stated she did not have access to the medication machine and was unaware of the process for contacting the pharmacy if medication was unavailable. The Director of Nursing (DON) could not confirm what medication was offered to the resident, and the consulting pharmacist indicated that no order was placed in the Electronic Health Record (EHR) for the Tramadol. Additionally, another staff member confirmed that if a medication order is not reflected on the MAR, it would not be administered, especially narcotics.
Deficiencies in Medical Record Maintenance and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care. For the first resident, who was admitted for aftercare following joint replacement surgery, the facility did not file a nursing admission data collection, which should have included admission details, cognition, communication preferences, skin issues, systems review, falls assessment, elopement risk assessment, and patient medication orders. The resident was discharged with uncontrolled pain, and the facility lacked a physical chart or paperwork, relying solely on the Electronic Health Record (EHR), which only contained vitals and a pain score. Interviews with staff revealed issues with access to medication machines and computers, hindering proper documentation and medication administration. The second resident, admitted with pneumonia due to pseudomonas, lung cancer, chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia, did not receive intravenous (IV) antibiotics on the day of admission. The clinical record lacked documentation to verify whether the antibiotics were administered, and there was no admission time recorded. The nurse's progress notes did not include notification of the physician for medication verification. The consulting pharmacist confirmed that the orders for IV Cefepime were received late and sent to the facility with a delay. Interviews with various staff members, including the Medical Records Director, Regional Nurse, and Director of Operations, highlighted systemic issues with documentation and access to necessary resources. The facility's policy required the nursing department to record specific clinical data upon admission, but this was not consistently followed. The lack of proper documentation and medication administration verification contributed to the deficiencies observed in the care of both residents.
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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