Brookwood Gardens Rehabilitation And Nursing Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Homestead, Florida.
- Location
- 1990 S Canal Drive, Homestead, Florida 33035
- CMS Provider Number
- 105550
- Inspections on file
- 22
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Brookwood Gardens Rehabilitation And Nursing Cente during CMS and state inspections, most recent first.
The facility did not ensure that food was procured from approved sources or that food was stored, prepared, distributed, and served according to professional standards.
Surveyors found that the walk-in refrigerator and freezer were not maintaining safe temperatures, with the refrigerator reaching 55°F and the freezer at 40°F. Food items, including meats, eggs, and ice cream, were improperly stored and not kept at required temperatures, and condensation was observed. Maintenance staff were aware of the issue, but the equipment had not been repaired, and temperature logs did not reflect the actual unsafe conditions.
The facility was cited for repeated failures to effectively implement and sustain QAPI and QAA activities, resulting in ongoing deficiencies related to food procurement, storage, preparation, sanitary practices, and resident dignity during dining. Despite regular QAPI committee meetings and established policies, the same issues were identified in multiple surveys.
Surveyors identified repeated deficiencies related to resident dignity during dining, food procurement and sanitary practices, and essential equipment safety. Despite the presence of a QAPI committee with regular meetings and a policy in place, the facility did not demonstrate that effective corrective actions were implemented to resolve these ongoing issues.
Fifteen residents experienced delayed lunch tray delivery when CNAs waited for nurses to check and hand over trays, resulting in a 15-minute wait after the food cart arrived. Staff interviews confirmed that only nurses could remove trays from the cart, causing the delay and affecting residents' dining experience.
The facility did not properly organize or support Resident Council meetings, resulting in unresolved issues such as missing clothing, delayed call light responses, inadequate snacks, and dissatisfaction with food quality. Residents reported ongoing grievances, and staff interviews revealed that food preferences and alternative meal options were not consistently addressed or communicated. Documentation of follow-up and resolution for concerns raised in meetings was lacking.
Confidential resident health insurance information was left unattended and visible on a medication cart at one nursing station. A RN acknowledged the lapse, stating the information should have been covered according to facility protocol, but was not due to being occupied with resident care. The DON confirmed the expectation for all resident information to remain covered.
The facility did not maintain an effective pest control program, as evidenced by multiple sightings of roaches in resident areas and reports of bugs in rooms. Pest control services were reportedly provided weekly, but pests, including roaches and lizards, were still observed inside and outside the building.
The facility failed to ensure proper food safety and sanitation practices, including undated food items in the refrigerator, lack of a thermometer in the milk box, and a rust-laden dish machine hood ventilation system. These issues have the potential to affect the majority of residents who consume food orally.
The facility failed to provide advance directives documentation for seven residents. Record reviews and interviews revealed that while advance directives are part of the admission package, there is no documentation confirming that residents or their representatives were offered and declined to execute these directives. The facility's policy requires that any existing advance directives be included in the medical record, but this was not followed for the sampled residents.
The facility failed to implement an effective QAPI program, resulting in repeated deficiencies related to the labeling and storage of drugs and biologicals, sanitary food handling, and infection control. Despite having a QAA committee and PIPs in place, the facility did not address these issues effectively, putting 142 residents at potential risk.
A CNA improperly disposed of a biohazard bag in a bin with a white lid instead of the designated biohazard box, leading to a deficiency in infection control practices. The CNA later corrected the mistake, and the Director of Nursing confirmed the proper disposal procedures as per the facility's policy.
The facility failed to ensure the high temperature dish machine reached the required temperatures for the wash and final rinse cycles, affecting the sanitation of dishware for residents. Observations and interviews confirmed the issue, which was caused by a knife stuck in the dish machine drain.
A CNA was observed standing while assisting a resident with breakfast, contrary to the facility's protocol requiring staff to be seated to maintain resident dignity. The DON confirmed the requirement, and the facility's policy emphasizes treating residents with respect and dignity during daily activities.
The facility failed to accurately code the MDS for a resident who was discharged home, incorrectly indicating that the resident was discharged to a hospital. The error was identified through record reviews and acknowledged by the MDS Coordinator as an oversight.
The facility failed to maintain accurate drug records for a resident's Clonazepam 0.5 mg tablets. A narcotic count revealed a discrepancy between the blister pack and the Controlled Drug Receipt/Proof of use/Disposition form. The nurse admitted to forgetting to sign the form after administering the medication due to being distracted. The facility's policy mandates special handling and record-keeping for controlled drugs, which was not followed in this instance.
A facility failed to properly store medications for a resident, as two tablets were found in the resident's room without staff present. The resident, who has Systemic Lupus Erythematosus, was not approved to self-medicate. Facility protocol was followed after the discovery.
A facility failed to ensure a resident with multiple contractures wore prescribed splints to prevent worsening of their condition. Despite a physician's order and multiple observations, the resident was not consistently wearing the required splints, and the care plan lacked necessary interventions.
A resident with multiple health conditions, including dementia, experienced severe constipation and fecal impaction due to the facility's failure to monitor and document bowel movements. Despite care plans and physician orders, staff did not implement necessary interventions, leading to the resident's hospitalization and subsequent death from septic shock and other complications.
A resident with multiple health conditions was found to have a fecal impaction upon hospital admission, leading to septic shock and death. The facility failed to consistently monitor and document the resident's bowel movements, despite having a bowel management protocol in place. The resident's condition deteriorated after a fall, highlighting significant lapses in care and communication among staff.
Non-Compliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating non-compliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Maintain Safe Temperatures in Walk-In Refrigerator and Freezer
Penalty
Summary
The facility failed to ensure that the walk-in refrigerator and walk-in freezer were functioning properly, as observed during a kitchen tour. The walk-in refrigerator was found to have an exterior temperature of 50°F and an interior temperature of 55°F, with condensation noted on stored items such as produce, pasteurized eggs, juices, and thawed meats. The walk-in freezer was observed with an exterior temperature of 38°F and an interior temperature of 40°F, and foods inside, including breakfast foods, vegetables, meats, and ice cream, were not frozen and were soft to the touch. Photographic evidence was submitted to document these findings. Interviews revealed that maintenance staff had been aware for some time that the temperatures in both units were not within acceptable ranges, but repairs had not been completed. Review of temperature logs for the walk-in refrigerator and freezer showed recorded temperatures within acceptable ranges, which did not match the actual observed temperatures during the survey. The facility's Food Storage Policy required refrigerators to be maintained at 41°F or below and freezers at 0°F or below, with daily temperature recordings and internal thermometers, but these requirements were not met at the time of the survey.
Repeated Deficiencies in QAPI and QAA Implementation
Penalty
Summary
The facility failed to ensure effective implementation and sustainability of its Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities, as evidenced by repeated deficiencies identified during multiple recertification surveys. Specifically, the facility was cited for ongoing issues related to food procurement, storage, preparation, and sanitary practices, as well as resident rights concerning dignity during dining. These deficiencies were noted in both the previous and current recertification surveys, indicating a pattern of non-compliance and insufficient corrective action over time. During a QAPI review, it was confirmed that the QAPI committee, which includes the NHA, DON, Assistant DON, Medical Director, Pharmacy Representative, and all department heads, had met recently and reviewed activities and goals related to previously cited deficiencies. Despite having a documented policy outlining the purpose and scope of the QAA committee and QAPI program, the facility continued to exhibit repeated deficient practices in the same areas, demonstrating a lack of effective and sustained improvement.
Repeated Deficiencies in Dignity, Food Safety, and Equipment Despite QAPI Oversight
Penalty
Summary
The facility failed to demonstrate that effective plans of action were implemented to correct previously identified quality deficiencies. Repeated deficiencies were cited in the areas of resident dignity during dining (F550), food procurement, storage, preparation, and sanitary practices (F812), and essential equipment in safe operating condition (F908). These deficiencies were observed during both the previous and current recertification surveys, indicating that the same issues persisted over time. The survey history shows that the facility was cited for F550 and F812 in both surveys, and F908 was added in the most recent survey. During a review of the Quality Assurance and Performance Improvement (QAPI) committee activities, it was found that the committee, which includes the NHA, DON, Assistant DON, Medical Director, Pharmacy Representative, and all department heads, had last met on 08/15/2025. Despite the existence of a QAPI committee and a policy outlining its purpose and scope, the facility did not provide evidence that effective corrective actions were implemented to address the recurring deficiencies. The report is based on observations, interviews, and record reviews conducted by surveyors.
Delayed Meal Tray Delivery Compromises Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents who dined in their rooms, as lunch trays for 15 out of 22 residents on the 300 South Cart 1 were not delivered in a timely manner. Observations showed that after the food cart arrived, Certified Nursing Assistants (CNAs) waited by the cart and did not deliver trays to residents until nurses handed the trays to them. The lunch cart sat for approximately 15 minutes before the trays were distributed, resulting in a delay in meal service for the affected residents. Interviews with staff revealed that CNAs were not permitted to deliver trays until a nurse checked the consistency of the food with the meal ticket and physically handed the tray to the CNA. The Director of Nursing and a Registered Nurse confirmed this process, stating that only nurses could remove trays from the cart and that trays should be passed within five minutes of arrival. However, the observed practice led to a significant delay, impacting the residents' right to a dignified and timely dining experience.
Failure to Organize and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that resident group meetings, specifically the Resident Council, were organized and structured in a manner that supported residents' rights to participate and have their concerns addressed. Observations of a Resident Council meeting showed low attendance, with only one consistent council member and several first-time attendees. Review of meeting minutes from January through May revealed ongoing, unresolved issues such as missing clothing, delayed call light responses, inadequate snack availability, and dissatisfaction with food quality. There was no meeting held in June, and no documentation was found regarding follow-up or resolution of previously raised concerns. Interviews with residents indicated continued dissatisfaction with food quality, small portion sizes, and repetitive meals, as well as ongoing issues with missing clothing and unresolved grievances. The Food Service Director stated that menus are developed corporately and only slightly adjusted based on resident input, with no always available menu. Alternative meal options are dependent on leftovers or available items, and residents dining in-room must request alternatives to be informed of them. CNAs are expected to offer alternatives and report unmet needs, but there was no verification of this process. Portion increases are only made after reported weight loss or formal requests to the dietitian. The facility's policy requires prompt action on grievances and documentation of responses, but these steps were not demonstrated.
Unattended Resident Health Information Left Visible at Nursing Station
Penalty
Summary
A deficiency occurred when confidential resident information, specifically a census containing health insurance details, was left unattended and visible on top of a medication cart at the East Nursing Station. This was observed by a surveyor, who noted that the information was accessible and not secured while staff were away from the cart. Upon return, a registered nurse acknowledged that the facility's protocol requires resident information to be covered at all times, but admitted to not following this protocol due to assisting a resident and forgetting to secure the documents. The Director of Nursing confirmed that the expectation is for all resident information to remain covered. Facility policy also states that resident health information must be kept private and confidential.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches within the building. During observations, a roach was seen crawling on the wall behind a resident who was in bed, and another roach was observed outside a resident's room in the 300 South Wing. Additionally, while interviewing a resident's wife, a roach was seen crawling up the wall in the same wing. The resident's wife also reported the presence of bugs in the room. The Administrator confirmed that pest control services are provided weekly and acknowledged recent sightings of pests, including lizards and baby lizards, both inside and outside the facility. The facility's pest control policy requires ongoing efforts to keep the building free of insects and rodents, with services provided by an external company and assistance from maintenance staff as needed.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen, affecting the majority of its residents. During an initial kitchen tour, surveyors observed opened and undated mozzarella cheese and egg salad in the walk-in refrigerator. The Accounts Manager/Food Service Director confirmed that these items should have been dated when opened and discarded if not properly labeled. Additionally, the milk box was found to lack a thermometer, which is necessary to ensure that cold foods are maintained at temperatures of 41 degrees Fahrenheit or below. The Accounts Manager/Food Service Director acknowledged the absence of the thermometer and stated that one would be placed in the milk box immediately. Further observations revealed that the dish machine hood ventilation system was rust-laden, despite a previous citation for the same issue. The Accounts Manager/Food Service Director admitted that the vent should be cleaned daily. Even after an attempt to clean the vent, rust was still present. These deficiencies in food storage, labeling, and equipment maintenance have the potential to affect one-hundred and thirty-two out of one-hundred and forty-two residents who consume food orally in the facility.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to provide advance directives documentation for seven out of seven sampled residents. Record reviews for Residents #102, #137, #305, #307, #65, #76, and #77 showed no written documentation related to advance directives. Interviews with the Administrator, Social Services Director, and Admission Director revealed that while advance directives are part of the admission package, there is no documentation confirming that residents or their representatives were offered and declined to execute these directives. The facility's policy requires that any existing advance directives be included in the medical record, but this was not followed for the sampled residents. The Social Services Director and Admission Director confirmed that advance directives are explained to residents or their representatives upon admission, and they are informed to bring any existing documents to the facility. However, there is no signed documentation indicating that residents were offered advance directives and chose not to execute them. This lack of documentation was acknowledged by the Administrator and Social Services Director during interviews, indicating a systemic issue in the facility's process for handling advance directives.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to ensure an effective Quality Assessment and Assurance (QAA) committee/Quality Assurance/Performance Improvement (QAPI) program, as evidenced by not implementing corrective plans of action for repeated deficiencies. These deficiencies were related to the labeling and storage of drugs and biologicals, sanitary food handling, and infection control. The facility's survey history revealed that these issues were previously cited during the last recertification survey. Despite having a QAA committee that meets monthly and includes various key staff members, the facility did not address these repeated deficiencies effectively. During an interview, the Administrator mentioned that the committee has Performance Improvement Plans (PIPs) in place, such as those for decreasing falls, but did not provide evidence of effective plans for the cited deficiencies. The facility's policies and procedures outline a comprehensive QAPI plan, but the repeated citations indicate a failure to implement these plans effectively. At the time of the survey, there were 142 residents residing in the facility, potentially at risk due to these ongoing issues.
Improper Disposal of Biohazard Material
Penalty
Summary
The facility failed to properly dispose of biohazard material for one resident. During a wound care observation, a CNA disposed of a biohazard trash bag into a bin with a white lid instead of the designated biohazard box. The CNA admitted to placing the bag in the wrong bin due to nervousness and later corrected the mistake by moving the bag to the proper biohazard container. This incident was observed and documented by surveyors, who noted the improper disposal of biohazard material in the soiled utility room. The Director of Nursing confirmed that all materials containing blood or body fluids should be placed in a biohazard bag and then into a box labeled Biohazard. The facility's policy on waste disposal, dated October 2019, mandates that all infectious and regulated waste be handled in a safe and appropriate manner, using color-coded or labeled containers. The policy also specifies that the Infection Preventionist and the environmental services director are responsible for ensuring proper waste disposal. Despite this policy, the CNA's error in disposing of the biohazard bag led to a deficiency in infection control practices.
Dish Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure the high temperature dish machine for the wash cycle and the final rinse cycle was working properly. Observations revealed that the wash dial was at 150 degrees Fahrenheit and the final rinse dial was at 174 degrees Fahrenheit, which did not meet the required temperatures of 160 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the final rinse cycle. This issue was observed during multiple cycles, indicating a consistent problem with the dish machine's temperature regulation. Interviews with the Accounts Manager/Food Service Director and Staff A, Dietary Aide, confirmed that the dish machine was not reaching the required temperatures. The Accounts Manager/Food Service Director noted that the dish machine log for breakfast showed different temperatures, which were also incorrect. The issue was identified to be caused by a knife stuck in the dish machine drain, which was later resolved by a technician. However, the deficiency was present at the time of the survey, affecting the sanitation of dishware for the residents who eat orally in the facility.
Failure to Provide Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide dignity while dining for one resident, as evidenced by a CNA standing while assisting the resident to eat breakfast. The observation occurred on 04/24/2024 at 8:46 AM, where Staff E, a CNA, was seen standing while assisting Resident #27. The resident had been admitted with a diagnosis that included morbid obesity and had a care plan initiated for potential nutritional problems, which included assistance with meals. The CNA acknowledged awareness of the facility's protocol to be seated while assisting residents but cited the bed height as a reason for standing. The Director of Nursing confirmed that staff are required to be seated next to residents while assisting with meals to provide dignity. The facility's policy on dignity, dated 12/2017, mandates treating each resident in a manner that promotes their quality of life, including being seated while assisting with eating. The failure to follow this protocol was observed and confirmed through staff interviews and record reviews, highlighting a deficiency in maintaining resident dignity during meal assistance.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who was discharged. Specifically, the MDS for one resident indicated that the resident was discharged to a hospital, while the resident was actually discharged to home. This discrepancy was identified during a review of the resident's records, which showed that the resident was admitted to the facility and later discharged home in stable condition. The resident's care plan also indicated that the resident wished to be discharged to home with a sister-in-law, and the discharge summary confirmed that the resident was discharged home with signed discharge instructions. The error was acknowledged by the MDS Coordinator during an interview, who stated that it was an oversight and would be corrected immediately. The facility's policy on Resident Assessment Instrument (RAI) emphasizes the importance of accurate and comprehensive documentation of the MDS to ensure proper assessment and care planning for residents. However, in this instance, the policy was not adhered to, resulting in inaccurate coding of the resident's discharge status.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain accurate drug records for controlled substances, specifically for a resident's Clonazepam 0.5 mg tablets. During a narcotic count, it was observed that the blister pack contained 33 tablets, while the Controlled Drug Receipt/Proof of use/Disposition form indicated 34 tablets. The discrepancy was noted on 04/24/24, with the last recorded administration on 4/23/2024. The electronic medication administration record showed that the medication was administered on 4/24/2024 at 1:16 PM, but the nurse, Staff C, admitted to forgetting to sign the form after administering the medication due to being distracted. The Director of Nursing confirmed that nurses are required to sign out controlled medications on the appropriate form at the time of removal from the blister pack. The facility's policy on controlled drugs, dated 10/2017, mandates special handling, storage, disposal, and record-keeping for Schedule II, III, and IV drugs. The policy specifies that a control sheet must be maintained for each substance, including the number on hand, time of administration, and the signature of the administering nurse. The failure to adhere to these procedures led to the observed discrepancy in the controlled drug records.
Improper Medication Storage
Penalty
Summary
The facility failed to properly store medications for one resident, as evidenced by the observation of medication in the resident's room without staff present. During a survey, two small, white, circular tablets were found inside a transparent medicine cup on a side table next to the resident's bed. The resident stated that the medication was given by the overnight nurse and kept due to not wanting to take it on an empty stomach. The LPN on duty was unaware of any medication being administered to the resident and confirmed that the resident was not approved to self-medicate. Facility protocol requires that any found medication be retrieved, the resident educated, the medication disposed of, and the supervisor notified, which was followed in this instance after the surveyor's observation. The resident involved had a diagnosis of Systemic Lupus Erythematosus and was cognitively intact with a BIMS score of 14. The resident's care plan included interventions for pain management related to lupus, depression, weakness, and decreased mobility. The resident had a physician's order for Acetaminophen 325 mg to be taken as needed for pain. The facility's policy on medication storage mandates that drugs and biologicals be stored in a safe, secure, and orderly manner, and no residents are allowed to have medications in their rooms without staff present. The Director of Nursing confirmed that no residents in the facility are approved to self-medicate and that education is provided to prevent unauthorized medication in resident rooms.
Failure to Ensure Splint Device Usage for Contracture Management
Penalty
Summary
The facility failed to ensure that a splint device was in place to prevent worsening of left hand and left elbow contractures for a resident. Multiple observations over several days revealed that the resident, who had contractures on both elbows and hands, was not wearing the prescribed hand rolls or splints. Despite a physician's order for the resident to wear a left grip hand splint and left elbow contracture management splint daily, these devices were not observed on the resident during the survey period. The resident, who has a history of multiple sclerosis, diabetes mellitus, functional quadriplegia, and contractures, was admitted to the facility in 2016 and had recently returned from a hospital stay. The resident's care plan, which was revised in February 2024, did not include interventions with splints, despite the resident's significant contractures. Interviews with staff indicated that the resident had only started wearing the splint on 4/23/2024, and even then, it was only tolerated for a few hours per day. The Director of Rehab confirmed that the resident was evaluated and prescribed the splints on 4/23/2024, but the resident had not been wearing them consistently. The facility's policy on assistive devices and equipment requires that all residents be screened and evaluated for appropriate rehab equipment upon admission, transfer, or return. However, this policy was not adequately followed, leading to the deficiency in the resident's care.
Failure to Prevent Fecal Impaction Leading to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident was free from abuse and neglect, resulting in the resident's death due to fecal impaction. The resident, who had multiple clinical diagnoses including cachexia, anorexia, and dementia, was admitted to the facility and had orders for medications to manage constipation. Despite these orders, the facility staff did not adequately monitor or document the resident's bowel movements, leading to severe constipation and fecal impaction. The resident was found hypotensive and hypothermic upon arrival at the hospital and was diagnosed with septic shock, fecal impaction of the colon, metabolic acidosis, and a closed traumatic brain injury, ultimately leading to the resident's death. The resident's care plans indicated a risk for constipation and included interventions such as encouraging fluids, monitoring medications, and documenting bowel movements. However, the facility staff failed to implement these interventions effectively. The last documented bowel movement was several days before the resident's fall, and there was no follow-up to ensure the resident's bowel health was maintained. The resident's condition deteriorated, leading to a fall and subsequent transfer to the hospital, where the severe complications were identified. Interviews with facility staff revealed inconsistencies in monitoring and documenting the resident's bowel movements. The Director of Nursing and other staff members acknowledged that the resident was independent but required assistance at times. Despite this, the staff did not adequately track the resident's bowel movements or respond to signs of constipation. The facility's policy on preventing abuse and neglect was not followed, resulting in the resident's severe health decline and eventual death.
Failure in Bowel Management Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice related to bowel management. The resident, who had a history of cachexia, anorexia, nutritional anemia, type 2 diabetes mellitus, and disease of the esophagus, was found to have a fecal impaction upon admission to the hospital. The resident's care plan included interventions for constipation, but these were not adequately followed, leading to the resident's hospitalization and subsequent death due to complications from fecal impaction and septic shock. The resident's medical records indicated that the last documented bowel movement was several days before the incident. Despite having orders for medications to manage constipation, there was a lack of consistent monitoring and documentation of the resident's bowel movements. The facility's bowel protocol, which included steps to be taken when a resident had not had a bowel movement for three days, was not effectively implemented. Interviews with staff revealed that while they were aware of the protocol, there was a failure in communication and documentation, leading to the resident's condition being overlooked. On the day of the incident, the resident was found pale and lethargic after falling from a wheelchair. Despite being assessed and transferred to the hospital, the resident's condition deteriorated, and she was diagnosed with septic shock, fecal impaction, metabolic acidosis, and a closed traumatic brain injury. The facility's failure to adhere to its bowel management protocol and adequately monitor the resident's condition contributed to the resident's severe health decline and eventual death.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
