Broward Oaks Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Plantation, Florida.
- Location
- 7751 W Broward Blvd, Plantation, Florida 33324
- CMS Provider Number
- 105237
- Inspections on file
- 20
- Latest survey
- October 8, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Broward Oaks Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of a healed sacral wound did not receive timely preventive interventions such as an air mattress and wedge cushions, despite being at risk for pressure ulcers and dependent on staff for care. Preventive measures were delayed for several weeks, and weekly skin assessments were not consistently performed or documented by the LPN. The resident subsequently developed a stage 4 pressure ulcer, with staff interviews revealing inconsistent monitoring and delayed response to the resident's changing condition.
The facility did not follow professional standards or its own policies for indwelling urinary catheter care for two residents, including delayed initiation of Enhanced Barrier Precautions, inconsistent catheter securement, lack of timely care plan updates, and poor infection control practices such as failure to change gloves and perform hand hygiene. One resident developed a UTI and required antibiotic treatment.
A resident with multiple chronic conditions experienced severe, unaddressed weight loss due to the facility's failure to promptly identify and intervene according to policy. Despite eating most meals and expressing willingness to take supplements, the resident's significant weight loss was not acted upon by the clinical dietitian, and inconsistent weight monitoring practices, including use of uncalibrated scales, contributed to the deficiency.
The facility failed to accurately document comprehensive assessments for four residents, resulting in discrepancies between the MDS, care plans, and medical records regarding diagnoses, vision status, and oxygen use. Staff interviews and record reviews revealed that some residents were incorrectly coded for certain diagnoses or lacked documentation of significant conditions such as legal blindness, PTSD, and oxygen therapy.
The facility failed to consistently implement fall prevention and elopement policies, resulting in one resident leaving the premises without authorization and another experiencing an unwitnessed fall with delayed physician notification and inconsistent use of fall interventions such as floor mats. Staff interviews revealed gaps in knowledge and training regarding emergency alarms and care plan adherence.
A resident with an indwelling urinary catheter was observed multiple times with the catheter tubing unsecured to the leg, despite care plan interventions requiring it to be secured every shift. CNAs performed catheter care without securing the tubing, and both staff and the DON acknowledged the expectation to follow care plan interventions, but the required practice was not followed.
Surveyors found that the facility did not consistently follow physician orders for oxygen therapy, failed to document oxygen use accurately in the MDS, and did not ensure respiratory equipment was changed and dated as required. Several residents with respiratory conditions either did not receive prescribed oxygen, received it inconsistently, or had care plans and documentation that did not reflect their actual therapy.
The facility failed to ensure accurate management and documentation of controlled substances, including discrepancies in medication records, failure to remove discontinued medications, and inconsistencies between the controlled drug record and the MAR. Staff and the DON acknowledged these issues, which affected several residents with complex medical and psychiatric conditions.
The facility did not properly monitor or document behaviors and side effects for residents prescribed psychotropic medications and anticoagulants. Despite care plans and physician orders requiring observation of symptoms and adverse reactions, staff failed to record this information in the MAR/TAR, and pharmacy audits did not confirm monitoring. Interviews revealed that staff believed monitoring was occurring, but no evidence was provided, and adverse events such as falls were not consistently linked to medication side effects.
A resident with diabetes received multiple doses of Novolog insulin from a flex pen that had been used beyond the recommended 28-day expiration period. An LPN, unaware of the correct expiration timeframe, administered the expired insulin before the issue was identified during a medication pass observation. Facility policy and pharmacy guidance both required disposal of the insulin after 28 days, but this was not followed.
Two residents were found with unsecured medications and supplements at their bedsides, including prescription ointment and multiple over-the-counter products, without physician orders or approval for self-administration. Staff confirmed that facility policy prohibits medications at the bedside unless specifically assessed and ordered, but these requirements were not followed.
Pureed pancakes served to residents on a pureed diet were observed to be lumpy, grainy, and sticky, rather than having the required smooth and uniform texture. This issue was identified during a kitchen observation and confirmed by a SLP, potentially affecting 20 residents receiving pureed diets.
Multiple lapses in food service safety and sanitation were observed, including staff not wearing facial hairnets, improper thawing of raw ground beef, exposed cooked vegetables, lack of proper sanitizing solution for cleaning rags, storage of dirty items on clean equipment, undated and unlabeled chef salads, and the use of a food thermometer without gloves.
Staff failed to follow Enhanced Barrier Precautions (EBP) for two residents with indwelling devices, including not wearing gowns during catheter care and lacking EBP signage for a resident receiving tube feeding. Multiple staff members were unaware of EBP requirements or which residents qualified, and EBP signage and supplies were inconsistently available or visible.
Delayed Pressure Ulcer Prevention and Inadequate Monitoring
Penalty
Summary
The facility failed to adhere to professional standards for the care and management of pressure ulcers for one resident. Upon admission, the resident had a history of a healed sacral wound with no open areas or drainage, and the initial skin assessment did not identify any current pressure ulcers. Despite being dependent on staff for most activities of daily living and having multiple comorbidities, preventive interventions such as an air mattress and wedge cushions were not implemented until several weeks after admission. The care plan for skin integrity was initiated, but specific interventions for pressure ulcer prevention were delayed, with the air mattress ordered approximately four weeks after admission and the wedge cushion about seven weeks after admission. Interviews with the wound care LPN revealed that although the resident was identified as being at risk for pressure ulcers, preventive measures were not immediately provided because there was no open wound at admission. The LPN admitted to not performing weekly skin assessments as required and only reassessed the resident after being notified of skin breakdown. Documentation was inconsistent, with late entries in the nursing progress notes, and the LPN acknowledged not knowing why weekly skin notes were not completed. The resident's condition deteriorated, and within a month, a stage 4 pressure ulcer developed, which the LPN stated was unusual for a resident with no initial skin openings. Additional staff interviews indicated that while some preventive measures such as barrier creams and frequent repositioning were reportedly followed, there was a lack of consistent monitoring and oversight of these interventions. The staff also noted the resident's frequent refusal of care, but could not specify when this behavior began. The delay in implementing appropriate preventive measures and inconsistent documentation and monitoring contributed to the development and worsening of the resident's pressure ulcer.
Failure to Follow Catheter Care Standards and Infection Control Practices
Penalty
Summary
The facility failed to adhere to professional standards and its own policies regarding the care and management of indwelling urinary catheters for two residents. For one resident, the facility did not initiate Enhanced Barrier Precautions (EBP) as required by its policy for residents with indwelling medical devices, delaying implementation for approximately seven weeks after catheter placement. Additionally, catheter care was not documented as performed every shift as ordered, and the catheter was not consistently secured with a holder to prevent migration, as required by physician orders and facility policy. For another resident, observations revealed that the urinary catheter was not secured to the thigh and was freely moving, with the securement device not attached or dated. Staff interviews confirmed that catheter securement was inconsistently performed, with CNAs indicating that reattachment was the responsibility of nurses and that they reported detachment to nursing staff. During care observations, a CNA failed to change gloves between tasks, using the same gloves to clean the resident, handle the catheter tubing, and touch various surfaces and items, which is inconsistent with infection control standards. The resident also reported that staff did not perform hand hygiene before providing urinary care. Record reviews showed that catheter care was not initiated in the care plan until several days after the physician's order for catheter placement, and EBP interventions were not included in the care plan. Documentation also indicated that catheter securement was not performed on specific shifts as required. One resident developed a urinary tract infection, for which antibiotic treatment was ordered. Staff interviews revealed inconsistent practices regarding the timing and performance of catheter care, as well as monitoring for signs of infection.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address a significant weight loss in a timely manner for a resident with multiple medical conditions, including Type 2 Diabetes, End Stage Renal Disease, Anemia, and dependence on dialysis. The facility's policy required prompt re-weighing, notification of the dietitian, and intervention when significant weight loss was detected. Despite these protocols, the resident experienced a 7.5% severe weight loss over a six-week period, which was not addressed by the clinical dietitian or reflected in the nutrition progress notes. The resident's care plan indicated a need to maintain weight within a specific range and to receive dietary evaluation and changes as needed, but these actions were not taken when the weight loss occurred. Observations and interviews revealed that the resident was eating 75-80% of meals and was cognitively intact, able to express preferences and concerns about food choices. The resident reported a decreased appetite and a willingness to consume nutritional supplements, but there was no evidence that additional supplements or interventions were provided after the significant weight loss was identified. The facility's documentation showed inconsistencies in weight monitoring practices, with weights being taken by both facility staff and the dialysis team, sometimes using uncalibrated or malfunctioning scales. This led to discrepancies in recorded weights and confusion about the resident's actual nutritional status. Further compounding the issue, communication between staff members regarding significant weight changes was inconsistent. The dietary technician and CNAs described different processes for weight monitoring and reporting, and the clinical dietitian was not notified or did not respond to the severe weight loss in a timely manner. The facility administrator acknowledged issues with scale accuracy and had recently arranged for calibration, but this action occurred after the deficiency was identified. As a result, the resident continued to lose weight, dropping to 80% of ideal body weight, without appropriate assessment or intervention from the clinical team.
Inaccurate Documentation of Resident Assessments
Penalty
Summary
The facility failed to ensure accurate documentation of comprehensive assessments for four residents, specifically regarding diagnoses, vision, and oxygen use. For one resident, the Minimum Data Set (MDS) included a diagnosis of schizophrenia, despite no supporting documentation in the medical or psychiatric records. The MDS Registered Nurse acknowledged this discrepancy during a side-by-side review of the resident's records. Another resident's MDS assessment did not reflect the use of oxygen or impaired vision, even though physician orders, care plans, and direct observation confirmed the use of oxygen therapy and a diagnosis of legal blindness. The MDS Coordinator was informed of these inconsistencies but did not provide an immediate explanation for the discrepancies. A third resident's MDS assessment omitted a diagnosis of Post Traumatic Stress Disorder (PTSD), despite it being listed among the resident's medical diagnoses. Interviews with various staff members, including CNAs and nurses, revealed a lack of awareness or documentation regarding the resident's PTSD triggers. The MDS Coordinator confirmed that PTSD should be documented in Section I of the MDS but acknowledged the omission and noted that other MDS Coordinators were not present to address the issue. For the fourth resident, the MDS assessment indicated adequate vision and clear speech, while the care plan documented impaired communication and vision loss due to glaucoma and cataracts. Interviews with the MDS Coordinator and Social Services Director revealed conflicting assessments of the resident's vision status, with the care plan and medical history indicating impairment, but the MDS and social services staff reporting adequate vision. These inconsistencies demonstrate a failure to accurately assess and document residents' conditions in the MDS, as required.
Failure to Prevent Elopement and Inconsistent Fall Prevention Measures
Penalty
Summary
The facility failed to follow its own policies regarding fall prevention and elopement, resulting in deficiencies related to accident hazards and inadequate supervision. In one instance, a resident with a history of hydrocephalus, dementia, and other medical conditions was able to leave the facility without authorization during the night. Staff last observed the resident in bed during routine checks, but later discovered the resident missing after an alarm sounded. The nurse on duty was unfamiliar with the alarm system and did not immediately recognize the significance of the alarm sounds, delaying the response. The resident was eventually found outside the facility by police and returned unharmed. Interviews revealed that not all staff were clear on the alarm system's operation or had participated in elopement drills as required by facility policy. In another case, a resident with severe cognitive impairment and multiple risk factors for falls experienced an unwitnessed fall. The resident was found on the floor by staff during a midnight round and was unable to be oriented to reality. Documentation showed that the physician was not notified of the fall until more than 24 hours after the incident, contrary to facility policy which requires immediate notification. Additionally, the resident's care plan included the use of floor mats as a fall intervention, but observations revealed inconsistent implementation of this intervention. The resident's family member reported having to place a floor mat herself, indicating lapses in staff adherence to the care plan. These events demonstrate that the facility did not consistently implement or monitor required interventions for fall prevention and elopement risk. Staff interviews highlighted gaps in knowledge and training regarding emergency procedures and the use of safety equipment. The lack of timely physician notification and inconsistent application of care plan interventions contributed to the deficiencies identified during the survey.
Failure to Secure Indwelling Urinary Catheter as Required by Care Plan
Penalty
Summary
The facility failed to follow its policy and care plan interventions for urinary catheter care for a resident with multiple diagnoses, including neurogenic bladder and chronic kidney disease. The resident had an indwelling urinary catheter, and the care plan specified that the catheter should be secured to the leg every shift to prevent migration and accidental dislodgement. Multiple observations over several days revealed that the catheter tubing was not secured to the resident's leg as required. Certified Nursing Assistants (CNAs) performed catheter care without securing the catheter tubing, and both CNAs confirmed that the tubing was not secured. After providing care, they still did not secure the catheter tubing to the resident's leg. Additionally, the Director of Nursing (DON) stated that nurses are educated to follow care plan interventions, but the observations and staff interviews indicated that the care plan was not being followed in practice. The failure to secure the catheter tubing as outlined in the care plan and facility policy constituted a deficiency in providing appropriate catheter care and in preventing potential catheter-related complications.
Failure to Follow Physician Orders and Document Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders and provide safe and appropriate respiratory care for all eight sampled residents requiring oxygen therapy or respiratory support. Surveyors observed that oxygen therapy was not administered as ordered, with several residents either not receiving oxygen when prescribed, or receiving it inconsistently. In multiple cases, oxygen tubing and nebulizer equipment were not dated or changed according to physician orders or facility policy, and documentation in the Minimum Data Set (MDS) assessments was inaccurate or incomplete for residents receiving oxygen therapy. For example, one resident with diagnoses including heart failure and COPD had physician orders for oxygen therapy as needed to maintain oxygen saturation above 93%, but the care plan did not include goals or interventions for oxygen therapy, and the MDS did not reflect oxygen use despite documented administration. Another resident with heart failure and pneumonia was observed receiving oxygen, but the tubing was not dated, and the MDS assessment did not indicate oxygen therapy. Similar issues were found with other residents, including missing or outdated documentation of oxygen and nebulizer tubing changes, lack of care plan interventions, and discrepancies between observed care and physician orders. Additionally, some residents were not provided with the prescribed oxygen therapy at all, as observed in the case of a resident with an order for continuous oxygen who was repeatedly found without oxygen equipment in her room. Staff interviews revealed inconsistent knowledge and practices regarding the frequency of changing and dating respiratory equipment, and MDS coordinators were unable to verify the accuracy of assessments for residents under their care. These findings demonstrate a pattern of noncompliance with physician orders, inadequate documentation, and failure to ensure safe and appropriate respiratory care for residents requiring oxygen therapy.
Failure to Accurately Manage and Document Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure the accurate acquisition, receipt, dispensing, administration, and recordkeeping of medications, particularly controlled substances, for several residents. In one instance, a resident with severe cognitive impairment had a discontinued order for Clonazepam that remained in the medication cart, and the medication label did not match the order in the resident's medical record. Both the RN and the DON acknowledged that the medication should have been removed when discontinued, and that the documentation on the medication bingo card and control record did not align with the physician's order. For another resident with multiple psychiatric diagnoses, a review of the controlled substance record for Clonazepam revealed discrepancies in the documentation of the number of tablets on hand and those administered, with no explanation for the inconsistencies. Similarly, a resident with diabetes and other complex conditions had discrepancies in the administration and documentation of Tramadol, including tablets being removed from the controlled substance box without corresponding documentation on the Medication Administration Record (MAR), and instances where more tablets were removed than documented as administered. The staff involved were unable to explain these discrepancies during interviews. Additionally, a resident with a recent femur fracture and good cognitive status had a controlled drug signed out as administered, but there was no documentation in the MAR to confirm administration. Staff interviews confirmed that the expected process is to document administration both on the controlled drug record and the MAR, but this was not done. The DON acknowledged that reconciliation of controlled substances is supposed to occur at every shift change, but the observed discrepancies indicate this was not consistently followed.
Failure to Monitor Behaviors and Side Effects for Residents on Psychotropic Medications and Anticoagulants
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not accurately monitoring behaviors and side effects for residents prescribed psychotropic medications and anticoagulants. Multiple residents with diagnoses such as dementia, depression, anxiety, and psychotic disorders were prescribed medications including antidepressants, antipsychotics, and anticoagulants. Despite care plans and physician orders specifying the need for monitoring of targeted symptoms, behaviors, and adverse drug reactions, there was a lack of documented evidence in the Medication Administration Records (MAR) and Treatment Administration Records (TAR) that such monitoring was performed. For several residents, including those with severe cognitive impairment and complex psychiatric and medical histories, the required monitoring for both the effectiveness and side effects of psychotropic medications was not documented. In some cases, care plans outlined specific symptoms and behaviors to be observed, such as changes in mood, appetite, involuntary movements, and signs of bleeding for those on anticoagulants. However, reviews of the MAR/TAR revealed either no documentation or only check marks indicating medication administration, without any indication that behaviors or side effects were assessed or recorded as required. Interviews with nursing staff, pharmacy consultants, and the Director of Nursing confirmed that while staff believed monitoring was being conducted and documented electronically, they were unable to provide evidence of this documentation. Additionally, pharmacy audits did not verify the presence of behavior or side effect monitoring, and staff were often unaware of the frequency or details of adverse events such as falls, which could be related to medication side effects. This lack of monitoring and documentation was consistent across all sampled residents receiving psychotropic medications and anticoagulants.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of expired insulin. During a medication administration observation, an LPN prepared to administer Novolog insulin from a flex pen that had been opened and used beyond its manufacturer-recommended expiration period of 28 days. The LPN initially stated that all insulin in the facility expired in 35 to 45 days, but upon review of the label, acknowledged that the insulin had expired and confirmed that doses had been administered to the resident after the expiration date. The LPN then obtained a new insulin pen before proceeding with the administration. The resident involved had a history of obstructive sleep apnea, hypertension, and type 2 diabetes mellitus with diabetic neuropathy, and had a physician's order for Novolog insulin per sliding scale. The facility's policy and the pharmacist consultant both confirmed that Novolog insulin should be discarded after 28 days at room temperature. Review of the medication administration record showed that the resident had received multiple doses of Novolog insulin after the pen's expiration date, indicating a failure to adhere to both facility policy and manufacturer guidelines regarding medication expiration.
Failure to Secure and Store Medications Properly
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly secured and stored in accordance with professional standards for two residents. For one resident with a diagnosis of Type 2 Diabetes Mellitus and a BIMS score indicating intact cognition, a tube of prescription Mupirocin ointment 2% was observed on the dresser in plain sight on two separate occasions. There was no physician's order for this medication, nor an order permitting self-administration. Staff confirmed that medications should not be kept at the bedside unless the resident has been assessed and approved for self-administration, which was not the case for this resident. In another instance, a different resident with similar diagnoses and cognitive status was found to have four large bottles of over-the-counter supplements, including Calcimate Plus with Magnesium and Vitamin D-3, Magnesium Citrate, Probiotic gummies, and High-Metabolite Immunogens, unsecured and accessible on the bedside table. The resident reported that her daughter brought the supplements, but she had not taken them and was unaware of any physician's order for their use. Record review confirmed there were no orders for these supplements or for self-administration, and the care plan did not address self-administration. Staff interviews indicated that medications at the bedside should be confiscated and held for family pickup, and the assigned nurse was unaware of the presence of these supplements.
Failure to Provide Proper Pureed Food Consistency for Residents
Penalty
Summary
During an observation in the facility's central kitchen, pureed pancakes prepared for residents on a pureed diet were found to have a lumpy and grainy texture, rather than the required smooth consistency. The food was also noted to be firm and sticky when tested with a spoon, which does not meet the International Dysphagia Diet Standardization Initiative guidelines for pureed foods. The cook responsible for preparing the meal acknowledged the issue and indicated that a new blender would be used to achieve the correct consistency. The Speech Language Pathologist confirmed that pureed foods should have a uniform, smooth texture similar to pudding, applesauce, or hummus. This deficiency had the potential to affect 20 residents out of 98 who were on a pureed diet.
Food Service Sanitation and Safety Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitation during multiple observations in the main kitchen. The Dietary Service Manager and a diet aide were observed walking in the food production area without facial hairnet protection on several occasions. Raw ground beef was left thawing in a sink without running water, and a metal container of cooked vegetables was found partially opened and exposed in the reach-in refrigerator. Additionally, a dirty, used rag was stored in a red bucket without sanitizing solution, and empty food boxes and dirty gloves were placed on top of a clean pot in the food production area. Two plates of chef salad in the refrigerator were not dated or labeled. The Dietary Service Manager was also seen using a thermometer to check food temperatures without wearing gloves, further compromising food safety protocols.
Failure to Follow Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) guidelines for two residents who required such precautions due to the presence of indwelling medical devices. For one resident with hemiplegia, muscle weakness, aphasia, diabetes, dysphagia, and chronic kidney disease, staff were observed performing urinary catheter care without donning gowns as required by EBP protocols. Both CNAs involved only wore gloves and admitted to forgetting to wear gowns, despite EBP signage and supplies being available in the resident's room. Additionally, the catheter care procedure did not follow the facility's policy, as the CNA wiped the catheter tubing before the perineal area and used the same gloves throughout the process, including for handling supplies and applying ointment. For another resident with muscle weakness, dysphagia, expressive language disorder, and adult failure to thrive, who was receiving tube feeding, there was no EBP signage posted in the room or on the door. Multiple staff members, including a registered nurse and two CNAs, were unaware of which residents required EBP or the criteria for implementing EBP. The registered nurse, who was responsible for residents with devices such as a dialysis access port, did not recognize the need for EBP and could not identify the location of necessary supplies or signage. Observations confirmed the absence of EBP signage for residents with qualifying devices, and staff interviews revealed a lack of knowledge regarding EBP requirements. The infection preventionist confirmed that EBP should be implemented for all residents with devices such as PEG tubes, dialysis ports, tracheostomies, colostomies, or wounds, and that staff must wear gowns and gloves during care. The infection preventionist also acknowledged the absence of required EBP signage for the resident receiving tube feeding and confirmed that staff education on EBP was lacking at the time of the survey.
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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