Childrens Comprehensive Care Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Pompano Beach, Florida.
- Location
- 200 Se 19th Avenue, Pompano Beach, Florida 33060
- CMS Provider Number
- 106110
- Inspections on file
- 19
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Childrens Comprehensive Care Center Inc during CMS and state inspections, most recent first.
A RN administered insulin from a vial that lacked an open-date label, contrary to facility policy requiring all opened insulin to be dated. During a med pass, the nurse retrieved an unlabeled insulin vial, confirmed she believed she was allowed to use it and had done so previously, and then administered the dose to a resident with multiple complex conditions, including endocrine and metabolic disease and COPD. Other RNs and the DON reported that their practice is to ensure all insulin vials are labeled with opening dates and that they would not administer insulin from an unlabeled vial, highlighting a discrepancy between stated policy and observed practice.
Surveyors identified multiple deficiencies in food storage and kitchen sanitation, including undated and expired food items, visible spoilage, and unsanitary equipment and surfaces. These issues had the potential to affect all residents receiving oral diets, as confirmed by staff during the inspection.
A facility failed to notify a resident's representative about a significant change in the resident's skin condition. The resident, who was medically fragile, developed sores that were not communicated to the representative, despite facility policies requiring such notification. The lack of documentation and communication was acknowledged by the DON, highlighting a deficiency in compliance with regulatory requirements.
The facility failed to develop care plans for ADLs for two residents and a skin impairment care plan for another, despite their dependence on staff. Additionally, seizure precautions were not followed for a resident, as bed rails lacked required padding. Staff acknowledged inconsistencies and unavailability of necessary equipment.
The facility failed to ensure proper use of Enhanced Barrier Precautions and hand hygiene during high-contact resident care activities. Staff were observed not wearing appropriate PPE, such as gowns, and there was confusion due to inconsistent signage. Additionally, hand hygiene lapses were noted during medication administration, and some staff did not adhere to the facility's policy on nail length.
A facility failed to assist a resident with feeding in a dignified manner. The resident, who was dependent on staff for all ADLs and had a care plan due to dysphagia, was observed being assisted with a meal by a staff member standing over them. This was not in line with promoting dignity, and the concern was acknowledged by the Activities Director.
The facility failed to provide proper fingernail grooming for four residents who were dependent on staff for ADLs. Observations showed long, jagged fingernails with black matter underneath, indicating a lack of hygiene care. Staff were unclear about responsibility for nail care, leading to inadequate grooming for residents with complex medical conditions.
A facility failed to obtain a physician order for pressure injury care for a resident and did not administer medications within prescribed time frames for several residents. A nurse performed wound care without authorization, and medication administration was delayed due to staffing issues. Additionally, a resident's tube feeding was not connected on time, leading to further delays in care.
Two residents with complex medical needs did not receive the prescribed enteral nutrition and water flushes as per physician orders. Observations revealed issues with feeding pump operation and labeling, leading to insufficient nutrition and hydration. The Consultant Registered Dietitian confirmed the discrepancies and acknowledged the need for further staff education.
The facility failed to assess and obtain informed consent for bed rail use for two residents who were dependent on staff for ADLs and had multiple medical conditions. Despite care plans indicating the use of bed rails for safety, there were no documented assessments, physician's orders, or consents. The facility's administration acknowledged these omissions during an interview.
A medication error rate of 14% was identified in an LTC facility, exceeding the acceptable 5% threshold. A resident with multiple complex medical conditions experienced late administration of medications, including Phenobarbital and Propranolol, by an RN. The RN acknowledged the delay, and the DON was informed of the issue.
The facility failed to secure medication and respiratory therapy carts, leading to unauthorized access. Expired biologicals were not removed, and medications requiring refrigeration were left out at improper temperatures. Additionally, improper disposal of medications was observed, with staff flushing medications down the toilet and discarding pills in regular trash. The facility's policies on medication storage and disposal were not consistently followed.
The facility failed to ensure qualified oversight of kitchen operations, affecting meal preparation for residents. A resident received improperly prepared pureed meals, with food items pooling on the plate and lacking proper consistency. The Food Service Manager was not a Certified Dietary Manager, and the Registered Dietitian was only present weekly, leaving the Operations Officer, who lacked food service management qualifications, to supervise the kitchen.
A facility failed to provide meals consistent with a resident's dietary orders for a pureed diet. The resident was observed receiving meals that were not properly prepared, with food items pooling on the plate and containing chunks. The Food Service Manager confirmed the meals were not prepared according to the recipe or dietary needs.
The facility's assessment inaccurately documented the qualifications and staffing requirements for the dietitian and omitted the requirement for a Director of Food and Nutrition Services. The Workforce Profile incorrectly listed the education level for a dietitian as a 'High School Diploma.' This was acknowledged during an interview with the Administrator and other staff.
Failure to Label Opened Insulin Vial Before Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring that opened insulin vials be labeled with the date they are opened. The facility’s written policy on insulin administration, dated 06/15/20 and reviewed on 07/20/25, specifies that opened insulin must be labeled with the date. During a medication administration observation, a RN (Staff E) retrieved an insulin vial that did not have an open date on the label. When questioned, Staff E stated that she was allowed per facility policy to administer insulin without an open date and acknowledged that she had administered insulin from vials without open date labels before. She then drew up insulin based on the resident’s blood sugar reading and administered it to Resident #3 using this unlabeled vial. Resident #3’s record showed admission on a specified date with diagnoses including Disseminated Intravascular Coagulation (Defibrination Syndrome), a personal history of endocrine and metabolic diseases, peritoneal abscess, and COPD with acute exacerbation. The most recent MDS assessment documented a disabled BIMS score and noted the use of hypoglycemic and anticonvulsant medications. In contrast to Staff E’s practice, another RN (Staff F) reported that her responsibility for insulin administration includes checking expiration dates and ensuring vials have an open date label, and she stated she would not administer insulin from a vial without an open date. A third RN (Staff G) similarly stated that all medications, including insulin, are labeled with opening dates and that he would not administer insulin from a vial lacking an opening date. The DON also stated that all insulin vials are labeled with opening dates, which conflicted with the observed practice involving Resident #3.
Food Storage and Kitchen Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the safe and sanitary storage, preparation, and handling of food. During an initial kitchen tour, it was found that several food items, such as chicken broth and mayonnaise, were not labeled with the date they were opened, and staff were unaware of how long these items remained safe for consumption after opening. Expired food, including turkey bacon and sliced lemons with visible spoilage, was present in the refrigerator. Additionally, there were broken eggs and visible residue and debris inside the refrigerator, including on the gaskets and shelves. The cook confirmed these findings and disposed of some spoiled items during the inspection. Further unsanitary conditions were noted throughout the kitchen and storage areas. The can opener had brown debris on the blade, spice containers had visible residue from handling with soiled gloves, and a bin containing single-serve peanut butter packets was contaminated with various debris. The dry goods storage room floor was dirty, with dried liquids and food particles under the shelves. The oven and its knobs were also found to have accumulated residue. These conditions had the potential to affect all four residents on oral diets at the time of the survey.
Failure to Notify Resident's Representative of Skin Condition
Penalty
Summary
The facility failed to notify a resident's representative regarding a significant change in the resident's skin condition. The resident, who was medically fragile and dependent on staff for care, developed a skin condition that was not communicated to the resident's mother. The mother discovered the condition during a visit and was informed by the care doctor that the resident had sores, which she had not been previously notified about. The facility's policy required prompt notification of changes in a resident's condition, but this was not adhered to in this case. The facility's documentation practices were inadequate, as there was no record of communication with the resident's representative about the skin condition. The nursing staff, including an LPN, failed to document the resident's skin condition in the progress notes or any other relevant records. The Director of Nursing (DON) acknowledged the lack of documentation and the failure to notify the resident's representative as required by the facility's policy. The report highlights that the facility did not maintain proper records or communication regarding the resident's skin condition. Despite the presence of policies for skin care management and notification of changes, these were not followed, leading to a deficiency in the facility's compliance with regulatory requirements. The lack of documentation and communication with the resident's representative was a significant oversight by the facility's staff.
Plan Of Correction
Internal and External communication is being focused upon, following our in-service for improved communication with patients, staff, providers, social services, families, parents and legal guardian/representatives. The staff will increase documentation, as evidenced by skin assessment, progress note and charting by exception. The DON will monitor for compliance with progress notes, assessments and appropriate notifications. This Plan of correction will be addressed in our QAPI Meeting scheduled for.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in meeting their needs. For two residents, there was no care plan developed for activities of daily living (ADLs), despite their dependence on staff for all ADLs. The Resident Care Manager acknowledged the inconsistency in care plan development, as some residents had ADL care plans while others did not. Additionally, the facility did not develop a care plan for a resident with a skin impairment, specifically a Deep Tissue Injury (DTI) on the left dorsal foot. Although there were active physician orders for wound care, a care plan addressing the skin impairment was not created. The Resident Care Manager confirmed the absence of a skin impairment care plan, which should have been developed. Furthermore, the facility failed to follow seizure precautions for a resident with a seizure disorder. The care plan required padding on the bed rails, but observations revealed that the rails were metal with no padding. Interviews with staff indicated a lack of awareness and availability of the necessary pads, as they were not found in the expected locations. The Director of Medical Operations was unable to access the pads, highlighting a failure in ensuring seizure precautions were in place.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to ensure the proper use of Enhanced Barrier Precautions (EBP) and hand hygiene during high-contact resident care activities. Observations revealed that staff did not consistently wear appropriate personal protective equipment (PPE), such as gowns, when providing care to residents with indwelling medical devices or those on EBP. For instance, the Activities Director was observed clipping the fingernails of a resident on Enhanced Contact Precautions without wearing a protective gown. Similarly, a respiratory therapist provided care to a resident with a tracheostomy without donning the necessary PPE. Additionally, the facility did not maintain clear and consistent signage for EBP, leading to confusion among staff about the required precautions. During the survey, it was noted that there was only one PPE isolation cart with mixed signage, causing uncertainty about which precautions to follow. Interviews with staff revealed a lack of understanding and adherence to EBP, with some staff members admitting to not wearing gowns during high-contact activities unless there was a risk of splatter. The facility also failed to practice appropriate hand hygiene during medication administration. For example, a staff member was observed administering eye drops to a resident without performing hand hygiene after removing gloves. Another staff member was seen with long, polished fingernails, which is against the facility's policy, as long nails can harbor microorganisms. These deficiencies highlight a systemic issue with infection control practices within the facility.
Failure to Promote Dignity During Feeding Assistance
Penalty
Summary
The facility failed to assist a resident with feeding in a manner that promotes dignity. Resident #17, who was admitted to the facility and assessed as rarely or never understood, was dependent on staff for all Activities of Daily Living, including eating. The resident's care plan, initiated due to dysphagia and other risk factors, included assistance with meals as needed. During an observation, Staff L was seen standing over and to the right of Resident #17 while assisting with a lunch meal, which was not in line with promoting dignity. This concern was acknowledged by the Activities Director.
Failure to Provide Adequate Fingernail Grooming for Residents
Penalty
Summary
The facility failed to provide adequate fingernail grooming for four residents who were dependent on staff for activities of daily living (ADLs). Observations revealed that these residents had long, jagged fingernails with black matter underneath, indicating a lack of proper hygiene care. The facility's policy required that personal hygiene, including nail care, be performed as needed, but this was not adhered to for the residents in question. Resident #7, who had multiple complex medical conditions and was non-verbal, was observed on two occasions with untrimmed fingernails. Staff members were unclear about who was responsible for nail care, with conflicting statements from a CNA and an RN. Similarly, Resident #12, who was also dependent on staff for ADLs, had long fingernails and redness on the palm of his hand due to the nails digging into the skin. Staff were unaware of any refusal of care by the resident, and there was no care plan addressing nail care refusal. Resident #19, who was non-verbal and dependent on staff, was observed with long, jagged fingernails. The resident's mother expressed a preference for the facility to cut his nails to prevent self-injury. Staff interviews revealed confusion about responsibility for nail care, with some stating it was the nurses' duty, while others mentioned the Activities Director. Resident #8, who was medically fragile and dependent on staff, was also found with long, untrimmed fingernails despite documentation indicating that personal hygiene care had been provided. The DON acknowledged the deficiency in maintaining proper nail care for these residents.
Deficiencies in Physician Orders and Medication Administration
Penalty
Summary
The facility failed to notify and obtain a physician order prior to providing pressure injury care for a resident with a deep tissue injury (DTI) on the left dorsal foot. The resident, who was dependent on staff for all activities of daily living, had an active physician order for wound care that expired, yet care was continued without a new order. Staff B, a registered nurse, performed wound care without a physician order, and there were no nursing notes related to the dressing change that occurred without authorization. Additionally, the facility failed to administer medications within the prescribed time frames for several residents. During an observation, it was noted that medications for multiple residents were administered late, with the medication administration record screens turning red to indicate the delay. Staff G, a registered nurse, attributed the delay to staffing issues, as there was only one nurse available for a larger number of residents than usual. The report also highlighted that a resident's tube feeding was not connected at the scheduled time, and the assigned nurse was unaware of the resident's assignment until later in the morning. This resulted in a delay in administering medications and performing necessary assessments. The Director of Nursing and the Director of Medical Operations were informed of these deficiencies, which included late medication administration and delayed assessments.
Inconsistent Administration of Enteral Nutrition
Penalty
Summary
The facility failed to ensure that the administration of enteral nutrition was consistent with the practitioner's orders for two residents. Resident #7, who has multiple complex medical conditions including cerebral palsy and feeding difficulties, was observed not receiving the prescribed amount of enteral feeding and water flushes. Over a 48-hour period, the resident received significantly less formula and water than ordered by the physician. Observations revealed issues with the feeding pump being inactive and the feeding bag not being properly labeled, indicating a lack of adherence to the prescribed feeding regimen. Similarly, Resident #15, who also has complex medical needs including tracheostomy and feeding difficulties, did not receive the prescribed amount of enteral nutrition and water flushes. Observations showed that the resident was not connected to the feeding pump at various times, and the feeding bag was not labeled with the hanging time. The feeding pump history indicated that the resident received less formula and water than ordered over a 48-hour period. Interviews with staff revealed confusion and lack of clarity regarding the resident's feeding schedule and pump operation. The Consultant Registered Dietitian confirmed the discrepancies in the administration of enteral nutrition for both residents and acknowledged the need for further education and training for the nursing staff. The facility's failure to administer enteral nutrition as per physician orders highlights a deficiency in ensuring proper nutrition and hydration for residents dependent on tube feeding.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess residents for the use of bed rails and obtain informed consent for their use for two residents. Resident #10, who was dependent on staff for activities of daily living and had multiple diagnoses including quadriplegia and seizure disorder, was not assessed for cognition and had no physician's orders or informed consent for bed rail use. The care plan for Resident #10 included the use of side rails for safety, but there was no documented assessment or consent. Similarly, Resident #130, who was also dependent on staff for all activities of daily living and had diagnoses including aphasia and seizure disorder, had a care plan that included the use of bed rails for injury prevention. However, there was no order, assessment, or signed consent for the use of bed rails. During an interview, the facility's Director of Medical Operations and Administrator acknowledged the lack of assessments and informed consent, and it was revealed that the 'Consent for Treatment' did not include the use of bed rails.
Medication Administration Errors in LTC Facility
Penalty
Summary
The report identifies a medication error rate of 14 percent, which exceeds the acceptable threshold of 5 percent. This was determined through observation, interview, and record review, where four medication errors were identified out of 28 opportunities. The errors affected a resident who was dependent on staff for all activities of daily living and had multiple diagnoses, including acute respiratory failure, tracheostomy status, diabetes insipidus, anoxic brain damage, convulsions, gastrostomy status, retinopathy, disease of the stomach and duodenum, and dependence on a ventilator. The resident's physician orders included medications such as Phenobarbital, Propranolol HCl, Simethicone, and an eye lubricant, all of which were scheduled to be administered at specific times. During a medication administration observation, a registered nurse, Staff G, was noted to be late in administering the resident's medications. The nurse acknowledged that the medication screen turns red one hour after the scheduled time, indicating a delay. The medications, including Propranolol, artificial tears, Phenobarbital, and Simethicone, were administered late, with the process starting at 9:37 AM and completing at 10:16 AM, despite being scheduled for earlier times. The Director of Nursing was informed of the multiple instances of late medication administration, highlighting a systemic issue in timely medication delivery.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medication carts and respiratory therapy carts. On multiple occasions, medication carts were observed unlocked and unattended in common hallways, accessible to unauthorized individuals. Staff members, including a Registered Nurse and a Certified Respiratory Therapist, were responsible for these carts but failed to secure them, leaving medications such as Albuterol inhalation solution and Ventolin inhalers vulnerable to unauthorized access. The facility also neglected to remove expired biologicals from the medication room and crash cart. Expired items, including BD vacutainers and blood culture containers, were found during a review with the Director of Nursing. The responsibility for checking expiration dates was unclear, as staff members assumed it was the duty of a previous Resident Care Manager. Additionally, opened medication bottles were not properly labeled with dates, and medications requiring refrigeration were left out at inappropriate temperatures for extended periods. Improper disposal of medications was another significant issue. Staff members were observed flushing medications like Omeprazole and Gabapentin down the toilet due to a lack of proper disposal methods. Furthermore, a white round pill was discarded in a regular trash can instead of a sharps container. The facility's policy on medication storage and disposal was not consistently followed, as confirmed by interviews with the Director of Nursing and other staff members.
Deficiency in Kitchen Oversight and Meal Preparation
Penalty
Summary
The facility failed to ensure that the day-to-day kitchen operations were overseen by a qualified nutrition professional, which has the potential to affect all residents consuming food prepared in the kitchen. The facility's assessment highlighted the need for sufficient staff with appropriate competencies in food and nutrition services. However, the Food Service Manager, who was responsible for overseeing the kitchen operations, was not a Certified Dietary Manager (CDM) and had not completed the necessary courses to obtain this certification. Additionally, the Registered Dietitian (RD) was only present in the facility once a week and did not have oversight of purchasing and receiving, leaving the Operations Officer, who lacked qualifications in food service management, to supervise the kitchen. Observations during meal service revealed issues with the preparation and presentation of pureed meals for a resident, including food items pooling on the plate and not holding their shape, indicating improper consistency. The Food Service Manager and staff were unable to locate appropriately sized scoops for portioning pureed food, which was required by the approved menu. Interviews with staff confirmed the lack of proper oversight and management in the kitchen, with the Operations Officer admitting to overseeing multiple departments without specific qualifications in food service management. This lack of qualified oversight and management in the kitchen operations led to deficiencies in meal preparation and service.
Failure to Provide Properly Prepared Pureed Diet
Penalty
Summary
The facility failed to provide meals consistent with the dietary orders for a resident requiring a pureed diet. The resident, who was admitted to the facility with orders for a pureed diet with thin liquids for all meals, was observed receiving meals that did not meet these specifications. During a lunch observation, the resident was served pureed broccoli, chicken, and pasta that were not properly prepared, as they pooled on the plate and contained chunks, failing to maintain the shape of the scoop used for portioning. Similarly, during a breakfast observation, the resident received pureed cream of wheat, pancakes, and sausage, which also pooled on the plate. The Food Service Manager confirmed responsibility for these meals and acknowledged that the pureed foods were not prepared according to the recipe or the resident's dietary needs.
Inaccurate Facility Assessment in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure an accurate Facility Assessment, specifically in the area of Food and Nutrition Services. The assessment, dated June 2024, inaccurately documented the qualifications and staffing requirements for the dietitian and did not include the requirement or qualifications for a Director of Food and Nutrition Services. The Workforce Profile incorrectly listed the education level for a dietitian as a 'High School Diploma.' During an interview with the Administrator, Staff Coordinator, and Medical Operations Director, it was acknowledged that the Facility Assessment did not accurately reflect the qualifications of the dietitian or the requirement for a Director of Food and Nutrition Services.
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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