Creekside Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sarasota, Florida.
- Location
- 5511 Swift Road, Sarasota, Florida 34231
- CMS Provider Number
- 105454
- Inspections on file
- 20
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Creekside Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident’s right to be free from misappropriation of property was violated when multiple unauthorized transfers totaling over $13,000 were made from the resident’s bank account to a CNA’s mobile money transfer application. The issue came to light when the resident questioned high charges, prompting the Business Office Manager to review bank statements and identify transfers to the CNA. The DON, after obtaining permission, confirmed that the money transfer app used for the transactions was not installed on the resident’s phone or bedside computer. The resident reported keeping a debit card in a bedside dresser, denied giving anyone permission to use it, and could only vaguely recall possibly giving the card to the CNA once for a purchase, while facility-provided bank records showed multiple transfers to the CNA.
A cognitively intact resident was moved to a secured memory care unit and reported being confined in his room with a taped "do not enter" sign on the door for several days, stating the move occurred against his will. The facility lacked a physician’s incapacity statement to override the resident’s decision-making, despite only having POA paperwork that applied if he could not decide for himself. Leadership reported the move was for the safety of female residents due to the resident’s inappropriate statements and behaviors and claimed the resident agreed, but there was no signed consent. A psychologist documented the resident’s self-harm statements tied to distress over the room change, and social services confirmed he had contacted a VA suicide hotline and later denied intent to harm himself.
The facility did not test fire alarm interface equipment according to NFPA 72, risking smoke detection failure. Only five of eight duct smoke detectors were tested, with no sensitivity tests conducted, potentially endangering building occupants.
The facility failed to maintain proper sanitation and cleaning practices in the kitchen, with an unchecked ice machine, improper use of the 3-compartment sink, and unaddressed bio growth on ceilings and vents. The CDM confirmed a lack of training for staff on proper procedures, and the Maintenance Director had not addressed these issues despite being aware of them.
The facility failed to follow infection prevention practices during blood glucose monitoring and catheter care for two residents. An RN did not perform hand hygiene before and after glove use and failed to clean the glucometer. Additionally, urinary catheter drainage bags were observed touching the floor, contrary to the facility's policy.
The facility failed to document COVID-19 vaccine education and acceptance/refusal for residents, lacking proper consent forms and verification processes. The DON and ADON were unaware of any documentation procedures, and the current process did not ensure informed consent or refusal was recorded.
The facility failed to provide a safe and homelike environment, with issues such as improper storage of personal items, unsanitary conditions, and broken shower facilities. Residents expressed dissatisfaction with the lack of proper hygiene facilities and the overall living conditions. The facility's maintenance logs confirmed that these issues had persisted for months without resolution.
The facility failed to provide necessary care and assistance for activities of daily living to eight residents, including bathing and meal assistance. Residents reported not receiving showers due to broken facilities and lack of staff help. Observations confirmed inadequate meal assistance, with residents left without necessary supervision. Documentation practices were also lacking, with missing records of scheduled showers and meal assistance.
Two residents in the facility did not receive care according to their established plans, specifically regarding the application of compression stockings. One resident with chronic heart failure was observed without the prescribed stockings, despite documentation indicating they were applied. Another resident with a femur fracture was also not wearing the ordered compression sock, although records inaccurately showed it was used. Nursing staff admitted to signing off on these treatments without verification.
A resident with epilepsy was not informed in advance about the discontinuation of their seizure medication, Epidiolex, by the facility. The resident, who had intact cognition, experienced two seizures after the medication was stopped without prior notification to them or their guardian. The ADON issued a verbal order to discontinue the medication without informing the resident or guardian, and the facility's records lacked documentation of any notification.
A facility failed to create a care plan for a resident who smoked, despite the resident's agreement to the smoking policy and the need for such a plan. The resident, diagnosed with COPD, smoked outside with her sister, but the care plan lacked goals and interventions for smoking. Staff interviews confirmed the oversight.
The facility failed to ensure proper medication storage for two residents and on one unit. A resident had unsecured acetaminophen at his bedside without an evaluation for self-administration. Another resident had unsecured antacid tablets without a physician order. Additionally, a box of Ipratropium Bromide was left unattended on a nursing desk. These incidents were confirmed by LPNs and the DON.
A facility failed to support a resident's right to voice grievances without fear of reprisal. A resident with multiple sclerosis and other conditions was found in unsanitary conditions, indicating a lack of care. After discussing her situation with a survey team, the resident was approached by management staff, making her feel guilty and insecure. The ADON confirmed asking about the interview but did not file a grievance, violating the resident's rights.
The facility's Memory Care unit was found to have several environmental deficiencies, including peeling wallpaper, missing cove moldings, cracked sheetrock, and missing pull cords on overbed lights. The shower room had a broken blind, broken lights, and tiles covered with an orange and brown film. These issues were confirmed by the Administrator.
Failure to Protect Resident From Misappropriation of Funds
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property, specifically unauthorized transfers of money from the resident’s bank account to a CNA’s money transfer application. The facility’s ANEMMI policy defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. During November 2025, the facility initiated an investigation into an allegation that funds had been transferred from Resident #1’s bank account to CNA Staff A via a mobile money transfer application. Documentation from local law enforcement, reviewed as part of the facility’s investigation, showed that between 10/6/25 and 10/31/25, transactions totaling $13,250.00 were transferred from the resident’s bank account to CNA Staff A’s money transfer account. The Business Office Manager reported that during her rounds on 11/13/25, the resident questioned why he was being charged $14,000 per month for his stay, and she informed him that the Veterans Administration paid for his stay and that the facility did not receive any funds from him. At the resident’s request, she reviewed his bank statements and observed transfers made to CNA Staff A through the money transfer application, after which the resident asked for help and requested that the police be called. The DON interviewed the resident the same day; with the resident’s permission, he reviewed the resident’s cell phone and bedside computer and confirmed that the money transfer application used for the transactions was not linked to either device. The resident stated he kept his debit card in his bedside dresser, did not give anyone permission to use it, and could only recall possibly giving the card to CNA Staff A once to purchase items, though he was unsure. Bank statements from October 2025 provided by the facility showed multiple transfers to CNA Staff A through the application, supporting the allegation of misappropriation.
Failure to Protect Resident From Involuntary Seclusion and Unconsented Transfer to Secured Unit
Penalty
Summary
The facility failed to protect a resident’s right to be free from involuntary seclusion when a cognitively intact resident was moved to a secured memory care unit and restricted in his room without clear consent or appropriate capacity determination. The resident, who had a BIMS score of 15 indicating intact cognition, reported that he had been moved "back here against my will" and that his door had been taped with a sign stating "do not enter," leaving him locked in his room for three days. Although the clinical record contained Power of Attorney paperwork authorizing his children to make health care decisions if he could not decide for himself, the record lacked a physician’s incapacity statement indicating that he was unable to make his own decisions. The Director of Regional Operations stated that the resident was moved to the secured memory care unit for the safety of female residents due to his inappropriate statements and behaviors, and asserted that the resident had confusion but made the decision himself, referencing progress notes but acknowledging there was nothing signed by the resident agreeing to the move. She also confirmed there was no physician statement of lack of capacity. A stop sign was placed across the resident’s door as an intervention to prevent others from entering his room. A psychology progress note documented that the resident made self-harm statements related to distress about being moved to a different room and that he linked these statements directly to his upset about the room change, stating he would not make such statements if moved back to his previous room. Social services confirmed that the resident had contacted the VA suicide hotline, denied intent to harm himself when interviewed, and that psychiatry had been notified. A Regional Nurse reported that an audit of advance directives and incapacity statements had been completed but did not determine whether residents actually needed incapacity statements.
Failure to Test Fire Alarm Interface Equipment
Penalty
Summary
The facility failed to test fire alarm interface equipment in accordance with NFPA 72, which could result in smoke detection devices failing to operate as designed, thereby endangering the occupants of the building. During a review of the facility's fire alarm inspection report, it was found that the report did not include complete results for the differential pressure testing of the duct smoke detectors. The report listed eight detectors in the system, but only four were reported as having been tested. Additionally, the report did not indicate that the sensitivity had been tested on any of the duct detectors. Further communication with the facility revealed that only five out of the eight detectors were tested, and there was still no indication that sensitivity tests were completed on any of the detectors. Differential pressure testing of tube-type duct detectors is a requirement of NFPA 72, and the failure to conduct these tests as required could compromise the safety of the building's occupants in the event of a fire.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. What corrective actions will be accomplished for those residents found to have been affected by this deficient practice. On 04/10/25 differential pressure testing of the smoke detectors was completed. The report lists 8 detectors in the system and all 8 were tested. Sensitivity testing was completed on 04/21/2025 for the 8 duct detectors. No specific residents were affected by this alleged deficient practice. 2. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. No residents affected by the alleged deficient practice. On 04/21/25 the Maintenance Director/designee completed an audit of smoke detectors and duct detectors to ensure documentation in place for completion of biennial smoke detector sensitivity testing and annual duct detector differential testing; no other concerns identified. 3. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur. The Maintenance Director was educated on 04/17/2025 related to maintaining documentation of the Fire Alarm System in accordance with National Fire Protection Association (NFPA) 101 by the Administrator. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Random audits will be completed by the NHA/designee of smoke detectors and duct detectors to ensure documentation in place for completion of biennial smoke detector sensitivity testing and duct detector differential testing once a week for 4 weeks and then monthly for 2 months. Findings and audits will be reported to the QAPI committee for follow-up and recommendations monthly.
Improper Sanitation and Maintenance Practices in Kitchen
Penalty
Summary
The facility failed to adhere to proper sanitation and cleaning practices in the kitchen, which could potentially lead to foodborne illness. During an initial tour, it was observed that the ice machine had not been checked since August 2024, despite having a maintenance log indicating monthly checks. The Certified Dietary Manager (CDM) confirmed that no checks had been conducted since her employment began three months prior. Additionally, a Dietary Aide was observed improperly using the 3-compartment sink, failing to fully submerge dishes in the sanitizing solution as required by the instructions. The CDM could not provide documentation that the Dietary Aide had been trained on the proper use of the sink. Further observations revealed a staff member entering the kitchen without a hair restraint, citing the absence of hairnets at the entrance. The kitchen also had multiple areas of black bio growth on the ceiling and vents, which had not been cleaned since the CDM's employment began. The Maintenance Director, who had been employed for three weeks, acknowledged ongoing issues but had not addressed the bio growth or ceiling maintenance. The Administrator confirmed that kitchen ceilings should be cleaned monthly and that appliances with a monthly sign-in sheet require monthly servicing.
Infection Control Deficiencies in Blood Glucose Monitoring and Catheter Care
Penalty
Summary
The facility failed to ensure proper infection prevention practices during blood glucose monitoring for two residents. A registered nurse (RN) was observed not performing hand hygiene before donning gloves and after removing them while conducting fingerstick blood glucose tests and administering insulin to two residents. The RN also failed to clean or disinfect the glucometer before and after use, and did not perform hand hygiene after handling the glucometer and before accessing the medication cart and computer. The RN admitted to not being aware of the need for hand hygiene before and after glove use and believed that using a sanitizing wipe on the glucometer was sufficient. Additionally, the facility did not maintain urinary catheter drainage bags in a sanitary manner for two residents. Observations revealed that the drainage bags were touching the floor, which is against the facility's catheter care policy. The policy requires that the drainage spigot should not touch the floor and that the catheter should be kept at an appropriate level to promote urine flow. These deficiencies indicate a lack of adherence to infection control guidelines, potentially increasing the risk of infection for the residents involved.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to ensure that residents or their representatives were given the opportunity to accept or refuse a COVID-19 vaccine, and that their medical records included documentation of education regarding the benefits and potential risks associated with the vaccine. This deficiency was identified for five residents reviewed for vaccinations. The facility's policy indicated that COVID-19 vaccines should be offered in accordance with CDC guidance, particularly emphasizing the importance for residents aged 65 and older, those at high risk for severe COVID-19, or those living in long-term care facilities. However, the facility did not have proper documentation to verify that education or acceptance/refusal discussions took place. During the survey, it was revealed that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, were unaware of any forms or documentation being used to record these discussions. The ADON acknowledged that they had not been using consent forms for COVID vaccinations and that the current process did not allow for verification of resident or representative education or acceptance/refusal. The documentation provided by the Regional Nurse showed historical vaccination dates for some residents, but did not include any recent vaccination status or evidence of informed consent or refusal.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. In several rooms, including Rooms #238, #240, and #243, there were issues such as personal items and food stored improperly, soiled linens and towels left on the floor, and unlabeled personal care items stored inappropriately. Additionally, some rooms had damaged or missing fixtures, such as frayed mattresses and missing ceiling tiles, which contributed to an unsafe and uncomfortable living environment. Residents were observed with personal care items stored in unsanitary conditions, such as urinary catheter drainage bags placed on the floor and urinals left on bedside tables. In one instance, a resident's room had a pungent smell of urine and feces, and soiled gloves and linens were left unbagged on the floor. Interviews with residents revealed dissatisfaction with the lack of proper storage and the inability to maintain personal hygiene due to broken shower facilities. The facility's shower rooms on Units 2A and 2B were found to be in disrepair, with broken and missing shower heads, leaving only two functioning showers for the entire floor. This situation had persisted for months, as confirmed by staff and residents, and was documented in the facility's maintenance logs. Residents expressed frustration over the lack of access to showers, feeling neglected and disrespected in their living environment. The facility's failure to address these maintenance issues and provide adequate personal care facilities contributed to the overall deficiency in maintaining a homelike environment.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance for activities of daily living to eight residents who were dependent on staff for such care. Residents reported not receiving showers for extended periods due to broken facilities and lack of staff assistance. For instance, one resident stated that the showers had been broken for several months, and they had to resort to sponge baths. Another resident mentioned that they had not received a shower in five weeks, and any bathing was provided by a family member. In addition to bathing issues, there were significant deficiencies in meal assistance. One resident, who required supervision and assistance during meals, was observed without staff assistance in the dining room. The resident's family member expressed concerns about the lack of staff during mealtimes, fearing the resident could choke. Observations confirmed that the resident did not receive necessary cueing and encouragement during meals, and there was no documentation of meal assistance for several days. The facility's documentation practices were also inadequate, as there was a lack of records indicating that residents received scheduled showers or meal assistance. Several residents' care plans and Kardexes did not include shower schedules, and staff were unaware of residents' needs. The Assistant Director of Nursing verified the absence of documentation for scheduled showers, highlighting a systemic issue in the facility's care provision and record-keeping.
Failure to Apply and Document Compression Stockings
Penalty
Summary
The facility failed to provide care in accordance with the established plan for two residents, leading to deficiencies in their treatment. Resident #6, who was admitted with chronic diastolic congestive heart failure, was observed multiple times without the prescribed compression stockings, which were ordered to manage her bilateral lower extremity edema and orthostatic hypotension. Despite the absence of these stockings, the Treatment Administration Record (TAR) was inaccurately documented by nursing staff, indicating that the stockings were applied daily. Interviews with the resident and nursing staff revealed that the stockings were never provided or applied, and documentation was completed without verification. Similarly, Resident #123, admitted with a fracture of the lower end of the right femur, was not wearing the prescribed compression sock on her right leg during observations. The Medication Administration Record (MAR) was inaccurately signed by nursing staff, indicating the sock was applied and removed as ordered, despite the resident stating it was never applied. The compression sock was found in the resident's drawer, unused, and the nursing staff admitted to signing the MAR without verifying the application of the sock. These actions demonstrate a failure to adhere to the care plans and accurately document the care provided.
Failure to Inform Resident and Guardian of Medication Discontinuation
Penalty
Summary
The facility failed to inform a resident and their guardian in advance about the discontinuation of a critical medication, Epidiolex, which was prescribed to manage the resident's epilepsy. The resident, who had intact cognition and a diagnosis of seizure disorder, was admitted from an acute care hospital with a discharge summary indicating the need for Epidiolex. Despite this, the facility stopped administering the medication on 12/29/24 without notifying the resident or the guardian beforehand. The resident experienced two seizures shortly after the medication was discontinued. The Assistant Director of Nursing (ADON) wrote a verbal order to discontinue the medication while working from home, and the physician signed the order a week later. The facility's records did not document any prior notification to the resident or the guardian about the discontinuation or the reasons behind it. The guardian discovered the discontinuation only after checking the medication list and was informed by the facility's administrator that the corporate office had instructed them not to administer the medication. This lack of communication and failure to involve the resident and guardian in care decisions led to the deficiency.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was identified as a smoker. The resident, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease, was evaluated for smoking and agreed to the facility's smoking policy, including the removal of the oxygen source before smoking. However, the care plan did not include any goals or interventions related to the resident's smoking habits. Interviews with the resident and staff revealed that the resident smoked outside with her sister during visits, and staff acknowledged that a smoking care plan should have been in place but was not developed.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications for two residents and on one unit. Resident #107 was observed with an unsecured bottle of acetaminophen at his bedside, which he used as needed for headaches. However, there was no documentation in his clinical record indicating that the Interdisciplinary Team had evaluated his ability to safely self-administer the medication or ensure its secure storage. Licensed Practical Nurse (LPN) Staff K confirmed the lack of evaluation and the unsafe storage of the medication. Similarly, Resident #81 was found with two unsecured bottles of antacid tablets, one on his computer desk and another on the floor next to his wheelchair. There was no physician order or assessment in his clinical record to self-administer the medication. LPN Staff L confirmed the unsecured medications and the absence of necessary documentation. Additionally, on Unit 1A, a box of Ipratropium Bromide belonging to another resident was left unsecured on the nursing desk without staff presence, as confirmed by the Director of Nursing.
Failure to Support Resident's Right to Voice Grievances
Penalty
Summary
The facility failed to uphold a resident's right to voice grievances without fear of discrimination or reprisal. Resident #103, who was readmitted with diagnoses including multiple sclerosis, anxiety, and major depressive disorder, was observed in her room with a strong odor of urine and feces, indicating she had not received incontinent care since the previous night. The resident, who was bedbound and dependent on staff for toileting, expressed awareness of her condition and discomfort with the situation. Following an interview with a survey team member, Resident #103 reported that two management team staff members approached her to inquire about the interview, which made her feel guilty and insecure. The Assistant Director of Nursing confirmed asking the resident about the interview but did not file a grievance on her behalf. This interaction suggests a failure to support the resident's right to voice grievances without fear of reprisal, as required by the facility's policy.
Deficiencies in Memory Care Unit Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in the Memory Care unit, as observed on two separate occasions. The observations included peeling wallpaper along the seams and ceiling in the Memory Care Hallway, missing cove moldings, and cracked sheetrock with holes in the walls of certain rooms. Additionally, resident rooms were missing pull cords on the overbed lights. The Memory Care shower room had a broken blind, broken lights in the bathroom and shower stall, and floor tiles covered with an orange and brown film. These deficiencies were verified by the Administrator during 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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