Delaney Park Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Orlando, Florida.
- Location
- 215 Annie Street, Orlando, Florida 32806
- CMS Provider Number
- 105791
- Inspections on file
- 20
- Latest survey
- July 18, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Delaney Park Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not have a qualified Infection Preventionist overseeing the IPCP after the ADON position became vacant. The DON, who was assigned the role, lacked current specialized training and certification as required, with only outdated training and no CBIC certification provided.
Ceiling vent covers in 30 resident rooms were observed to have discoloration and rust, with surfaces ranging from black to white and rust-colored edges. A resident's representative expressed concerns about the unsanitary appearance, and the Maintenance Director confirmed the vents were old, had been painted, and were maintained by scraping and repainting rather than replacement.
The facility did not implement enhanced barrier precautions for residents with wounds, indwelling devices, or MDRO colonization on one unit, failed to ensure transmission-based isolation was the least restrictive for a resident colonized with C. auris, and did not document or conduct process surveillance of infection control practices. Staff were unclear about required precautions, PPE was not available or used as required, and signage for TBP was missing for a resident with C. diff. The DON, acting as interim IP, confirmed these deficiencies and the lack of accurate records.
A resident with a recent femur fracture and pulmonary disease developed pain, swelling, redness, and warmth in her surgical leg. Nursing staff documented these symptoms and administered pain medication but did not notify the physician as required by facility policy. The resident was later hospitalized and diagnosed with DVT, revealing a failure to ensure prompt physician notification and intervention.
A resident with dementia and no documented history of psychosis was prescribed and later had an increased dose of Risperdal for a new diagnosis of schizophrenia, despite assessments and behavior records showing no evidence of psychosis or behavioral symptoms. The care plan lacked resident-centered interventions, and facility leadership could not provide documentation to support the diagnosis or medication changes.
A resident with multiple medical conditions was discharged AMA without proper documentation, investigation, or provision of essential discharge information. Facility staff could not provide evidence of a physician's discharge order, an AMA form, notification to the physician, or that the resident received a medication list and follow-up instructions.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to individualized care planning and delivery.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
A resident with significant physical and cognitive impairments was not consistently provided with a physician-ordered right elbow splint, despite documentation by an LPN indicating otherwise. The resident was repeatedly observed without the splint, and the LPN acknowledged documenting its application without direct verification. The unit manager and DON confirmed that staff were expected to ensure the splint was applied and documentation was accurate, but this did not occur.
The QAPI committee did not identify or address ongoing systemic non-compliance with infection prevention and control, as shown by repeat deficiencies and the absence of a current PIP or audits. The Administrator confirmed that monitoring of the previous plan of correction had ended, and there was no documentation of ongoing QAPI activities for infection control.
The facility did not ensure that oxygen concentrators were kept in safe, working order for several oxygen-dependent residents. Multiple concentrators in use showed caution lights or were labeled as failed, and staff could not consistently explain or track the status of these units. Family members reported malfunctioning equipment, but some units remained in use despite warnings, and there was no clear process for removing or replacing failed concentrators.
A resident with severe respiratory conditions and impaired cognition was observed receiving oxygen at a higher flow rate than ordered by the physician. Staff confirmed the oxygen concentrator was set at 3 LPM instead of the prescribed 2 LPM, and the DON stated that nurses are expected to verify and follow physician orders for oxygen therapy.
A facility failed to follow a physician's order for a resident's oxygen therapy, setting it at 3 LPM instead of the prescribed 5 LPM. The resident, who had been working to reduce her oxygen dependency, was distressed by the adjustment. Nursing staff documented administering 5 LPM despite not doing so, and the discrepancy went unnoticed until a survey. The DON confirmed the requirement to follow orders and check settings each shift, which was not adhered to.
The facility failed to store food in accordance with safety standards, with a walk-in refrigerator left open, resulting in unsafe temperatures, and improperly stored food items in the freezer. The facility's policy of sealing, labeling, and dating opened food items was not followed.
A cognitively intact resident was found with medications on her nightstand, administered by her spouse without physician orders or a self-administration evaluation. The facility's policy required such evaluations and orders, which were not in place, leading to a deficiency.
A facility failed to complete a discharge MDS Assessment for a resident who was discharged home. The Clinical Reimbursement Director admitted the oversight, noting the assessment was 124 days overdue due to inconsistent report running. The MDS 3.0 RAI Manual requires discharge assessments to be completed and submitted within specific timeframes, which were not met in this case.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in evaluating their functional abilities related to eating, vision, and dental status. One resident was inaccurately assessed as independent in eating despite requiring assistance, while another's vision and dental status were misrepresented, showing no need for corrective lenses or dental issues despite evidence to the contrary.
A resident with a midline catheter did not receive timely IV dressing changes as required by facility policy. The resident, who was immunocompromised and diabetic, had an IV site dressing dated 5/24/24, but the last documented change was on 5/29/24. RN H admitted to not documenting a change on 5/24/24 and incorrectly documenting a change on 5/29/24. RN F also failed to notice the overdue dressing change. The DON confirmed the expectation for timely dressing changes to prevent infection.
A resident with infections requiring contact isolation was not placed on the necessary precautions upon admission to the facility, despite having a physician's order. The resident informed staff of her isolation status from the hospital, but PPE and other measures were not implemented until days later. The nursing staff acknowledged the oversight, despite having the necessary equipment and procedures available.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was responsible for the Infection Prevention and Control Program (IPCP). The Assistant Director of Nursing (ADON), who was previously responsible for overseeing the IPCP, had vacated the position three weeks prior to the survey. In the absence of the ADON, the Director of Nursing (DON) was designated by the Administrator to serve as the IP, in addition to her full-time responsibilities as DON. The job description for the ADON required maintaining Infection Preventionist Certification, and the role included oversight of the IPCP and the Antibiotic Stewardship Program. Upon review of the DON's qualifications, it was found that she had professional nursing training and an active RN license, but lacked current specialized training or certification as an Infection Preventionist. The only evidence of relevant training provided was participation in a Nursing Home Infection Preventionist Training Course over four years prior and a certificate for 2.5 continuing education units in Universal Infection Prevention and Control from the previous year. The DON confirmed she was not certified in Infection Prevention and Control from the Certification Board of Infection Control and Epidemiology (CBIC) and had not worked as an IP since completing the earlier educational activity.
Failure to Maintain Clean and Sanitary Vent Covers in Resident Rooms
Penalty
Summary
The facility failed to maintain a homelike environment in 30 resident rooms on the first floor by not ensuring that ceiling vent covers were kept clean and sanitary. Observations revealed that the vent covers displayed a range of discoloration from black to white, with rust-colored substances present around the edges. A resident representative reported concerns about the unsanitary appearance of the vents, describing them as having a mold-like substance or debris accumulation. The Maintenance Director confirmed that all vent covers on the first floor showed signs of wear and tear, had been painted black, but still exhibited visible white and rust colors. He acknowledged that the black color could be interpreted as mold by some, but stated it was not mold. The vents were maintained by scraping off rust and repainting rather than replacing them, as they were old and worn.
Failure to Implement and Document Infection Control Precautions and Surveillance
Penalty
Summary
The facility failed to implement and follow infection prevention and control policies and procedures, resulting in multiple deficiencies related to enhanced barrier precautions (EBP), transmission-based precautions (TBP), and process surveillance. On the first floor (100 unit), there was no evidence of EBP implementation for residents with conditions such as pressure ulcers, tube feeding, indwelling catheters, or tracheostomies, despite facility policy and CDC guidance requiring such measures. PPE was not readily available, and signage indicating EBP was absent. The policy and procedure for EBP lacked critical language from regulatory guidance, and staff, including the unit manager, were unaware of the requirements. The DON, acting as interim infection preventionist, acknowledged the lack of EBP implementation and inaccurate resident lists for precautions. A resident with a history of cerebral palsy, tracheostomy, gastrostomy tube, and colonization with Candida auris was placed on contact isolation upon admission, despite only being colonized and not actively infected. The care plan and physician's order indicated indefinite contact isolation, but there was no documentation supporting the need for such restrictive measures, nor was the use of least restrictive isolation considered. Staff were unclear about the appropriate use of EBP versus contact precautions, and the resident was not listed as having an active infection in the facility's records. The facility also failed to document and conduct process surveillance of infection control practices, as required by its own policies. The infection control risk assessment lacked supporting data and documentation of surveillance activities. Additionally, another resident admitted with C. difficile infection was placed on TBP, but appropriate signage was not posted on the door, and staff were unaware of the specific precautions required. The DON, acting as interim IP, confirmed the lack of signage and process surveillance documentation, and staff did not consistently follow TBP protocols.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition, resulting in a deficiency related to prompt diagnosis and treatment. A resident admitted for short-term rehabilitation with a history of orthopedic aftercare, a femur fracture, shortness of breath, and interstitial pulmonary disease, was documented by nursing staff to have pain, swelling, redness, and warmth in her surgical leg. On one occasion, the nurse noted these symptoms and administered pain medication but did not notify the physician or document any such notification, despite the facility's policy requiring physician notification for significant changes in condition. Previous assessments had shown no edema at admission, but subsequent notes indicated the development of generalized edema, pain, and warmth in the lower extremities. Although the physician was notified on an earlier date when similar symptoms were present, there was no documentation of physician notification when the symptoms recurred and worsened. The resident was later transferred to the hospital, where she was diagnosed with deep vein thrombosis (DVT) in the affected leg. The facility's policy required timely notification and documentation of such changes, which was not followed in this instance.
Unnecessary Antipsychotic Use Without Supporting Documentation
Penalty
Summary
A resident was admitted with multiple diagnoses, including hypertension, type 2 diabetes, unspecified dementia without behavioral disturbance, and anxiety. Initial and quarterly assessments indicated no evidence of psychosis, behavioral symptoms, or a diagnosis of schizophrenia. Behavioral notes documented no psychiatric history and no further need for psychological intervention. Despite this, the resident was prescribed Risperdal, an antipsychotic medication, for 'psychosis with paranoia/auditory hallucinations' after being observed scratching himself. The care plan focused on administering psychotropic medication and documenting behaviors but did not include resident-centered interventions specific to the scratching behavior or address the circumstances surrounding it. Behavior monitoring records showed no observed behaviors during the relevant period. A nurse reported the resident was generally happy, with only a brief mention of expressed worries at night. Following a visit from a Mental Health Nurse Practitioner, the Risperdal dose was increased and a new diagnosis of schizophrenia was added, despite documentation indicating no psychotic symptoms. The facility was unable to provide documentation supporting the new diagnosis or the medication increase, and the behavioral services group emphasized the need for extensive documentation and clear symptoms before such changes. No further explanation or documentation was provided by facility leadership.
Failure to Document and Ensure Safe AMA Discharge
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including a clavicle fracture, abnormal gait, morbid obesity, and malaise, was discharged against medical advice (AMA) without proper documentation or investigation by facility staff. The resident was responsible for her own care and had a daughter, but the medical record lacked a discharge summary and a physician's discharge order. There was no evidence in the record that the resident was safely discharged, and staff could not explain why the resident did not complete her prescribed six weeks of therapy. The Rehabilitation Director, Social Worker, Business Office Manager, and Unit Manager all confirmed the absence of required documentation and could not provide details regarding the circumstances of the resident's departure or the provision of necessary discharge information. Further review revealed that the Social Worker was unable to locate an AMA form or evidence that the physician was notified of the resident's AMA discharge. There was also no documentation that the resident received a medication list or instructions to follow up with her provider. The Business Office Manager confirmed that the resident was not informed about potential Medicare non-payment for leaving AMA, and the Unit Manager could not identify the nurse responsible at the time of discharge. Overall, the facility failed to ensure a safe and documented discharge process for the resident who left AMA, as required.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with regulatory requirements for individualized care planning and execution.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Accurately Document and Implement Physician Orders for Splint Care
Penalty
Summary
The facility failed to maintain accurate medical records and ensure proper implementation of physician orders for a resident requiring a right elbow splint. The resident, who had a history of stroke, hemiplegia, vascular dementia, and an acquired absence of the right leg below the knee, was dependent on staff for most activities of daily living. Despite a physician's order for the resident to wear a right elbow splint during the daytime for four to six hours daily, multiple observations over several days showed the resident was not wearing the splint. The resident reported that staff did not apply the splint and that an aide was unaware of its location. Review of the Medication Administration Record revealed that nursing staff, specifically an LPN, documented that the splint was applied on several days when, in fact, the resident was not wearing it. The LPN admitted to documenting the application of the splint without verifying with the CNA or directly observing the resident. The unit manager and DON confirmed that CNAs were responsible for applying the splint and nurses were expected to ensure compliance with orders and provide accurate documentation. The inaccurate documentation and lack of verification led to the deficiency in maintaining medical records according to professional standards.
Failure to Sustain Infection Control QAPI Activities
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify and address a systemic issue with the Infection Prevention & Control Program, as evidenced by repeat deficiencies cited during consecutive annual surveys. Despite a history of infection prevention and control deficiencies, the facility was unable to provide documentation of an active Process Improvement Plan (PIP) or current audits related to infection prevention and control at the time of the survey. During an interview, the Administrator acknowledged that monitoring for a previous plan of correction had been discontinued several months prior. The facility's policy requires the QAA&C Committee to review data, implement process improvement plans, and monitor their effectiveness, but there was no evidence that these steps were being followed for infection prevention and control.
Failure to Maintain Safe and Functional Oxygen Concentrators
Penalty
Summary
The facility failed to ensure that oxygen concentrators were maintained in safe and functional condition for multiple oxygen-dependent residents. Observations and interviews revealed that several concentrators in use displayed yellow caution lights or were labeled as failed, indicating potential issues with oxygen purity or equipment malfunction. Family members reported malfunctioning units to staff, but some units continued to be used despite visible warnings. The Central Supply Coordinator and Nursing Home Administrator were unable to clearly explain the meaning of the yellow indicator lights or confirm which units had been replaced following failed inspections. Documentation showed that a significant number of concentrators had failed inspection, but there was no clear tracking of which units were removed from service or replaced. During a tour, four out of fourteen concentrators in resident rooms displayed yellow caution lights, and one had a failed sticker. The outside oxygen concentrator service provider confirmed that a yellow light could indicate a failure in oxygen purity and that such units should be removed from use. The facility's own policy required all essential equipment to be maintained in safe operating condition, but failed or potentially compromised concentrators were not promptly removed from use, placing residents at risk of receiving inadequate oxygen support.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen therapy for a resident with multiple respiratory conditions, including respiratory failure with hypoxia, COPD, and heart failure. The resident, who had severely impaired cognition, was readmitted from an acute care hospital with an order for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. The resident's care plan also directed nurses to administer oxygen therapy as ordered by the physician. During an observation, the oxygen concentrator for the resident was found set at 3 LPM instead of the ordered 2 LPM. This discrepancy was confirmed by a registered nurse, who acknowledged the physician's order and stated that she had not yet checked the setting during her shift. The Director of Nursing confirmed that staff were expected to verify oxygen settings against physician orders. The facility's policy required oxygen to be provided according to physician orders.
Failure to Follow Prescribed Respiratory Therapy Orders
Penalty
Summary
The facility failed to follow physician-prescribed respiratory therapy orders for a resident, leading to a deficiency in care. The resident's oxygen was set at 3 liters per minute (LPM), contrary to the physician's order of 5 LPM. This discrepancy was observed during a survey, and the assigned RN confirmed the order was for 5 LPM. The resident expressed distress when the oxygen level was adjusted to the prescribed 5 LPM, explaining that she had been working to reduce her oxygen dependency over the past two years. The resident believed the physician was aware of her preference for 3 LPM, and the nursing staff had been adjusting the oxygen level according to her request for about a year. The nursing staff, including RN C, failed to verify and administer the correct oxygen level as per the physician's order, despite documenting that the resident received 5 LPM of oxygen for the past six months. The Director of Nursing acknowledged that the nursing staff was required to follow doctors' orders and check oxygen settings at every shift, but this was not done. The resident's oxygen saturation level was regularly checked and found to be satisfactory, but the discrepancy in the oxygen setting went unnoticed until the survey. The failure to adhere to the prescribed oxygen therapy order resulted in a pattern of non-compliance with the physician's directives.
Food Safety Standards Violation in Storage
Penalty
Summary
The facility failed to adhere to food safety standards in the storage of food items in the freezer and walk-in refrigerator, which could lead to foodborne illness. During an inspection, the walk-in refrigerator was found with its door left open, resulting in a temperature of 48 degrees Fahrenheit, which is above the acceptable range for safe food storage. A carton of Mighty Shake inside the refrigerator was measured at 47 degrees Fahrenheit, leading to the disposal of nine Mighty Shakes. Additionally, in the freezer, there were unlabeled, undated, and unsealed bags of sausage patties and vegetarian burger patties, both covered with ice crystals and frozen together, indicating improper storage. The facility's policy requires all food items to be sealed, labeled, and dated once opened, which was not followed in these instances.
Failure to Conduct Medication Self-Administration Assessment
Penalty
Summary
The facility failed to conduct a medication self-administration assessment for a resident who was observed with medications on her nightstand. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15, had been admitted with diagnoses including sequelae of cerebral infarction, anemia, heart failure, diabetes, and constipation. During an observation, the resident's spouse was seen administering eye drops and hydrocortisone cream, which he had brought from a previous facility, to the resident without any physician orders or a completed self-administration evaluation. The Licensed Practical Nurse (LPN) confirmed that there were no physician orders for the medications found on the resident's nightstand and acknowledged that a self-administration evaluation had not been completed. The Director of Nursing (DON) stated that for a resident to self-administer medications, a physician's order and a self-administration evaluation were required, along with a care plan and a lock box for safe storage. The facility's policy required a prescriber's order and an interdisciplinary team assessment to ensure the safety of self-administration, which were not in place for this resident.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) Assessment for one resident who was reviewed for resident assessments. The resident was admitted to the facility and later discharged home with her daughter and husband. However, a review of the MDS tab in the medical record showed that a Discharge Assessment was neither initiated nor completed. The Clinical Reimbursement Director acknowledged the oversight, noting that the discharge assessment was 124 days overdue. She admitted to not running the necessary report consistently, which led to the missed assessment. According to Chapter 2 of the MDS 3.0 RAI Manual, a Discharge Assessment is required for all discharges and must be completed when the resident is not expected to return within 30 days. The assessment should be completed within 14 days after the discharge date and submitted within 14 days after the MDS completion date. The failure to adhere to these requirements resulted in the deficiency.
Inaccurate MDS Assessments for Eating, Vision, and Dental Status
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in evaluating their functional abilities related to eating, vision, and dental status. For one resident, the MDS assessment inaccurately indicated independence in eating, despite multiple observations and documentation showing the resident required assistance. The resident, diagnosed with conditions such as muscle wasting and dysphagia, was observed being fed by staff and was noted to have difficulty chewing. The MDS Director and RN acknowledged the assessment error, confirming the resident needed partial to moderate assistance with eating. Another resident's MDS assessment inaccurately reflected her vision and dental status. Despite having full upper and lower dentures and requiring glasses, the assessments indicated adequate vision without corrective lenses and no dental issues. Interviews and documentation revealed the resident had ill-fitting dentures, affecting her ability to chew, and was waiting for new glasses. The Clinical Reimbursement Director confirmed the inaccuracies in the MDS assessments, acknowledging the resident's use of dentures and glasses. The deficiencies were identified through a combination of observations, interviews, and record reviews, highlighting discrepancies between the residents' actual needs and the documented assessments. The facility's policy required interdisciplinary team participation in the assessment process, but the inaccuracies suggest a failure to adhere to these guidelines, resulting in the misrepresentation of the residents' functional abilities and needs.
Failure to Timely Change IV Dressing for Resident
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) care and services for a resident with a midline catheter, which is a type of IV access used for administering medications. The resident, who was readmitted with conditions including osteomyelitis, type 2 diabetes, and pneumonia, had an order for Ceftazidime, an IV antibiotic, and required regular monitoring and maintenance of the IV site. The care plan specified that the IV dressing should be changed every seven days or as needed if soiled or dislodged. However, observations revealed that the dressing on the resident's IV site was not changed as required, with the last documented change occurring on 5/29/24, despite the dressing being dated 5/24/24. Registered Nurse (RN) H admitted to not documenting a dressing change on 5/24/24 and incorrectly documenting a change on 5/29/24. The nurse acknowledged the importance of maintaining the dressing to prevent complications, especially given the resident's immunocompromised and diabetic status. Another nurse, RN F, also failed to notice the overdue dressing change during her shifts. The Director of Nursing confirmed the expectation for timely dressing changes and acknowledged the oversight. The facility's policy required dressing changes every seven days to prevent infection, which was not adhered to in this case.
Failure to Implement Contact Isolation Precautions
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident who required contact isolation due to infections with Vancomycin-resistant enterococci (VRE) and Extended-spectrum beta-lactamase (ESBL). The resident, who was admitted with a history of bacteremia, was not placed on contact isolation upon arrival, despite having a physician's order for such precautions. The resident herself reported that she had been in isolation at the hospital for a urine infection and informed the nursing staff upon her arrival at the facility. However, the necessary precautions, including the use of personal protective equipment (PPE), were not implemented until several days later. The primary nurse confirmed that the resident should have been placed on contact isolation immediately upon admission. The Director of Nursing stated that a checklist was used to ensure all orders were implemented, but it was not part of the medical record. Despite the availability of PPE and signage on the unit, the staff failed to follow the orders promptly, leading to a delay in implementing the necessary infection control measures. This oversight was acknowledged by the nursing staff, who confirmed that the resident's medical records and orders were reviewed, but the implementation of contact precautions was delayed.
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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