Egret Cove Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 550 62nd St S, Saint Petersburg, Florida 33707
- CMS Provider Number
- 105293
- Inspections on file
- 19
- Latest survey
- December 3, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Egret Cove Center during CMS and state inspections, most recent first.
Two residents experienced significant delays in medication administration, affecting thirty-one residents overall. Medications were administered outside the facility's timing parameters, with some doses not given at all. Staff shortages and shift changes contributed to the delays, and there was a lack of physician notification as required by facility policy.
The facility failed to ensure call bell lights were within reach for six residents, including those with severe contractures and cognitive impairments. Observations showed call bell lights on the floor or wrapped around bed legs, making them inaccessible. Staff confirmed the expectation for call bell lights to be within reach, highlighting a deficiency in providing necessary access to call assistance equipment.
A facility failed to provide a resident and their representative with a summary of the baseline care plan within 48 hours of admission. The resident, admitted with a UTI, multinodular goiter, and carotid artery issues, and their spouse were not informed about the care plan, duration of stay, or services. Despite requests, no evidence of the care plan being shared was provided.
Several residents in the facility were found to have deficiencies in their care plans and safety measures. A resident with severe contractures did not have an appropriate care plan, and there were inconsistencies in his feeding status and meal documentation. Other residents were unable to reach their call bells, despite care plans indicating they should be within reach. The DON confirmed the expectation for call bells to be accessible, highlighting a failure to adhere to facility policies.
A resident with chronic respiratory conditions experienced distress due to inadequate respiratory care and assessment. Despite the resident's need for oxygen therapy and a CPAP machine, there were no physician orders for the device. A PCA reported the resident's distress to the weekend supervisor, who dismissed the concerns. An RN later assessed the resident and sent them to the hospital after a nebulizer treatment was ineffective. The facility's response was delayed, and there was a lack of documentation and adherence to care policies.
A facility failed to document meal consumption for a resident with severe medical conditions, including muscle wasting and dysphagia. Despite a care plan involving tube feeding and oral intake, the resident's meal consumption was not consistently recorded, with 34 out of 57 meal opportunities lacking documentation. The DON confirmed the staff's responsibility to document meals and refusals, highlighting a deficiency in maintaining accurate medical records.
The facility failed to initiate an Enhanced Barrier Precautions (EBP) isolation program for thirteen residents and did not implement effective infection control practices in the laundry area. Clean linens were exposed to the elements, and improper drying methods were used, leading to unsanitary conditions.
The facility failed to develop and update comprehensive care plans for two residents, resulting in incomplete and outdated care plans. One resident's care plan included outdated information, while another resident's care plan lacked necessary interventions for fall prevention and infection control.
The facility failed to honor a resident's right to self-determination by not providing options for urinal placement and not addressing the need for a longer bed frame. Despite repeated requests and complaints, staff did not provide alternative solutions, and the facility's grievance log showed no grievances filed for the resident.
The facility failed to accurately code the MDS assessments for two residents, one with a contracted left hand and another with multiple diagnoses including Secondary Parkinsonism. Staff acknowledged the errors, and the DON emphasized the importance of accurate MDS coding.
The facility failed to develop a trauma-informed care plan for a resident diagnosed with PTSD, despite the diagnosis being documented in her chart. Interviews revealed that staff were unaware of the PTSD diagnosis until recently, and the resident's care plans did not include any measures addressing her PTSD, contrary to the facility's policy.
The facility failed to provide ADL grooming for a resident who was observed with missing teeth and facial hair. The resident's care plan lacked hygiene interventions, and a CNA did not assist with shaving because the resident did not ask for it. The DON stated that staff should assist with personal hygiene care regardless of requests.
The facility failed to ensure a physician order for oxygen administration for a resident with COPD and did not have emergency tracheostomy supplies readily available for another resident. Staff were unsure of the correct oxygen order, and the resident's medical record lacked an order for oxygen. Additionally, the resident's room lacked necessary tracheostomy tubes, which were later provided by the DON.
A resident with multiple diagnoses, including end-stage renal disease, did not receive breakfast or a snack for dialysis, despite physician orders and care plan requirements. Staff interviews revealed a lack of communication and coordination between nursing and dietary staff, leading to unmet dietary needs.
The facility failed to post the nurse staffing data on two of four days during the survey. Observations on two separate days revealed that the total number and actual hours worked per shift for licensed and unlicensed staff were not posted. Staff P, the CNA staffing coordinator, confirmed the delay in posting due to the surveyors' arrival and other issues.
The facility failed to ensure that a resident with multiple cognitive impairments understood the arbitration agreement they signed. The resident, who had diagnoses including Schizophrenia and Intellectual Disability, was unable to read or write and had moderate cognitive impairment. Despite this, the resident signed the agreement without adequate communication or review by the facility.
The facility failed to coordinate transportation for residents to attend medical appointments, resulting in missed appointments for four residents. Additionally, the facility did not properly apply and monitor a medication patch for a resident, leading to a buildup of secretions. Staff interviews revealed a lack of communication and coordination in arranging transportation and ensuring proper medication administration.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure timely administration of medications for two residents, resulting in thirty-one residents receiving medications outside of the facility's medication timing parameters. Resident #2's Medication Administration Audit Report for October 2024 showed multiple instances of late medication administration, including medications scheduled for 9:00 a.m. being administered as late as 10:54 a.m. and 5:00 p.m. medications being administered as late as 7:36 p.m. Additionally, on certain dates, medications scheduled for 9:00 p.m. were not administered at all. The facility's progress notes did not include notification to the resident's primary physician regarding these late administrations. Observations and interviews conducted on December 2 and 3, 2024, revealed systemic issues with medication administration. Staff A, a Registered Nurse/Unit Manager, acknowledged that medications were late for 15 residents due to a sick call that was not communicated to her. Similarly, Staff C, an RN who normally works the night shift, struggled with the day shift's medication demands, resulting in late administration for 16 residents. The Director of Nursing and Assistant Director of Nursing were aware of these issues but could not provide a clear explanation for the delays. Resident #3's Medication Administration Audit Report for October 2024 also showed numerous instances of late medication administration across various dates and times. Despite these repeated occurrences, there was no documentation of physician notification regarding the late administration of medications. The facility's policy requires medications to be administered within 60 minutes of the scheduled time and mandates physician notification if medications are not administered as ordered, but these protocols were not followed.
Inadequate Placement of Call Bell Lights
Penalty
Summary
The facility failed to ensure adequate placement of call assistance equipment for six residents, leading to a deficiency in providing necessary access to call bell lights. During a facility tour, it was observed that several residents, including those with severe contractures and cognitive impairments, did not have their call bell lights within reach. For instance, one resident with severe contractures was unable to access the call bell light, which was found on the floor at the bottom of the tube feeding pole. Another resident confirmed she could not reach her call bell light, which was looped over the bed's side rail and obstructed by padding. Additional observations revealed that other residents had their call bell lights on the floor or wrapped around the bed's leg, making them inaccessible. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the expectation was for call bell lights to be within reach of all residents, especially those who are cognitively impaired. The deficiency was identified as a failure to ensure that residents could call for assistance when needed, as evidenced by the placement of call bell lights out of reach.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide evidence of a summary of the baseline care plan to a resident and their representative within 48 hours of admission. On observation, the resident was found in bed with eyes closed, and during an interview, the resident's spouse expressed that she had not received any communication regarding the care plan, duration of stay, or services to be provided. The resident also expressed a desire to understand the services and reasons for his stay. The resident was admitted with diagnoses including a urinary tract infection, nontoxic multinodular goiter, and occlusion and stenosis of an unspecified carotid artery. Despite requests made to the Nursing Home Administrator, Director of Nursing, and Traveling MDS Coordinator, no evidence was provided to show that the baseline care plan was shared with the resident or their representative.
Deficiencies in Care Plan Implementation and Resident Safety
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for several residents, leading to deficiencies in care. Resident #7, who was observed in a fetal position with severe contractures and dry lips, did not have a care plan addressing his contractures. Despite being on a tube feeding regimen, there was confusion about his feeding status, as he was observed with an untouched meal tray and expressed a desire for water. The resident's call bell was found on the floor, out of reach, and there were inconsistencies in the documentation of his meal consumption, with many meals undocumented. Resident #8 was observed unable to reach her call bell, which was looped over the bed's side rail, obstructed by padding. Her care plan included interventions to ensure the call light and frequently used items were within reach, but this was not implemented. Similarly, Resident #9's call light was found on the floor, despite her care plan specifying that the call light should be within reach due to her fall risk. Resident #11 also had her call bell on the floor, contrary to her care plan's intervention to keep it within reach. The Director of Nursing confirmed that it was expected for call bells to be within reach for all residents, especially those who are cognitively impaired. The facility's policy emphasized the importance of providing necessary care and services to maintain residents' well-being, including monitoring conditions and responding with appropriate interventions. However, the observations and interviews revealed a lack of adherence to these policies, resulting in deficiencies in the care provided to the residents.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide timely respiratory assessment and care for a resident with a history of chronic respiratory conditions, including COPD, acute and chronic respiratory failure, and dependency on oxygen. The resident was admitted with a BIMS score indicating cognitive intactness and required substantial assistance for daily activities. Despite the resident's complex medical history and the need for oxygen therapy, there were no physician orders for a CPAP machine, which was necessary for the resident's care. The resident experienced shortness of breath and elevated blood pressure, but the facility's response was delayed and inadequate. On the morning of the incident, a Patient Care Assistant (PCA) noticed the resident was in distress and reported it to the weekend supervisor, who dismissed the concerns. The PCA then informed a Registered Nurse (RN) who assessed the resident and decided to send them to the hospital after a nebulizer treatment proved ineffective. The RN noted the resident's increased respiratory rate and distress, but the initial response from the weekend supervisor was insufficient, as she did not assess the resident or take immediate action. Interviews with staff revealed inconsistencies in the facility's response to the resident's condition. The weekend supervisor claimed to have assisted with paperwork and reported the situation to the Director of Nursing (DON), but there was no documentation of a thorough assessment or timely intervention. The DON confirmed the lack of a CPAP order and acknowledged the facility's failure to locate the resident's admission paperwork. The facility's policies on physician orders and care planning were not adequately followed, contributing to the deficiency in care provided to the resident.
Failure to Document Meal Consumption for Resident
Penalty
Summary
The facility failed to ensure proper documentation of meal consumption for a resident with severe contractions and multiple medical conditions, including muscle wasting, dysphagia, and spinal stenosis. The resident, who was observed in a fetal-like position, reported inconsistencies in receiving pleasure foods and water by mouth. Despite having a care plan that included tube feeding and oral intake during waking hours, the resident's meal tray was found untouched, and there was a lack of documentation regarding meal consumption. Upon review, it was found that from September 29 to October 17, there were 34 instances out of 57 meal opportunities where the resident's meal consumption was not documented. The Director of Nursing confirmed that the staff were supposed to document meal consumption and refusals, but the records did not consistently reflect the offering of three meals a day. This lack of documentation indicates a failure to adhere to the care plan and maintain accurate medical records for the resident.
Failure to Implement Enhanced Barrier Precautions and Maintain Proper Laundry Practices
Penalty
Summary
The facility failed to initiate an Enhanced Barrier Precautions (EBP) isolation program for thirteen residents identified as requiring EBP due to increased risk for infection from conditions such as tube feedings, wounds, and indwelling catheters. The Director of Nursing (DON) acknowledged awareness of the CDC's new EBP recommendations but admitted that the facility had not yet implemented the program. The DON mentioned plans to place bins for gloves and gowns and order proper signage, but no specific dates for staff education were provided. The DON also expressed concerns about compliance from staff and residents and deferred the responsibility to the new Infection Control Preventionist. During a tour of the laundry area, several deficiencies were observed in the handling, storage, processing, and transportation of linens and laundry. Clean linen carts were found with tattered covers, exposing the linen to the elements, and were located near bird nests and garbage bins. The Housekeeping/Linen Manager (HM) demonstrated improper drying methods for rags, which were left moist and musty-smelling. Clean and soiled linens were stored together, and the laundry area had issues with wastewater overflow and inadequate air conditioning, leading to unsanitary conditions. The facility's policies on barrier precautions and laundry operations were reviewed and found to be inconsistent with observed practices. The policies emphasized the importance of preventing the spread of infections through proper handling and storage of linens, but the facility failed to adhere to these guidelines. The lack of proper implementation of EBP and the unsanitary conditions in the laundry area contributed to the overall deficiency in the facility's infection control program.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure the development, revision, and/or implementation of comprehensive care plans for two residents. Resident #73, who had multiple diagnoses including end-stage renal disease and diabetes, did not have an updated care plan upon readmission. The resident's care plan included outdated information such as being on isolation for COVID-19 and having an elopement risk, which the resident denied. The Clinical Reimbursement Director confirmed that the care plan should have been reviewed and revised at readmission but was not. Resident #259, who had a history of falls and multiple infections, also did not have a comprehensive care plan developed upon admission. The resident was observed in a high bed position without floor mats or a reachable call light, despite having a history of falls. The resident's care plan did not include necessary interventions for fall prevention or infection control. The Clinical Reimbursement Director confirmed that the care plan should have been developed and revised as needed but was not. The facility's policies and procedures require that each resident receive necessary care and services in accordance with a comprehensive assessment and plan of care. The care plan should be an interdisciplinary communication tool that is reviewed and revised periodically. However, the facility failed to adhere to these policies for the two residents, resulting in incomplete and outdated care plans.
Failure to Honor Resident's Self-Determination and Address Needs
Penalty
Summary
The facility failed to honor Resident #104's right to self-determination by not providing options for urinal placement and not addressing the need for a longer bed frame. Despite the resident's repeated requests and complaints about the urinal being placed on the over bed table, which caused discomfort and an unpleasant smell during meals, the staff did not provide an alternative solution. Additionally, the resident, who is cognitively intact with a BIMS score of 15/15, expressed discomfort due to his feet pressing against the footboard of the bed, but the staff only provided a temporary solution by placing a pillow under his feet instead of addressing the need for a longer bed frame. Interviews with various staff members, including CNAs, an LPN, an RN, and the DON, revealed a lack of awareness and action regarding the resident's requests. The facility's grievance log showed no grievances filed for the resident, and the Social Service Director confirmed that no grievances were recorded. The DON admitted to being unaware of the resident's requests and could not explain why the requests were not facilitated. The facility also failed to produce a policy for choices or accommodation of need when requested during the survey.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for two residents. Resident #24, who was admitted with diagnoses including Hemiplegia and Hemiparesis, was observed with a contracted left hand and reported that staff had not assisted him with putting on his splint. Despite this, his MDS assessment inaccurately indicated no upper extremity impairment. Staff A, a Registered Nurse/Clinical Reimbursement Specialist, acknowledged the mistake, stating that the resident did have an upper extremity impairment due to left hemiparesis, which should have been identified in the MDS assessment. Resident #17, who had multiple diagnoses including Secondary Parkinsonism and Schizoaffective Disorder, was observed in a wheelchair with both legs bent and feet resting on the seat cushion. The resident's MDS assessment failed to mark the PASRR Level II section, inaccurately indicating that the resident did not have a Level II PASRR. Staff A confirmed that the resident did have a PASRR Level II prior to the completion of the MDS and acknowledged the error in coding. The Director of Nursing emphasized the importance of accurate MDS coding. The facility's policy and procedure for the Resident Assessment Instrument (RAI) require interdisciplinary team members to participate in the MDS completion process and ensure accurate coding. However, the errors in the MDS assessments for Residents #24 and #17 indicate a failure to adhere to these guidelines, resulting in inaccurate documentation of the residents' conditions and needs.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a care plan related to trauma-informed care for a resident diagnosed with PTSD, schizoaffective disorder, bipolar type, major depressive disorder, and adjustment disorder with anxiety. The resident confirmed her PTSD diagnosis and mentioned receiving weekly psychiatric and psychological care, including medication for PTSD-related nightmares. However, a review of her medical record revealed no assessment for PTSD and no care plan addressing her PTSD. The psychosocial history and assessment incorrectly indicated that the resident had no history of PTSD or trauma, and the care plans did not include any trauma-informed care measures. Interviews with the Director of Nursing and the Clinical Reimbursement Director revealed that the staff was unaware of the resident's PTSD diagnosis until recently, despite it being documented in her chart. The Clinical Reimbursement Director confirmed that the PTSD diagnosis should have triggered a trauma-informed care plan, which was not developed. The facility's policy on trauma-informed care mandates providing culturally sensitive care for residents with PTSD, but this was not followed in the case of the resident.
Failure to Provide ADL Grooming for Resident
Penalty
Summary
The facility failed to ensure that Activities of Daily Living (ADL) grooming was provided for one resident out of eight sampled. Observations on two separate occasions revealed that the resident was lying in bed with missing teeth and facial hair, indicating a lack of grooming. The resident's care plan, which focused on ADL, did not include any interventions related to the resident's hygiene. The resident had a BIMS score of 00, indicating an inability to complete the interview and a need for assistance with personal care due to reduced mobility and other health issues. During an interview, a Certified Nursing Assistant (CNA) stated that she did not shave the resident because he did not ask for it, only providing assistance when requested. The Director of Nursing (DON) clarified that staff were expected to assist residents with personal hygiene care regardless of whether the resident asked for help, especially if the resident was not independent. The CNA job description also indicated that ensuring residents' personal care needs were met was an essential duty, including shaving patients.
Deficiencies in Respiratory Care and Emergency Preparedness
Penalty
Summary
The facility failed to ensure a physician order was in place for the administration of oxygen for one resident and failed to ensure emergency tracheostomy supplies were readily available for another resident. Resident #21 was observed using an oxygen concentrator set to 1.5 liters per minute (LPM) without a physician order. The resident, who has chronic obstructive pulmonary disease (COPD), reported that she was supposed to be on 6 LPM and had been asking for oxygen on her wheelchair. Multiple staff members were unsure of the correct oxygen order, and the resident's medical record did not contain an order for oxygen. The resident experienced shortness of breath and mild chest pain, leading to a physician's order for a chest x-ray, which revealed pneumonia. The care plan indicated the need for oxygen therapy, but the lack of a physician order and proper monitoring led to the deficiency. In another instance, the facility failed to ensure emergency tracheostomy supplies were readily available for Resident #97. During an observation, it was confirmed that the resident's room lacked an extra or emergency tracheostomy tube. The resident's medical record indicated the need for an ambu bag and replacement tracheostomy tubes of equal size and one size smaller to be maintained at the bedside every shift. The Director of Nursing (DON) directed staff to obtain the necessary tracheostomy tubes and place them in the resident's room, highlighting the initial oversight. These deficiencies indicate lapses in the facility's adherence to physician orders and emergency preparedness protocols. The lack of a physician order for oxygen administration and the absence of emergency tracheostomy supplies could have serious implications for resident safety and care quality. The observations and interviews conducted revealed gaps in staff knowledge and documentation, contributing to the identified deficiencies.
Failure to Provide Dietary Needs for Dialysis Resident
Penalty
Summary
The facility failed to follow the comprehensive person-centered care plan and physician orders for a resident who required dialysis. Specifically, the resident did not receive breakfast or a snack to take to dialysis, despite having a physician's order and care plan indicating the need for a bag meal/snack. The resident reported having to leave for dialysis at 5:45 a.m. and not returning until lunch, resulting in a long period without food. Interviews with staff revealed that the refrigerator was broken, and the kitchen staff had not received a list of residents needing bag meals, leading to the resident not receiving the necessary dietary provisions. The resident had multiple diagnoses, including end-stage renal disease, heart failure, diabetes type 1, cachexia, hyperkalemia, protein-calorie malnutrition, and muscle wasting and atrophy. The care plan included specific interventions to manage the resident's dietary needs, such as providing a bag meal/snack for dialysis days. However, due to a lack of communication and coordination between nursing and dietary staff, the resident's dietary needs were not met. The facility's policy on dialysis management emphasized the importance of coordinating care and services, including managing special dietary regimens, but this was not effectively implemented in this case.
Failure to Post Nurse Staffing Data
Penalty
Summary
The facility failed to post the nurse staffing data to ensure the information was readily accessible to all residents and visitors during two of four days of the survey. On 5/13/2024 at 9:52 a.m., an observation revealed that the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care were not posted. Similarly, on 5/16/2024 at 8:52 a.m., the same information was found to be missing. This deficiency was confirmed during an interview with Staff P, the CNA staffing coordinator, who stated that the posting was delayed due to the surveyors' arrival on Monday and the same issue occurred on the morning of 5/16/2024. The facility's policy and procedure, effective April 2015, require that each nursing center has sufficient nursing staff to provide necessary services and that staffing plans are reevaluated and monitored on an ongoing basis. The policy also mandates that the daily staffing hours be posted. Despite these requirements, the facility failed to comply on the specified dates, leading to the deficiency noted by the surveyors.
Failure to Ensure Understanding of Arbitration Agreement
Penalty
Summary
The facility did not ensure that a resident who entered into an arbitration agreement understood the contract contents. During an interview, the Nursing Home Administrator (NHA) stated that all residents were presented with the option to review and sign arbitration agreements upon admission, and the Admission Director (AD) was responsible for ensuring that everyone understood what was being signed. However, a review of the Admission Record for a resident with multiple diagnoses, including Schizophrenia and Intellectual Disability, showed that the resident had signed the arbitration agreement despite having moderate cognitive impairment and being unable to read or write. The resident's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form indicated that the resident was alert but disoriented and could follow simple instructions. Additionally, the Occupational Therapy Plan of Care and the Admission Minimum Data Set (MDS) further confirmed the resident's cognitive impairments. The AD stated that the goal was to have residents signed in within 48-72 hours and that the Admission Coordinator (AC) completed the sign-ins, including the Arbitration Agreement. The AD confirmed that the resident had signed the arbitration agreement with the AC as the facility representative. The resident's representative stated that there had been very little communication with the facility regarding admission paperwork and that the resident had been diagnosed with an Intellectual Disability from a young age, never learning to read or write. The facility did not provide a Policy and Procedure for Arbitration Agreements despite multiple requests before the survey exit.
Failure to Coordinate Transportation and Properly Apply Medication Patch
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Specifically, the facility did not coordinate transportation for residents to attend their medical appointments, resulting in missed appointments for four residents. Resident #209 missed multiple appointments for her skin grafts due to transportation issues, causing her significant distress and potentially delaying her healing process. The Medical Records Manager was unaware of the appointments and did not arrange transportation, leading to further missed appointments. Additionally, Resident #33 missed a CT scan because the facility did not provide the necessary paperwork, and Resident #7 missed a dental appointment due to transportation not showing up. Resident #58 expressed frustration with the facility's transportation arrangements and chose to make her own arrangements to avoid further issues. The facility also failed to properly apply and monitor a medication patch for Resident #81. The resident was observed with a scopolamine patch that was not intact and not labeled, leading to a buildup of secretions in his mouth. The patch was supposed to be changed every 72 hours, but the Medication Administration Record (MAR) showed inconsistent documentation of the patch's application and removal. The Director of Nursing confirmed that the staff should have documented medication administration on paper MARs when the internet was down, but this was not done. The facility's policy required patches to be labeled, monitored for placement every shift, and documented on the MAR, but these procedures were not followed for Resident #81. Interviews with staff revealed a lack of communication and coordination in arranging transportation and ensuring proper medication administration. The Medical Records Manager, Director of Nursing, and Nursing Home Administrator all acknowledged the issues but did not take timely action to resolve them. The facility's policies and procedures for transportation services and transdermal delivery systems were not effectively implemented, leading to deficiencies in resident care and treatment.
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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