Emerald Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hollywood, Florida.
- Location
- 4200 Washington St, Hollywood, Florida 33021
- CMS Provider Number
- 105495
- Inspections on file
- 32
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Emerald Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently provide enough qualified nursing staff or ensure a licensed nurse was in charge on each shift. Staff interviews revealed unclear supervisory coverage and frequent weekend staffing shortages, leading to increased resident assignments for CNAs and LPNs and rushed care.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including improper ware washing temperatures, expired and undated food items, unsanitary handwashing practices, and staff hygiene lapses such as incomplete hair covering and failure to wash hands after contamination. These issues were acknowledged by facility leadership.
Sharps containers in two facility wings were found without required liners or inner boxes, resulting in used sharps, connector tubing, and other discarded items being placed directly in the bottom of the containers. Multiple nurses and the DON confirmed the absence of liners, and the containers were not properly maintained until after surveyor intervention.
A resident who was cognitively intact and required physical assistance for self-care was repeatedly unable to access the call light, as it was found wedged between the bedrail and mattress and hanging out of reach. Multiple observations and interviews confirmed the call light was not accessible, and staff had to adjust the bed to retrieve it, contrary to facility policy.
A resident with a heel wound and an order for offloading heels was repeatedly observed with heels resting on pillows or the mattress, rather than being properly offloaded as required by facility policy and physician orders. Staff interviews revealed a lack of understanding of correct offloading technique, and training materials did not include instruction on this preventative measure.
A resident with significant medical needs was found with a Foley catheter strap that was improperly secured, old, and frayed, contrary to physician orders and facility policy. Staff were unable to identify when the strap was last changed or the correct replacement schedule, and documentation of compliance did not match direct observations. Nursing staff demonstrated a lack of knowledge regarding proper catheter strap care, and the issue was not addressed until after surveyor intervention.
A resident with end stage renal disease and a central venous catheter for hemodialysis did not have an order in place to monitor the dialysis access site for bleeding, bruising, or infection, despite care plan requirements and facility protocols. The necessary order was only entered into the electronic system after the issue was identified during review.
The facility failed to accurately reconcile and document controlled substance medications for multiple residents, including administering medication without a current physician order and inconsistencies between the declining inventory sheets and Medication Administration Records. Nursing staff confirmed that documentation did not consistently match between records, affecting residents with various medical conditions who received controlled medications.
Two residents receiving psychotropic medications were not properly monitored for behavioral symptoms and side effects as required by physician orders and facility policy. Nursing staff documented only check marks or yes/no responses in the MAR and TAR, rather than using the specific behavior, intervention, and outcome codes mandated for tracking. This failure resulted in incomplete monitoring of the residents' responses to their medication regimens.
A resident with severe cognitive impairment and multiple diagnoses did not receive scheduled medications within the required time frame. An LPN administered Divalproex Sodium, Carbidopa-Levodopa, and Tramadol more than an hour after the scheduled time, contrary to facility policy. Both the DON and President of Clinical Practice confirmed the delay, resulting in a significant medication error.
Surveyors found that medication and wound care carts were left unlocked and unattended, containing unsecured prescription and OTC drugs accessible to residents, visitors, and staff. A loose, unidentified pill was discovered in a medication cart, and a bottle of Elder Tonic was found without an opening date or readable expiration date. Staff interviews confirmed that these practices were not in line with facility policy, which requires all medications to be properly labeled and secured.
Two residents with orders for pureed diets, both with dysphagia and complex medical histories, were served foods and snacks that did not meet the required pureed consistency, including lumpy oatmeal and inappropriate snacks. Kitchen observations also revealed pureed menu items with irregular textures, not in compliance with IDDSI standards, potentially affecting multiple residents.
Staff failed to follow CDC and facility infection control protocols for Enhanced Barrier Precautions, including improper cleaning and storage of nebulizer equipment after use, failure to perform hand hygiene before entering an EBP resident's room, and improper handling and disposal of blood glucose monitoring supplies. Leadership staff also did not adhere to hand hygiene requirements or ensure proper disposal of potentially contaminated items.
A diabetic resident experienced a significant health event due to the facility's failure to administer insulin and monitor blood sugar levels as per physician's orders. Despite policies requiring verification of medication orders and blood glucose monitoring, these were not followed, leading to the resident's deteriorating condition and eventual hospital transfer. Communication lapses and lack of documentation contributed to the oversight.
Failure to Maintain Sufficient Nursing Staff and Supervision
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were always available to meet residents' needs and to have a licensed nurse in charge on each shift. During a facility tour, surveyors found that no specific person was designated as in charge, and nursing staff were unclear about who to contact in case of an emergency. The staff board listed unit supervisors, but none were present on the units during the survey. Interviews with nursing staff revealed uncertainty about supervisory coverage, particularly on weekends. Multiple staff members reported that staffing shortages, especially on weekends, resulted in increased resident assignments for CNAs and LPNs. CNAs described having to care for more residents than usual due to staff call-outs, with some reporting assignments of 12 or more residents. An LPN reported being responsible for 30 residents at times. Staff consistently indicated that these staffing patterns led to rushed care and difficulty meeting residents' needs. The DON acknowledged awareness of low weekend staffing and recent management changes.
Deficiencies in Food Safety, Sanitation, and Staff Hygiene
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, preparation, and sanitation practices during two visits to the facility's main kitchen. The mechanical ware washing machine failed to reach the required 160°F for hot water sanitizing, and residue was found on its spray arms and nozzles. The Food Service Director acknowledged that the machine defaults to chemical sanitizing when hot water is insufficient. During meal service, a staff member poured coffee into the only handwashing sink in the dining room, and another staff member washed her hands in the same sink without cleaning it first. Single-serve condiments and disposable utensils were stored directly under a pest control device with a glue board. Additional observations included clogged and soiled air conditioning filters, a refrigerator operating at 59°F (above the required 41°F), expired food items, undated raw ground beef, and food containers with no expiration dates. Cooking pots were coated with a black residue, and several light bulbs in the hood area were not working. The dry storage area contained expired thickened liquids, and the Food Service Director was observed with a hairnet that did not fully cover her hair. The Director also incorrectly calibrated a thermometer for food temperature checks. Further observations included a dietary aide without a facial hairnet, a cook who donned new gloves without washing hands after touching contaminated surfaces, and a staff member plating food while wearing large loop earrings. These findings were acknowledged by the Food Service Director and the Administrator during interviews. The report documents failures to adhere to professional standards for food safety and sanitation, as well as lapses in staff hygiene and food handling protocols.
Failure to Provide Liners for Sharps Containers in Resident Rooms
Penalty
Summary
The facility failed to provide liners for sharps containers in two out of four wings, as observed during resident room tours. Multiple wall-mounted sharps containers in resident rooms were found to contain used sharps, connector tubing, and other discarded items directly in the bottom of the containers, without any red container receptacle liners or inner boxes to house the waste. These observations were documented with photographic evidence and occurred in both the east and south wings, including the newer section of the 400 South wing. The facility's policy requires that regulated medical waste, including contaminated sharps, be managed according to federal, state, and local regulations, and that sharps containers be closable, puncture-resistant, leak-proof, and properly maintained. Interviews with several nursing staff, including RNs, LPNs, and the DON, confirmed that the sharps containers in resident rooms did not have liners or inner boxes as required. The containers were not emptied, cleaned, lined, or properly maintained until after surveyor intervention. The deficiency was identified through direct observation and staff interviews, with no mention of specific residents' medical histories or conditions at the time of the deficiency.
Call Light Accessibility Not Ensured for Resident Requiring Assistance
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident who required physical assistance for self-care needs. According to the facility's policy, staff are required to ensure that the call light is accessible to residents during every interaction in the resident's room. However, during multiple observations and interviews, it was found that the call light for this resident was not accessible. Specifically, the call light cord was wedged between the bedrail and the bottom of the mattress, with the bulb hanging close to the floor and out of the resident's reach. Photographic evidence was obtained during these observations. The resident, who was cognitively intact as indicated by a BIMS score of 14, reported on several occasions that he could not reach the call light when he needed assistance, including when he needed help to get changed. Staff confirmed the call light was not accessible and had to adjust the bed to retrieve the call bell cord. These findings were based on policy review, observation, interview, and record review.
Failure to Offload Heels for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow its own policy and physician orders regarding the prevention and treatment of pressure ulcers for a resident with a documented heel wound. The facility's wound care policy required the use of pressure-relieving surfaces and offloading of heels as preventative measures. However, review of staff training materials revealed that Certified Nursing Assistants (CNAs) were not trained on the specific policy requirements for utilizing pressure-relieving surfaces and floating heels. The resident in question was cognitively intact but required physical assistance for self-care and had a care plan and physician order in place to offload heels with a pillow while in bed. Multiple observations over several days showed that the resident's heels were consistently not offloaded as required. Instead, the heels were found resting directly on pillows or the mattress, rather than being suspended off the surface to relieve pressure. Interviews with staff confirmed a lack of understanding of proper offloading technique, as one CNA acknowledged that the resident's heels were not appropriately offloaded and that the pillow should have been positioned under the calf to keep the heel off the edge. Photographic evidence was obtained to document these findings.
Failure to Properly Secure and Maintain Foley Catheter Strap
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including Alzheimer's Disease, Chronic Kidney Disease, and Diabetes Mellitus, was observed with a Foley catheter strap that was not properly secured as per physician orders and facility policy. During peri and Foley catheter care, surveyors observed that the catheter strap was old, frayed, discolored, and triple wrapped around the resident's leg, causing it to slip and not remain anchored in place. Staff present during the procedure were unable to state when the strap was last changed or how often it should be replaced, and acknowledged that the strap was not fitting properly. Further interviews with nursing staff revealed a lack of knowledge regarding the proper placement and replacement schedule for the catheter strap. Record review showed that staff had documented compliance with physician orders to monitor and keep the leg strap on, but direct observation contradicted these records, as the strap was not properly secured or changed until after surveyor intervention. The facility's policy required catheter care every shift and as needed, with monitoring and documentation, but these procedures were not followed. The Director of Nursing confirmed that the catheter strap should be routinely monitored, positioned, and changed according to protocol.
Failure to Monitor Dialysis Catheter Site
Penalty
Summary
A deficiency was identified when the facility failed to monitor the central venous catheter (CVC) access site for a resident who required dialysis. The resident, who had diagnoses of end stage renal disease and anemia and was dependent on renal dialysis, was readmitted to the facility with a right upper chest catheter for hemodialysis. Although the care plan documented the need to check the access site daily for signs and symptoms of infection, pain, or bleeding, a review of the physician's orders did not show an order to monitor the CVC dialysis site for bleeding, bruising, or signs of infection. Interviews with the DON and a registered nurse confirmed that monitoring the CVC access site is part of facility protocol and should be documented in the electronic system. However, a chart review revealed that the order to assess the hemodialysis site for bruising, bleeding, or symptoms of infection was not entered into the electronic system until after the surveyor's inquiry, indicating that the required monitoring was not in place prior to that time.
Controlled Substance Documentation and Physician Order Deficiencies
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of controlled substance medications for four out of nine sampled residents, and did not obtain a physician order for a controlled medication for one resident. For one resident with dementia, schizoaffective disorder, and major depressive disorder, Lorazepam was administered after the physician's order had expired, and there was no current order in place. Additionally, discrepancies were found between the declining inventory sheet (DIS) and the Medication Administration Record (MAR), with some administrations recorded on the DIS but not on the MAR, and vice versa. For another resident with a history of nasal bone fracture and injury as a pedestrian, Percocet was administered with inconsistencies between the DIS and MAR, including documentation of administration at times that did not match between the two records. Similarly, a resident with osteomyelitis had Oxycodone administrations recorded on the DIS that did not correspond with entries on the MAR, and vice versa. These discrepancies were confirmed during interviews with nursing staff, who acknowledged that the DIS and MAR should correlate but did not in these cases. A fourth resident with cerebral infarction, spinal stenosis, and colon cancer also had inconsistencies in the documentation of Oxycodone administration. The narcotic sheet indicated a dose was removed and signed out by a nurse, but this administration was not documented on the MAR. Staff interviews confirmed that every removal of a controlled substance should be documented on both the narcotic sheet and the MAR with matching details, but this was not consistently done.
Failure to Monitor and Document Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of residents receiving psychotropic medications, as required by physician orders and facility policy. For one resident with diagnoses including Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Anxiety, the care plan and physician orders specified the use of behavior codes to track symptoms and side effects related to antipsychotic therapy. However, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that behaviors were either not documented or only marked as '0' for no behaviors, without use of the required codes. Nursing staff confirmed that the electronic system only allowed for a yes/no response, and the Director of Nursing acknowledged that documentation was not being completed according to the specific orders. For another resident with multiple diagnoses, including dementia, psychotic disturbance, and anxiety, physician orders required the use of specific behavior, intervention, and outcome codes to monitor the effects of several psychotropic medications. Review of the MAR showed that, on multiple occasions, only check marks and nurses' initials were recorded, with no behavior codes or appropriate intervention codes documented. In one instance, an intervention code not listed in the physician order was used. The required outcome codes were also not documented, with only check marks and initials present for several days. Interviews with nursing staff indicated that they believed they were monitoring and documenting behaviors as required, but the documentation did not align with the specific codes outlined in the physician orders. The Medical Director noted the importance of monitoring behaviors and side effects for residents on multiple psychotropic medications and indicated that medication adjustments might be necessary based on such monitoring. The lack of proper documentation and monitoring represents a failure to ensure that residents' drug regimens are free from unnecessary drugs and that their mental, physical, and psychosocial well-being is being appropriately managed.
Significant Medication Error Due to Late Administration
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Parkinson's Disease, dementia, and major depressive disorder, did not receive scheduled medications within the facility's defined time frame. The resident, who had severely impaired cognition and was under hospice care, was prescribed several medications to be administered at specific times. During a medication administration observation, an LPN was found preparing and administering the resident's 9:00 AM medications significantly later than scheduled, with the actual administration occurring at 11:05 AM. The facility's policy and staff interviews confirmed that medications are to be given within one hour before or after the scheduled time, which was not followed in this instance. The medications involved included Divalproex Sodium, Carbidopa-Levodopa, and Tramadol, all of which were administered outside the acceptable time window. The LPN acknowledged the delay, and the medication administration system indicated the late administration with a pink color code. Both the DON and the President of Clinical Practice confirmed the facility's expectations for timely medication administration, and verified that the medications were given late. This failure to administer medications within the required time frame constituted a significant medication error for the resident.
Failure to Secure and Properly Label Medications and Biologicals
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals. During an observational tour, an unlocked wound care cart was found on the East wing containing various resident prescription and over-the-counter topical medications, as well as wound care supplies. The cart was unattended and accessible to residents, visitors, and staff. A registered nurse admitted to being the last to use the cart and acknowledged it should have been locked. Additionally, an unlocked medication administration cart was observed on the East wing, containing twenty-four active prescription and OTC medications, all unsecured and unattended. Both a licensed practical nurse and a registered nurse/unit manager confirmed that the cart should have been locked and not left unattended. On a separate occasion, a medication cart on the Center wing was found to contain a loose, unidentified pill in one of its drawers, which staff acknowledged should not have been present and should have been secured. Further, a medication storage observation revealed a bottle of Elder Tonic in a medication cart without an opening date label and with an unreadable expiration date. The LPN present could not provide the required information and stated that nurses are supposed to check for expiration and opening dates during shift changes. The DON confirmed that facility policy requires all medications to be properly labeled and secured at all times.
Failure to Provide Proper Pureed Diet Consistency for Residents with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for residents requiring pureed diets. One resident with severe cognitive impairment, multiple diagnoses including dysphagia, and a care plan specifying a pureed diet with nectar thickened liquids, was observed with pre-packaged snacks on their overbed table that were not consistent with their prescribed diet. The Speech Language Pathologist (SLP) confirmed that these snacks were not appropriate for a pureed diet and identified risks associated with not following the prescribed diet. Another resident, cognitively intact but with diagnoses including dysphagia and a care plan for a pureed, nectar thickened, renal diet, was observed with oatmeal that contained lumps and was not smooth, contrary to the requirements for a pureed diet. The SLP reviewed a photo of the oatmeal and confirmed it did not meet the pureed diet standard. The resident was unable to be interviewed during the observation as they fell asleep during the meal. Additionally, during a kitchen observation, pureed foods such as seasoned spinach and chorizo and cheddar quiche were found to have irregular textures, including lumps and fibrous strands, and did not meet the IDDSI standard for pureed foods. The Food Service Director acknowledged these findings. The facility's policy requires pureed foods to be smooth and require no chewing, but this standard was not met for at least two residents and in the main kitchen, potentially affecting 22 residents.
Failure to Follow Infection Control Protocols for EBP and Equipment Cleaning
Penalty
Summary
The facility failed to adhere to CDC guidelines and its own policies regarding infection prevention and control, specifically in the application of Enhanced Barrier Precautions (EBP) and the handling of medical equipment. In one instance, a resident with a history of cerebral infarction, hemiplegia, diabetes, and pleural effusion received nebulizer therapy from an LPN who, after administering the treatment, placed the used nebulizer mask back into a plastic bag without cleaning or disinfecting it as required by facility policy. The LPN did not follow the procedure of rinsing, drying, and storing the equipment properly after use, and did not clean the equipment even after being observed for an extended period post-treatment. Another deficiency involved a resident with partial arterial traumatic amputation, diabetes, peripheral vascular disease, immunodeficiency, and a local skin infection, who was under EBP. During a blood glucose monitoring procedure, an LPN failed to perform hand hygiene before entering the resident's room, placed uncleaned supplies on the resident's meal table without disinfecting it, and did not allow the alcohol to dry before pricking the resident's finger. The LPN also brought a whole container of glucose strips into the room, used it during the procedure, and then returned it to the medication cart without disinfecting it, contrary to both CDC guidelines and facility policy. The LPN also failed to disinfect the resident's table after the procedure and did not discard supplies that should not be reused. Additionally, the Assistant Director of Nursing (ADON) entered the EBP resident's room without performing hand hygiene, despite clear signage indicating EBP protocols. The ADON admitted to not following hand hygiene protocols, even though he was aware of the EBP status. The Infection Preventionist confirmed that reusable supplies should not be brought into EBP rooms and that any such items must be discarded if they enter the room. The Director of Nursing (DON) was informed of the improper handling of the glucose strip container but did not take immediate corrective action. These actions and inactions demonstrate a failure to implement and follow infection prevention and control protocols as required.
Failure to Administer Insulin and Monitor Blood Sugar Levels
Penalty
Summary
The facility failed to follow physician's orders for administering insulin and monitoring blood sugar levels for a diabetic resident, leading to a significant health event. The resident, who had a history of Type II Diabetes Mellitus, was admitted with other diagnoses including a fracture and hypertension. Despite having intact cognition, the resident experienced an elevated blood sugar level of 499 mg/dL, which was not properly managed according to the physician's orders. The facility's policies required verification of medication orders and blood glucose monitoring, but these were not adhered to in this case. On multiple occasions, the resident's blood sugar levels were not recorded, and insulin doses were not administered as ordered. Specifically, there was no documentation of insulin administration for several prescribed doses, including long-acting insulin in the morning and at bedtime, as well as fast-acting insulin before meals. The lack of documentation and administration of these medications contributed to the resident's deteriorating condition, which included symptoms such as sweating, altered mental status, and somnolence, raising concerns for diabetic ketoacidosis. Interviews with staff revealed communication lapses and a failure to document new orders or changes in the resident's condition. The LPN responsible for the resident's care did not document the administration of insulin or the resident's blood sugar levels, and there was no evidence of communication with the physician regarding the elevated blood sugar levels. The Director of Nursing acknowledged that the physician's orders were not followed, which ultimately led to the resident being transferred to the hospital for further evaluation and management.
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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