Gainesville Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Gainesville, Florida.
- Location
- 4000 Sw 20th Ave, Gainesville, Florida 32607
- CMS Provider Number
- 105664
- Inspections on file
- 30
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Gainesville Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents with multiple comorbidities experienced significant weight loss when the facility failed to implement and follow up on RD assessments and recommendations. For one resident, the RD documented substantial weight decline, recommended appetite stimulation with Remeron, and noted variable intake despite supplements, but nursing staff did not communicate these recommendations or the weight loss to the physician or the resident’s representative, and no corresponding orders were obtained. For the second resident, who had documented weight loss and an RD recommendation to increase nutritional supplements, there were no subsequent RD reassessments despite ongoing weight decline, and the RD and DON confirmed that continued weight loss was not communicated to dietary, and monitoring processes did not identify the need for further intervention, contrary to the facility’s nutritional management policy.
The facility failed to notify representatives and physicians of significant weight loss in two residents, despite a policy requiring prompt communication of changes in condition and completion of an SBER change-in-condition evaluation. One resident with multiple chronic conditions, including dementia and diabetes, experienced more than a 12% weight loss over several months without documented notification to the representative or physician, and the representative reported not being informed of the weight loss or related interventions. Another resident with extensive cardiovascular, neurologic, and psychiatric diagnoses, including CHF, vascular dementia, and mild protein-calorie malnutrition, also lost more than 12% of body weight over six months, with no documented family or physician notification. An LPN acknowledged that the physician and representative had not been contacted, the RD stated that notification was a nursing responsibility, and the DON confirmed the absence of documentation of required notifications.
Surveyors found that the facility failed to maintain a safe, clean, and comfortable environment in multiple hallways and rooms. Strong urine odors were present throughout two hallways and in all rooms toured on one hallway, even though residents were observed to be clean and dry. Floors in several rooms had dried, sticky residue and multiple stains, vents and grates had thick dust buildup, and debris such as straws and cup lids was found under beds. Handrails had missing paint with wet underlying paint, shower rooms had thick brown substances in the corners, and three of four hallways had missing or unsecured flooring pieces that could be lifted easily. A housekeeping closet lacked a doorknob. The NHA, DON, and Assistant Maintenance Director acknowledged these environmental issues, which did not align with the facility’s policy requiring a safe, functional, sanitary, and comfortable interior.
Surveyors found that several residents did not have accurate assessments reflecting their current diagnoses and treatments, including psychiatric conditions, skin disorders, dialysis, and CPAP use. LPNs responsible for MDS completion either omitted or failed to properly code these conditions, sometimes due to uncertainty or human error, resulting in incomplete documentation of residents' health status.
Two dependent residents were assisted with breakfast by a CNA who stood between their beds and alternated feeding them, rather than providing individualized attention. The CNA reported being unsure of the correct feeding method due to inexperience. Facility policy requires residents to be treated with respect and dignity.
A resident with cardiac and anemia diagnoses was observed self-administering oxygen therapy without a physician's order, and staff were unaware of the resident's use of oxygen. Facility policy requires a physician's order for oxygen administration except in emergencies, but no such order was present in the medical record.
Surveyors found that drugs and biologicals were not properly labeled or securely stored, including instances where a resident had unidentifiable pills and an unlabeled cream at bedside, another had a prescription ointment left out, and a third kept prescription medications at bedside without proper orders. Expired and undated medications were also found on a medication cart, and staff confirmed these practices were not in line with facility policy.
A resident's medical record contained conflicting information regarding code status, with some documents indicating full code and others indicating DNR. The resident did not recall discussing DNR status, and the DON confirmed the resident was full code with no DNR order on file, attributing the error to social services. Facility policy for verifying and updating code status was not properly followed.
A facility failed to follow professional standards for tube feeding administration for a resident with multiple diagnoses, including cerebral infarction and dysphagia. A CNA improperly paused and restarted the feeding pump, a task reserved for nurses, and both the CNA and an LPN provided care without adhering to universal precautions, such as wearing gowns, gloves, or performing hand hygiene. The facility's policy mandates that only nurses handle feeding pumps and that universal precautions be followed.
A long-term care facility failed to adhere to infection control protocols for two residents on Enhanced Barrier Precautions. Staff did not perform hand hygiene or use appropriate PPE, such as gowns and gloves, during high-contact activities with residents who had feeding tubes and indwelling catheters. Interviews revealed a misunderstanding of the facility's policy, which aligns with CDC guidelines requiring PPE for high-contact activities to prevent the spread of infections.
The facility failed to provide written bed hold notices to residents or their representatives upon hospital transfer. Three residents, each with different medical conditions, were transferred to a hospital without receiving the required notification. Interviews with facility staff confirmed the absence of a process for issuing these notices, despite policy requirements.
Failure to Implement Dietician Recommendations and Monitor Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to maintain acceptable nutritional status for two residents experiencing significant weight loss by not following or acting upon dietician assessments and recommendations. For the first resident, who had multiple diagnoses including dementia, hypertension, anemia, type 2 diabetes, hyperlipidemia, hypothyroidism, and vitamin deficiencies, serial weights showed a decline from 106.2 pounds to 93.2 pounds over several months, representing a significant weight loss of over 10%. The registered dietician (RD) documented that the resident was on a regular diet with milkshakes three times daily and Med Pass, with variable intake, and identified a significant 3‑month weight loss likely related to worsening dementia. The RD recommended considering Remeron to stimulate appetite and noted the need to encourage meals, snacks, supplements, and fluids. Despite these documented recommendations on multiple RD weight notes, the resident’s medical record contained no physician orders for Remeron during the relevant periods. The RD stated in interview that she had recommended Remeron, placed the recommendation in a binder at the nurses’ station, and had spoken with the unit manager and DON, but the recommendation was not conveyed to the physician and was not acknowledged in the communication book. The RD indicated she does not write orders or contact the family or physician, and that this responsibility lies with nursing. An LPN confirmed that nursing did not communicate the RD’s Remeron recommendation or the weight loss to the physician or the resident’s representative, and that staff had incorrectly assumed the RD could write orders. For the second resident, who had extensive diagnoses including cerebral infarction, peripheral vascular disease, CHF, vascular dementia, mood disorders, insomnia, benign prostatic hyperplasia, neuropathy, and mild protein‑calorie malnutrition, weights showed a decline from 185.4 pounds to 163.1 pounds over six months, a 12.3% loss. A physician order had been written for an in‑house dietician consult for weight loss, and the RD completed a weight note documenting significant 1‑ and 6‑month weight loss, variable intake, and current use of Ensure Plus twice daily. The RD recommended increasing Ensure Plus to three times daily and noted the need to monitor intake, weight trends, and labs. However, there were no additional RD assessments in the record after this note, and the RD acknowledged she had not seen the resident again, was unaware of the continued weight loss, and lacked access to targeted weight‑loss reports. The DON stated there should have been dietary reassessments and that nurses and unit managers should have notified the RD of the continued weight loss, but there was no evidence this occurred, contrary to the facility’s nutritional management policy requiring systematic assessment, individualized interventions, monitoring, and physician notification of significant weight changes.
Failure to Notify Representatives and Physicians of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to promptly inform resident representatives and physicians of significant changes in condition, specifically substantial weight loss, for two residents. Resident #1 had multiple diagnoses including dementia with mood disturbance, bilateral knee pain, vitamin B and D deficiencies, essential hypertension, anemia, type 2 diabetes mellitus without complications, hyperlipidemia, and hypothyroidism. Weight records showed a decline from 106.2 pounds on 10/6/2025 to 93.2 pounds on 3/2/2026, a 12.24% weight loss. Review of nursing progress notes from October 1, 2025 through March 2, 2026 revealed no documentation that the resident’s representative or physician was notified of this change in condition. The resident’s representative reported not being informed of the weight loss, any interventions, or dietician involvement, and an LPN acknowledged that the physician and representative had not been contacted or that such communication had been documented. Resident #2 had diagnoses including cerebral infarction, peripheral vascular disease, history of falling, hyperlipidemia, essential primary hypertension, unspecified systolic congestive heart failure, urinary retention, pseudobulbar effect, vitamin D deficiency, major depressive disorder, primary insomnia, bipolar disorder, benign prostatic hyperplasia, atherosclerosis of other arteries, idiopathic peripheral autonomic neuropathy, vascular dementia, and mild protein calorie malnutrition. Weight records showed a decline from 185.4 pounds on 10/3/2025 to 163.1 pounds on 3/3/2026, a 12.3% weight loss over six months. The Registered Dietician stated that notifying families and physicians about weight loss was the responsibility of nursing staff. The DON confirmed there was no documentation of family or physician notification for these significant weight losses, despite a facility policy titled “Change in Condition Process” requiring prompt notification of the resident, physician, and representative when there is a change requiring such notification, including changes necessitating significant alteration of treatment and completion of an SBER Change in Condition evaluation in the electronic medical record.
Failure to Maintain Clean, Safe, and Well-Maintained Environment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide housekeeping and maintenance services necessary to ensure a safe, clean, comfortable, and homelike environment in multiple hallways and resident rooms. During an initial tour, a strong urine odor was noted throughout the 200 and 300 hallways, including common areas, and all rooms toured in the 300 hallway had a pronounced urine odor despite residents being observed as clean, dry, and appropriately dressed. In the 200 hallway, two rooms had floor grates with thick dust buildup, and several rooms had floors with dried, sticky residue. In the 300 hallway, the linen closet door vent had a heavy layer of dust. Several rooms had sticky floors with multiple dried stains, scuffed walls, missing paint, and significant dust and debris, including straws and cup lids, under the beds. Additional environmental issues were observed in common areas and service spaces. The 300 hallway handrail had missing paint beneath a hand sanitizer dispenser, and the underlying paint was wet and easily scraped off. Shower rooms in two hallways had thick brown substances in the corners that could be easily removed by hand. Three of the four hallways toured had missing or unsecured pieces of flooring that could be lifted without effort, and one housekeeping closet was missing a doorknob. The Nursing Home Administrator and DON acknowledged the strong urine odor, sticky residue and dried stains on floors, dust and debris under beds, dust accumulation on vents and grates, and missing or loose flooring. The Assistant Maintenance Director acknowledged chipped or missing flooring and areas no longer properly adhered. These conditions were inconsistent with the facility’s own policy, which requires maintaining a safe, functional, sanitary, and comfortable environment and providing housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Inaccurate Resident Assessments for Diagnoses and Treatments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of four residents in areas including psychiatric diagnosis, skin conditions, dialysis treatment, and respiratory care. For one resident with a documented history of schizophrenia and a current prescription for Aripiprazole, the Minimum Data Set (MDS) admission assessment did not record an active diagnosis of schizophrenia, despite supporting documentation from the discharging hospital and physician orders. Staff responsible for MDS completion expressed uncertainty about the requirements for documenting this diagnosis. Another resident with a history of skin disorders and a dermatologist-confirmed diagnosis of Prurigo Nodularis, presenting with visible rashes and lesions, was not coded for any skin problems in the MDS quarterly assessment. Staff stated they did not code for rashes and were unaware of the lesions. Additionally, a resident with end stage renal disease and active physician orders for dialysis was not documented as receiving dialysis treatments in the MDS quarterly assessment, which staff attributed to human error. Similarly, a resident with chronic respiratory failure and obstructive sleep apnea, who had a physician order for nightly CPAP use, was not documented as using CPAP in the MDS. Staff again cited human error for the omission. These findings were based on interviews, record reviews, and direct observations, demonstrating a pattern of incomplete or inaccurate resident assessments.
Failure to Promote Dignified Dining Experience During Resident Feeding
Penalty
Summary
Staff failed to promote a dignified and homelike dining experience for two dependent residents during breakfast. Both residents, who were assessed as dependent on staff for eating per their Minimum Data Set (MDS) quarterly assessments, were observed in bed with breakfast trays on their bedside tables. A CNA was seen standing between the two residents, alternating assistance by feeding each a spoonful of breakfast in turn, rather than providing individualized attention. During an interview, the CNA stated uncertainty about the correct feeding procedure, citing limited experience as a CNA. The facility's policy on resident rights, last reviewed on 2/26/2025, requires residents to be treated with respect and dignity.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including heart failure, atherosclerotic heart disease, and anemia was observed multiple times with oxygen tubing and an oxygen concentrator in their room, but without a physician's order for oxygen therapy. The resident reported self-administering oxygen as needed when experiencing shortness of breath, and stated that the oxygen machine was already set to 4 liters. Despite these observations, there was no documentation of a physician's order for oxygen in the resident's medical record. The Assistant Director of Nursing confirmed unawareness of the resident's use of oxygen and acknowledged that a physician's order is required for PRN oxygen use. Facility policy also specifies that oxygen must be administered under a physician's order except in emergencies, with orders to be obtained as soon as practicable. The lack of a physician's order for the resident's ongoing use of oxygen therapy was inconsistent with professional standards of practice and facility policy.
Failure to Properly Label and Secure Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, as evidenced by multiple observations and interviews. In one instance, unidentifiable pills and an unlabeled cream-like substance were found in a resident's room, left on bedside tables for extended periods. The resident confirmed that staff routinely left medications at the bedside for later consumption, and staff interviews acknowledged this was not the facility's expectation. Additionally, another resident had a tube of Aquaphor with a prescription label left on the bedside table, and a third resident kept prescription medications, including Trelegy and Triamcinolone, at the bedside without proper orders or security. The DON confirmed that no residents were authorized to have medications at bedside. Further deficiencies were identified during a review of a medication cart, where expired Folic Acid and undated Latanoprost eye drops were found. Staff interviews confirmed that all resident-specific bottles should be dated and expired medications should not be present on the cart. Facility policy requires all medications to be stored in locked compartments and under direct observation during medication passes, which was not adhered to in these instances. The findings demonstrate a failure to comply with labeling and storage requirements for drugs and biologicals.
Inaccurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that the medical records for a resident were accurate and complete regarding advanced directives. The resident's admission record and physician's order both indicated a full code status, while the social services assessment and care plan documented a Do Not Resuscitate (DNR) order. This inconsistency in documentation led to conflicting information about the resident's code status across different parts of the medical record. During interviews, the resident stated not recalling any discussion about DNR status, and the Director of Nursing confirmed that the resident was a full code with no DNR order on file. The Director also acknowledged that the assessment and care plan were inaccurate due to an error by social services. The facility's policy requires code status to be verified upon admission and reviewed regularly, but this process was not properly followed for the resident in question.
Failure to Follow Professional Standards in Tube Feeding Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in administering tube feedings for a resident diagnosed with cerebral infarction, dysphagia, aphasia, and major depressive disorder. The resident was prescribed continuous enteral feeding with Jevity via a feeding pump. During an observation, it was noted that the feeding pump was on hold, and the feeding was not running. A Certified Nursing Assistant (CNA) was observed handling the feeding pump, which is against the facility's policy that only nurses should manage the feeding pump. The CNA admitted to pausing the feeding pump during care and restarting it afterward, a practice she had been following without being instructed otherwise. Additionally, the CNA and a Licensed Practical Nurse (LPN) were observed providing care to the resident without wearing gowns or gloves and without performing hand hygiene, which violates universal precautions and clean technique protocols. The Director of Nursing confirmed that CNAs should not handle the feeding pump and should seek assistance from a nurse to pause and restart the feeding. The facility's policy on enteral feeding emphasizes the use of universal precautions and clean techniques, which were not followed in this instance.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to prevent the possible spread of infection by not adhering to proper hand hygiene and personal protective equipment (PPE) protocols for two residents on Enhanced Barrier Precautions (EBP). Resident #7, who was admitted with conditions including cerebral infarction, dysphagia, aphasia, and major depressive disorder, was observed without EBP supplies such as gowns near his room. Staff B, a Certified Nursing Assistant (CNA), and Staff C, a Licensed Practical Nurse (LPN), entered Resident #7's room without performing hand hygiene or donning gowns and gloves. They assisted in repositioning the resident in bed and handling his feeding tube without the necessary PPE, subsequently failing to perform hand hygiene after exiting the room. Resident #9, admitted with diagnoses including neuromuscular dysfunction of the bladder, cervical spinal cord injury, epilepsy, Type 2 Diabetes Mellitus, and viral hepatitis B, was also on EBP due to an indwelling catheter. Staff D, a CNA, and Staff E, an Occupational Therapist (OT), were observed assisting Resident #9 without wearing gowns, only gloves, and failing to perform hand hygiene before and after care activities. Staff D handled the resident's urinary catheter and personal items without changing gloves or performing hand hygiene, while Staff E did not perform hand hygiene after removing gloves and exiting the room. Interviews with the staff revealed a lack of adherence to the facility's EBP policy, which requires gowns and gloves for high-contact activities such as transferring, providing hygiene, and handling devices like feeding tubes and catheters. The Director of Nursing (DON) confirmed the policy but indicated a misunderstanding of when gowns are necessary, believing they were only required if the resident had an actual infection. The facility's policies and CDC guidelines clearly state the need for PPE during high-contact activities to prevent the spread of multidrug-resistant organisms.
Failure to Provide Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital, as required. This deficiency was identified for three residents who were transferred to a hospital for various medical reasons. Resident #1, diagnosed with Huntington's disease and other conditions, was transferred for a psychiatric evaluation after becoming combative. Resident #2, with conditions including heart failure and diabetes, was transferred for a possible blood transfusion due to low hemoglobin levels. Resident #3, suffering from systemic lupus erythematosus and other ailments, was transferred due to chest pain. In all cases, there was no documentation of a written bed hold notice being provided. Interviews with the facility's Administrator and Director of Nursing revealed that the facility considered residents discharged upon hospital transfer and did not have a process for providing bed hold notifications. The facility's policy required providing a notice of transfer and the bed hold policy to residents and their representatives, but this was not followed. The facility's failure to provide these notices was confirmed by the absence of documentation and the statements from the facility staff.
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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