Garden View Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Vero Beach, Florida.
- Location
- 2180 10th Avenue, Vero Beach, Florida 32960
- CMS Provider Number
- 106075
- Inspections on file
- 28
- Latest survey
- July 15, 2025
- Citations (last 12 mo.)
- 19 (2 serious)
Citation history
Health deficiencies cited at Garden View Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dysphagia was not supervised during meals and was served a whole hot dog, contrary to her mechanically altered diet order. Staff failed to follow care plan interventions and did not document required supervision, resulting in the resident consuming inappropriate foods without monitoring.
Several residents with dysphagia and other nutritional concerns were served foods that did not meet their prescribed mechanically altered or pureed diets, including one resident who was given a whole hot dog instead of a ground version, and others who received lumpy pureed foods or inappropriate snacks. Staff did not consistently verify diet orders or understand the differences between diet textures, leading to the provision of foods that did not align with physician orders or professional standards.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including dirty kitchen equipment, food and condiment packets on the floor, dead insects in storage areas, and a dishwasher that did not reach the required temperature. These issues had the potential to affect most residents who consume food PO.
Surveyors observed that linen carts in multiple units were torn, opened, or not fully covered, leaving linens exposed to potential contaminants. This occurred while several residents were under transmission-based precautions for conditions such as COVID-19, MRSA, ESBL, and Shingles. The Infection Preventionist confirmed the issue during a follow-up tour.
Two residents experienced a lack of dignity in their care, including delayed responses to call lights, staff displaying negative attitudes, and CNAs failing to offer assistance or handling a post-surgical resident roughly despite his requests and reports of pain. The DON acknowledged these issues and agreed that residents were not treated with dignity.
Two residents with cognitive impairment and significant physical limitations did not have their call bells within reach as required by their care plans. Observations showed that the call bells were placed out of reach or on the floor, and staff did not consistently ensure accessibility, despite the residents' dependence on staff for assistance.
Two residents voiced concerns during Resident Council meetings about the poor condition and lack of maintenance of the outdoor patio and courtyard, including issues such as old plants, debris, and safety hazards. Despite these grievances being raised, there was no documentation or follow-up, and observations confirmed the area was not maintained to the same standard as the rest of the grounds, with litter, leaks, and misuse of planters noted.
A resident receiving Seroquel and Oxcarbazepine for mood was not monitored for behaviors as required, despite psychiatric notes indicating the need for such monitoring. The DON confirmed that staff did not document behavior monitoring in the electronic medical record.
Surveyors found that the facility did not accurately complete MDS assessments for three residents by failing to document weights taken within the required 30-day period before the assessment reference date. In some cases, outdated weights were used, and in others, the standard code for missing information was not applied when no recent weight was available. These issues were confirmed by the MDS Coordinator.
Nursing staff did not follow physician orders for wound care for a resident with stage 4 pressure ulcers and osteomyelitis. An LPN cleansed both wounds with Dakin's-soaked gauze instead of using normal saline or wound cleanser and patting dry as ordered. The ADON confirmed the care did not comply with the prescribed wound care protocol.
A resident did not receive appropriate care to maintain or improve ROM or mobility, and the facility did not ensure necessary interventions were provided unless a decline was medically justified.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, and that catheter care and UTI prevention measures were inadequate. These deficiencies were observed in the care practices for residents requiring assistance with continence management and catheter maintenance.
A resident with severe cognitive impairment and multiple diagnoses had family members, including those designated as POA and HCS, repeatedly request a copy of the admission contract. Despite multiple follow-up emails, the BOM failed to respond or provide the requested records, having forwarded the request to the wrong staff. Staff interviews revealed inconsistent handling and lack of documentation regarding the records request.
Two residents experienced delays in receiving prescribed medications upon admission to the facility. One resident with Type 1 Diabetes did not receive insulin or the antibiotic Zosyn timely, with nearly 24-hour delays due to lack of specific dosing and order confirmation issues. Another resident with Diabetes faced similar delays, with short-acting insulin administered 15 hours after admission and long-acting insulin 21 hours later. The ADON confirmed these delays during interviews.
A resident with severe cognitive impairment and multiple medical conditions developed a pressure injury under a knee immobilizer due to a failure in monitoring skin integrity. The facility's policy required weekly skin assessments, but a 14-day gap occurred, during which the injury developed. Staff were unclear about whether the immobilizer could be removed for skin checks, leading to the oversight.
Failure to Provide Supervision and Appropriate Diet During Meals
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for three of nine sampled residents, specifically in the areas of nutrition and fall prevention. One resident with a history of cerebral infarction, hemiplegia, severe cognitive impairment, and dysphagia was not supervised during meals as required by her care plan. Despite being on a mechanically altered diet due to swallowing difficulties, she was served a whole hot dog by a CNA, which she consumed without staff supervision. The resident had also previously been given inappropriate foods such as potato chips and Goldfish crackers by staff, contrary to her dietary requirements. Observations and record reviews revealed that the resident's care plan and physician orders specified the need for a mechanically altered diet and supervision during meals to monitor for signs of aspiration or choking. However, documentation in the electronic medical record showed no evidence of supervision being provided during meals over a two-week period. During direct observation, the resident was left alone with her meal and was not monitored by staff, even when she was offered and consumed foods not consistent with her prescribed diet. Interviews with staff confirmed that the CNA provided the resident with a whole hot dog and did not ensure it was prepared according to the resident's dietary needs. The dietary manager was unaware that the hot dog was for this resident and confirmed that no ground hot dogs were prepared that day. Further, the resident was observed eating without supervision on another occasion, and staff interviews indicated a lack of adherence to protocols for verifying diet orders and providing required supervision during meals.
Failure to Provide Foods in Appropriate Texture for Residents with Swallowing Disorders
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents with swallowing difficulties and other nutritional concerns. Four out of five sampled residents were affected, including individuals with diagnoses such as dysphagia, cerebral infarction, malnutrition, and muscle weakness. In one instance, a resident with severe cognitive impairment and a physician-ordered mechanically altered diet was served and consumed a whole hot dog, which was not prepared according to her dietary requirements. Staff involved did not verify the appropriateness of the food texture, and the kitchen did not prepare the hot dog in the required ground form, despite the menu specifying a ground hot dog for those on mechanically altered diets. Additionally, staff provided this resident with snacks such as potato chips and Goldfish crackers, which were not suitable for her prescribed diet. Other residents on pureed diets were observed receiving foods that did not meet the required texture standards. One resident received soup containing whole grains of rice and intact corn kernels, and another was served pureed foods that were lumpy and not homogenous, as required for a pureed diet. Observations in the kitchen confirmed that some pureed foods, such as baked ham, were not consistently smooth and contained small lumps. Staff interviews revealed a lack of understanding regarding the differences between diet textures and the importance of matching meal tickets and physician orders. The facility's policies and professional standards, including those from the National Dysphagia Diet Task Force and the International Dysphagia Diet Standardization Initiative, were not consistently followed. There were discrepancies between diet orders in the electronic medical record and the meal ticket software, leading to confusion among staff. Staff members were not always aware of the specific dietary needs of residents or the consequences of serving inappropriate food textures, resulting in the provision of foods that posed a risk to residents with swallowing difficulties.
Deficient Food Storage, Sanitation, and Equipment Maintenance in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and sanitation practices. During a tour of the main kitchen, the reach-in cooler was found to have gaskets with dark brown/black streaks and spots, and the bottom of the gasket was torn with pieces of rubber hanging down. In the dry food storage area, a bag of pasta was found on the floor behind the lowest shelf, and two large dead insects were observed on the floor, one near the pasta and another under the area where cookies were stored. A yellow condiment packet was also found on the floor. Muffin pans and the storage rack for clean serving scoops and baking sheets were noted to have brown, yellow, and black residues, and the baking sheets themselves had visible residue as well. Additionally, the low-temperature dishwasher did not reach the required wash cycle temperature of 120°F, only reaching 100°F. The Vulcan fryer contained food residue and was not clean at the time of inspection. The CDM confirmed these findings during the tour. These deficiencies had the potential to affect 63 out of 66 residents who consume food by mouth.
Improper Storage of Linens Exposes Linens to Contamination
Penalty
Summary
The facility failed to ensure the proper storage of linens in three out of three observed linen carts. On the day of the survey, four residents were under transmission-based precautions for conditions including COVID-19, MRSA, ESBL, and Shingles. During multiple observations, linen carts in the [NAME] Wing, East Wing, and North Unit were found to be either torn, opened, or not fully covered, resulting in exposed linens. Additionally, a glove was found on the floor next to one of the linen carts. The Infection Preventionist acknowledged that the linen carts were torn and uncovered, which exposed the linens to potential contaminants.
Failure to Maintain Resident Dignity During Care and Assistance
Penalty
Summary
Two residents were not provided care and services in a manner that maintained their dignity. One resident, who was cognitively intact, reported that when using the call light for assistance, it sometimes took over 30 minutes for staff to respond. Upon arrival, staff would occasionally tell her she would have to wait because they were busy, and some staff appeared to be stressed or had negative attitudes. The resident expressed that this treatment made her feel disrespected and not good. The DON agreed that this did not reflect dignified treatment. Another cognitively intact resident described two incidents where he felt disrespected by CNAs. In one instance, a CNA watched him struggle to pick up an item from the floor without offering assistance. In another, during ADL care, the resident, who had a recent hip surgery, reported being handled roughly by CNAs who did not allow him time to move at his own pace and grabbed his surgical hip area, causing pain. Despite informing the CNAs of his pain, they continued without adjusting their approach, and their facial expressions did not change, making the resident feel unheard. The DON was not previously aware of these complaints but stated that CNAs should handle all residents gently, regardless of surgical history.
Failure to Maintain Call Bell Accessibility for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain the call bell within reach for two residents who were cognitively impaired and required significant assistance with activities of daily living. For the first resident, who had diagnoses including non-Alzheimer's dementia, muscle weakness, and a history of polio, the care plan specifically required the call bell to be within reach due to her dependence on staff for most ADLs. Observations revealed that the call bell was placed out of her reach, coiled above her right shoulder, and later found on the floor. The resident expressed that she needed the call bell within reach and had needed help in recent days. Staff entered the room but did not ensure the call bell was accessible, only noticing and correcting the issue after it was pointed out. The second resident, who had renal insufficiency, diabetes, hemiplegia, and muscle weakness, also had a care plan intervention requiring a reachable call bell. During interviews and observations, the resident was unable to locate her call bell, which was found dangling between the mattress and the floor, and later behind the bed close to the wall. The resident stated she did not know where her call bell was and agreed it would be beneficial to have it within reach. These findings demonstrate that staff did not consistently follow care plan interventions to ensure the call bell was accessible to residents who were dependent on staff for assistance.
Failure to Address Resident Grievances Regarding Patio Maintenance
Penalty
Summary
The facility failed to promptly address grievances voiced by two cognitively intact residents regarding the condition of the outdoor patio and courtyard area. One resident reported making recommendations during Resident Council meetings about improving the patio with additional plants and mulch, noting that the concern was voiced approximately five months prior but no action had been taken. The resident stated that the issue was documented but not followed up on. Another resident agreed with these concerns, adding that the outdoor area was not maintained as it used to be, with old plants, fallen debris on walkways, and safety concerns about tripping hazards. Both residents indicated that the issue had been raised during Resident Council meetings, but there was no documentation of the concern in the meeting minutes for the relevant period. Observations of the patio and courtyard area revealed several maintenance issues, including areas of dirt and rocks with minimal vegetation, litter such as milk cartons and used masks, and a planter being used as a trash receptacle. The roof over the screened patio was noted to have several leaks, and trees and shrubbery were growing out of the overhanging awning. Staff interviews confirmed that residents had voiced concerns about the patio needing improvement and that the area was not maintained to the same standard as the rest of the facility grounds. The Maintenance Director acknowledged the misuse of the planter and the overall poor condition of the patio area.
Failure to Document Behavior Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper behavior monitoring for a resident who was prescribed psychotropic medications, specifically Seroquel and Oxcarbazepine, both administered twice daily for mood management. Record review showed that although psychiatric progress notes documented the need to monitor for agitation, aggression, combativeness, refusal of care, refusal of medications, and symptoms of depression, there was no evidence of staff behavior monitoring documented in the resident's record. During an interview, the DON confirmed that nurses are expected to document behaviors on behavior monitoring forms in the electronic medical record, but acknowledged that such documentation was missing for this resident.
Inaccurate MDS Weight Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three out of five sampled residents in relation to their nutritional status, specifically regarding the documentation of resident weights. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines, the most recent weight within 30 days of the Assessment Reference Date (ARD) should be used for MDS entries. In the case of one resident with multiple diagnoses including malnutrition and dementia, the MDS recorded a weight from a week prior to the ARD, despite a more recent weight being available on the ARD itself. The MDS Coordinator confirmed that the incorrect, earlier weight was entered instead of the most current one. For two other residents, the MDS assessments documented weights that were not obtained within the required 30-day window prior to the ARD. In one instance, the weight entered was from 41 days before the ARD, and there were no documented weights within the appropriate timeframe. The correct procedure, as outlined in the RAI manual, would have been to use the standard code for no information and document the rationale in the medical record. In the third case, the weight recorded in the MDS was from several months prior to the ARD, again not meeting the 30-day requirement. These findings were confirmed through interviews with the MDS Coordinator, who acknowledged the discrepancies.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
Nursing staff failed to follow physician orders for wound care for a resident with a history of osteomyelitis and two stage 4 pressure ulcers, one located on the right buttock and the other on the left hip. The facility's wound treatment management policy requires that wound treatments be provided in accordance with physician orders, specifying the cleansing method, type of dressing, and frequency of dressing change. Physician orders for this resident directed staff to cleanse both pressure ulcers with normal saline or wound cleanser, pat dry, apply wet to dry gauze with Dakin's solution at 1/4 strength, and secure with bordered gauze daily. During an observed wound care session, an LPN cleansed both wounds using Dakin's-soaked gauze, rather than following the prescribed method of cleansing with normal saline or wound cleanser and then patting dry before applying the Dakin's solution. The Assistant Director of Nursing confirmed that the wound care provided did not adhere to the physician's orders as required by facility policy.
Failure to Provide Care to Maintain or Improve Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that the resident received necessary interventions to prevent a decline in ROM or mobility, except in cases where such decline was due to a documented medical reason. This deficiency was based on observations and findings that the required care and services to address the resident's ROM or mobility needs were not provided as expected.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care practices for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Timely Respond to Resident Record Requests
Penalty
Summary
The facility failed to respond in a timely manner to requests for a resident's records, specifically for a resident with severe cognitive impairment and diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression. The resident's family, including individuals designated as Power of Attorney (POA) and Health Care Surrogates (HCS), made multiple attempts to obtain a copy of the admission contract, which they did not possess and did not recall signing. Despite repeated requests via email to the Business Office Manager (BOM), there was no documented response or provision of the requested records. The BOM acknowledged forwarding the request to the wrong staff members and did not provide a rationale for failing to respond to the family's emails. Interviews with facility staff revealed inconsistent awareness and handling of the records request. The Medical Records Clerk described a process for handling such requests but had no documentation of receiving or processing the family's requests. The Administrator stated there were no requests from the family and cited restrictions on releasing records to individuals not designated as POA or HCS, despite evidence that the requests came from appropriately designated family members. Email records confirmed multiple follow-up attempts by the family, with no timely or appropriate response from the facility.
Delayed Medication Administration for Two Residents
Penalty
Summary
The facility failed to ensure the timely provision of medications for two residents upon their admission. Resident #1, who was admitted with Type 1 Diabetes, did not receive insulin or the antibiotic Zosyn as prescribed. The hospital discharge paperwork for Resident #1 lacked specific insulin dosing, which required clarification from the physician. Despite an order for Novolog FlexPen being entered by the pharmacy, it was not confirmed by nursing staff until 14 hours later, resulting in a delay of nearly 24 hours before insulin was administered. Similarly, the antibiotic Zosyn was not administered until nearly 24 hours after admission, with no documented reason for the delay. Resident #2, also admitted with Diabetes, experienced a delay in receiving insulin. The pharmacy ordered a substitute for the prescribed insulin due to insurance coverage, but the nursing staff did not confirm the order until 15 hours after admission, delaying the first dose of short-acting insulin. The long-acting insulin was also delayed, with the first dose administered 21 hours after admission. The Assistant Director of Nursing confirmed these delays during interviews, acknowledging the lack of timely medication administration for both residents.
Failure to Monitor Skin Under Immobilizer Leads to Pressure Injury
Penalty
Summary
The facility failed to assess a resident's skin under a knee immobilizer, leading to the development of a pressure injury. The resident, who was transferred from a hospital with a left knee immobilizer due to a fracture, was not properly monitored for skin integrity under the immobilizer. The facility's policy required weekly skin assessments, but there was a 14-day gap between documented assessments, during which a pressure injury developed. Staff interviews revealed confusion about whether the immobilizer could be removed for skin checks, with some CNAs stating they were told not to remove it, while others indicated they would follow orders regarding its removal. The resident had a severe cognitive impairment and multiple medical conditions, including a fracture of the lower end of the left femur, pleural effusion, and chronic obstructive pulmonary disease. The pressure injury was discovered after drainage was noticed on the resident's linen. The Director of Rehabilitation stated that the immobilizer could be removed for skin care unless there were specific orders not to do so. The resident's physician confirmed that the pressure injury was preventable and emphasized the importance of checking skin integrity and circulation under immobilizers, which he assumed was standard practice for the nursing 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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