Golfview Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 3636 10th Ave N, Saint Petersburg, Florida 33713
- CMS Provider Number
- 105409
- Inspections on file
- 20
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Golfview Nursing Center during CMS and state inspections, most recent first.
A resident filed a formal grievance about ants in her room, but the facility failed to document the grievance in the log, did not maintain the original grievance form, and did not provide evidence of prompt resolution. Staff were unaware of the outcome, and the process outlined in the grievance policy was not followed.
A resident alleged that a staff member spoke to her aggressively and yelled, submitting a grievance through facility channels. The grievance was passed among staff but was not documented or reported to the state agency as required by policy and law. The resident was not informed of the outcome, and the original grievance form was missing.
A resident was transferred or discharged without adequate consideration of their needs and preferences, and without proper preparation to ensure a safe transition. The facility did not complete the necessary steps to support the resident's well-being during and after the transfer/discharge.
A resident with cognitive issues sustained skin tears during an altercation with a CNA, who reported the incident internally. However, the facility failed to report the abuse allegation to authorities within the required two-hour timeframe, leading to a four-hour delay. Interviews revealed communication breakdowns and a failure to recognize the incident as an abuse allegation promptly.
A facility failed to ensure a safe and orderly discharge for a resident with psychiatric conditions, who was cleared to return from the hospital but was not accepted back by the facility. The resident's discharge plan was not evaluated, and the bed hold agreement was not honored. Despite being stable, the facility's administrator refused the resident's return, leading to the resident's discharge to another LTC facility.
A facility failed to readmit a resident after hospitalization, despite the hospital rescinding the involuntary hospitalization and deeming the resident stable. The resident, with a history of psychiatric conditions, was initially hospitalized for aggressive behavior. The facility's NHA refused readmission, citing concerns about the short hospital stay and previous behavior. The facility's policy on transfer and discharge was not followed, and there was a lack of proper documentation and communication regarding the resident's discharge and potential readmission.
A resident accused a CNA of causing bruises during care, but the facility failed to report the allegation within the required two-hour timeframe. The incident involved the resident becoming combative, and the CNA calling for help. Despite staff awareness, the report was delayed, leading to a deficiency finding.
A resident with chronic pain and bed confinement status requested therapy to regain mobility but did not receive it due to the facility's reliance on a full body mechanical lift, which caused her pain. Despite her requests and the DON's referral, therapy services were not provided, citing lack of motivation. The NHA questioned this assessment, as the resident repeatedly asked for therapy.
The facility failed to maintain complete medical records for 24 current residents. A beneficiary notice requested for a resident could not be provided because the facility did not have access to the previous electronic medical record system. The facility began using a new system in May 2023 and did not have access to records prior to 4/31/2023. Policies indicated that records should be retained for 7 years or as outlined by payer contracts, and in accordance with State and Federal regulations.
The facility failed to adhere to professional standards for food service safety, including improper storage and labeling of food in the upright freezer, unsanitary conditions and improper temperature control in the walk-in cooler, and uncleanliness and improper labeling in Station #2's nourishment refrigerator. There was also confusion regarding the responsibility for cleaning the nourishment room refrigerators.
The facility failed to provide requested medical records for a resident due to a transition to a new electronic medical record system and lack of access to the old system. Despite facility policies requiring record retention, the facility could not fulfill the request, leading to a deficiency in compliance with state and federal regulations.
Failure to Promptly Resolve and Document Resident Grievance
Penalty
Summary
A resident reported the presence of ants in her room and filed a formal grievance regarding this issue. The grievance was submitted on 12/22/2025, and the resident provided a photo of the written grievance. However, a review of the facility's grievance log for December 2025 did not show any record of this grievance. Staff interviews confirmed that the grievance was submitted to the Nursing Home Administrator (NHA) by Social Services, but there was no follow-up or documentation of the outcome. The NHA acknowledged receiving the grievance and stated that the Plant Director observed ants in the resident's room, but the original grievance form could not be located. The facility's policy requires that all grievances be documented, tracked, and resolved promptly, with evidence of the results maintained for at least three years. Despite these requirements, the facility failed to document the grievance in the log, did not maintain the original grievance form, and did not provide evidence of prompt resolution. Staff involved were unaware of the outcome, and the process outlined in the facility's grievance policy was not followed.
Failure to Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident was reported to the appropriate state agency in accordance with state law and facility policy. A resident filed a grievance alleging that a staff member, the Plant Director, was aggressive and yelled at her. The grievance was submitted to the Activities Director, who then passed it to the Social Services Director, and subsequently to the Nursing Home Administrator (NHA). Despite this, the resident was not informed of the outcome, and the original grievance form could not be located by the NHA. Interviews with involved staff confirmed the sequence of reporting, but none were aware of any further action or outcome regarding the grievance. A review of facility records revealed no documentation of the grievance for the relevant month, and the facility's policies require that all allegations of abuse, neglect, or mistreatment be reported to the state survey agency and other officials within five working days. The investigation found that the facility did not follow its own procedures or state law in reporting the alleged abuse, as there was no evidence that the incident was reported to the governing agency or that the results of any investigation were submitted as required.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. This deficiency was identified based on observations and documentation that indicated the resident's individual requirements and choices were not fully considered or addressed during the transfer/discharge planning process. As a result, the resident was not properly prepared for a safe transition, and the necessary steps to ensure their well-being during and after the transfer/discharge were not completed as required.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe for a resident who had sustained skin tears during an altercation with a Certified Nursing Assistant (CNA). The incident occurred when the resident, who had a history of cognitive and behavioral issues, became combative with the CNA, resulting in the CNA grabbing the resident's arm to protect herself. The resident later alleged that the CNA's actions caused the skin tears. The incident was first reported internally at 10:30 a.m. by the CNA involved, but the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were not informed until approximately 2:30 p.m., leading to a delay in the official reporting of the abuse allegation to the authorities. The facility's policy mandates that such allegations be reported within two hours, but the report was not made until 4:30 p.m., four hours after the incident was initially reported internally. Interviews with staff revealed a breakdown in communication and reporting procedures. The Licensed Practical Nurse (LPN) on duty did not immediately recognize the incident as an abuse allegation and failed to initiate the reporting process promptly. The DON and NHA both acknowledged that they should have been notified earlier, and the facility's training materials clearly outlined the requirement for immediate reporting of abuse allegations.
Plan Of Correction
1. The allegation related to Resident #1 was reported promptly upon notification to Administrator/Coordinator and within 2-hour timeframe. CNA was suspended immediately upon notification of allegation by Director of Nursing. Resident #1 received appropriate interventions, including emotional support and follow-up assessments. Resident #1 remained at her behavioral baseline, in no mental anguish, and participating in her normal activities. 2. Administrator/Designee interviewed all alert and oriented residents on Staff D CNA's assignment were interviewed on and all not alert and oriented residents had skin assessments completed to observe for any possible signs of. No other residents were affected. Administrator/Designee conducted staff interviews on to identify any possible concerns. No concerns identified. A comprehensive review of all incidents over the last 90 days was completed by Director of Nursing/Designee to identify any potential un-reported allegations. No new findings were identified. 3. Administrator/Designee educated all staff on Neglect and Misappropriation Reporting Policies and Procedures and completed Post-Test. All education and post-tests were completed by or prior to their next scheduled shift. Administrator/Designee to educate all new hires on Policies and Procedures and post-test completed during new-hire orientation. DON/Designee completed written coaching with Staff F, Weekend Supervisor and Staff H, RN to ensure moving forward reporting process is followed. Administrator implemented random interviews with residents, staff, and families to be conducted by different members of the Interdisciplinary Team weekly x 3 months to ensure no events go un-reported. Administrator/Designee will review completed interviews daily to determine if any concerns need to be reported. 4. Administrator/Designee will complete daily audits of all incident reports x4 weeks then 3x a week audits for 3 months or until substantial compliance is achieved. Non-compliance in the reporting process will result in corrective training and disciplinary actions. Results of audits will be taken to monthly QAPI x3 months or until substantial compliance is achieved.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who wished to return to the community when medically cleared. The resident's discharge plan was not evaluated, and her wish to return to the community was not honored. An involuntary hospital transfer was rescinded, but the facility did not document any attempts to ensure a safe and orderly transfer back to the facility. The resident remained in the hospital for an additional 17 days awaiting an appropriate discharge location, and the bed hold agreement was not honored without documentation of the cause. The resident, who had a history of psychiatric conditions including PTSD, conversion disorder, depression, schizophrenia, anxiety, bipolar disorder, and insomnia, was admitted to the hospital for altered mental status and aggressive behavior. Despite being deemed stable and cleared to return to the facility by the hospital's psychiatry services, the facility's administrator refused to accept the resident back, citing previous aggressive behavior. The facility did not respond to multiple attempts by the hospital to contact them regarding the resident's discharge. The facility's policy required notification and preparation for transfer or discharge, but the Nursing Home Transfer and Discharge Notice for the resident was incomplete and lacked necessary signatures. The facility's failure to follow its own procedures and communicate effectively with the hospital resulted in the resident being discharged to another long-term care facility instead of returning to the original facility.
Plan Of Correction
1. Resident #2 was discharged to the hospital due to endangering herself or others in the facility. Resident #2 did not return to the facility. 2. Administrator/designee reviewed all discharges in the last 3 months to ensure discharge preferences were followed, bed hold agreements were completed, and Nursing Home Transfer and DC Notice forms were completed. 3. Administrator/Designee educated licensed nurses and Social Services Director to ensure Discharge policies and procedures are followed. Administrator/Designee will conduct daily audits to ensure residents' Discharge Care Plan was followed, bed hold, and Nursing Home Transfer & DC Forms are completed accurately for 4 weeks and then 3 times weekly for 3 months or until substantial compliance is achieved. 4. Administrator/Designee to report all audit findings to monthly QAPI meetings for 3 months or until substantial compliance is achieved.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit the readmission of a resident from the hospital after an involuntary hospitalization, which exceeded the bed-hold policy. The resident, who had a history of psychiatric conditions including PTSD, schizophrenia, and bipolar disorder, was initially admitted to the hospital due to aggressive behavior. Despite being deemed stable and safe to return by the hospital's psychiatric services, the facility's Nursing Home Administrator (NHA) refused to readmit the resident, citing concerns about the short duration of the hospital stay and the resident's previous behavior. The facility's policy on admission, transfer, and discharge was not adhered to, as the resident was not allowed to return despite the hospital rescinding the involuntary hospitalization. The NHA did not receive further communication from the hospital or the resident's family, and assumed the resident went with a family member. The facility's records showed an incomplete discharge notice and a bed-hold agreement that was not rescinded, indicating a lack of proper documentation and communication regarding the resident's discharge and potential readmission. Interviews with staff revealed inconsistencies in handling residents with aggressive behaviors, as other residents with similar issues were managed with 1:1 supervision and psychiatric follow-up without being involuntarily hospitalized. The facility's failure to readmit the resident after hospitalization, despite the hospital's clearance, highlights a deficiency in adhering to transfer and discharge rights, as well as a lack of consistent application of policies for managing residents with behavioral issues.
Plan Of Correction
1. Resident #2 was discharged to the hospital due to being a danger to herself and others. NHA spoke to the hospital and requested additional testing and a true evaluation be completed and then did not hear from the hospital after. Resident #2 was admitted to another Skilled Nursing Facility in the area. 2. Administrator/Designee reviewed all transfers to the hospital for the last 3 months. No other residents identified as not being permitted to return. 3. Administrator/Designee educated all licensed nurses and Social Services Director on Discharge Policies and Procedures. Administrator/Designee to conduct daily audits on all facility transfers x4 weeks and then 3 x weekly or until substantial compliance is achieved to ensure resident preferences to return to the facility are upheld. 4. Administrator/Designee to bring all audits to monthly QAPI meetings x 3 months or until substantial compliance is achieved.
Delayed Reporting of Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect within the required two-hour timeframe for a resident. The incident involved a Certified Nursing Assistant (CNA) and a resident, where the resident accused the CNA of grabbing her arm and causing bruises. The facility's policy mandates immediate reporting of such allegations, especially if they result in serious bodily injury, but the report was delayed. The incident began when the resident requested assistance from the CNA, who was attending to another resident at the time. Upon returning to assist the resident, the CNA reported that the resident became combative, grabbing the CNA's shirt and hitting her. The CNA called for help, and other staff members responded. The resident later alleged that the CNA had grabbed her arm tightly, causing bruises. The incident was not reported to the Nursing Home Administrator until several hours later, despite staff being aware of the situation earlier in the day. Interviews with staff revealed that the CNA involved was suspended during the investigation, and the Director of Nursing was informed of the incident later in the afternoon. The delay in reporting was attributed to a lack of immediate investigation and communication among staff. The resident's care plan noted self-neglect behaviors and a history of refusing care, which may have contributed to the incident. However, the facility's failure to adhere to its reporting policy resulted in a deficiency finding.
Plan Of Correction
1. The allegation related to Resident #1 was reported promptly upon notification to Administrator/Coordinator and within 2-hour timeframe. CNA was suspended immediately upon notification of allegation by Director of Nursing. Resident #1 received appropriate interventions, including emotional support and follow-up assessments. Resident #1 remained at her behavioral baseline, in no mental anguish, and participating in her normal activities. 2. Administrator/Designee interviewed all alert and oriented residents on Staff D CNA's assignment were interviewed on and all not alert and oriented residents had skin assessments completed to observe for any possible signs of. No other residents were affected. Administrator/Designee conducted staff interviews on to identify any possible concerns. No concerns identified. A comprehensive review of all incidents over the last 90 days was completed by Director of Nursing/Designee to identify any potential un-reported allegations. No new findings were identified. 3. Administrator/Designee educated all staff on Neglect, and Misappropriation Reporting Policies and Procedures and completed Post-Test. All education and post-tests were completed by or prior to their next scheduled shift. Administrator/Designee to educate all new hires on Policies and Procedures and post-test completed during new-hire orientation. DON/Designee completed written coaching with Staff F, Weekend Supervisor and Staff H, RN to ensure moving forward reporting process is followed. Administrator implemented random interviews with residents, staff, and families to be conducted by different members of the Interdisciplinary Team weekly x 3 months to ensure no events go un-reported. Administrator/Designee will review completed interviews daily to determine if any concerns need to be reported. 4. Administrator/Designee will complete daily audits of all incident reports x4 weeks then 3x a week audits for 3 months or until substantial compliance is achieved. Non-compliance in the reporting process will result in corrective training and disciplinary actions. Results of audits will be taken to monthly QAPI x3 months or until substantial compliance is achieved.
Failure to Provide Requested Therapy Services
Penalty
Summary
The facility failed to preserve the quality of life related to therapy services for a resident who expressed a desire to regain strength and mobility. The resident, who was admitted with multiple medical diagnoses including chronic pain and bed confinement, reported that she had not received therapy for over a year despite her requests. She expressed a desire to participate in therapy to regain the ability to sit on the side of her bed and use her wheelchair, but stated that the CNAs had not been assisting her as expected. The resident also mentioned that the use of a full body mechanical lift caused her significant pain, leading to a hospital visit. Interviews with the Director of Therapy and the Director of Nursing (DON) revealed discrepancies in the facility's response to the resident's requests for therapy. The Director of Therapy indicated that the resident was screened but not picked up for therapy services due to her refusal to use the full body mechanical lift, which was deemed necessary for therapy. The DON, however, had put in a referral for therapy services and questioned the therapy department's decision, as the resident had expressed a desire for therapy and could potentially have experienced a decline in her condition. The Nursing Home Administrator (NHA) noted that the resident was documented as lacking motivation, which was cited as a reason for not providing therapy services. However, the NHA was uncertain about this assessment, given the resident's repeated requests for therapy. The facility's policy on providing specialized rehabilitative and restorative services was not effectively implemented, as the resident's care plan and therapy needs were not adequately addressed, leading to a deficiency in maintaining the resident's quality of life.
Failure to Maintain Complete Medical Records
Penalty
Summary
The facility failed to maintain complete medical records for 24 current residents out of a total resident census of 47. On 5/14/24, a beneficiary notice was requested for a resident, but the facility could not provide it because they did not have access to the resident's full medical record. The Interim Nursing Home Administrator stated that the facility did not have access to the previous electronic medical record system, which contained the necessary document. The Medical Records Director confirmed that the facility began using a new electronic medical record system in May 2023 and did not have access to any residents' medical records prior to 4/31/2023. A review of the facility's policies revealed that medical records should be retained for a period of 7 years from the date of discharge or as outlined by payer contracts, and in accordance with State and Federal regulations.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial tour of the kitchen, several open and undated bags of vegetables were found in the upright freezer, with one bag being punctured. The walk-in cooler was observed to have a liquid puddle and food debris under a crate containing bags of onions. The Dietary Manager was unaware of the issue and did not clean the area promptly. Additionally, the walk-in cooler's temperature was recorded at 52 degrees Fahrenheit, which was later corrected to 36 degrees Fahrenheit after the food was inspected and potentially unsafe items were discarded. However, the initial unsanitary conditions and improper temperature control were noted as deficiencies. Further observations revealed that Station #2's nourishment refrigerator contained undated and improperly labeled food items, including a take-out container and a covered bowl of mashed potatoes and gravy. The freezer section had frost and an open frozen bottle of soda, along with food debris in both compartments. There was confusion between the Dietary Manager and the Director of Nursing regarding the responsibility for cleaning the nourishment room refrigerators. The contracted Registered Dietitian confirmed that there was no specific facility policy for cleaning these refrigerators, and it was suggested that this task should fall under the general Dietary/Kitchen Policy for maintenance and cleaning of dietary equipment.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to obtain and provide copies of a portion of a medical record requested for a resident. A subpoena dated 1/29/2024 required the facility to deliver medical treatment records, billing statements, and Power of Attorney documentation for the resident from 8/1/2022 to the current date by 2/28/2024. However, the Medical Records Director (MRD) reported that the facility changed to a new electronic medical record system in April 2023 and was unable to provide documents prior to 4/31/2023. The party requesting the records was not informed that records from 2022 to 4/31/2023 were missing in the provided documents. The Nursing Home Administrator (NHA) had sent an email to the corporate office about the inability to access medical records prior to 4/31/2023 due to lack of payment, but no resolution was achieved, and the facility remained without access to these records. A review of facility policies revealed that it was the facility's policy to maintain medical records for a period of 7 years from the date of discharge or a period outlined by payer contracts, whichever is longer. Despite this policy, the facility was unable to fulfill the medical record request due to the transition to a new electronic medical record system and the subsequent lack of access to the old system. The NHA had inquired about updates to allow access to the old medical record system, but no additional documentation related to access was provided. This failure to provide the requested medical records constitutes a deficiency in the facility's compliance with state and federal regulations regarding medical record retention and access.
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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