Greenville Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Florida.
- Location
- 13455 W Us Hwy 90, Greenville, Florida 32331
- CMS Provider Number
- 105824
- Inspections on file
- 22
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Greenville Nursing And Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to submit a valid Emergency Management Plan to the County Emergency Management Office and instead provided a falsified document. The administrator, responsible for submitting the plan and maintaining the Emergency Plan binder, could not account for the origin of the falsified letter and had not contacted the County to submit the required plan. The County Emergency Management Director confirmed that no plan had been received and that the documentation provided was not authentic.
Surveyors found that the facility lacked an effective compliance and ethics program, as shown by the submission of a falsified Emergency Management Plan approval letter. The administrator was unable to confirm the existence of a current compliance program and only referenced general policy statements after further inquiry.
Confidential resident information, including protected health information and discarded medication packets, was found unsecured in overflowing garbage cans and loose on the ground outside the laundry building. The facility's Maintenance Director confirmed the documents were awaiting destruction, and the Administrator was unaware the documents had been left outside or if all had been retrieved.
Surveyors found that two outside gates were left unlocked, a resident had access to fingernail scissors at bedside, and the laundry area had overflowing garbage, burned residue, and lint accumulation. Staff confirmed these conditions were not in line with facility policy and expectations for accident prevention.
Surveyors identified failures in infection control practices, including improper cleaning and disinfecting of a glucometer by a nurse, inadequate handling and storage of laundry and linens, and lack of evidence for required Legionella testing. Staff did not consistently use PPE correctly in the laundry area, and the environment was not maintained in a cleanable state. Maintenance staff were unable to provide documentation or confirm responsibility for Legionella testing, contrary to facility policy.
Surveyors found extensive garbage, debris, and broken equipment around and inside the laundry building, with staff unable to confirm how long these items had been present or provide details about waste removal. Inside, one washing machine had been broken for months, the water heater was unplugged, and the handwashing sink lacked hot water. Staff reused disposable PPE between loads, and there was significant buildup of lint and debris. In the dryer and utility rooms, only one dryer worked, lighting was poor, the smoke detector was missing, and equipment was broken or rusted. The shower room had decaying cabinetry, rust, and a broken shower chair with no alternative available.
A urine specimen collector was found unlabeled, unbagged, and stained on the floor of a shared resident bathroom, remaining there over multiple days. Facility staff confirmed this was not in accordance with policy. Additionally, widespread cleanliness and maintenance issues were observed, including dirty and worn floors, rusty plumbing fixtures, chipped door jams, and unclean walls and doors throughout the facility. The Administrator acknowledged these ongoing problems during a facility tour.
A resident with a history of Major Depressive Disorder, Bipolar Disorder, and Schizoaffective Disorder was not properly identified as having a serious mental illness on their annual MDS assessment. Both the DON and MDS coordinator confirmed the assessment was incorrectly coded after reviewing the resident's record.
Three residents with serious mental illness diagnoses, including major depressive disorder, bipolar disorder, schizoaffective disorder, psychosis, paranoid schizophrenia, and anxiety disorder, did not have evidence of a completed Level II PASARR screening in their medical records as required by facility policy. The Administrator confirmed the absence of these screenings after reviewing the records.
A resident with severe contractures and a history of TBI and hemiplegia was repeatedly observed without prescribed splints or restorative interventions. Therapy staff had discontinued services due to lack of progress, and no restorative nursing program or care plan was in place. Despite facility policy requiring identification of restorative needs and staff training, no orders or documented interventions were provided to maintain or improve the resident's ROM.
The facility did not maintain sufficient nurse staffing on a 24-hour basis, as evidenced by PBJ data showing failure to meet minimum requirements and excessively low weekend staffing. The Administrator was aware of the issue, which was linked to the previous owner's refusal to submit staffing data for two months, and did not report any attempt to correct the missing PBJ information.
Surveyors found that daily nurse staffing information was not posted in a location easily visible to residents and visitors, and the evening shift was left blank on the posted sheets. The DON, responsible for posting, was unaware of the requirement to post the full day's staffing and to ensure visibility for residents and visitors.
Surveyors found that staff repeatedly left medication carts unlocked and unattended during medication administration, and prepared medications were left unattended in resident rooms. Additionally, expired over-the-counter medications were discovered stored in the clean utility room. These actions were not in accordance with facility policy or professional standards for medication storage and security.
A resident who had received education and signed consent for the influenza vaccine did not receive the vaccination, as confirmed by record review and DON interview.
Failure to Submit Valid Emergency Management Plan and Falsification of Documentation
Penalty
Summary
The facility failed to ensure proper administration and use of resources to maintain the highest practicable physical wellbeing of each resident by not submitting a valid Emergency Management Plan to the County Emergency Management Office as required. During a Life Safety Code annual survey revisit, surveyors requested the most recent Emergency Management Plan, and the administrator provided a document dated 05/08/25. Upon review, it was determined that this document was falsified, as confirmed by the County Emergency Management Director, who stated that no plan had been submitted for review and that the form provided used an outdated logo, further indicating its inauthenticity. The administrator acknowledged responsibility for submitting the Emergency Management Plan and for the contents of the Emergency Plan binder, which was kept in her office but also accessible to the maintenance director. Despite this responsibility, she stated she did not know the origin of the falsified letter and had not contacted the County Emergency Management Director to submit the required plan since the previous survey or revisit. The facility's Executive Director position description confirms the administrator's accountability for compliance with all state and federal regulations, including the submission and maintenance of required emergency documentation.
Failure to Maintain Effective Compliance and Ethics Program; Falsified Emergency Management Plan Approval
Penalty
Summary
The facility failed to maintain an effective compliance and ethics program, as evidenced by the submission of a falsified Emergency Management Plan approval letter during a Life Safety Code annual survey revisit. When surveyors requested the most recent Emergency Management Plan approved by the County, the administrator provided a document dated 05/08/25. Upon review and comparison with documentation from the County Emergency Management Director, surveyors determined that the approval letter was falsified. During an interview, the administrator was unable to confirm the existence of a current compliance and ethics program, initially stating uncertainty and referencing a previous program with a Human Resources representative as the compliance officer. She later stated that she, as the administrator, was responsible for compliance, as indicated in her job description. The facility's policies and employee handbook included general statements about ethical conduct and compliance but did not demonstrate the presence of an effective compliance and ethics program as required.
Failure to Secure Resident Confidential Information
Penalty
Summary
The facility failed to ensure that confidential resident information was stored securely, as observed during a tour of the laundry area. Two burned and rusted metal garbage cans overflowing with bagged garbage were found outside the laundry building. The Maintenance Director confirmed that the bags contained confidential documents awaiting destruction by burning. The plastic bags were clear, unsealed, and open to the air, and the paperwork inside was confirmed to contain protected health information (PHI). Additionally, numerous pieces of paper containing PHI were found loose on the ground, along with a garbage bag filled with discarded medication packets that also contained PHI. The Maintenance Director was unable to confirm how long the confidential information had been present outside the building. The facility Administrator stated that the garbage bags of confidential documents had since been retrieved and brought inside the facility, in accordance with the facility's policy to burn confidential documents on-site. However, she was not aware that the documents had been left outside and had not checked to ensure that all documents, including those loose on the ground, had been retrieved. The report does not mention any specific residents by name or provide details about their medical history or condition at the time of the deficiency.
Unsecured Gates, Access to Sharp Instruments, and Laundry Lint Accumulation Identified as Accident Hazards
Penalty
Summary
Surveyors observed multiple deficiencies related to accident hazards and inadequate supervision within the facility. During facility tours, two external gates—one outside the therapy room and another outside the resident smoking area—were found to be unlocked and unsecured, despite staff being trained to keep them locked. The Maintenance Director and Administrator both confirmed that the locks were functional and that staff were expected to secure the gates, but the gates were left open without explanation. Additionally, a pair of fingernail scissors was found at a resident's bedside, which was confirmed by a Registered Nurse to be against facility policy. In the laundry area, surveyors noted two burned and rusted metal garbage cans overflowing with bagged garbage, a large area of ash and burned residue next to the laundry building, and a thick layer of lint on the back wall. The Maintenance Director acknowledged that the facility routinely burned materials in this area, which was directly adjacent to the laundry building.
Infection Control Deficiencies in Glucometer Use, Laundry Handling, and Legionella Testing
Penalty
Summary
The facility failed to maintain infection control standards in several key areas, as observed during surveyor visits. During a blood glucose monitoring procedure, a registered nurse did not follow proper cleaning and disinfecting protocols for the glucometer. The nurse did not don gloves or use a secondary disinfectant wipe as required by both the manufacturer's instructions and the facility's own competency assessment. The nurse was also unclear about the required wet time for the disinfectant wipe, and the process did not ensure the glucometer was disinfected according to established guidelines. In the laundry area, multiple deficiencies were observed. There was a hole in the ceiling of the secondary storage room with outdoor debris present, and resident clothing and personal belongings were stored on the floor and in uncovered carts for periods exceeding the stated 30-day retention policy. The washing machine area had a non-functioning water heater, and staff could not confirm if hot water was used for laundry. The laundry aide did not change disposable gowns and gloves between loads and was unaware of this requirement. The laundry environment was not maintained in a cleanable state, with a cement subfloor, rusted laundry carts without liners or covers, and a folding table with chipped laminate, all of which compromised the cleanliness of laundry handling. Regarding Legionella testing, the facility lacked evidence of required testing within the past year. The maintenance staff were unclear about their responsibilities for Legionella testing and could not provide documentation of any recent testing or results. The facility's own policy required regular risk assessments, action plans, and microbiological monitoring, but these were not demonstrated during the survey.
Failure to Maintain Laundry and Shower Areas in Safe and Sanitary Condition
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's laundry and shower areas, including significant accumulation of garbage, debris, and broken equipment around the laundry building. Overflowing garbage cans, burned residue, and a thick layer of lint were present near the building, along with discarded mattresses, toilets, and numerous wooden pallets and broken furniture. The perimeter also contained various pieces of broken medical equipment and containers with remnants of laundry chemicals. Facility staff, including the Maintenance Director and Assistant, were unable to confirm how long these items had been present or provide details about waste removal procedures. Inside the laundry building, storage rooms were cluttered with boxes, broken lights, and a hole in the ceiling containing outdoor debris. Resident belongings were stored in the laundry area for longer than the stated 30-day period, with staff unable to confirm exact durations. One washing machine had been broken for at least eight months with no clear plan for repair or replacement, and the water heater was unplugged, leaving staff uncertain about its functionality. The handwashing sink lacked hot water, and the floor was unfinished cement, making it unsuitable for maintaining cleanliness. Staff were observed reusing disposable gowns and gloves between loads, and there was a significant buildup of lint, debris, and rust behind machines and on surfaces, with no clear cleaning schedule. In the dryer room, only one dryer was operational, and the area was poorly lit due to broken lights. The smoke detector was missing, and the dryer drum had a buildup of melted substances and lint. Laundry carts were rusted and uncovered, and the folding table was chipped and discolored. In the soiled utility and shower rooms, hot water was unavailable, water ran discolored, and broken equipment was stored alongside cleaning chemicals. The shower room contained decaying cabinetry, rust, and a broken shower chair, with no alternative available for resident use. Staff could not confirm how long equipment had been left in these conditions.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for residents. In a shared resident bathroom, an unlabeled, unbagged urine specimen collector with brown stains was found on the floor next to the toilet. This item remained in place during a follow-up observation the next day. Staff interviews confirmed that the urine collector should not have been left in the bathroom and that facility policy required disposable collectors to be labeled, bagged, and disposed of after use. A general tour of the facility revealed widespread cleanliness and maintenance issues. Floors throughout the facility were worn and dirty, with a buildup of dirt and debris in corners. Plumbing fixtures in resident bathrooms were rusty and stained, and there were scrapes, dirt, and a lack of fresh paint on walls in halls, resident rooms, and bathrooms. Door jams were rusty and chipped, and some doors appeared unclean. There was a large area of missing floor tiles exposing concrete, and a wall in the staff breakroom had an open hole with years of dirt and dust buildup. The Administrator confirmed these maintenance and cleanliness concerns during the tour.
Inaccurate MDS Coding for Serious Mental Illness
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status. Record review showed that a resident with a medical history of Major Depressive Disorder, Bipolar Disorder, and Schizoaffective Disorder was not identified as having a history of serious mental illness on their annual MDS assessment. During interviews, both the DON and the MDS coordinator independently reviewed the resident's record and confirmed that the MDS was incorrectly coded and should have indicated serious mental illness.
Failure to Complete Required PASARR Level II Screenings for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that residents with diagnoses of serious mental illness received a Level II Pre-admission Screening and Resident Review (PASARR) as required. Specifically, three residents with documented histories of major depressive disorder, bipolar disorder, schizoaffective disorder, psychosis, paranoid schizophrenia, and anxiety disorder did not have evidence of a completed Level II PASARR screening in their medical records. Record reviews confirmed the absence of the required screenings for these residents, and the facility's Administrator acknowledged that the screenings were not present in the records upon independent review. The facility's policy states that it is responsible for ensuring appropriate PASARR screenings are conducted and documented prior to admission, and for coordinating screenings if indicated after admission, but this process was not followed for the identified residents.
Failure to Provide and Implement Restorative ROM and Splinting Interventions
Penalty
Summary
A deficiency was identified when a resident with a history of traumatic brain injury, hemiplegia, and contractures was observed multiple times without prescribed splinting devices or restorative interventions to maintain or improve range of motion (ROM). The resident, who had moderate cognitive impairment, was seen lying in bed with severe contractures of both hands and no splints in use, despite the presence of a labeled splint in the therapy room and two hand splints found in the resident's dresser. There were no physician orders or care plans addressing splint use or restorative nursing services for this resident. Interviews with therapy staff revealed that the resident had been discharged from occupational and physical therapy due to lack of progress, and no restorative nursing program was in place. The therapy director acknowledged responsibility for training staff on splint use but confirmed that no such training or program was active. The physical therapist admitted to only verbally instructing staff to use pillows for positioning, with no written orders or follow-up assessments to ensure implementation. Facility policy required identification of restorative needs and staff training, but these steps were not followed for the resident in question.
Failure to Maintain Minimum Nurse Staffing and PBJ Reporting
Penalty
Summary
The facility failed to ensure sufficient nurse staffing numbers on a 24-hour basis to meet the needs of all residents. Review of the Payroll Based Journal (PBJ) staffing data for Quarter 1 of 2024 showed that the facility did not meet minimum staffing requirements, resulting in excessively low weekend staffing. During an interview, the Administrator acknowledged awareness of the low staffing trigger and explained that the previous owner did not submit staffing information for two months due to anger. There was no indication that the Administrator attempted to provide additional information to the PBJ system after learning about the missing submissions.
Failure to Properly Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to maintain and post daily nurse staffing information in a location that was easily visible to residents and their visitors. During two separate tours, surveyors observed that the nurse staffing information was posted on the wall behind the nurse's station desk, making it not fully visible to residents and visitors. Additionally, on both occasions, the evening shift staffing information was left blank on the posted sheet. Interviews with staff revealed that the Director of Nursing (DON) was responsible for posting the staffing information daily but was unaware that the entire day's staffing, including the evening shift, needed to be posted in advance. The DON also stated she was unaware that the posting needed to be visible to residents and visitors.
Failure to Secure Medications and Remove Expired Drugs
Penalty
Summary
Surveyors observed multiple instances where medications were not properly secured or stored according to facility policy and accepted professional standards. During medication administration, a registered nurse left her medication cart unlocked and unattended in the hallway while entering a resident's room. In another instance, the same nurse left prepared medications unattended on a resident's dresser while she walked away to wash her hands. A licensed practical nurse was also observed leaving her medication cart unlocked and unattended in the hallway while assisting a resident, with photographic evidence obtained. During this time, other staff members and residents walked past the unattended cart, and the Director of Nursing was seen placing pudding into the cart's cooler. Additionally, a review of the clean utility room revealed six bottles of expired Vitamin C tablets, with expiration dates from the previous year, stored among other over-the-counter medications. Staff present during this observation acknowledged the presence of expired medications and indicated they would notify the facility's administrator and pharmacist. The facility's policy requires all drugs and biologicals to be stored securely and prohibits the use of outdated or discontinued medications, mandating their return or destruction.
Failure to Administer Influenza Vaccine After Consent
Penalty
Summary
The facility failed to ensure that the influenza vaccination was administered to one of five residents sampled for vaccine review. Record review showed that the resident received education and signed a consent form indicating a desire to receive the influenza vaccine. However, there was no documentation in the medical record that the vaccination was actually administered. During an interview, the DON confirmed that although the consent was signed, the influenza vaccine had not been given to the resident.
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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