Grove Healthcare And Rehabilitation Center And Reh
Inspection history, citations, penalties and survey trends for this long-term care facility in Hernando, Florida.
- Location
- 124 W Norvell Bryant Hwy, Hernando, Florida 34442
- CMS Provider Number
- 106036
- Inspections on file
- 25
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Grove Healthcare And Rehabilitation Center And Reh during CMS and state inspections, most recent first.
Two residents did not have accurate MDS assessments reflecting their nutritional status, including unreported weight loss and omission of therapeutic diets, despite documentation in their medical records and acknowledgment by the dietician and MDS Coordinator.
A resident was admitted without a diagnosis of serious mental illness or intellectual disability, but later developed multiple mental health conditions, including delusional disorders and major depressive disorder. Despite these changes and a new prescription for Olanzapine, the facility did not update the PASRR assessment as required, as confirmed by both the DON and Regional Nurse Consultant.
A resident with ESRD and a tunneled dialysis catheter did not have their care plan updated after dialysis treatments were placed on hold. The care plan continued to list regular dialysis sessions and did not address the need for CVC dressing changes or new orders, despite the resident not receiving dialysis or proper dressing care for over two weeks. Staff confirmed the lapse, and facility policy requires care plan updates after significant changes.
Two residents did not receive care according to professional standards: one with a central venous catheter had an undated dressing and no documented dressing changes after dialysis was paused, and another with a pressure injury received wound care without a physician order or proper documentation, contrary to facility policy.
Two residents did not receive respiratory care in accordance with physician orders and facility policy. One resident with COPD received oxygen without the required humidity and was found with an almost empty oxygen tank, while another resident's CPAP mask was improperly stored on the bed rail instead of in its designated bag. Staff interviews confirmed these practices did not meet established standards.
Surveyors identified a medication error rate of 5.88% due to two incidents: an LPN administered a heparin flush in a volume inconsistent with the physician's order, and another LPN prepared to crush and administer a delayed-release omeprazole tablet via G-tube, contrary to both the order and facility policy. The DON confirmed that staff are expected to follow physician orders and protocols.
A resident with a physician-ordered vegetarian, no added salt (NAS) diet was served a meal containing cabbage with bacon, despite clear documentation of dietary preferences. The resident declined to eat the bacon-containing item and expressed dissatisfaction with the vegetarian options provided. Staff interviews confirmed awareness of the resident's dietary needs, but the error occurred during meal assembly and verification.
A resident with type 2 diabetes did not have required blood sugar checks and insulin administration documented on two occasions, despite staff recalling that the care was provided. The MAR was left blank for these events, and interviews with LPNs and the DON confirmed that documentation was expected but not completed, in violation of facility policy.
Staff failed to use required PPE when entering a resident's room under contact precautions and did not wear gloves while directly handling food during meal distribution. A CNA entered a resident's room on contact isolation without donning gown and gloves, and an LPN handled multiple residents' food items with bare hands, despite facility policy requiring glove use. Both staff acknowledged the lapses during interviews.
A resident with diabetes experienced severe hypoglycemia, and an LPN administered glucose gel without a physician's order and failed to notify the provider. Despite further declines in blood sugar and a physician's order for Glucagon administration and possible ER transfer, staff did not follow these orders or document interventions appropriately. The resident became unresponsive, was eventually sent to the hospital, and did not survive. This failure to follow professional standards and physician orders led to Immediate Jeopardy.
A resident with diabetes experienced multiple episodes of hypoglycemia, during which an LPN administered glucose gel without a physician's order, failed to notify the provider, and did not follow physician orders for glucagon administration and emergency transfer. Documentation was incomplete, and the DON was not promptly informed. The resident became unresponsive and later died after being transported to the hospital. The facility's failure to implement change in condition protocols and follow physician orders led to Immediate Jeopardy.
A resident with diabetes experienced multiple episodes of hypoglycemia, during which an LPN administered glucose gel without a physician's order and failed to notify the provider. Despite physician orders for Glucagon administration and possible ER transfer, staff did not follow these instructions as the resident's condition worsened. The QAPI process failed to identify or address these deficiencies, and the resident ultimately died after delayed emergency intervention.
A resident with type 2 diabetes mellitus experienced multiple episodes of low blood sugar, requiring interventions including oral glucose gel and glucagon. The LPN on duty did not consistently document blood glucose checks, the administration of glucose gel lacked a physician's order, and there was no record of physician notification regarding the low blood sugar event. The DON confirmed documentation gaps, including missing post-intervention blood sugar values, which did not meet facility policy for complete and accurate medical records.
A facility failed to ensure staff used appropriate PPE for a resident on contact precautions. Despite a sign indicating the need for gowns and gloves, two CNAs entered the room and provided care without the required PPE. Interviews revealed a lack of awareness about which resident required precautions, and the DON confirmed the necessity of PPE in such situations.
Inaccurate MDS Assessments for Nutrition and Diet
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents in relation to their nutritional status. For one resident, a significant weight loss of 10.13% over six months was documented in the medical record and noted by the registered dietician, who had identified the resident as at risk for malnutrition and weight loss. Despite this, the quarterly MDS assessment did not reflect the weight loss in Section K0300. The MDS Coordinator acknowledged that the section was coded incorrectly and confirmed the resident had experienced weight loss during the specified period. For another resident, physician orders indicated the use of nutritional supplements and a fortified, mechanical soft diet due to dementia with behavioral disturbance. However, the quarterly MDS assessment did not document the therapeutic diet under the relevant section. The resident's dietary profile confirmed the use of supplements and fortified foods, and the MDS Coordinator admitted that the therapeutic diet should have been marked as present in the assessment.
Failure to Update PASRR Assessment for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate assessments for a resident with newly identified or possible serious mental disorders. Review of the resident's Preadmission Screening and Resident Review (PASRR) showed no diagnosis or suspicion of serious mental illness or intellectual disability at the time of admission. However, subsequent documentation in the resident's admission record included diagnoses such as cognitive communication deficit, dementia with psychotic disturbance, delusional disorders, persistent mood disorders, recurrent major depressive disorder, and generalized anxiety disorder, with onset dates after the initial PASRR. Additionally, a physician order was present for Olanzapine to treat delusional disorders. Interviews with the Director of Nursing and the Regional Nurse Consultant confirmed that the PASRR was outdated and did not reflect the resident's current mental health status, and both indicated that a new PASRR should have been completed. Facility policy requires ongoing coordination with the state-designated authority and reassessment when a significant change in a resident's status occurs, which was not done in this case.
Failure to Revise Care Plan After Dialysis Placed on Hold
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident following a significant change in their dialysis treatment. The resident, who had a right-sided tunneled dialysis catheter placed for treatment of end stage renal disease (ESRD), reported not having received dialysis for over two weeks and noted that their access dressing had not been changed appropriately. The resident stated that the original dressing had fallen off and was replaced with gauze by a nurse, but there was no ongoing order for dressing changes since dialysis had been placed on hold. Staff interviews confirmed that the last dialysis session occurred on May 29, 2025, and that only RNs are permitted to perform central venous catheter (CVC) dressing changes, with no current orders in place for this care. Review of the resident's care plan showed it still reflected ongoing dialysis treatments and did not indicate that dialysis had been placed on hold after the last treatment date. The care plan also did not address the need for updated orders or care instructions regarding the CVC dressing in the absence of regular dialysis visits. Facility policy requires that care plans be reviewed and revised by the interdisciplinary team after each assessment, including significant changes, but this was not done in this case.
Failure to Provide Proper CVC and Wound Care per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide health care services consistent with professional standards of practice for two residents. One resident with a central venous catheter (CVC) had a dressing that was not dated and reported that the dressing had not been changed for over two weeks after dialysis was held. The resident stated that the dressing fell off and a nurse replaced it with gauze, but no formal dressing change was performed. Staff interviews revealed that only RNs were permitted to change CVC dressings, and there was no current order for dressing changes after dialysis was paused. The facility did not have a policy for care of hemodialysis CVCs, and there was a lack of clear direction or physician orders for ongoing site care after dialysis was discontinued. Another resident with a pressure injury on the coccyx area did not have a physician order for wound care, and the treatment administration record did not document any wound care provided. Staff interviews indicated that nurses occasionally applied zinc cream to the area, but there was no consistent documentation or evidence of provider notification or wound care orders. The facility's policy required wound care to be performed according to physician orders and documented in the clinical record, but these steps were not followed, resulting in the wound being overlooked.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents as required by professional standards and physician orders. One resident with chronic obstructive pulmonary disease had a physician order for oxygen at 2-4 liters per minute via nasal cannula with humidity to maintain oxygen saturation above 90%. Observations revealed that the resident was repeatedly receiving oxygen at various flow rates without the required humidity, both from a portable tank and a concentrator. The resident also reported feeling she was not getting enough oxygen and was found with an almost empty oxygen tank, requiring staff intervention to switch to a concentrator. The Director of Nursing confirmed that staff should check oxygen tank levels and that humidity orders should be followed. Another resident with a physician order for CPAP every shift was observed with the CPAP mask hanging from the bed rail and not stored in the designated bag, which was undated and placed on the bedside table. The resident expressed concern about improper storage of the mask, and an LPN confirmed that the mask should be stored in the bag and not hung on the bed. Review of facility policy indicated that respiratory equipment should be used per physician orders and infection control techniques should be maintained, but these procedures were not followed for the residents involved.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with an observed error rate of 5.88%. One incident involved an LPN administering a heparin flush to a resident using a 5-milliliter dose instead of the 10-milliliter dose ordered by the physician. The LPN stated that their usual practice was to perform a heparin flush before and after medication administration, but the physician order specified a 10-milliliter flush every shift. The Director of Nursing confirmed that staff are expected to follow physician orders and the SASH protocol, and the facility's competency checklist also required adherence to proper dosage and administration guidelines. Another incident involved an LPN preparing to crush and administer a delayed-release omeprazole tablet via a gastric tube for a resident, contrary to the physician's order, which specified an oral capsule to be given via G-tube. The LPN acknowledged that delayed-release medications should not be given via G-tube and indicated the need to clarify the order with the provider. The Director of Nursing reiterated that nurses should clarify any questionable orders before administration, and the facility's policy stated that certain medications, including delayed-release forms, should not be crushed and administered via enteral feeding tubes.
Failure to Accommodate Vegetarian Diet Preferences
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered vegetarian, no added salt (NAS) diet was served a meal containing cabbage with bacon. The resident's dietary profile and meal ticket clearly indicated vegetarian preferences, yet the meal tray included an item inconsistent with these requirements. The resident identified the presence of bacon in her cabbage and declined to eat it, stating she does not eat bacon due to her vegetarian diet. Photographic evidence was obtained to document the meal tray contents. Interviews with staff revealed that the dietary and nursing teams were aware of the resident's vegetarian status, and the facility had policies in place requiring nursing staff to verify meal accuracy and dietary staff to accommodate resident preferences. Despite these procedures, the error occurred, and staff could not recall how the incorrect item was served. The resident reported dissatisfaction with the vegetarian options provided, and staff interviews confirmed the process for meal assembly and verification, but did not identify how the mistake was made.
Incomplete Documentation of Insulin Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident receiving insulin for type 2 diabetes mellitus with hyperglycemia. Specifically, review of the resident's physician order indicated that blood sugar checks and insulin administration were to be documented according to a sliding scale protocol. However, the Medication Administration Record (MAR) showed missing documentation for both blood sugar readings and insulin coverage on two separate occasions. Interviews with nursing staff revealed that while they recalled performing the required blood sugar checks and insulin administration, they could not explain why the documentation was left blank. The Director of Nursing confirmed that staff are expected to document medication administration accurately and as required. Facility policies on medication administration and charting require that all medications administered and services performed be documented in the resident's clinical record or MAR. Despite these policies, the required documentation was not completed for the resident on the specified dates, resulting in incomplete medical records. The deficiency was identified through observation, interview, and record review, confirming that the facility did not adhere to its own documentation standards for medication management.
Failure to Use PPE and Perform Proper Hand Hygiene During Resident Care and Meal Distribution
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) and perform proper hand hygiene in two separate instances. In the first instance, a Certified Nurse Assistant (CNA) entered the room of a resident who was on contact precautions without donning the required gown and gloves, despite clear signage and available PPE supplies at the room entrance. The CNA then exited the room with a breakfast tray, placing it in the food cart, and acknowledged during interview that proper PPE should have been worn. Facility policy required gloves and gowns to be worn upon entry into rooms under contact precautions, with hand hygiene performed before leaving the care environment. In the second instance, an LPN was observed distributing meals in the memory care unit dining room and directly handling residents' food items, such as spreading jelly on bread, without wearing gloves. The LPN performed hand hygiene between residents but did not use gloves while touching the food, contrary to facility policy and expectations. The Director of Nursing confirmed that gloves should be used when staff touch food items for residents. The LPN stated unfamiliarity with the unit and acknowledged the omission of glove use, despite having sanitized hands.
Failure to Follow Hypoglycemia Protocol and Physician Orders Results in Immediate Jeopardy
Penalty
Summary
A facility failed to provide treatment and care according to professional standards of practice for a resident experiencing a change in condition related to hypoglycemia. The resident, who had a history of Type 2 Diabetes Mellitus and was under orders for regular blood glucose monitoring, experienced a series of low blood sugar readings. At one point, an LPN administered glucose gel without a physician's order and did not notify the provider of the resident's low blood sugar value. Subsequent blood sugar checks revealed further declines, and the resident became less responsive. Despite a physician's order to administer Glucagon intramuscularly if blood sugar dropped below 60 and to send the resident to the emergency room if there was no positive response, the facility did not follow these orders. When the resident's blood sugar dropped to 50 and then to 32, Glucagon was not administered as directed, the provider was not notified, and the resident was not sent to the emergency room as required. Documentation of blood sugar checks and interventions was incomplete, and the facility's policies for change in condition and physician notification were not followed. The resident was eventually transported to the hospital by emergency medical services but did not survive. Interviews with staff and review of records confirmed that physician orders were not followed, documentation was lacking, and professional standards for the management of hypoglycemia were not met. The failure to implement appropriate interventions and notify the physician placed all residents at risk and resulted in a determination of Immediate Jeopardy.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH (return to hospital) as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA (Quality Assurance) meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON (Assistant Director of Nursing) when hypoglycemic interventions initiated.
Failure to Follow Hypoglycemia Protocol and Physician Orders Results in Immediate Jeopardy
Penalty
Summary
The facility failed to administer care in a manner that ensured effective and efficient use of resources to maintain the highest practical well-being of each resident, as evidenced by the handling of a resident experiencing hypoglycemia. The resident, who had a history of Type 2 Diabetes Mellitus and was under orders for regular blood glucose monitoring and emergency glucagon administration for low blood sugar, experienced a series of hypoglycemic episodes. On one occasion, the resident's blood sugar was found to be 72, and an LPN administered glucose gel without a physician's order and did not notify the provider. Subsequently, the resident became less responsive, and later, a critically low blood sugar of 42 was recorded. The on-call physician was contacted and ordered glucagon administration, monitoring, and transfer to the emergency room if there was no positive response. Despite these orders, when the resident's blood sugar dropped again to 50 and then to 32, glucagon was not administered as directed, the provider was not notified, and the resident was not sent to the emergency room as per the physician's instructions. Documentation was incomplete, and there was a lack of timely and appropriate follow-up on the resident's deteriorating condition. Interviews with staff and review of records revealed that the nurse did not document all blood sugar checks, did not follow the expected protocol for hypoglycemia management, and lacked documented competency training regarding glucagon administration. The DON and other clinical leaders were not promptly informed, and the incident was not identified as a reportable event or brought to the facility's QAPI process in a timely manner. The resident ultimately became unresponsive and was transported to the hospital, where they did not survive. The facility's failure to implement its policies and procedures for change in condition, notify the physician as required, and follow physician orders for hypoglycemia management resulted in a determination of Immediate Jeopardy. This deficiency placed all residents at risk who might experience a change in condition requiring prompt and appropriate intervention.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH (return to hospital) as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA (Quality Assurance) meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received one on one education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON (Assistant Director of Nursing) when hypoglycemic interventions initiated.
- VPCS (Vice President of Clinical Services) reeducated the Clinical Management Team including the Administrator and Director of Nursing on the components of job descriptions.
- The Administrator/designees and Director of Nursing Services designee will ensure that the safety and well-being as it related to blood glucose monitoring and treatment is maintained by the continued participation, evaluation, and intervention through Dashboard, Risk reports, RTH Resident records and hour report review during clinical standup and stand down meeting, and maintaining QA/PI (Quality Assurance/Performance Improvement) process.
Failure to Follow Physician Orders and QAPI Process in Hypoglycemia Event
Penalty
Summary
The facility failed to utilize its Quality Assessment and Performance Improvement (QAPI) process to investigate, identify, and implement an effective performance improvement plan regarding the management of a resident's change in condition and adherence to physician orders. Specifically, a resident with Type 2 Diabetes Mellitus and a history of blood sugar monitoring experienced multiple episodes of hypoglycemia. On one occasion, an LPN administered glucose gel without a physician's order and did not notify the provider when the resident's blood sugar was 72. Subsequently, the resident became less responsive, and further blood sugar checks revealed dangerously low values. Despite a physician's order to administer Glucagon intramuscularly and send the resident to the emergency room if there was no positive response, the facility staff did not follow these instructions. When the resident's blood sugar dropped below 60 for a second time and the resident was unresponsive, the provider was not notified, Glucagon was not administered as ordered, and the resident was not sent to the emergency room. The resident's condition continued to deteriorate, with a blood sugar value of 32, and only then was emergency medical services contacted. The resident was transported to a hospital and did not survive. Interviews and record reviews revealed that the facility's QAPI process did not identify this event as a reportable incident or an area in need of improvement. The DON and nurse managers reviewed the case but failed to recognize deficiencies in care, documentation, and adherence to professional standards. The facility's policies and procedures for change in condition, physician notification, and following physician orders were not implemented, leading to a determination of Immediate Jeopardy.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON when hypoglycemic interventions initiated.
- VPCS reeducated the Clinical Management Team including the Administrator and Director of Nursing on the components of job descriptions and 5 elements of QAPI, root cause analysis, QAPI at a glance, and QAPI self-assessment tool.
- The Administrator/designees and Director of Nursing Services designee will ensure that the safety and well-being as it related to blood glucose monitoring and treatment is maintained by the continued participation, evaluation, and intervention through Dashboard, Risk reports, RTH Resident records and hour report review during clinical standup and stand down meeting, and maintaining QA/PI process.
- An Ad Hoc QAPI meeting was convened to review the components of ongoing PIP and review the findings of F867 QAPI/QAA.
Incomplete and Inaccurate Medical Record Documentation for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident's medical records were complete and accurate, specifically for a resident with type 2 diabetes mellitus and a foot ulcer. Physician orders required blood glucose monitoring before meals and at bedtime, and the use of a glucagon emergency injection kit if blood sugar dropped below 60, with rechecks every two hours. On one occasion, the resident experienced low blood sugar, received oral glucose gel, and later glucagon was administered per on-call provider instructions. However, there was no documentation of a physician's order for the glucose gel, nor was there documentation that the physician was notified of the low blood sugar event and the administration of glucose gel. Additionally, blood sugar checks were not consistently documented, including post-administration values after glucagon was given. Interviews with the LPN involved revealed that blood sugar was checked more frequently than documented, and the Director of Nursing confirmed that documentation was incomplete, particularly regarding post-intervention blood sugar levels. Facility policies required that all medication administration, changes in condition, and interventions be documented in the clinical record, but these requirements were not met in this case. The lack of complete and accurate documentation constituted a failure to maintain medical records in accordance with accepted professional standards.
Failure to Use PPE for Resident on Contact Precautions
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) while providing direct care to a resident on transmission-based precautions. During an observation, it was noted that a sign on the door of the room shared by two residents indicated contact precautions, requiring staff to perform hand hygiene and wear gowns and gloves before entering and exiting the room. However, two certified nursing assistants (CNAs) were observed entering the room and providing care without wearing the required PPE. Staff A, a CNA, took vital signs of a resident with a diagnosis of MRSA without wearing a gown or gloves. Staff B, another CNA, entered the room, interacted with both residents, and handled linens without wearing a gown or gloves. Interviews with the CNAs revealed a lack of awareness regarding which resident was on contact precautions, despite the presence of a sign on the door. Both CNAs acknowledged that they should have worn the appropriate PPE. The Director of Nursing confirmed that staff should always wear PPE in rooms with contact precaution signs, not just during direct patient care. The facility's policy on transmission-based precautions was reviewed, which clearly outlined the requirement for wearing gloves and gowns when entering rooms with contact precautions.
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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