Haines City Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Haines City, Florida.
- Location
- 409 S 10th St, Haines City, Florida 33844
- CMS Provider Number
- 105442
- Inspections on file
- 20
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Haines City Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with CVA, diabetes, CKD, hypertension, and Alzheimer’s disease returned from an orthopedic procedure with new post-surgical orders for Tramadol and Cephalexin 500 mg QID for 10 days. An LPN documented the antibiotic order after a call from the orthopedic office but did not ensure timely entry of the order into the physician orders, and the medication was not started until the following day with only evening doses given. Additional doses were held while staff awaited MD approval due to a documented penicillin allergy, resulting in multiple missed or delayed Cephalexin doses. The resident’s care plan called for medications to be administered as ordered, and facility policies required prompt transcription and administration of medications in accordance with prescribing orders and time limits.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in activities, hospice care, and fall prevention. Residents were not adequately engaged in activities, and there was a lack of documentation for hospice services and fall prevention devices. Staff interviews revealed communication and coordination issues, resulting in unmet resident needs.
The facility's QAPI failed to address deficiencies in maintaining a clean environment, timely insulin administration, and effective infection control. Observations revealed unclean conditions in a shower room, delayed blood glucose checks and insulin administration for two residents, and improper PPE use by staff. The DON confirmed the need for timely insulin administration and proper PPE use.
The facility failed to maintain a clean and organized environment in the B Hall community shower room, which was cluttered and soiled with various substances. Observations revealed issues such as a dirty shower bed, soiled equipment, and ripped curtains. Staff interviews indicated a lack of awareness and responsibility for the room's condition, with housekeeping and CNAs not adequately addressing the cleanliness. The NHA was unaware of the issues, and cleaning policies lacked specific guidance for community shower rooms.
A resident with severe cognitive impairment and requiring maximal assistance with ADLs did not receive adequate fingernail care over several days. Despite the resident's requests, staff failed to address her needs, leaving her with elongated, cracked, and debris-filled nails. The facility's policy emphasized the importance of maintaining personal hygiene, but staff did not adhere to these guidelines.
A resident's room was found with air freshener sprays, which are prohibited in the facility. The resident, with moderate cognitive impairment, had the sprays accessible in her room, which was open to other residents. The facility lacked a specific policy on aerosol sprays, and the Director of Nurses was unaware of the situation, indicating a need for staff training.
A facility failed to ensure call lights were within reach for three residents, compromising their ability to summon assistance. One resident, with cognitive deficits, often found her call light out of reach, leading her to yell for help. Another resident's call light was inaccessible, placed on the roommate's bed, and a third resident's call light was hanging through the bed rail, out of reach. Staff confirmed these issues, and the facility's policy requiring call lights to be within reach was not adhered to.
A resident was not offered or assisted with activities that met his interests, despite being observed in bed and not participating. The facility lacked documentation and awareness of the resident's preferences, and the Activities Director could not provide evidence of compliance with regulations.
The facility failed to administer medications on time for two residents and did not properly monitor or treat wounds for another resident. A resident with heart conditions received her medication late due to a nurse's oversight, while another resident with diabetes had insulin administered late on multiple occasions. Additionally, a resident with skin issues was not adequately monitored, leading to the development of pressure ulcers. These deficiencies indicate lapses in adherence to medication administration and skin care policies.
A resident with severe cognitive impairment was administered Seroquel at incorrect doses due to a lack of clarification of the physician's order. The resident was prescribed Seroquel for agitation and anxiety, but discrepancies in the Medication Administration Record showed incorrect dosing. The Director of Nursing did not clarify the order with the attending physician, who later confirmed the error.
The facility failed to maintain a medication error rate below 5%, resulting in an 8.82% error rate. An RN incorrectly documented the administration of a refused medication and used incorrect eye drops for a resident. An LPN delayed administering insulin to another resident due to unavailability, administering it after the resident had eaten. The DON was informed, revealing procedural lapses in medication availability notification.
A resident in a LTC facility experienced a deficiency in care due to the facility's failure to coordinate dental services. The resident, who had missing teeth and needed dentures, was not assisted in obtaining them, leading to difficulty eating. Despite having a care plan for dental issues, there was a lack of communication and follow-up among staff, resulting in the resident's continued struggle with eating.
A resident with Alzheimer's, dementia, malnutrition, and dysphagia received a lunch meal that was not presented attractively. The meal, meant to be pureed, was observed as a soupy consistency with foods running together. The Dietary Manager confirmed the presentation was unacceptable.
The facility failed to implement an effective infection control program, with deficiencies in PPE use, staff fingernail hygiene, and oral care equipment storage. A resident on contact precautions did not have PPE available outside their room, and staff entered without donning PPE. Several staff members had artificial or long fingernails, against facility policy and CDC guidelines. Additionally, a resident's oral hygiene items were improperly stored, despite their need for assistance due to cognitive impairments.
Delayed Initiation and Missed Doses of Post-Surgical Antibiotic
Penalty
Summary
The deficiency involves the facility’s failure to timely initiate and consistently administer a prescribed antibiotic for one resident following an orthopedic surgical procedure. The resident, who had diagnoses including CVA with hemiplegia, diabetes, stage III chronic kidney disease, hypertension, and Alzheimer’s disease, required substantial to maximal assistance with ADLs and was rarely or never understood per the MDS. On 12/12/25, an orthopedic office called with new post-surgical treatment orders, including Tramadol 50 mg every 8 hours as needed and Cephalexin 500 mg four times daily for 10 days. A progress note documented these new orders and indicated the facility was awaiting the resident’s return. However, the Cephalexin order was not entered into the physician orders on 12/12/25, and the medication was not started until 12/13/25 with only the 5 p.m. and 9 p.m. doses administered that day, resulting in two missed doses on 12/13/25. Further record review showed that on 12/14/25, the 9 a.m. Cephalexin dose was held while awaiting MD approval due to the resident’s penicillin allergy, and the resident did not receive that 9 a.m. dose, resulting in a total of five missed or delayed doses across the period reviewed. Progress notes showed Cephalexin 500 mg QID post-surgical for 10 days was entered on 12/13/25 at 2:29 p.m., and on 12/14/25 at 8:16 a.m. staff documented they were awaiting MD approval to administer due to allergies. The resident’s care plan identified impaired cognitive function related to CVA with an intervention to administer medications as ordered. During interview, the LPN/Unit Manager stated that the resident usually went with family for procedures, that staff had been unable to locate any paperwork from the orthopedic doctor, and acknowledged that staff had depended on the family for orders instead of obtaining them directly from the physician. The LPN/Unit Manager also stated she wrote the note about the antibiotic order on 12/12/25, gave the orders to the floor nurse, and acknowledged that the orders may not have been entered until the next day and that she should have entered them herself, verifying there was a delay in doses. Facility policies required that medications be administered as soon as practicable upon written order, that orders be recorded and transcribed into the electronic chart, and that medications be administered in accordance with prescribing orders and time limits.
Deficiencies in Care Plan Implementation and Documentation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their needs related to activities, hospice care, and fall prevention. Observations and interviews revealed that residents were not adequately engaged in activities, with some residents not being informed of daily activities or having access to activity calendars. For instance, one resident with impaired vision and a language barrier was not provided with appropriate auditory or visual stimulation, despite having preferences for music and social activities. Another resident, who was rarely understood due to cognitive impairment, was not provided with a program of activities that accommodated their communication abilities. Additionally, the facility did not have a care plan in place for a resident receiving hospice services, and there was a lack of documentation regarding the hospice care being provided. Interviews with staff indicated confusion about the hospice services schedule and the integration of hospice care into the resident's care plan. Furthermore, the facility failed to document the use of fall prevention devices for a resident with a history of falls. The resident was observed with large fall mats and side rails, but these interventions were not included in the care plan or physician's orders, indicating a lack of proper documentation and oversight. The deficiencies were further highlighted by the lack of communication and coordination among staff members. Interviews revealed that activity staff did not document residents' refusals to participate in activities, and there was a lack of clarity regarding the roles and responsibilities of staff in implementing care plans. The facility's failure to ensure that care plans were comprehensive and accurately documented resulted in unmet needs for several residents, compromising their quality of care and safety.
Deficiencies in Cleanliness, Insulin Administration, and Infection Control
Penalty
Summary
The facility's Quality Assurance Performance Improvement Program (QAPI) failed to implement an effective plan of action to correct deficiencies identified during a recertification and complaint survey. One of the deficiencies involved the failure to maintain a safe, clean, and homelike environment in the B Hall community shower room. Observations revealed that the shower bed and chair were unclean, with black spots, clumps of hair, and various stains, which the Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged. Another deficiency was the failure to ensure timely blood glucose checks and insulin administration for two residents. One resident's blood glucose was checked after meals, contrary to the requirement to check before meals, leading to delayed insulin administration. The resident expressed concerns about the insulin dosage, resulting in a call to the doctor for a revised order. The Medication Admin Audit Report showed multiple instances of late insulin administration for both residents. The DON confirmed that blood glucose levels should be checked before meals and insulin administered at mealtime. The facility also failed to implement an effective Infection Control program. Staff members did not use personal protective equipment (PPE) appropriately for residents on transmission-based precautions. Observations showed staff entering rooms without the required PPE and failing to perform hand hygiene. The DON and Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed the expectations for PPE use and hand hygiene, noting that these precautions apply to all individuals entering the rooms, including visitors and contractors.
Facility Fails to Maintain Cleanliness in Community Shower Room
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in the B Hall community shower room, as observed on two consecutive days. The room was cluttered with various items, including wheelchair parts, a Hoyer lift, a bedside commode, and a walker, making it difficult to access the sinks. The shower bed and foam mat were soiled with dried brown substances, and the room contained soiled gloves, a dirty band-aid, hair, and trash. The grout in the shower was dirty, and the shower curtains were ripped and stained. The Hoyer lift and its pad were also soiled with a brown substance. Interviews with staff revealed a lack of awareness and responsibility for the condition of the shower room. The Director of Environmental Services acknowledged the room's unclean state and stated that housekeeping was responsible for cleaning the shower rooms daily. However, the cleaning policies did not provide specific guidance for community shower rooms. A CNA mentioned that CNAs were responsible for cleaning up after resident showers but noted that they were often too busy to do so thoroughly. The Nursing Home Administrator was unaware of the issues and had not recently inspected the shower rooms.
Failure to Provide Adequate Nail Care to Resident
Penalty
Summary
The facility failed to provide adequate personal hygiene care, specifically fingernail care, to a resident who was unable to perform these activities independently. Over a period of four days, the resident's fingernails were observed to be elongated, cracked, chipped, and filled with dark debris. Despite the resident's requests for nail care, the staff did not address these needs, leaving the resident with unkempt nails that she found uncomfortable and undesirable. The resident, who had severe cognitive impairment and required maximal assistance with activities of daily living (ADLs), had expressed her need for nail care to several CNAs, but her requests were not fulfilled. The assigned CNA was unaware of the condition of the resident's nails and admitted that nail care should have been part of the daily personal hygiene routine. The Unit Manager and Director of Nursing were also unaware of the resident's need for nail care until it was brought to their attention during the survey. The facility's policy and procedure for ADL care and services emphasized the importance of providing necessary care to maintain residents' personal hygiene, including nail care. However, the staff failed to adhere to these guidelines, resulting in the resident's unmet hygiene needs. The resident's care plan and physician's orders did not indicate any refusal of personal hygiene care, highlighting a lapse in the facility's execution of its care responsibilities.
Failure to Maintain Hazard-Free Environment Due to Air Freshener Sprays
Penalty
Summary
The facility failed to ensure a hazard-free environment in a resident's room, as observed during a survey. Air freshener sprays were found in the room of a resident with moderate cognitive impairment, who had been admitted with conditions including dysarthria following cerebral infractions, type 2 diabetes mellitus, and unspecified asthma. The resident's room was accessible to other residents, and the air fresheners were placed on the dresser and bathroom rail, posing a potential hazard. Interviews with the Nursing Home Administrator and the Director of Nurses revealed that the facility's policy prohibits aerosol sprays, but there was no specific policy related to the prohibited use of such sprays. The Director of Nurses was unaware of the presence of the air fresheners and acknowledged the need for staff training regarding the facility's process. The resident had been informed that the sprays were not allowed, but this was only communicated after the surveyor's observation.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call light cords and buttons were placed within reach for three residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #61 was observed multiple times with her call light button out of reach, either hanging off the back of the mattress or lying on the floor. Despite her cognitive deficits, she was able to communicate that she often could not find the call light and had to yell for assistance, which was not always effective. Staff interviews confirmed that the call light was not consistently placed within her reach, and there was no documentation of her throwing or displacing the call light. Resident #34 was observed in situations where the call light was not accessible, such as when it was placed on the other side of the bed or on the roommate's bed. The Director of Nursing confirmed that the call light was not within reach and should have been ensured by the staff assisting the resident. The resident's care plan indicated a risk for falls and the need for staff assistance, which was not adequately supported by the placement of the call light. Resident #24 was found with the call light hanging through the bed rail and not within reach. The Director of Nursing acknowledged that the resident was unable to use the call light due to its placement. The care plan for Resident #24 also highlighted a risk for falls and the necessity for staff assistance, which was compromised by the improper placement of the call light. The facility's policy required call lights to be within reach and functional, but this standard was not met for these residents.
Failure to Offer and Assist Resident with Activities
Penalty
Summary
The facility failed to ensure that a resident was offered and assisted with scheduled activities that met his interests. Over several days, the resident was observed lying in bed, not dressed, and not participating in any activities. Despite the presence of an activities calendar, there was no documentation that the resident was offered or assisted with any activities, nor was there evidence of refusal. The resident's medical records indicated a cognitive impairment, making him non-interviewable, and he was receiving palliative care. His care plan included interventions to encourage participation in activities, but these were not implemented. The Activities Director confirmed the resident's interest in music, television, and small group outings but could not provide documentation of these activities being offered or conducted. Interviews with CNAs revealed a lack of awareness of the resident's interests and activities preferences. The facility lacked a specific policy for resident activities, and the Activities Director's documentation was insufficient to demonstrate compliance with state and federal regulations. The deficiency was identified due to the facility's failure to provide appropriate activities and documentation for the resident.
Medication and Wound Care Deficiencies
Penalty
Summary
The facility failed to ensure timely administration of medications for two residents and proper monitoring and treatment of wounds for another resident. One resident, admitted with chronic heart conditions, did not receive her scheduled dose of Enoxaparin Sodium on time due to a nurse's inability to locate the medication in the cart. The medication was eventually found and administered late, but there was no documentation of the late administration or communication with the physician in the resident's record. Another resident with diabetes received insulin injections late on multiple occasions, with 20 out of 24 doses administered beyond the scheduled time. The staff, including the Director of Nursing, were unaware of these delays, and no investigation results were provided by the time of the exit conference. A third resident, admitted with a fracture and other conditions, had existing and developing skin issues that were not properly monitored or documented. The resident had a deep tissue injury on the heel and a surgical incision that were not consistently assessed for signs of infection or deterioration. The facility's records did not show timely notification to the physician or representative about the resident's skin conditions, and there was a lack of documentation regarding the monitoring of these issues. The resident eventually developed unstageable pressure ulcers on both heels, which were not addressed until a wound doctor evaluated them days later. The facility's policies on medication administration and skin impairment prevention were not followed, leading to these deficiencies. Medications were not administered within the prescribed time frame, and there was a lack of documentation and communication regarding late administrations. Similarly, the facility did not adhere to its policy on skin assessment and monitoring, resulting in inadequate care for the resident with pressure ulcers. These failures highlight significant lapses in the facility's adherence to its own standards and guidelines for resident care.
Medication Administration Error for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that medications were administered at the correct dose for a resident with severe cognitive impairment. The resident was admitted with diagnoses including anxiety disorder and depression and was prescribed Seroquel for agitation and anxiety. The orders included Seroquel 25 mg three times at bedtime and 25 mg twice daily. However, the Medication Administration Record showed discrepancies in the administration, with only one tablet given at certain times instead of the prescribed three tablets at bedtime. The Director of Nursing was unaware of the correct order and had not clarified it with the attending physician, who later confirmed that the 75 mg dose was intended for a short period and not as an ongoing order. The physician acknowledged that the intervention was incorrect and should have been clarified. The facility was unable to provide a specific policy for unnecessary medication, only a policy for gradual dose reduction.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 8.82%. During medication administration, Staff P, an RN, incorrectly documented the administration of Megestrol AC Suspension to Resident #13, despite the resident's refusal. Additionally, the RN administered Artificial Tears lubricant eye drops that did not contain the prescribed ingredient, Carboxymethylcellulose Sodium, and applied the drops to both eyes instead of just the left eye as ordered. These actions contributed to the medication errors observed for Resident #13. In another instance, Staff Q, an LPN, failed to administer Insulin Lispro to Resident #11 at the scheduled time. The insulin was not available in the medication cart, leading to a delay in administration. The insulin was eventually administered approximately 30 minutes after the resident had eaten and nearly two hours after the scheduled time. The Director of Nursing was informed of these errors, and it was noted that the insulin was available in another refrigerator, but the procedure to notify the physician and family when medication is unavailable was not followed. These events highlight the facility's failure to adhere to medication administration policies.
Failure to Coordinate Dental Services for Resident
Penalty
Summary
The facility failed to coordinate dental services for a resident, leading to a deficiency in care. The resident expressed concerns about missing teeth and the need for dentures to chew food properly. Despite the resident's intact cognition, as indicated by a BIMS score of 13, she was not assisted with obtaining dental services, and her dentures were missing. Observations showed the resident struggling to eat due to the lack of dentures, and staff were unaware of the resident's dental needs. The care plan for the resident indicated a need for dental care coordination, but there was a lack of communication and follow-up among staff. The care plan coordinator admitted that the resident's care plan was not updated to reflect the missing dentures, and the social service director was unaware of the impressions taken for new dentures. The resident's care plan had interventions for dental care, but these were not effectively implemented, leading to the resident's continued difficulty in eating. Interviews with staff revealed a breakdown in communication and procedure. The CNA mistakenly believed the resident had her dentures, and the Director of Nurses stated that aides should report issues with dentures to the nurse, which did not occur. The facility's policy on dental consults was not followed, as the resident's dental needs were not addressed in a timely manner, resulting in the deficiency.
Inadequate Meal Presentation for Resident with Special Dietary Needs
Penalty
Summary
The facility failed to ensure that a resident's meal was presented in an attractive and appealing manner. Resident #816, who has diagnoses including Unspecified Alzheimer's disease, Unspecified Dementia, Unspecified Protein-Calorie Malnutrition, and Dysphagia Oropharyngeal Phase, was observed during a lunch meal. The resident's diet order was for Pureed Texture Thin Consistency. During the observation, the resident was in bed, and a CNA placed the lunch meal on the overbed table, removed the lid, and exited the room. The meal consisted of a dinner-sized plate filled with a soupy consistency of pureed foods that were running together, which was documented with photographic evidence. The Dietary Manager, upon reviewing the photograph, acknowledged that the presentation was unacceptable and expressed surprise at how the meal was allowed to leave the kitchen in that condition.
Infection Control Deficiencies in PPE Use, Staff Hygiene, and Oral Care
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by several deficiencies observed during the survey. Firstly, there was a lack of Personal Protective Equipment (PPE) available outside the room of a resident on contact precautions for a urinary tract infection caused by E. coli. Staff members entered the resident's room without donning PPE, despite a contact precaution sign being posted. The Infection Preventionist confirmed that PPE should have been available outside the room and that staff were required to wear PPE when entering the room, contradicting the observed practice. Additionally, the facility did not ensure that staff maintained appropriate fingernail hygiene, which is crucial for infection control. Several staff members, including a CNA, an LPN, and the Director of Nursing, were observed with artificial or long fingernails, contrary to the facility's policy and CDC guidelines. The staff handbook specified that fingernails should not interfere with care and should be no longer than 1/4 inch, with no artificial nails allowed. The DON acknowledged that the current practice did not align with the handbook's requirements. Furthermore, the facility failed to properly store personal hygiene equipment for a resident requiring assistance with oral care. The resident's bathroom contained uncovered toothbrushes and multiple tubes of toothpaste, which were not stored hygienically. The resident, who wore dentures, reported that staff did not clean them. The LPN/Unit Manager confirmed that the storage of oral hygiene items was inappropriate. The resident's care plan indicated a need for assistance with oral hygiene due to cognitive impairments, yet the facility did not ensure proper storage and handling of oral care items.
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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