Harborview Sarasota
Inspection history, citations, penalties and survey trends for this long-term care facility in Sarasota, Florida.
- Location
- 4783 Fruitville Road, Sarasota, Florida 34232
- CMS Provider Number
- 105983
- Inspections on file
- 22
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harborview Sarasota during CMS and state inspections, most recent first.
A resident with dementia and a history of multiple falls did not consistently receive care planned fall prevention interventions, such as a low bed, perimeter mattress, and enabler bars, despite documentation indicating otherwise. The facility also failed to conduct and document thorough investigations after several unwitnessed falls, including one resulting in a femur fracture and hospitalization. Staff interviews revealed a lack of awareness and oversight regarding required interventions and incident follow-up.
The facility did not maintain an effective pest control program, resulting in ongoing cockroach and ant infestations in resident rooms, bathrooms, and common areas. Multiple residents and staff reported and observed live pests, pest droppings, and black bio growth in personal spaces and on belongings. Pest control services were inconsistent due to unprepared rooms and unresolved structural and sanitation issues, leading to persistent pest problems and resident distress.
A resident with multiple health conditions and cognitive impairment did not receive adequate assistance with personal hygiene and activities of daily living. The individual was observed unkempt, unshaven, with matted hair, soiled bedding, and poor oral hygiene. Documentation showed missed scheduled showers, and staff interviews confirmed that grooming was not consistently provided as required by facility policy.
A resident with acute respiratory failure and pulmonary fibrosis did not receive physician-ordered continuous oxygen therapy, as there was no documentation of administration over several days. Staff and DON interviews confirmed the lack of implementation and documentation of the order, and there was also no admission or transfer assessment or investigation into the resident's change in condition.
Surveyors found that the facility did not maintain required records for monthly and weekly maintenance and testing of its emergency generator, including battery testing, load testing, and visual inspections, as required by NFPA standards. The last documented load test was several months prior to the review, and the Maintenance Director confirmed the lack of documentation.
A deficiency was identified in a facility where residents experienced neglect and mental abuse by CNAs. A resident reported rough handling and verbal threats during care, while another resident corroborated the account, describing the CNA as intimidating. Two other residents raised concerns about a different CNA's aggressive behavior, leading to feelings of fear and discomfort. The facility's investigation resulted in the termination of both CNAs due to violations of resident rights and customer service standards.
A resident at moderate risk for pressure injuries did not receive necessary preventive interventions, leading to the development of a pressure injury. The care plan failed to address the risk, and there was no documentation of preventive measures. A darkened area was later identified on the resident's heel, but the prescribed treatment was not documented as applied. The facility was undergoing changes with new management and procedures.
A resident at moderate risk for pressure injuries developed a pressure injury due to the facility's failure to implement an effective care plan. The resident's care plan did not address their skin condition or risk for pressure injuries, and a treatment plan for a darkened area on the heel was not documented or applied. The facility was in the process of implementing new procedures for skin assessments, but these were not in place at the time of the incident.
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving CNAs who were verbally and physically rough with residents. A resident reported being handled roughly during a shower by a CNA, who also used inappropriate language. Another incident involved two residents who felt intimidated by a CNA's aggressive behavior. Despite reports and witness accounts, the facility's investigation was inconclusive, and the CNA's employment was terminated based on customer service concerns. The facility did not adequately communicate with residents about the outcomes, leaving them in fear.
Failure to Implement and Document Fall Prevention Interventions and Investigations
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls was adequately protected from accident hazards and that appropriate supervision and interventions were consistently implemented. Despite the resident's documented history of dementia, gait abnormalities, impulsivity, and multiple falls, the facility did not maintain required fall prevention interventions as outlined in the care plan. Observations revealed that the resident's bed was not in the lowest position, the perimeter mattress was not in place, and bilateral enabler bars were missing, even though nursing documentation indicated these interventions were present. The facility also failed to conduct and document thorough investigations following several unwitnessed falls, including a significant incident that resulted in a right femur fracture and subsequent hospitalization for surgical repair. Progress notes and care plan reviews did not include root cause analyses for the falls or specify whether all prescribed interventions were in place at the time of each incident. Additionally, there was no documentation provided for the investigation of the fall that led to the femur fracture, despite requests from the survey team and concerns raised by the resident's responsible party. Staff interviews confirmed a lack of awareness and oversight regarding the implementation of fall prevention measures. The DON was unaware that certain interventions, such as the perimeter mattress, were part of the resident's care plan, and acknowledged that documentation in the Medication Administration Record did not reflect the actual status of interventions. The Administrator also confirmed the absence of investigation documentation for the critical fall event and did not address the incident in a subsequent abuse/neglect investigation, citing a change in facility administration.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policies, resulting in ongoing infestations of cockroaches and ants throughout resident rooms, bathrooms, and common areas. Multiple residents reported seeing cockroaches in their bathrooms, bedrooms, dresser drawers, and even on their bodies and personal items. Observations confirmed the presence of live cockroaches and ants in various locations, including behind soap dispensers, in dresser drawers, and on floors and walls. Photographic evidence was obtained of live insects, pest droppings, and black bio growth in resident areas and on personal belongings. Staff interviews revealed that pest sightings were being logged, but the problem persisted and was not fully addressed. Several staff members, including LPNs and the Housekeeping Supervisor, acknowledged the ongoing issue with roaches and described their own actions to kill or report pests. The pest control company’s logs indicated that treatments were not consistently performed because rooms were not prepared for service, and the technician eventually stopped weekly visits due to unresolved structural and sanitation issues. Documentation showed gaps in pest control services and incomplete follow-through on pest control recommendations. Residents expressed embarrassment and distress over the pest infestations, with some avoiding showers or having family members assist in killing insects during visits. The pest control company’s records and statements from facility leadership confirmed that pest control visits were inconsistent and that recommendations for structural and sanitation improvements were not implemented in a timely manner. The deficiency was further evidenced by direct observations of live pests and pest droppings in resident living spaces and common areas, as well as by resident council minutes and pest sighting logs.
Failure to Provide Necessary Personal Hygiene and ADL Assistance
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who had diagnoses including a displaced intertrochanteric fracture of the right femur, type 2 diabetes mellitus, dementia, and anxiety, required partial to maximum assistance with oral hygiene and bathing according to the clinical record and care plan. Observations revealed the resident was unkempt, unshaven with a long beard and mustache, had matted and greasy hair, and was lying in bed with soiled sheets and a strong foul odor of urine in the room. The resident's teeth had black spots and a thick white coating, and his mouth was dry with foul breath. The resident reported not having been shaved or had a haircut in a long time and expressed a desire to be shaved. Review of CNA documentation showed missed scheduled showers on multiple dates, with no documentation that the resident received showers as planned. The facility's policy required staff to provide grooming and personal hygiene services for residents unable to perform these tasks. Interviews with staff confirmed that shaving typically occurred during showers or upon request, and that assistance was provided with oral care. However, the lack of documented and observed care indicated a failure to follow the care plan and facility policy, resulting in the resident not receiving adequate assistance with personal hygiene.
Failure to Provide Ordered Respiratory Care and Documentation
Penalty
Summary
A deficiency occurred when the facility failed to provide respiratory care as ordered for a resident with acute respiratory failure with hypoxia and idiopathic pulmonary fibrosis. The physician's order specified that oxygen should be administered continuously at 2 liters per minute via nasal cannula. However, review of the Medication Administration Record (MAR) for the relevant period showed no documentation that the oxygen was administered as ordered from 11/22/25 through 11/24/25. Nursing progress notes also did not specify whether the resident was receiving oxygen at the time of a noted change in condition. Interviews with staff and the Director of Nursing confirmed the lack of documentation and implementation of the oxygen order. The resident was described as cognitively intact and was able to answer questions appropriately earlier in the day. On the day of the incident, the resident became lethargic, and family members requested transfer to the hospital. The DON verified the absence of an admission assessment, a transfer out assessment, and any documented investigation into the resident's change in condition.
Failure to Maintain and Test Emergency Generator per NFPA Standards
Penalty
Summary
The facility failed to provide evidence of proper maintenance and testing of its 135 KW diesel-powered generator in accordance with National Fire Protection Association (NFPA) standards. During a record review with the Maintenance Director, surveyors found that the facility did not have documentation for monthly specific gravity or conductance testing of the generator's maintenance-free battery, weekly voltage testing of the battery, monthly load testing of the life safety generator, or weekly visual inspections of the generator. The last documented monthly load test was dated several months prior to the review. These deficiencies were confirmed during an interview with the Maintenance Director, who acknowledged the lack of required records. The absence of these maintenance and testing records indicates that the facility did not adhere to the required schedules and procedures outlined in NFPA 99, NFPA 110, and NFPA 101 for ensuring the reliability of the essential electrical system, specifically the emergency generator and its components.
Neglect and Mental Abuse in Resident Care
Penalty
Summary
The deficiency involves the failure of a facility to protect residents from neglect and mental abuse, as evidenced by the experiences of four residents. Resident #699 reported that a CNA was verbally abusive and rough during care, failing to follow proper hygiene procedures and threatening to leave the resident unattended. The resident expressed fear and anxiety due to the CNA's behavior and was not informed promptly about the CNA's termination, which prolonged the resident's distress. Resident #700 corroborated the account of Resident #699, describing the CNA as intimidating and rough during care. The resident witnessed the CNA's inappropriate handling of Resident #699 and reported the incident to the facility. Despite the facility's investigation, the CNA's behavior was deemed inconsistent with facility standards, leading to her termination. Additionally, Residents #800 and #850 raised concerns about another CNA, Staff B, who displayed aggressive behavior and was rough during care. Resident #850 reported being left uncovered and in a soiled state for an extended period, feeling demeaned and hurt by the CNA's actions. The facility's investigation into these allegations was inconclusive, but due to concerns about customer service, CNA Staff B's employment was terminated.
Plan Of Correction
Tag Cited: F-600 Free from and Neglect CFR(s): 483.12(a)(1) 1. Immediate action(s) taken for the resident(s) found to have been affected include: CNA Staff A and CNA Staff B were immediately removed from the schedule and terminated from employment and reported to board. Affected residents (R699, R700, R800, R850) received assessments from Social Services and were offered ongoing emotional support. The facility formally notified residents R699, R700, R800, and R850 (and/or their representatives) that CNA Staff A and B were no longer employed. 2. The Identification of other residents having the potential to be affected was accomplished by: Starting a facility-wide audit of grievance reports and residents with of 12 or higher was conducted by Social Services to identify any other concerns related to or neglect and was completed by . 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On Human Resources re-conducted Prevention Training and Customer Service education for all staff to be completed by . Any staff who are unable to meet the compliance date will be educated prior to their next working shift. All new hires must complete Prevention and Customer Service modules in Relias during orientation. The facility doesn't currently utilize agency staffing at this time. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will complete 10 resident interviews weekly for 2 weeks, and then 5 residents weekly for 4 weeks to monitor any concerns about staff behavior or . With any allegation of neglect a licensed psychologist/social Worker will conduct an initial interview and determine plan for resident(s) emotional or needs. Customer service satisfaction rounds will be completed 5x weekly by the Department Heads for a total of 80 residents by the end of the week and submitted to the Administrator and/or Designee for review by the end of each day 5 x weekly for 6 weeks. The Administrator will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25.
Failure to Prevent Pressure Injuries in Resident
Penalty
Summary
The facility failed to provide necessary interventions to prevent the development of avoidable pressure injuries for a resident identified as at risk. The resident, who was dependent for bed mobility, transfers, toileting, and bathing, was admitted without any pressure injuries and was initially assessed as not at risk. However, a subsequent assessment indicated a moderate risk for pressure injuries, yet the care plan did not address this risk. There was no documentation of preventive measures being implemented to decrease the risk of pressure injuries for the resident. A darkened area was later identified on the resident's left heel, and a treatment plan was developed, but there was no documentation that the prescribed skin preparation was ordered or applied. The resident was transferred to the hospital at the family's request, and the facility's investigation noted that a pressure injury developed during the resident's stay, which was documented and treated according to facility protocol. The facility was undergoing changes with a new company and new Director of Nursing, and they were in the process of implementing new procedures for skin assessments.
Plan Of Correction
Tag Cited: F686 Treatment/Svcs to Prevent/Heal CFR(s): 483.25(b)(1)(1)(ii) 1. Immediate action(s) taken for the resident(s) found to have been affected include: The facility failed to implement skin integrity interventions for Resident R799. Resident R799 was transferred to hospital and didn't return to the facility. 2. Identification of other residents having the potential to be affected was accomplished by: On the Director of Nursing, Assistant Director of Nursing, and Unit Manager conducted a 100% skin sweep audit for current residents to establish a baseline skin assessment by completed by. On a 100% audit for Braden Assessments was completed for current residents to address moderate to high-risk Braden Scores. This audit was conducted by the Director of Nursing. Assistant Director of Nursing, and Unit Manager completed by. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On the Director of Nursing conducted an audit of all current residents to review and identify those with and/or Braden scores of moderate to high risk by and completed by. Any resident with or Braden Scores of moderate to high had care plans initiated or revised care plan focusing on skin integrity and prevention needs. All new admissions are ordered skin prep to heels for the first 14 days of admission and then reassessed by nurse for further skin integrity needs. A designated treatment nurse was hired on. Starting, the Assistance Director of Nursing began re-education for Licensed Nursing staff (RN and LPN) on Care Best Practices including timely documentation. All licensed nursing staff will be educated by anyone not in compliance with this date will be educated prior to the next working shift. All newly hired licensed nursing staff (RN and LPN) will complete this education during orientation. The facility is not currently utilizing agency staffing. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: Starting the Care Nurse or designee will audit new admissions five times a week for 2 weeks, and 5 new admission records weekly for 4 weeks, to ensure residents with high-risk Braden Scores have appropriate interventions in place for skin integrity. The Care Nurse will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25
Failure to Prevent Pressure Injury in Resident
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of avoidable pressure injuries for a resident identified as at risk. The facility's policy on 'Pressure Injury Prevention and Management' was not effectively implemented, as evidenced by the lack of a care plan addressing the resident's skin condition and potential risk for pressure injuries. The resident, who was dependent for bed mobility, transfers, toileting, and bathing, was initially assessed as not at risk for pressure injuries upon admission. However, a subsequent assessment indicated a moderate risk, which was not reflected in the care plan. A darkened area on the resident's left heel was identified, but the treatment plan, which included skin preparation, was not documented as ordered or applied. The resident was transferred to the hospital at the family's request and did not return to the facility. Interviews with the facility's new administration and nursing staff revealed that they were in the process of implementing new procedures for skin assessments and care, but these were not in place at the time of the incident. The facility's investigation confirmed the development of a pressure injury during the resident's stay, which was documented and treated according to protocol.
Plan Of Correction
Tag Cited: F686 Treatment/Svcs to Prevent/Heal CFR(s): 483.25(b)(1)(i)(ii) 1. Immediate action(s) taken for the resident(s) found to have been affected include: The facility failed to implement skin integrity interventions for Resident R799. Resident R799 was transferred to hospital and didn't return to the facility. 2. Identification of other residents having the potential to be affected was accomplished by: On the Director of Nursing, Assistant Director of Nursing, and Unit Manager conducted a 100% skin sweep audit for current residents to establish a baseline skin assessment by completed by. On a 100% audit for Braden Assessments was completed for current residents to address moderate to high-risk Braden Scores. This audit was conducted by the Director of Nursing, Assistant Director of Nursing, and Unit Manager completed by. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On the Director of Nursing conducted an audit of all current residents to review and identify those with and/or Braden scores of moderate to high risk by and completed by. Any resident with or Braden Scores of moderate to high had care plans initiated or revised care plan focusing on skin integrity and prevention needs. All new admissions are ordered skin prep to heels for the first 14 days of admission and then reassessed by nurse for further skin integrity needs. A designated treatment nurse was hired on. Starting the Assistance Director of Nursing began re-education for Licensed Nursing staff (RN and LPN) on Care Best Practices including timely documentation. All licensed nursing staff will be educated by, anyone not in compliance with this date will be educated prior to the next working shift. All newly hired licensed nursing staff (RN and LPN) will complete this education during orientation. The facility is not currently utilizing agency staffing. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: Starting the Care Nurse or designee will audit new admissions five times a week for 2 weeks, and 5 new admission records weekly for 4 weeks, to ensure residents with high-risk Braden Scores have appropriate interventions in place for skin integrity. The Care Nurse will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents' rights to be free from abuse and neglect, as evidenced by multiple incidents involving inappropriate and rough handling by certified nursing assistants (CNAs). Resident #699 reported that CNA Staff A was verbally abusive and physically rough during a shower, failing to follow proper hygiene procedures and leaving the resident feeling afraid and intimidated. The resident was not informed of the CNA's termination, leaving her in fear of potential retaliation. Resident #700 corroborated the account, describing the CNA's aggressive demeanor and improper care practices. In another incident, Residents #800 and #850 raised concerns about CNA Staff B's aggressive behavior. Resident #850 reported feeling intimidated and uncomfortable due to the CNA's rough handling and verbal aggression. Central Supply Staff D witnessed the CNA's inappropriate behavior and reported it to the nurse on duty. Despite these reports, the facility's investigation was inconclusive, and the CNA's employment was terminated based on customer service concerns rather than confirmed abuse. The facility's response to these allegations was inadequate, as there was no documentation of increased monitoring or protective measures for the affected residents. The Administrator acknowledged the need for improved customer service and staff education but did not provide evidence of effective measures to prevent future incidents. The lack of communication with residents about the outcomes of investigations contributed to their ongoing fear and discomfort.
Plan Of Correction
Tag Cited: F-600 Free from and Neglect CFR(s): 483.12(a)(1) 1. Immediate action(s) taken for the resident(s) found to have been affected include: CNA Staff A and CNA Staff B were immediately removed from the schedule and terminated from employment and reported to board. Affected residents (R899, R700, R800, R850) received assessments from Social Services and were offered ongoing emotional support. The facility formally notified residents R699, R700, R800, and R850 (and/or their representatives) that CNA Staff A and B were no longer employed. 2. The Identification of other residents having the potential to be affected was accomplished by: Starting a facility-wide audit of grievance reports and residents with of 12 or higher was conducted by Social Services to identify any other concerns related to or neglect and was completed by. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On Human Resources re-conducted Prevention Training and Customer Service education for all staff to be completed. by Any staff who are unable to meet the compliance date will be educated prior to their next working shift. All new hires must complete Prevention and Customer Service modules in Rellas during orientation. The facility doesn't currently utilize agency staffing at this time. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will complete 10 resident interviews weekly for 2 weeks, and then 5 residents weekly for 4 weeks to monitor any concerns about staff behavior or. With any allegation of or neglect a licensed psychologist/social Worker will conduct an initial interview and determine plan for resident(s) emotional or needs. Customer service satisfaction rounds will be completed 5x weekly by the Department Heads for a total of 80 residents by the end of the week and submitted to the Administrator and/or Designee for review by the end of each day 5 x weekly for 6 weeks. The Administrator will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25.
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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