Jupiter Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jupiter, Florida.
- Location
- 17781 Thelma Ave, Jupiter, Florida 33458
- CMS Provider Number
- 105555
- Inspections on file
- 27
- Latest survey
- July 14, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Jupiter Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food handling and sanitation, including improper storage of raw eggs above pasteurized eggs, failure to store sanitized utensils correctly, use of chipped plates, and staff not performing required hand hygiene before donning gloves or after leaving food preparation areas. Additionally, a knife used for food prep was not properly cleaned and sanitized before being stored.
Surveyors found that the facility failed to provide adequate housekeeping and linen services, resulting in unclean dining and resident areas, persistent odors, and a lack of incontinence pads and clean linens. Staff and residents reported insufficient cleaning, especially on weekends, and observations confirmed soiled and threadbare linens, debris, and foul odors in multiple areas. Facility leadership acknowledged the deficiencies during the survey.
A resident with mild cognitive impairment reported missing blankets to multiple staff members over nearly two weeks without timely response or resolution. Despite facility policy requiring prompt grievance handling, staff failed to document or address the complaint until the issue was escalated, and the grievance form remained incomplete.
Surveyors identified that two residents received inaccurate MDS assessments: one resident's assessment incorrectly documented a contraindication for a Gradual Dose Reduction of an antipsychotic, despite no supporting evidence in the record, and another resident's assessment listed a weight that did not match the most recent entry in the electronic medical record. The MDS Coordinator and RD confirmed these discrepancies during interviews.
Surveyors identified that two residents did not have care plans addressing their specific clinical needs: one with PTSD and severe cognitive impairment lacked a care plan for PTSD, and another with diabetes and an insulin order had no care plan for diabetes management or insulin use. Staff interviews revealed gaps in awareness and understanding of these conditions and their management.
The facility did not update care plans for two residents after changes in their diet and medication orders. One resident's care plan did not match the physician's prescribed diet, and another resident's care plan listed anti-anxiety medication use despite no current order for the medication.
A resident with severe cognitive impairment developed a skin rash and received a one-time dose of Permethrin cream as ordered by the NP, with a plan for reassessment. The resident continued to experience itching and rash in multiple areas, but no further treatment or timely follow-up was provided, and staff were unaware of additional interventions or dermatology consultations.
A resident with severe cognitive impairment developed a right heel pressure ulcer, and staff failed to follow physician orders for wound care. Observations showed the foam dressing was not changed as ordered, was partially detached and exposing the wound, and had not been replaced for several days despite documentation indicating otherwise. The resident experienced discomfort, and the dressing was found to have foul odor and drainage before being changed by an LPN.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility did not provide fortified foods or prescribed meals to three residents with nutritional concerns, including those who were underweight or had experienced weight loss. Despite dietary orders and care plans specifying the need for fortified foods at each meal, observations and interviews confirmed that these items were not consistently provided. One resident also reported not receiving the correct meal as ordered, and staff acknowledged the discrepancies.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
A resident with multiple psychiatric diagnoses was prescribed Divalproex Sodium, and a physician ordered a valproic acid level to be measured. The clinical record lacked documentation of the test result, and the DON confirmed the absence of the result after reviewing records and contacting the lab.
The facility did not consistently follow infection control protocols, including TBP and EBP, for three residents. One resident on contact isolation for possible C. diff was repeatedly seen outside their room, another resident on EBP for dialysis and a central line lacked proper signage after a room change, and a third resident with an MDRO and wound received personal care from a CNA who did not wear a gown as required. Staff interviews revealed gaps in knowledge and adherence to PPE protocols.
Surveyors observed live roaches in multiple kitchen and food service areas, including on a table near the conveyor toaster and behind a cart with trays and single service items. Numerous roaches in all stages of life were present, and attempts to contact the pest control company went unanswered.
The nursing staff failed to follow prescribed medication parameters for two residents. One resident with diabetes received insulin despite blood sugar levels below the threshold, while another with hypertension was given medication despite low blood pressure readings. The DON confirmed these discrepancies.
The facility failed to coordinate medication administration with dialysis services for two residents, resulting in medication omissions and incomplete dialysis communication records. One resident did not receive several prescribed medications due to being in dialysis, and the facility did not document pre and post-dialysis assessments. Another resident's blood pressure medications were held on dialysis days without provider orders, as confirmed by the Risk Manager. These deficiencies highlight a lack of coordination and documentation in ensuring appropriate care during dialysis.
A facility failed to ensure nurses followed physician's orders for medication administration. A resident received Midodrine HCl despite having a systolic blood pressure above the prescribed threshold, and insulin was administered when blood sugar levels were below the specified threshold. The Risk Manager confirmed these findings, indicating a lack of adherence to medication administration policies.
Deficient Food Handling and Sanitation Practices Identified
Penalty
Summary
The facility failed to ensure that food was prepared, stored, and served in a sanitary manner according to professional standards. During an initial kitchen tour, raw shell eggs were found stored directly above liquid pasteurized eggs in the walk-in cooler, creating a risk of cross-contamination. Additionally, cleaned and sanitized utensils were not stored inverted as required. These issues were acknowledged by the Certified Dietary Manager (CDM) at the time of observation. Further observations revealed that staff did not consistently perform proper hand hygiene before donning gloves, as required by facility policy. One cook was observed taking gloves without washing hands before returning to food service, and a dietary aide also failed to perform hand hygiene after leaving and re-entering the food preparation area before handling gloves and parchment paper. The kitchen also contained several chipped plates that could potentially cause skin tears, and a knife used for food preparation was only rinsed, not properly cleaned and sanitized, before being placed back on a magnetic strip. These deficiencies were acknowledged by the CDM and the staff involved.
Failure to Maintain Clean, Sanitary, and Homelike Environment Due to Housekeeping and Linen Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's maintenance, housekeeping, and linen services, resulting in an environment that was not clean, sanitary, or homelike. In the main dining room, a plastic table with accumulated food residue and debris was found, and trash containers were not emptied in a timely manner, leading to foul odors. Tablecloths on several tables were stained with food residue. The Food Services Director and Certified Dietary Manager confirmed these issues, noting that housekeeping was responsible for trash removal and kitchen staff for changing linens. In resident rooms, surveyors found soiled gowns left in showers, debris on floors, and strong urine odors, particularly in a shared room with four beds. Two residents in this room were totally dependent on staff for care, and one was observed lying on a mattress with a large wet spot and a persistent urine odor. Staff reported a lack of incontinence pads, resulting in urine soaking through sheets and into mattresses. Threadbare sheets were also observed in use. Laundry carts on all units lacked incontinence pads, and only a few were found in the laundry area. The Housekeeping Director acknowledged that pads should have been available but cited being pulled in different directions as a reason for the shortage. Interviews with residents and staff revealed concerns about reduced housekeeping staff on weekends, leading to delays and lower cleaning standards. The Housekeeping and Maintenance Directors were unsure about the replacement of odorous mattresses and agreed with the surveyors' findings upon inspection. The Director of Nursing stated that cloth incontinence pads were intended for all beds, but they were not consistently available. Photographic evidence was obtained to document the use of threadbare linens and the lack of incontinence pads.
Failure to Timely Address Resident Grievance Regarding Missing Personal Items
Penalty
Summary
Staff failed to respond in a timely manner to a resident's grievance regarding missing blankets, despite the resident voicing her concerns to multiple staff members over the course of nearly two weeks. The resident, who had mild cognitive impairment as indicated by a BIMS score of 11, reported the missing blankets to several staff, including at the nurses' station, but no action was taken initially. The resident eventually spoke to the housekeeping director after repeated complaints to other staff members. Facility policy required grievances to be documented and addressed promptly, with forms available at several locations. However, the grievance form for this incident was not completed in full and lacked documentation of follow-up or resolution. Interviews with the social worker and housekeeping director confirmed delays in addressing the complaint, and the resident's family was only contacted after the grievance was formally recognized. The resident's inventory did not list the missing blanket, and the issue remained unresolved at the time of the report.
Inaccurate MDS Assessments for Antipsychotic Use and Resident Weights
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment incorrectly documented that a Gradual Dose Reduction (GDR) for an antipsychotic medication was both attempted and contraindicated on the same date. Record review showed that the resident had been on Risperdal, an antipsychotic, for a neurological condition (Huntington's disease) since 2022, with no change in dosage and no documented contraindication for a GDR. The MDS Coordinator confirmed that the documentation of a contraindication was incorrect and that there had been no recent changes to the antipsychotic medication. Additionally, the discontinuation of an antianxiety medication was incorrectly associated with the antipsychotic medication in the assessment. For another resident, the MDS assessment inaccurately recorded the resident's weight. The assessment listed a weight of 134 pounds, while the most current weight in the electronic medical record prior to the assessment date was 132 pounds. The Registered Dietician (RD) stated that she obtains weights directly from the electronic medical record and uses the most recent weight before the assessment date. Upon review, the RD acknowledged the inconsistency between the documented weight in the MDS and the electronic medical record.
Failure to Develop and Implement Care Plans for PTSD and Diabetes Management
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents with specific clinical needs. For one resident with severe cognitive impairment and a diagnosis of Post Traumatic Stress Disorder (PTSD), there was no care plan in place to address PTSD, despite documentation of the diagnosis in the resident's assessment. Interviews with staff revealed a lack of awareness and understanding of the resident's PTSD, its triggers, and appropriate interventions. The resident's Power of Attorney identified specific triggers such as loud noises and fireworks, but this information was not incorporated into a care plan, and staff were either unaware of the PTSD diagnosis or unclear about how to address it. In a separate case, another resident with a diagnosis of diabetes and an active order for insulin did not have a care plan addressing diabetes management or insulin administration. The interdisciplinary team reviewed care plans but failed to develop one for the resident's diabetes or insulin use. The MDS Coordinator confirmed the absence of an active care plan for these needs. These omissions were identified through record review and staff interviews during the survey process.
Failure to Update Care Plans Following Changes in Diet and Medication Orders
Penalty
Summary
The facility failed to update and maintain accurate care plans for two residents following changes in their clinical status and physician orders. For one resident, the care plan did not reflect the current prescribed diet, as the physician ordered a regular, pureed texture with nectar thickened fluids, but the care plan listed a regular, mechanically altered ground texture with nectar thickened liquids. For another resident with an anxiety disorder, the care plan continued to indicate the use of anti-anxiety medication, even though there was no current physician order for such medication. The MDS Coordinator confirmed that the care plan was not updated to reflect the resident's current medication status.
Failure to Provide Ongoing Treatment and Follow-Up for Persistent Skin Rash
Penalty
Summary
A resident with severe cognitive impairment was admitted to the facility and developed a skin rash. The nurse practitioner (NP) assessed the resident and prescribed a one-time dose of Permethrin 5% cream for suspected scabies, with a plan to reevaluate the rash after treatment. However, there was no documented follow-up or reassessment by the NP as planned, and no additional treatments for itching were ordered. The resident continued to experience symptoms, including itching and the spread of the rash to multiple areas, as observed during interviews and skin assessments. Despite the resident's ongoing symptoms and reports of discomfort, staff interviews and record reviews confirmed that no further interventions or dermatology consultations were initiated in a timely manner. The unit manager and medical director were unaware of any additional treatment orders or scheduled dermatology visits, and the resident did not receive further care for the persistent rash. This lack of follow-up and failure to provide appropriate ongoing treatment according to the resident's needs and the NP's plan resulted in the resident remaining symptomatic.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
Staff failed to follow physician orders for the treatment of a facility-acquired pressure ulcer for one resident with severe cognitive impairment. The resident had a new right achilles (heel) pressure ulcer, and physician orders directed staff to cleanse the wound with normal saline, apply skin prep to the necrotic area, and cover with a foam dressing every day shift on Monday, Wednesday, and Friday, as well as as needed for saturation or dislodgment. Observations revealed that the foam dressing was partially hanging off and exposing the wound on multiple occasions, with photographic evidence obtained. The dressing was also noted to be dated several days prior, indicating it had not been changed as ordered. Review of the Treatment Administration Record (TAR) showed that an LPN had signed off on performing the wound care treatment on specific dates, but direct observation contradicted these records. The resident was observed experiencing discomfort and was found with a foul-smelling dressing with dark brownish drainage and eschar present. The dressing was removed by staff only after the resident indicated discomfort, and it was confirmed that the dressing had not been changed according to the physician's orders.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Prescribed Fortified Foods and Meals to Residents with Nutritional Concerns
Penalty
Summary
The facility failed to provide adequate nutrition to residents with identified nutritional concerns, as evidenced by the lack of fortified foods and missed prescribed meals for three residents. For two residents who were underweight or at risk for malnutrition, meal tickets and care plans specified the need for fortified foods such as fortified cereal and potatoes with all meals. However, direct observations on multiple occasions revealed that these fortified foods were not included on their trays, despite clear dietary orders and documentation. Staff confirmed that the residents did not receive the required fortified foods, and photographic evidence supported these findings. One resident with a diagnosis of malnutrition and a low BMI experienced significant weight loss over a short period. This resident reported dissatisfaction with the quality and temperature of the food and specifically noted not receiving the prescribed meal (spaghetti with meat sauce), instead receiving only the meat sauce. The registered dietitian confirmed that the meal provided did not match the meal ticket or the resident's dietary order. The resident's care plan had been updated to address his risk for malnutrition, but the prescribed interventions were not consistently implemented. Another resident with a history of Alzheimer's disease, anorexia nervosa, and dysphagia was also observed not receiving fortified foods as ordered. This resident had experienced a notable weight loss over six months, and the care plan included specific interventions to provide fortified foods at each meal. Despite these orders, observations showed that the resident's trays did not include the required fortified items, and the meal tickets continued to indicate the need for fortified foods. These failures were acknowledged by facility management and the registered dietitian during interviews.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Failure to Obtain Ordered Valproic Acid Level for Resident on Divalproex
Penalty
Summary
The facility failed to obtain a required laboratory test for one resident who was prescribed Divalproex Sodium for a mood disorder. Upon admission, the resident had diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder, and a physician's order was written for a valproic acid level to be measured on a specified date. Review of the clinical record showed no documented evidence that the valproic acid test was performed or that results were available. During an interview, the Director of Nursing confirmed the absence of the test result after reviewing the resident's records and contacting the laboratory, which also did not have the result.
Failure to Follow Infection Control Precautions and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices for three residents by not adhering to Transmission-Based Precautions (TBP), Enhanced Barrier Precautions (EBP), and appropriate use of Personal Protective Equipment (PPE) during direct care. For one resident with a recent diagnosis of a left thigh fracture and multiple episodes of loose stools, a physician ordered contact isolation to rule out Clostridium difficile (C. diff) infection. Despite this, the resident was observed multiple times in the hallway outside of their private room while still pending lab results for C. diff, contrary to the facility's TBP policy that requires residents on isolation to remain in their rooms except for medically necessary care. Another resident with end-stage kidney disease requiring dialysis and a central line was placed on EBP per physician order, with care plans specifying the use of gown and gloves during high-contact care activities. However, after the resident changed rooms, EBP signage was not posted on the new room door as required, potentially leading to lapses in staff adherence to EBP protocols. Observations confirmed the absence of EBP signage on the door during multiple checks. A third resident, who was treated for a multi-drug resistant organism (MDRO) of the urine and had an open wound, was on contact precautions followed by EBP. During direct care, a CNA was observed providing personal care and changing an adult brief while wearing gloves but not donning a gown, both when the resident was on contact precautions and later on EBP. The CNA was unfamiliar with the meaning of EBP, contact precautions, and the facility's system for identifying residents on precautions, as confirmed during interviews. The Infection Preventionist acknowledged that a gown should have been worn during these care activities.
Failure to Maintain Effective Pest Control in Food Service Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by direct observations of live roaches in multiple areas of the kitchen. During a kitchen tour with the Food Service Director/Certified Dietary Manager, two live mature roaches were seen on a table near the conveyor toaster in the hot holding area. Additionally, in the food service area where staff collect plates and prepare them for distribution, numerous live roaches in various stages of life were observed behind a cart containing trays and single service items such as sugar packets, condiments, and tea bags. The surveyor also attempted to contact the pest control company servicing the facility but did not receive a response. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Follow Prescribed Medication Parameters
Penalty
Summary
The nursing staff failed to adhere to prescribed parameters for administering medications to two residents, leading to deficiencies in care. Resident #5, who was admitted with a diagnosis of Diabetes Mellitus with Hyperglycemia, was prescribed Insulin Lispro to be administered before meals, with instructions to hold the dose if blood glucose levels were below 150. Despite this, the resident received insulin on multiple occasions when their blood sugar levels were below the specified threshold, with readings ranging from 110 to 123. Similarly, Resident #1, who was admitted with Congestive Heart Failure and Hypertension, was prescribed Entresto with instructions to hold the medication if systolic blood pressure was below 110. However, the medication was administered on two occasions when the resident's blood pressure was recorded at 106/60 and 92/58, respectively. The Director of Nursing confirmed that the medications were given despite the prescribed parameters, indicating a failure in following medical orders.
Failure to Coordinate Medication Administration with Dialysis Services
Penalty
Summary
The facility failed to coordinate medication administration times with dialysis services for two residents, leading to medication omissions. For one resident, the Medication Administration Records (MAR) indicated that several prescribed medications were not administered on specific dates because the resident was in dialysis. The facility did not ensure that medications were given as prescribed, which was confirmed by the Risk Manager during an interview. Additionally, the facility did not complete dialysis communication records to validate continuity of care, as evidenced by missing documentation of pre and post-dialysis assessments, including vital signs, condition of the access site, and signs of infection. For another resident, the facility failed to administer prescribed blood pressure medications on dialysis days without provider orders to hold them. The MAR showed that medications were held on specific dates with the reason noted as the resident having dialysis. The Risk Manager confirmed that the nurse likely held the medications due to concerns about blood pressure dropping during dialysis, but there were no orders to support this action. This lack of coordination and documentation led to deficiencies in ensuring the residents received appropriate care during dialysis.
Medication Administration Competency Deficiency
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated competency in following physician's orders for medication administration and documentation for a resident. The facility's policy on administering medications, last revised in April 2019, outlines that medications should be administered safely, timely, and as prescribed, with specific guidelines for checking and verifying medication details before administration. However, the clinical record review revealed that the resident received Midodrine HCl despite having a systolic blood pressure above the prescribed threshold on multiple occasions. Additionally, the medication was withheld when the blood pressure was below the threshold, indicating a failure to adhere to the physician's orders. Furthermore, the resident was administered Insulin Lispro despite blood sugar levels being below the threshold specified in the physician's order. The Medication Administration Records showed multiple instances where insulin was given when the blood sugar was below 200, contrary to the physician's directive. An interview with the Risk Manager confirmed these findings and highlighted the need for clarification in the insulin order for proper documentation. These actions demonstrate a lack of adherence to the facility's medication administration policy and physician's orders, leading to the identified deficiency.
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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