Life Care Center Of Port Saint Lucie
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Saint Lucie, Florida.
- Location
- 3720 Se Jennings Rd, Port Saint Lucie, Florida 34952
- CMS Provider Number
- 106012
- Inspections on file
- 25
- Latest survey
- October 15, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Life Care Center Of Port Saint Lucie during CMS and state inspections, most recent first.
The facility did not consistently perform or document weekly skin assessments for three residents at risk for pressure ulcers, despite facility policy, care plan interventions, and physician orders requiring these checks. Nursing staff confirmed that the electronic system was intended to prompt and record these assessments, but multiple weeks were missed for each resident, including periods where staff signed off on records without completing the required documentation.
A resident experienced a significant, unaddressed weight loss over several weeks due to the facility's failure to follow its weight monitoring policy, missed required weigh-ins, and lack of timely communication and intervention by staff. The resident's weight loss was not promptly reported to the physician or addressed in care planning meetings, and interventions were delayed despite clear evidence of nutritional decline.
A resident with a history of right femur fracture and fragile skin sustained bruises during a stand pivot transfer when a CNA failed to stop as requested. The facility did not document an assessment of the injuries, failed to complete an incident report, and did not conduct or document a thorough internal investigation or federal reporting, despite the incident being reported to the state agency. Staff interviews confirmed the lack of documentation and assessment, and the state agency substantiated the allegations.
The facility did not report allegations of abuse to the State Agency within the required timeframe for four residents involved in three separate incidents. In each case, the administrator reported the incidents to the Abuse Registry but delayed notification to the State Agency, sometimes by several hours or days. The administrator stated he was unaware of the 2-hour reporting requirement to the State Agency.
A resident with moderate cognitive impairment sustained a burn from hot tea due to inadequate temperature monitoring and management by the facility. The Dietary Aide and Cook failed to document temperature checks, and the Food Temperature Log showed multiple instances of hot beverages being served above the acceptable range. Additionally, the facility did not consistently follow physician-prescribed wound care orders, as indicated by missed treatments and incomplete documentation.
A resident with lumbar radiculopathy expressed dissatisfaction with her roommate and requested a room change, but the facility failed to document or address her grievance. Despite being alert and oriented, the resident's complaint was not logged or resolved, leading her to leave the facility AMA. Interviews with staff confirmed the lack of documentation and follow-up on the resident's request.
The facility failed to provide dignified care for several residents, with reports of staff having poor attitudes, delayed responses to call lights, and neglecting personal care needs. Residents reported feeling disrespected and ignored, with incidents of inappropriate comments, rushed care, and neglect of hygiene and comfort. These deficiencies highlight a pattern of inadequate care and lack of respect for residents' dignity.
The facility failed to maintain a safe, clean, and homelike environment in Units 100, 200, and 400. Observations revealed rusted and dusty ceiling vents, peeling paint, and damaged walls in several rooms. Additional issues included broken fixtures, dirty floors, and peeling paint on handrails, potentially causing safety hazards. The Director of Maintenance noted that wall damage was due to residents hitting them with wheelchairs or furniture.
The facility failed to provide adequate staffing, resulting in delayed and undignified care for residents. Multiple residents reported long wait times for assistance, leading to incidents of incontinence and rushed care. The Director of Nursing acknowledged staffing challenges, particularly on weekends, despite claiming there were enough CNAs. This deficiency affected the residents' well-being, as they were unable to receive timely and respectful care.
A facility failed to honor a resident's request to use an insulin sensor for glucose monitoring, opting instead for the more painful finger stick method. The resident, who was cognitively intact and had diabetes, expressed her preference for the sensor, which was not replaced or used by the facility. The necessary equipment remained at the associated Independent Living facility, and efforts were made to retrieve it.
A resident with hemiparesis, requiring substantial assistance with personal hygiene, experienced inadequate nail care despite multiple requests over two weeks. The resident's fingernails were long and unclean, with staff failing to address the issue during scheduled care opportunities. The responsible CNA was on vacation, leading to a lack of continuity in care.
The facility failed to follow physician-ordered parameters for medication administration for three residents, leading to deficiencies in care. A resident received midodrine despite high blood pressure readings, another experienced delays in antibiotic administration and PICC line dressing changes, and a third reported delays in receiving medications. Staff interviews revealed challenges in adhering to medication schedules due to workload.
A resident with moderate cognitive impairment and significant weight loss was not provided with the recommended nutritional supplements. Despite a dietician's note suggesting the addition of fortified foods and Med Pass, the physician's orders did not include these supplements, and the Registered Dietician confirmed the oversight.
A resident requiring tube feeding did not receive the prescribed amount of nutrition and fluids due to improper monitoring and administration. The resident was supposed to receive Glucerna 1.5, but observations showed an empty Jevity container instead. An LPN admitted to not clearing the pump volume and noted discrepancies in the canister's content, which were not questioned. The Unit Care Coordinator was unaware of the issue, and the Registered Dietician confirmed the resident's nutritional needs were unmet.
A resident with chronic pain did not receive timely pain management due to delays and missed doses of prescribed medications, including Gabapentin and topical patches. Staff interviews revealed challenges in adhering to medication schedules due to workload and logistical issues, resulting in the resident experiencing high pain levels.
A resident was found with open medications at their bedside due to suspicion about a medication, while another resident received expired Ferrex 150 mg from a medication cart containing expired medications.
The facility failed to provide an adequate protein portion during lunch, serving only 2.4 ounces of kielbasa instead of the required 4 ounces. This affected 70 residents on a regular diet, as the cook and CDM acknowledged the deficiency.
Failure to Perform and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to provide services to prevent skin breakdown for three sampled residents by not performing weekly skin assessments as required by facility policy and care plans. The policy mandated head-to-toe skin inspections upon admission and weekly thereafter, with documentation in the electronic medical record. For one resident, there were no documented skin assessments for several specified weeks, despite the resident having a history of pressure ulcers and a care plan intervention for weekly skin checks. The resident's daughter also reported a lack of communication regarding the resident's status and wounds. Another resident, who was at risk for pressure injury and had active wounds being treated, also did not have weekly skin assessments documented for multiple weeks, including an entire month with no assessments. The care plan for this resident included weekly skin checks as an intervention to address the risk of skin breakdown. Similarly, a third resident with impaired mobility and vascular disease, and an order for weekly skin checks, had multiple weeks where no skin assessments were documented, despite staff signing off on the treatment administration record that the checks were completed. Interviews with nursing staff and the wound care nurse confirmed that the electronic system was designed to prompt nurses when skin assessments were due, and that documentation was to be completed in the electronic record. However, the lack of documented assessments for all three residents indicated that the required skin checks were not consistently performed or recorded, contrary to facility policy and physician orders.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate care and services to address the nutritional status of a resident, as evidenced by not following its own weight monitoring policy and not addressing significant weight loss in a timely manner. According to facility policy, residents are to be weighed upon admission, weekly for four weeks, and then monthly, with more frequent assessments if indicated. However, the resident in question was not weighed on the day of admission or within 24 hours, and missed a weekly weight during the first month. The initial weight was recorded four days after admission, and a subsequent weekly weight was not documented as required by policy. Over the course of less than a month, the resident experienced a significant weight loss of 34 pounds, with documented weights showing a loss of 21 pounds in two weeks and a further decline the following week. Despite this, there was no documentation that the weight loss was reported to the physician, and the care plan meeting held during this period did not address the weight loss in detail. The care plan included monitoring for signs of malnutrition and reporting significant weight changes, but these interventions were not implemented as specified. Interviews with staff revealed a lack of clarity and consistency in the process for obtaining and documenting weights, as well as in the communication of significant weight changes to the appropriate clinical staff. The Registered Dietitian was not made aware of the significant weight loss until a week after it was documented, and interventions to address the weight loss were not initiated until several days later. The resident's family also reported difficulty obtaining updates on the resident's status during this period.
Failure to Investigate, Assess, and Report Resident Injury
Penalty
Summary
The facility failed to provide evidence of a thorough investigation, assessment, and appropriate reporting of an incident involving a resident who sustained new bruises of suspected origin. The facility's policy requires that all alleged violations, including abuse or neglect, be thoroughly investigated, with proper documentation and reporting to state and federal agencies as appropriate. In this case, there was no documented assessment of the resident's injury, no incident report, and no evidence of an internal investigation or federal reporting, despite the incident being reported to the state agency. The resident involved was admitted for a nondisplaced intertrochanteric fracture of the right femur and was documented as mentally intact with a BIMS score of 15. The incident in question involved the resident receiving two bruises during a stand pivot transfer from a wheelchair to bed, with the resident stating that the aide was rushed and did not stop when asked. The resident requested that the aide no longer care for her, and the aide was subsequently reassigned. Staff interviews confirmed that the incident was reported to the administrator, but there was no evidence of a clinical assessment of the bruises or a formal incident report being completed. Administrative and clinical record reviews revealed that the facility did not follow its own policy for incident and reportable event management. There was no documentation of the assessment of the resident's injuries, no incident report in the logs, and no evidence of an internal investigation or staff education related to the incident. The administrator was unable to provide documentation of the investigation or reporting, and staff interviews indicated a lack of recall regarding the assessment or documentation of the resident's injuries. The state agency's investigation substantiated the allegations, confirming that the resident sustained physical injuries during the transfer and that the facility did not have the required documentation or evidence of a thorough investigation.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse to the State Agency for four sampled residents involved in three separate incidents. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than 2 hours after the allegation is made if abuse or serious bodily injury is involved, or within 24 hours if not. In the first incident, a resident with moderate cognitive impairment was involved in an alleged physical abuse event. The administrator became aware of the incident and reported it to the Abuse Registry within the required timeframe, but did not submit the report to the State Agency until approximately 16 hours after the incident, exceeding the 2-hour requirement. In a second incident, another resident, unable to participate in a cognitive interview, was involved in an alleged physical abuse event. The administrator reported the incident to the Abuse Registry but did not notify the State Agency until more than a day later. In a third incident involving two cognitively intact residents, one as the perpetrator and one as the victim, the administrator again reported the event to the Abuse Registry but delayed reporting to the State Agency by approximately four days. During interviews, the administrator stated he was unaware of the requirement to report such incidents to the State Agency within 2 hours, believing only adult protective services needed to be notified within that timeframe.
Failure to Monitor Hot Beverage Temperatures and Adhere to Wound Care Orders
Penalty
Summary
The facility failed to provide adequate monitoring and management of hot beverage temperatures, leading to a resident sustaining a burn injury. The incident involved a resident with moderate cognitive impairment who was admitted with a displaced commuted fracture of the left tibia. During a dinner meal, the resident requested hot tea, which was placed on his tray by a Certified Nursing Assistant (CNA). The tea was accidentally spilled, resulting in a burn that required hospital evaluation. The facility's investigation revealed inconsistencies in staff accounts and a lack of temperature monitoring for hot beverages, which were often served at temperatures exceeding the facility's stated range. The facility's policy on hot liquids was not effectively implemented, as evidenced by the lack of temperature checks for hot beverages before serving. The Dietary Aide and Cook were unable to provide documentation of temperature checks, and the Food Temperature Log showed multiple instances of hot beverages being served at temperatures above the acceptable range. Despite the policy requiring corrective action for temperatures outside the specified range, there was no evidence of such actions being taken. This oversight contributed to the resident's burn injury, as the hot tea was served at a temperature that posed a risk for scalding. Additionally, the facility failed to adhere to physician-prescribed wound care orders for the resident. The Treatment Administration Record indicated missed treatments on several occasions, and weekly skin checks were not consistently documented. The Wound Care Nurse acknowledged lapses in treatment administration, and the Director of Nursing noted issues with the electronic documentation system. These deficiencies in wound care management further compromised the resident's safety and well-being.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to acknowledge and resolve a grievance for one of the residents, who was admitted with a diagnosis of lumbar radiculopathy. The resident, who was alert and oriented, expressed dissatisfaction with her roommate due to constant yelling and requested a room change. Despite the resident's clear communication of her needs, there was no evidence of a grievance being filed or addressed in the facility's grievance log. Interviews with the Social Services Director and a Licensed Practical Nurse revealed that the resident's complaint was not documented or followed up on. The nurse confirmed the resident's dissatisfaction and her request for a room change but could not recall the method of reporting or any subsequent actions taken. Ultimately, the resident left the facility against medical advice, indicating that her grievance was not resolved, and the facility did not make prompt efforts to address her concerns.
Inadequate and Undignified Care in LTC Facility
Penalty
Summary
The facility failed to ensure care and services were provided in a dignified manner for six of nine sampled residents. The report highlights several instances where residents felt disrespected or neglected by the staff. Resident #26, who has cognitive impairment, reported that some staff members had an attitude, especially during personal care, and mentioned an incident where a nurse refused to provide ibuprofen, citing a lack of order, which was perceived as having a nasty attitude. The Unit Care Coordinator denied having conversations about staff complaints, despite the resident's claims. Resident #49, who is cognitively intact, expressed concerns about understaffing and the rushed nature of care. She recounted an incident where she had an incontinent episode due to delayed response from a CNA and described being pushed over in bed if she did not move quickly enough. Similarly, Resident #54, also cognitively intact, reported staff attitudes suggesting they did not want to be there, with aides ignoring her requests and making inappropriate comments about her bathroom needs. She also mentioned being left exposed during care, which compromised her dignity. Resident #74, with cognitive intactness but physical impairments due to a stroke, described staff as grumpy and unresponsive to his needs, leading to discomfort and hygiene issues. He also faced challenges with nail care, which was neglected, causing physical discomfort. Resident #3, with moderate cognitive impairment, was observed in an uncomfortable position and reported being repositioned multiple times by a CNA who seemed frustrated. Lastly, Resident #372, with moderate cognitive impairment, expressed feeling ignored due to delayed responses to call lights, resulting in accidents. These incidents collectively demonstrate a pattern of inadequate and undignified care within the facility.
Environmental Deficiencies in Facility Units
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment across three units, specifically Units 100, 200, and 400. Observations made over several days revealed multiple environmental concerns, including rust and dust on ceiling vents, peeling paint, and damaged walls in various rooms. Specific issues included rusted and dusty ceiling vents in rooms 103, 105, 111, 115, 123-B, 126-B, 128-B, 203-B, 206-B, and 207-B. Additionally, rooms 104 and 105 had stains and peeling paint, while room 110-B had holes in the walls. Room 112-A had a broken closet door hinge and a torn bathroom seat pad, and room 113-B lacked a string for the light behind the bed. Room 114-B had a torn wheelchair pad, and room 203-B had dirty floors and walls in disrepair. Further observations noted that the hallway by rooms 107-116 had peeling paint on the handrail, exposing wood that could potentially cause splinters. The vinyl base of the wall was also peeling away. The ceiling vent in the laundry room was dusty, and the 400-unit's entrance light was very dusty. During a follow-up tour with the Director of Environmental, the Director of Maintenance, and the Regional President, it was confirmed that the ceiling vents in the 400-unit were very dusty. The Director of Maintenance attributed the wall damage to residents hitting them with wheelchairs or furniture.
Inadequate Staffing Leads to Delayed and Undignified Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, as evidenced by multiple complaints from residents and their families. Residents reported that Certified Nursing Assistants (CNAs) were rushing through care, leading to delays in assistance and unmet needs. For instance, a resident mentioned it took a week to get help with a broken fingernail, and another resident expressed fear of being transferred with a mechanical lift due to rushed procedures. The survey revealed that 25 out of 52 residents on a particular unit required two-person assistance, indicating a significant staffing challenge. Residents consistently reported long wait times for call bell responses, with some waiting up to two hours. This delay in response led to incidents of incontinence and undignified care, as residents were unable to receive timely assistance for toileting and repositioning. Several residents expressed feelings of being ignored and undignified care, such as being pushed over in bed if they did not turn quickly enough. Family members also noted insufficient staffing, particularly on weekends, which exacerbated the issue. The Director of Nursing acknowledged the staffing challenges, particularly on weekends, despite claiming there were enough CNAs. The survey highlighted the facility's failure to provide care and services in a dignified manner, as residents reported feeling neglected and undignified due to the lack of staff. This deficiency affected the physical, mental, and psychosocial well-being of the residents, as they were unable to receive the necessary care and attention in a timely and respectful manner.
Failure to Honor Resident's Request for Insulin Sensor Use
Penalty
Summary
The facility failed to honor a resident's request for the use of an insulin sensor, which is a less invasive method for monitoring blood glucose levels compared to the standard finger stick method. The resident, who was admitted to the skilled nursing facility from an associated Independent Living facility, was diagnosed with diabetes and had a BIMS score indicating she was cognitively intact. Despite her request to use the sensor, which was documented by a Nurse Practitioner, the facility continued to perform blood glucose monitoring through finger sticks. The resident expressed her desire to have her insulin sensor replaced and used, as it was more comfortable and less painful than the finger stick method. However, the facility did not replace or use the sensor, and it was noted that the necessary equipment was still at the Independent Living facility. The Unit Care Coordinator acknowledged the situation and indicated that efforts were being made to retrieve the sensor equipment from the neighboring facility.
Failure to Provide Adequate Nail Care for Resident with Hemiparesis
Penalty
Summary
The facility failed to provide proper nail care for a resident with hemiparesis secondary to a stroke, who required substantial to maximum assistance with personal hygiene. The resident, who was cognitively intact, had repeatedly requested assistance with trimming his fingernails over a period of two weeks. Despite having eight opportunities during this time frame, staff did not address the resident's requests, resulting in long fingernails with a black substance underneath and nails on the left hand nearly digging into the palm. The resident expressed frustration during interviews, noting that while his toenails were trimmed regularly, his fingernails were neglected. A CNA, who was responsible for the resident's care, stated that she trims nails as needed but had been on vacation for the past two weeks, indicating a lack of continuity in care. The resident confirmed that the issue of inadequate nail care had been ongoing, not just limited to the recent two-week period.
Medication Administration and Care Deficiencies
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for medication administration for three residents, leading to deficiencies in care. Resident #26 was prescribed midodrine to manage low blood pressure, with specific instructions to withhold the medication if the systolic blood pressure (SBP) exceeded 120. However, the medication was administered on multiple occasions despite the SBP being above the threshold, as documented in the Medication Administration Record (MAR) for July and August 2024. The Director of Nursing (DON) acknowledged the oversight during an interview. Resident #164 experienced a delay in receiving the antibiotic daptomycin, which was last administered by the hospital on 07/23/24. The facility did not provide the antibiotic until 07/28/24, despite the resident's admission on 07/25/24 and the availability of the IV access. Additionally, the facility failed to perform timely dressing changes for the resident's Peripherally Inserted Central Catheter (PICC) line, as required by their policy. The MARs for July and August 2024 lacked documentation of the dressing changes, and the Unit Care Coordinator confirmed the discrepancies during a review. Resident #76 reported delays in receiving medications, which were confirmed by a review of the Medication Administration Audit Report. The resident's medications, including Metformin, Carvedilol, and others, were not administered at the prescribed times on several occasions in July and August 2024. Staff interviews revealed challenges in adhering to medication schedules due to workload, with the DON acknowledging the issue and noting the heavy medication pass on certain units.
Failure to Implement Nutritional Supplements for a Resident
Penalty
Summary
The facility failed to implement nutritional supplements for a resident who was reviewed for nutrition. The resident was admitted with diagnoses including Adult Failure to Thrive, Dementia Without Behavioral Disturbances, Mood Disturbance, and Anxiety. The resident's quarterly MDS assessment indicated moderate cognitive impairment and documented significant weight loss of over 9% within a few months, without being on a prescribed weight-loss regimen. A dietician's progress note from May 2024 recommended adding fortified foods and Med Pass 120 ml three times a day due to a noted weight change. However, a review of the physician's orders from May to August 2024 did not include any orders for Med Pass, and the Registered Dietician confirmed the absence of such an order during an interview.
Failure to Properly Monitor and Administer Tube Feeding
Penalty
Summary
The facility failed to properly monitor and administer the continuous tube feeding for a resident, resulting in the resident not receiving the calculated amount of nutrition and fluids. The resident, who was admitted to the facility with a requirement for all nutrition and fluids to be administered via a feeding tube, had an order for Glucerna 1.5 at 65 ml per hour for 20 hours, totaling 1300 ml, along with 30 ml of water every hour for 20 hours, totaling 600 ml. Observations revealed discrepancies in the administration, with an empty 1000 ml container of Jevity 1.5 noted instead of the prescribed Glucerna, and a water flush bag with 600 ml remaining, indicating a failure to follow the prescribed regimen. Interviews with staff revealed a lack of clarity and adherence to the prescribed feeding regimen. A Licensed Practical Nurse (LPN) admitted to routinely not clearing the volume on the feeding tube pump and noted that the canister was always empty each morning, which was inconsistent with the prescribed amount. The LPN, who was new to the assignment, did not question the discrepancy. The Unit Care Coordinator was unaware of the issue, and the Registered Dietician confirmed the nutritional needs were not met as ordered. This lack of proper monitoring and administration led to the deficiency in care for the resident.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident, identified as Resident #76, who was experiencing chronic pain due to multiple medical conditions, including spinal stenosis, osteoarthritis, and chronic pain syndrome. The resident reported persistent pain in his right shoulder and arm following neck surgery. Despite having physician orders for various pain medications, including Gabapentin, Lidoderm patches, Biofreeze patches, and Acetaminophen, the medications were not administered at the prescribed times. The Medication Administration Audit Report indicated significant delays in administering these medications, with instances of missed doses and late applications, particularly for Gabapentin and the topical patches. Interviews with facility staff revealed systemic issues contributing to the deficiency. An LPN reported that the resident had been on stronger pain medications previously, but due to side effects, these were discontinued, leaving the resident with less effective pain management options. A newly employed RN admitted to struggling with the workload, stating that it was challenging to administer medications within the required time frame due to the number of patients and logistical issues, such as residents being in different locations during medication rounds. The resident confirmed that he did not refuse medications but noted that staff often forgot to apply patches after his showers, leading to increased pain levels.
Medication Security and Expiration Issues
Penalty
Summary
The facility failed to secure medications properly, as evidenced by an incident involving a resident who had dispensed and open medications at their bedside. The resident, who was cognitively intact with a BIMS score of 14/15, had medications administered orally in the mornings. During an interview, the resident was observed with medications on a napkin, explaining that they were waiting for a nurse to return with a medicine cup. The resident expressed suspicion about one of the medications, leading them to pour the medications onto a napkin. The nurse later returned, clarified the medications with the resident, and the resident took the medications in the nurse's presence. Additionally, the facility failed to ensure medication carts were free of expired medications. During a medication storage review, expired medications were found in one of the medication carts, including two bottles of Ferrex 150 mg and a bottle of Ibuprofen 200 mg, all expired in July 2024. It was discovered that a resident had been administered the expired Ferrex 150 mg on two consecutive days. This oversight in medication management could potentially affect the resident's health, as they were prescribed the expired medication.
Inadequate Protein Portion Served to Residents
Penalty
Summary
The facility failed to provide an adequate protein portion for residents consuming a regular diet during lunch on 08/07/24. The menu for that day included kielbasa with peppers and onions, with the diet spreadsheet indicating a serving size of 4 ounces of kielbasa and 2 ounces of vegetables. However, the production recipe instructed to serve 4 ounces of sausage with 3 ounces of vegetables. During the lunch service, the cook used a 4-ounce ladle to serve the kielbasa and vegetables, resulting in each resident receiving approximately 6 slices of kielbasa. Upon weighing the average portion of 6 slices, it was found to be only 2.4 ounces, which was less than the required 4 ounces of protein. Both the cook and the Certified Dietary Manager acknowledged that the protein portion served was inadequate. This deficiency had the potential to affect 70 residents on a regular diet, including several sampled residents, as the facility did not meet the nutritional needs as outlined in their menu and dietary guidelines.
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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