Martin Coast Center For Rehabilitation And Healthc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hobe Sound, Florida.
- Location
- 9555 Se Federal Hwy, Hobe Sound, Florida 33455
- CMS Provider Number
- 105300
- Inspections on file
- 21
- Latest survey
- November 7, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Martin Coast Center For Rehabilitation And Healthc during CMS and state inspections, most recent first.
The facility did not follow the approved menu for lunch, serving unbreaded chicken wings instead of 'Golden Fried Chicken' due to a supplier issue and lack of proper equipment. Residents were not informed of the menu change, and the portion size served did not meet the approved 4 ounces due to the presence of bones. The Dietary Manager acknowledged these issues during the survey.
The facility failed to adhere to food safety standards, as a dietary aide was observed without a beard restraint, and food items were stored at unsafe temperatures. Additionally, a carton of eggs brought in by a visitor was found unlabeled in a refrigerator, violating the facility's policy on handling outside food.
The facility failed to treat residents with dignity and respect, as evidenced by incidents involving four residents. A resident felt disrespected when CNAs spoke in another language, while another was denied a meal after dialysis. A cognitively impaired resident experienced neglect during meal times, and a resident with Alzheimer's was repeatedly prevented from standing, contrary to his care plan. These incidents highlight a lack of dignified care and communication by the staff.
A facility failed to provide showers according to a resident's preferences and schedule, despite the resident being cognitively intact and requiring assistance for mobility. The resident and her daughter reported infrequent showers since admission, contradicting the care plan that specified showers three times a week. Staff interviews revealed inconsistencies in communication and documentation, contributing to the deficiency.
The facility was found to have multiple deficiencies in maintaining a safe, clean, and homelike environment across several units. Observations included damaged walls, worn wheelchair seats, damaged over bed tables, a strong urine odor, stained ceiling tiles, and mold-like residue in the shower room. The Maintenance Director and Housekeeping/Laundry Supervisor acknowledged these issues, but no specific timeframe for repairs was provided.
A resident with mild cognitive impairment was not involved in his care planning process, despite having no documented power of attorney or health care surrogate. The resident's sister attended meetings and made decisions without his consent. Facility records lacked evidence of the resident being invited to participate, leading to a deficiency finding.
The facility failed to provide grooming assistance to three residents who required staff support for ADLs. Observations revealed unwashed, greasy hair and long fingernails, with staff interviews confirming neglect in care. Residents in the memory care unit, with severe cognitive impairments, did not receive regular showers or nail care, despite documented needs and expressed importance of such care.
Facility staff failed to assess lung sounds and vital signs before and after nebulizer treatments for three residents, contrary to the facility's respiratory care policy. An LPN relied on the absence of a cough to determine clear breathing for a resident, while another LPN was unaware of the need for additional assessments. A third LPN admitted to forgetting to check pulse oxygenation and did not auscultate lung sounds, indicating a consistent failure to adhere to required procedures.
A facility failed to manage a resident's pain appropriately by not following the physician's order for a lidocaine patch application and removal. An LPN applied the patch, but it was not removed or replaced the next day as required. The MAR inaccurately documented the patch's removal and replacement, which was contradicted by the observation of the dated patch. The DON was informed and agreed with the concern.
A resident in a facility expressed a desire to leave and reported being unable to make healthcare decisions, despite having no legal documentation appointing a power of attorney. The resident's sister was involved in care plan meetings without his consent, and his grievances about discharge wishes and financial concerns were not addressed. The social services director did not provide assistance in resolving these issues, leading to a deficiency in meeting the resident's needs and advocating for his rights.
The facility failed to use appropriate PPE for a resident with a tracheostomy and PEG tube, as an LPN did not don a gown or change gloves between procedures. Additionally, the facility delayed implementing contact isolation for a resident suspected of having C. difficile, starting precautions five days after symptoms began, contrary to the ICP's acknowledgment that precautions should start with symptom onset.
A resident experienced discomfort due to an inadequate mattress that allowed her to feel the bed frame, despite the mattress being rated to support her weight. The facility lacked proper communication and documentation regarding mattress audits and checks, leading to the oversight. Staff interviews revealed gaps in the process of ensuring appropriate mattresses for residents, particularly during room changes.
A facility failed to develop a protocol for releasing medical records requested by a resident's legal representative, leading to a deficiency. The medical record request log lacked entries for the resident, and requests were improperly forwarded to former owners without tracking. The NHA revealed that requests are sent to a third-party vendor for validation, but the process was mishandled due to a lack of written policy and new staff.
Failure to Follow Approved Menu and Notify Residents of Changes
Penalty
Summary
The facility failed to adhere to the approved menu for lunch on 11/06/24, which specified serving 'Golden Fried Chicken'. Instead, residents were served chicken wings that lacked the appearance and preparation of the specified dish. The kitchen lacked the necessary equipment, such as a fryolator or deep fryer, to prepare the chicken as per the approved recipe. The Dietary Manager explained that the supplier was out of the fried chicken that was supposed to be served, and the chicken was pan-fried instead. Additionally, the facility did not notify residents of the menu change, as the posted menu still indicated 'Golden Fried Chicken'. Furthermore, the facility did not serve the correct portion size as per the approved menu, which specified 4 ounces of fried chicken. During the meal service, it was observed that residents were served 3 bone-in chicken wings, which, when weighed, included a significant portion of inedible bone. The Dietary Manager acknowledged the oversight in portion size due to the presence of bones and instructed staff to add an additional chicken wing to the meals already plated. This failure to follow the approved menu and portion sizes resulted in a deficiency noted by the surveyors.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food safety standards during meal preparation, storage, and service. During an initial kitchen tour, a dietary aide was observed handling open foods and working with food equipment without wearing a beard restraint, which is a violation of sanitary practices. The Dietary Manager had to instruct the staff member to put on an appropriate hair restraint. Additionally, during a follow-up kitchen tour, it was found that cut melons and deli sandwiches were stored at unsafe temperatures, 51 degrees Fahrenheit and 49 degrees Fahrenheit respectively, due to being placed on a speed rack next to a hot holding area without adequate cooling measures. The Dietary Manager acknowledged the temperature issue and directed staff to move the items to a cooler. Furthermore, the facility's policy on food brought in by family or visitors was not adhered to, as evidenced by a carton of eggs found in a unit pantry refrigerator without proper labeling. The eggs were in a plastic grocery bag with no indication of which resident they were for or when they were placed in the refrigerator. This oversight in labeling and dating violates the facility's policy designed to ensure the safety of residents consuming food brought in from outside sources.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by multiple incidents involving four residents. Resident #36, who is cognitively intact, reported feeling disrespected when CNAs spoke in another language in front of her, making her feel as though they were talking about her. She also expressed that staff ignored her requests at the nurses' desk, leading to feelings of isolation and disrespect. Despite her desire to address these issues, she refrained from doing so out of fear of staff retaliation. Resident #86, also cognitively intact, recounted an incident where a CNA refused to provide her with a meal after returning from dialysis, instead offering a peanut butter and jelly sandwich, which she declined. The CNA's dismissive response, suggesting she retrieve the food herself despite her inability to walk, left her feeling disrespected. Like Resident #36, she did not report the incident due to fear of further mistreatment by the staff. Resident #8, who is cognitively impaired and visually impaired due to glaucoma, experienced neglect during meal times. Despite repeatedly asking if she would receive food, staff delayed serving her meal and failed to address her concerns. Resident #83, who has Alzheimer's dementia and is at high risk for falls, was repeatedly prevented from standing by staff, despite being able to walk with assistance. The staff's approach was not in line with the care plan, which emphasized gentle and supportive interaction to encourage mobility.
Failure to Provide Showers Per Resident's Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing showers according to the resident's preferences and the established shower schedule. Resident #309, who was cognitively intact and required substantial assistance for bed transferring and moderate assistance for bed mobility, expressed that she had not been showered since her admission. Her daughter corroborated this, stating that the resident had only been showered twice since admission. The resident's care plan specified showers on Tuesday, Thursday, and Saturday evenings, but records showed that the resident received showers only five times in the past 30 days, with no documentation of refusal. Interviews with staff revealed a lack of consistent communication and documentation regarding the resident's shower schedule. Staff C, a CNA, mentioned that the resident never refused showers and that any refusals would be reported to a supervisor. Staff D, an RN Supervisor, indicated that they signed off on shower sheets, which were then sent to the Unit Manager. Staff E, an LPN/UM, stated that the shower sheets matched the electronic health record and claimed to have daily conversations with the resident and her family, who reportedly did not mention any issues with showers. Despite these assertions, the facility did not adhere to the resident's shower schedule, leading to the deficiency.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across multiple units, as observed during a survey. On the 200 unit, several rooms had damaged walls, while on the 300 unit, issues included worn wheelchair seats, damaged over bed tables, and a persistent strong urine odor. The 400 unit had stained ceiling tiles, damaged wheelchair arms, missing television remotes, stained privacy curtains, and damaged walls and over bed tables. Additionally, the air conditioning unit indicated a need for filter maintenance. In the shower room on the 100 unit, there was damage to the baseboard and wall, a damaged kick plate on the door, and a black mold-like residue on the walls and grout. The Maintenance Director and Housekeeping/Laundry Supervisor acknowledged these issues, and the Administrator noted that the facility was undergoing changes following a recent Change of Ownership (CHOW). However, no specific timeframe for repairs and replacements was provided.
Resident Excluded from Care Planning Process
Penalty
Summary
The facility failed to ensure the participation of a resident in the development of his care plan and ongoing participation in care planning meetings. The resident, who was assessed to have a mildly impaired mental status, expressed his dissatisfaction with not being involved in his health care decisions and stated that he was not invited to any care plan meetings. Despite having no documented power of attorney or health care surrogate, the resident's sister was invited and attended the care plan meetings, making decisions on his behalf without his consent. The facility's records showed no documentation of the resident being invited to the meetings, and staff interviews confirmed the lack of evidence for such invitations. The resident claimed to be illiterate, which was contradicted by the social worker who observed him reading. The facility's failure to involve the resident in his care planning process and the absence of documentation supporting the sister's involvement without the resident's consent were identified as deficiencies.
Failure to Provide Grooming Assistance to Residents
Penalty
Summary
The facility failed to provide necessary grooming assistance, including hair washing and nail care, to three residents who were dependent on staff for their activities of daily living (ADLs). Resident #28, residing in a secured memory care unit, required substantial assistance for ADLs due to communication problems and impaired understanding. Despite this, the resident had only received one shower in the past month, and observations over several days revealed unwashed, greasy hair. Staff interviews indicated a lack of consistent care, with a CNA unable to confirm regular hair washing. Resident #40, also in the memory care unit, was severely cognitively impaired and needed substantial assistance for showering. Observations showed the resident's hair was consistently greasy over several days. Resident #44, with severe cognitive impairment, expressed the importance of bathing but had no documented refusals of care. Observations revealed greasy hair and excessively long fingernails, with the resident's Power of Attorney expressing concerns about the lack of grooming. Staff interviews confirmed the neglect in providing necessary ADLs, with a CNA admitting to not trimming the resident's nails and an LPN acknowledging the oversight.
Failure to Assess Respiratory Status During Nebulizer Treatments
Penalty
Summary
Facility staff failed to properly assess lung sounds and vital signs before and after administering nebulizer treatments to three residents. The facility's policy on respiratory care and oxygen administration requires evaluation of respiratory status, breath sounds, and response to treatment to be documented in the clinical record. However, observations revealed that staff did not adhere to these guidelines. For Resident #42, the LPN only checked oxygen saturation and pulse rate, relying on the absence of a cough to determine clear breathing, without using a stethoscope to assess lung sounds as required. Similarly, Resident #95 received nebulizer treatments without the necessary pre and post-treatment assessments. The LPN administering the treatment was unaware of the need to complete additional vitals or assess lung sounds. For Resident #63, the LPN administered a nebulizer treatment without performing any pre or post-administration assessments, admitting to forgetting to check pulse oxygenation and failing to auscultate lung sounds. These actions indicate a consistent failure to follow the facility's respiratory care policy, potentially compromising resident care.
Failure to Administer Pain Management as Ordered
Penalty
Summary
The facility failed to ensure proper pain management for a resident by not adhering to the physician's order for the application and removal of a lidocaine patch. The resident had an order for a lidocaine 5% patch to be applied to the lower back daily at 9 AM and removed at 9 PM. During a medication pass observation, it was noted that the patch on the resident's back was dated two days prior, indicating it had not been changed as required. The LPN confirmed that she applied the patch on the specified date and did not work the following day, suggesting the patch was not removed or replaced as per the order. The MAR inaccurately documented that the patch was removed and replaced on the subsequent day, which was not the case, as evidenced by the observation of the dated patch. The Director of Nursing was informed of this discrepancy and acknowledged the concern.
Failure to Provide Adequate Social Services and Resident Advocacy
Penalty
Summary
The facility failed to provide sufficient and appropriate social services to a resident, leading to a deficiency in meeting the resident's needs. The resident expressed a desire to leave the facility and reported feeling unable to make his own healthcare decisions, despite having no legal documentation appointing a power of attorney or healthcare surrogate. The resident's sister was involved in care plan meetings without the resident's consent, and there was no evidence that the resident was invited to or attended these meetings. The resident also voiced grievances about his discharge wishes and financial concerns, which were not addressed by the facility's social services. The resident, who was assessed with a Brief Interview Mental Status score indicating mild impairment, reported that his sister had taken his house, car, and money, and he requested assistance in finding a lawyer. Despite these requests, there was no documentation showing that the social services director offered any assistance in resolving these issues. The resident's mental health evaluations indicated that he was alert, oriented, and capable of making his own decisions, yet the facility continued to involve his sister in decision-making without his consent. The social services director acknowledged the lack of documentation supporting the resident's inability to make his own decisions and confirmed that no assistance was provided to the resident in addressing his grievances. The facility's failure to involve the resident in his care planning and to provide necessary social services to address his concerns resulted in a deficiency in meeting the resident's needs and advocating for his rights within the facility.
Inadequate PPE Use and Delayed Contact Isolation
Penalty
Summary
The facility failed to ensure the appropriate use of Personal Protective Equipment (PPE) during the care of a resident with a tracheostomy and a percutaneous endoscopic gastrostomy (PEG) tube. The resident required Enhanced Barrier Precautions (EBP), which included the use of gowns and gloves for high-contact care activities. During a medication pass observation, a Licensed Practical Nurse (LPN) administered medication through the resident's PEG tube and tracheostomy without donning a gown and failed to change gloves between procedures. The Infection Control Preventionist (ICP) confirmed that PPE should be used during direct care, including medication administration via tracheostomy and PEG, but the LPN did not adhere to these precautions. Additionally, the facility did not implement timely contact isolation for a resident suspected of having Clostridioides difficile (C. difficile). The resident exhibited symptoms warranting a stool sample to rule out C. difficile, and the test was ordered. However, contact precautions were not initiated until five days after the symptoms began, despite the ICP acknowledging that precautions should have started when symptoms were first observed. This delay in implementing contact precautions was confirmed during an interview with the ICP.
Inadequate Mattress Support for Resident
Penalty
Summary
The facility failed to provide an appropriate mattress for a resident, leading to discomfort and potential risk for pressure development. The resident, who was cognitively intact and required assistance for transferring and bed mobility, reported feeling the bars of the bed frame through the mattress and noted that the bed controls were non-functional. Upon investigation, it was confirmed that the mattress did not adequately support the resident's weight, allowing her body to rest on the metal bed frame. Despite the mattress being rated to support up to 300 pounds, the resident, weighing 189 pounds, experienced discomfort and inadequate support. Interviews with facility staff revealed a lack of communication and documentation regarding mattress audits and checks. The Maintenance Director could not provide details or documentation of any mattress audits, and the Wound Care Nurse was unaware of the resident's complaints. The Unit Clerk indicated that the Unit Manager was responsible for ensuring appropriate mattresses based on hospital information, but there was no evidence of this process being followed. Additionally, the Housekeeping/Laundry Supervisor confirmed that mattresses were not checked during room changes, and the most recent quarterly audit did not document any concerns related to the resident's bed.
Failure to Develop Protocol for Medical Record Requests
Penalty
Summary
The facility failed to develop a protocol for the release of medical records requested on behalf of a resident's legal representative, resulting in a deficiency. The medical record request log from January 2024 to September 2024 showed no entries related to the resident in question. An interview with the Medical Records staff revealed that two requests for the resident's records were received, but these were forwarded to the former owners without a tracking mechanism to verify completion. The Director of Nursing acknowledged the lack of a process to handle such requests when they cannot be honored by the current facility. Further interviews with the Nursing Home Administrator (NHA) revealed that legal requests for medical records are sent to a third-party vendor for validation. The first request was denied, and the outcome of the second request was unclear due to it being sent to the wrong person. The NHA noted that the staff responsible for handling these requests was new to the position and that there was no written policy or protocol to ensure that legal requests submitted on behalf of a resident's representative are honored.
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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