North Lake Care Center And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Park, Florida.
- Location
- 750 Bayberry Drive, Lake Park, Florida 33403
- CMS Provider Number
- 105640
- Inspections on file
- 20
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at North Lake Care Center And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment eloped from a facility through an unsecured second-floor door. The resident, identified as at risk for elopement, was able to exit due to inadequate supervision and security measures. The resident was found 0.3 miles away after crossing a busy road and railroad tracks. The facility's elopement risk evaluation and care plan interventions were not effectively implemented, and the door alarm was not audible to staff.
The facility failed to provide adequate housekeeping and maintenance services, resulting in a failure to maintain a clean, comfortable, sanitary, and homelike environment in 9 of 30 rooms and the Community Shower Room. Observations included clogged sinks and toilets, unsecured faucets, missing drain plugs, dirty basins and faucets, worn overbed tables, duct tape on air conditioning units, loose toilet seat rails, and debris under beds. The Community Shower Room had an odor similar to sewage.
The facility failed to follow its Enhanced Barrier Precautions (EBP) policies for 17 of 18 residents, as PPE was not available at or outside residents' doors. Additionally, the laundry rooms were inadequately maintained, with peeling paint, accumulated dirt, and debris in sorting bins, and foreign matter in industrial dryers, posing a risk of cross-contamination.
The facility failed to ensure that a resident received showers according to her preferences and the facility's schedule. Despite being cognitively intact and expressing a desire for weekly showers, the resident was rarely offered showers, and the facility's documentation did not specify whether she received a bath or a shower.
The facility failed to maintain the fingernails of two residents, leading to dissatisfaction and delayed care. Staff interviews revealed confusion about responsibility and restrictions regarding nail trimming, contributing to the deficiency.
The facility failed to ensure the safe transfer of a resident, resulting in skin damage, and did not provide necessary safety devices for residents while smoking. A resident sustained a 4-inch cut during a Hoyer lift transfer performed by a CNA alone, despite the expectation of two staff members for such transfers. Additionally, another resident was observed smoking without a required smoking apron on multiple occasions, contrary to the facility's smoking policy.
A facility failed to assess a resident for bed rail risks, obtain physician's orders, and initiate a care plan for bed rail use. The resident, with multiple diagnoses and dependent on staff for mobility, requested bed rails to prevent falls, but the facility did not follow its policy for evaluation and documentation.
The facility failed to follow physician's orders for medication administration timing for three residents, leading to late administration and potential drug interactions. One resident received two medications with a potential interaction at the same time, another reported inconsistent timing for night medications, and a third experienced late administration of ADHD medication, affecting sleep.
A pharmacist failed to identify a timing issue with a possible drug-to-drug interaction for a resident receiving both mirtazapine and alprazolam. The medications were administered together despite orders to separate them, which was overlooked in monthly reviews, potentially causing added sedative effects, CNS depression, and respiratory depression.
The facility failed to monitor behaviors as ordered by the physician for five residents on psychotropic medications. Multiple instances of missing documentation were found in the Behavior Monitoring Flow Sheets for April and May 2024. The Director of Nursing and Regional Clinical Consultant acknowledged these deficiencies.
A resident with multiple diagnoses left the facility and did not return as anticipated. The facility failed to document the resident's discharge accurately and promptly, leading to confusion about the resident's status. Staff interviews revealed attempts to contact the resident and involve the police, but these actions were not documented in the resident's chart until much later.
The facility failed to offer, educate, and obtain consent for the pneumonia vaccine for five residents. Documentation and education regarding the benefits and potential side effects of the vaccine were not provided as required by the facility's policy. The DON acknowledged the oversight, which was partly due to a misunderstanding of CDC guidelines.
The facility failed to maintain and inspect bed rails for a resident, leading to bed rails not staying in a raised position. The Director of Maintenance was unaware of the issue and could not provide documentation of regular inspections, despite the facility's policy requiring routine checks and reporting to the QAPI committee.
The facility failed to ensure the accessibility and functionality of call bells for two residents. One resident's call device was found on the floor and later not in sight, while another resident's call bell system was not functioning, requiring him to rely on his roommate for assistance. Staff were aware of the issues but did not resolve them in a timely manner.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide appropriate supervision to a resident assessed as at risk for elopement, resulting in the resident exiting the facility through an unsecured door on the second floor. The resident, who had severe cognitive impairment with a BIMS score of 00, was able to leave the facility on a Saturday evening when there were no staff present in the area. The resident was found approximately 0.3 miles away in an industrial area, having crossed a busy road and active railroad tracks. The resident's care plan, initiated a few days before the incident, identified the resident as having a potential for elopement due to cognitive impairment and wandering behavior. Despite this, the facility's elopement risk evaluation and care plan interventions were not effectively implemented. The resident was able to navigate through the facility and exit through a door that was not secured with a magnetic lock, as it was not considered a resident area. The alarm on the door was not audible to staff, and there were no staff present to respond to the alarm. Interviews with facility staff revealed that the resident had been seen in the upstairs area the previous evening and redirected, but this information was not communicated effectively. The facility's investigation determined that the second floor was not identified as a risk area, and the door was not secured in a manner consistent with other doors in the facility. The lack of supervision and inadequate security measures contributed to the resident's ability to elope from the facility.
Removal Plan
- An Ad hoc QAPI with Root Cause Analysis was performed with the IDT team, including: the Administrator, the Regional Director of Operations, the Regional Clinical Director, the Regional Maintenance Director. QAPI meetings were scheduled for the last Thursday of each month.
- All current residents' Elopement Assessment were reviewed and updated by nursing. There were no newly identified residents at high risk of elopement.
- Staff education was initiated to include Abuse and Neglect policy and procedure, Elopement policy and procedure, and new processes of closing the dining room door when the room is not in use.
- Elopement drills were conducted daily up to every shift daily to continue on for 14 days, then weekly for 4 weeks, then monthly thereafter.
- The Senior Safety and Technology company installed Maglock (mag) on the second-floor exit door next to HR department office and the door between the unit and the Activities/Dining room for added security.
- Education on the Identifying residents with behavioral symptoms that put the residents at risk for elopement was initiated.
- Daily audits of the doors and alarms were initiated and the results reported to QAPI/QA Committee of the findings.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in a failure to maintain a clean, comfortable, sanitary, and homelike environment in 9 of 30 rooms and the Community Shower Room. Specific deficiencies observed included clogged sinks and toilets, unsecured faucets, missing drain plugs, dirty basins and faucets, worn and exposed particle board on overbed tables, lack of overbed tables, duct tape covering screens on air conditioning units, loose toilet seat rails, and accumulation of debris under beds. Additionally, the Community Shower Room had an odor similar to sewage emanating from the shower and sinks. These observations were made during an environmental tour conducted with the Director of Maintenance, who acknowledged understanding of the findings. The deficiencies indicate a lack of proper maintenance and housekeeping services, compromising the residents' right to a safe, clean, comfortable, and homelike environment. The issues identified could potentially impact the residents' daily living and overall well-being.
Infection Control and Laundry Room Maintenance Deficiencies
Penalty
Summary
The facility failed to follow its own policies and procedures for Enhanced Barrier Precautions (EBP) for 17 of 18 residents, as evidenced by the absence of gowns at or outside the residents' doors. The Director of Nursing (DON) confirmed that the facility follows CDC guidelines, which require PPE (gowns and gloves) to be located at the residents' doors. However, observations revealed that multiple rooms with EBP signs did not have the required gowns available, and the existing PPE was inadequately distributed across divisions, with some divisions lacking the necessary PPE entirely. This failure was observed despite the DON's assertion that PPE was available on blue linen carts and in central supply rooms, indicating a significant lapse in adherence to infection control protocols. Additionally, the facility's laundry rooms were found to be inadequately maintained, posing a risk of cross-contamination. The dirty laundry room had peeling paint with loose edges, which could contaminate the laundry. Sorting bins in the dirty laundry area had accumulated dirt and refuse beneath their false bottoms, and similar issues were found in bins used for clean laundry. The clean laundry folding area also had debris under the false bottoms of bins, and workers were observed mishandling potentially contaminated items. Furthermore, the industrial dryers had foreign matter adhering to the drum surfaces, and the floors in both the dirty and clean laundry areas had large areas of peeling paint, further risking contamination of clean laundry. These deficiencies highlight significant lapses in the facility's infection prevention and control program, particularly in the areas of PPE availability and laundry room maintenance. The observations and interviews conducted during the survey indicate a failure to adhere to established policies and CDC guidelines, thereby compromising the facility's ability to prevent the spread of multi-resistant organisms (MDROs) and maintain a clean environment for residents and staff.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that Resident #19 received showers according to her preferences and the facility's schedule. Resident #19, who was cognitively intact with a BIMS score of 15, expressed that she was rarely offered showers and would like to have them at least weekly. The facility's documentation indicated that her bathing schedule was set for Mondays and Thursdays during the 3 PM to 11 PM shifts, but it did not specify whether she received a bath or a shower. Interviews with staff revealed that there was a shower book and that refusals were to be documented in the EMR after consulting with a nurse. However, the documentation did not differentiate between a bath and a shower, and there was no clear record of whether Resident #19's preferences were being honored. During interviews, staff confirmed the process for documenting showers but acknowledged that the records did not specify whether a bath or a shower was provided. This lack of specificity in the documentation and the failure to offer showers as per the resident's preference led to the deficiency. The facility did not ensure that Resident #19's right to choose between a bath and a shower was respected, as required by her comprehensive Admission MDS.
Failure to Maintain Residents' Fingernails
Penalty
Summary
The facility failed to maintain the fingernails of two residents, Resident #45 and Resident #48, as observed and reported during a survey. Resident #45 was noted to have fingernails extending about 1/2 inch past his fingertips on both hands. Despite expressing a desire to have his nails trimmed, the resident's fingernails remained untrimmed for several days until they were finally addressed. Similarly, Resident #48 had fingernails extending at least 1/2 inch beyond his fingertips and expressed dissatisfaction with their length. The resident mentioned having to pay for nail trimming services in the past and indicated that the facility staff had not trimmed his nails despite his requests. His nails were eventually trimmed after several days of waiting and asking the staff for assistance. Interviews with staff revealed a lack of clarity regarding the responsibility for nail care. A Certified Nursing Assistant (CNA) indicated that while the Activities staff typically performed nail trimming, the responsibility for ensuring it was done fell to the nurses and CNAs. The CNA also mentioned a belief that they were not allowed to trim the fingernails of diabetic residents, although this restriction was not clearly stated in the facility's policy. This confusion and lack of timely action led to the deficiency in maintaining proper nail care for the residents.
Failure to Ensure Safe Transfers and Smoking Safety
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in skin damage. Resident #18, who has multiple diagnoses including quadriplegia and contractures, was being transferred via a Hoyer lift by a CNA with the assistance of the resident's mother. During the transfer, the resident sustained a 4-inch cut on the left elbow. The Director of Nursing (DON) confirmed that the CNA performed the transfer alone, despite the facility's expectation that two staff members should be involved in such transfers. The facility does not have a formal policy requiring two staff members for Hoyer lift transfers, which contributed to the incident. Additionally, the facility failed to provide necessary safety devices for residents while smoking. Resident #80, who has a history of nicotine dependence and other medical conditions, was observed smoking without a required smoking apron on multiple occasions. The facility's smoking policy mandates the use of smoking aprons to ensure safety, but the aprons were not provided to the residents. Interviews with staff revealed that the aprons were kept in the Activities closet and were not consistently made available to residents, leading to lapses in safety measures. These deficiencies highlight lapses in the facility's adherence to safety protocols, both in the context of resident transfers and smoking safety. The lack of proper supervision and equipment contributed to the incidents involving Resident #18 and Resident #80, respectively. The facility's failure to follow established safety practices resulted in harm and potential risk to the residents involved.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for the risks associated with the use of bed rails, obtain physician's orders for the use of bed rails, and initiate a care plan for the use of bed rails for one resident. The facility's policy on bed safety and bed rails, revised in August 2022, outlines the necessary steps for evaluating and implementing bed rails, including an interdisciplinary evaluation, risk assessment, and obtaining input from the resident and/or responsible party. However, these steps were not followed for Resident #134, who was observed using half side rails on the bed without a documented assessment, care plan, or physician's orders. Resident #134, who was admitted with multiple diagnoses including anemia, hypertension, chronic lung disease, and dependence on renal dialysis, had a BIMS score indicating cognitive intactness. The resident was dependent on staff for transfer and bed mobility and was frequently incontinent of urine and always incontinent of bowel. Despite the resident's request for bed rails to prevent falling out of bed, the facility did not conduct the required risk assessment or obtain the necessary physician's orders and care plan documentation for the use of bed rails.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to follow physician's orders related to the timing for administration of medication for three residents. Resident #19 was receiving two medications, mirtazapine and alprazolam, which had a potential drug interaction and were ordered to be administered at different times. However, both medications were administered at 9:00 PM, contrary to the physician's order. This error was identified during a side-by-side record review and interview with the LPN/Unit Manager, who acknowledged the mistake in scheduling the alprazolam order upon the resident's admission. Resident #63, who was cognitively intact, reported not receiving his night medications at the prescribed bedtime of 9:00 PM. Instead, the medications were administered at varying times, ranging from 6:30 PM to after midnight. The review of the Medication Administration Record (MAR) confirmed that the medications were often given late, with timestamps showing administration times well past the scheduled 9:00 PM slot. The Consultant Nurse agreed with these findings upon review. Resident #68, who had diagnoses including Generalized Anxiety Disorder and ADHD, also experienced issues with medication timing. The resident's ADHD medication, Dextroamphetamine Sulfate, was ordered to be administered three times a day at specific times. However, the medication was given more than one hour late on nine occasions out of 45 opportunities, with one instance being over two hours late. The resident reported that the late administration interfered with her sleep. The Director of Nursing and the Regional Clinical Consultant acknowledged the discrepancies in medication administration times during an interview.
Pharmacist Overlooked Drug Interaction Timing Issue
Penalty
Summary
The pharmacist failed to identify a timing issue with a possible drug-to-drug interaction for Resident #19. The resident was admitted with diagnoses including major depression and anxiety disorders and was receiving both an antidepressant (mirtazapine) and an antianxiety medication (alprazolam). The order for alprazolam specifically stated it should not be administered with mirtazapine. However, the Medication Administration Record (MAR) showed that both medications were being administered at 9:00 PM, contrary to the order which scheduled alprazolam for 6:00 PM. This error was identified during a side-by-side record review and interview with a Licensed Practical Nurse (LPN)/Unit Manager, who confirmed the mistake was made upon the resident's admission. Pharmacy reviews from January 2024 through April 2024 did not include any recommendations for Resident #19, indicating that the Consultant Pharmacist overlooked the issue. During a phone interview, the Consultant Pharmacist acknowledged the oversight and explained that administering both medications together could cause added sedative effects, CNS depression, and respiratory depression. This deficiency highlights a failure in the monthly drug regimen review process, as the pharmacist did not identify the critical timing issue and potential drug interaction for the resident.
Failure to Monitor Behaviors as Ordered for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to monitor behaviors as ordered by the physician related to psychotropic medications for five of six sampled residents. Resident #19 was admitted with orders to monitor behaviors twice daily and document interventions and outcomes, but there were multiple instances in May and April 2024 where this monitoring was not performed. Specifically, there were 6 out of 29 shifts in May and 20 out of 60 shifts in April where behavior monitoring was not documented for Resident #19. Resident #35, who was admitted with diagnoses including Lymphedema, Major Depressive Disorder, and Anxiety Disorder, also had lapses in behavior monitoring. The Behavior Monitoring Flow Sheet for May 2024 showed that interventions, medication management, and side effects were not documented for 8 out of 30 opportunities. Similarly, Resident #68, with diagnoses including Generalized Anxiety Disorder and Major Depressive Disorder, had 15 out of 30 opportunities in May 2024 where behavior monitoring was not documented. Resident #64, admitted with Anxiety Disorder and Unspecified Psychosis, had severe cognitive impairment and also experienced lapses in behavior monitoring. The Behavior Monitoring Flow Sheet for May 2024 revealed that interventions, medication management, and side effects were not documented for 20 out of 45 opportunities. Lastly, Resident #236, with diagnoses including Dementia and Major Depressive Disorder, had 2 out of 3 opportunities in May 2024 where behavior monitoring was not documented. The Director of Nursing and Regional Clinical Consultant acknowledged these deficiencies during an interview on May 16, 2024.
Failure to Ensure Accurate Documentation of Resident Discharge
Penalty
Summary
The facility failed to ensure the accuracy of records for a resident, leading to a deficiency in maintaining accurate documentation of the resident's discharge. The resident, who had diagnoses including Anxiety Disorder, Alcohol Abuse, and Nicotine Dependence, left the facility after signing out and did not return as anticipated. Despite the resident's clear communication that he would not return until a later date, the facility did not document this information accurately in the resident's medical record until much later. Interviews with staff revealed that the resident had a history of signing out and returning the same day, but on this occasion, he informed the staff that he would not return until the following Monday. The staff attempted to contact the resident and his family, and even involved the police for a wellness check, but there was no immediate documentation of these actions in the resident's chart. The lack of timely documentation led to confusion about the resident's discharge status. The MDS Director initially coded the discharge as 'return anticipated' and only changed it to 'return not anticipated' after receiving supporting documentation much later. The Administrator and other staff acknowledged the absence of proper documentation in the resident's chart regarding the resident leaving against medical advice (AMA) and the subsequent actions taken by the facility. This failure to document accurately and promptly resulted in a deficiency in maintaining the resident's medical records according to accepted professional standards.
Failure to Offer and Document Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer, educate, and obtain consent for the pneumonia vaccine for five residents. Specifically, Residents #53 and #18 did not have Pneumococcal consents or refusals documented, and none of the five residents had evidence of being offered the vaccines or provided with education. The facility's policy requires that residents or their legal representatives receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine, and that this education is documented in the resident's medical record. However, this was not adhered to in the cases reviewed. During the review, it was found that Resident #53 had documentation of refusal for the Influenza vaccine but no consent or refusal for the Pneumonia and COVID-19 vaccines. Similarly, Resident #18 had consent for the Influenza vaccine but no other consents. The Director of Nursing (DON) acknowledged the lack of documentation and education, mistakenly believing that the CDC guidelines only required the Pneumonia vaccine for individuals of a certain age. This misunderstanding contributed to the failure to offer and document the necessary vaccinations and education for the residents.
Failure to Maintain and Inspect Bed Rails
Penalty
Summary
The facility failed to ensure bed rails were maintained in working condition and inspected for fitness and function for one of the two sampled residents reviewed for bed rails. The facility's policy required maintenance staff to routinely inspect all beds and related equipment to identify risks and problems, including potential entrapment risks. However, the Director of Maintenance was unaware of the concerns with the bed rails not staying in a raised position for the resident. The resident, who was cognitively intact and dependent on staff for transfer and bed mobility, reported that the bed rails had not stayed in a raised position since being admitted. The Director of Maintenance later fixed the bed rails by readjusting and tightening the holding mechanism and pin, but there was no documentation of regular inspections performed as required by the facility's policy. The resident's care plan included the use of bed rails as an enabler for bed mobility, and the resident had multiple diagnoses, including anemia, hypertension, chronic lung disease, and dependence on renal dialysis. Despite the facility's policy stating that maintenance staff should provide a copy of inspections to the administrator and report results to the QAPI committee, the Director of Maintenance was unable to generate documentation of audits or maintenance of the side rails and bed from the electronic system. This lack of documentation and awareness of the bed rail issues led to the deficiency identified by the surveyors.
Inaccessible and Non-Functional Call Bells for Residents
Penalty
Summary
The facility failed to ensure the accessibility and functionality of call bells for two residents. For Resident #9, observations revealed that the call device was on the floor next to the bed and later not in sight when the resident was in a wheelchair. Interviews with the resident confirmed that she was unaware of the call device's location, indicating a lack of accessibility to the call system. The resident's care plan emphasized the need for assistance with personal care tasks and mobility, but the call system's inaccessibility hindered this support. For Resident #53, the call bell system was not functioning, and the resident had to rely on his roommate to call for assistance. The resident had been waiting for a new bed for two months due to the malfunctioning call bell. The Maintenance Director was unaware of the issue until the surveyor's interview, and there was no documentation in the electronic work record system. The Maintenance Director attempted to fix the device but was unsuccessful, and a new device was arranged for delivery. Interviews with staff confirmed awareness of the problem but indicated a lack of timely resolution and proper documentation.
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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