Nspire Healthcare Lauderhill
Inspection history, citations, penalties and survey trends for this long-term care facility in Lauderhill, Florida.
- Location
- 2599 Nw 55th Ave, Lauderhill, Florida 33313
- CMS Provider Number
- 105680
- Inspections on file
- 22
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Nspire Healthcare Lauderhill during CMS and state inspections, most recent first.
A resident with complex medical needs received IV antibiotics and IV line flushing from an LPN who did not have the required IV therapy certification or training. Staff interviews confirmed that LPNs were performing IV-related tasks without proper certification, and the facility was unable to provide documentation verifying the LPN's qualifications, despite facility policy and professional standards requiring such certification.
The facility failed to treat residents with dignity during dining, leaving several waiting for meals while others ate. Additionally, a resident with severe cognitive impairment did not receive necessary assistance with eating, despite requiring substantial maximum assistance. Observations showed untouched meal trays, indicating a lack of staff support.
The facility failed to ensure that bathroom emergency call lights were accessible for residents and staff in a secure unit. Observations over three days revealed that emergency cords were tied, wrapped, or missing in the bathrooms of several residents with various medical conditions, including dementia and cognitive impairments. Despite staff acknowledgment of the issue, some bathrooms remained non-compliant until surveyor intervention.
A resident with PTSD and on anticoagulant medication did not have appropriate care plans in place. The resident, with moderate cognitive impairment, was admitted with multiple diagnoses including PTSD and was prescribed Eliquis for A-fib. Despite physician's orders to monitor for bleeding, the facility lacked care plans for both PTSD and anticoagulant use, as confirmed by the MDS Coordinator.
A resident with severe cognitive impairment did not receive necessary vision services due to the facility's failure to arrange an eye doctor appointment, despite a family member's request. The Social Service Director initially believed the appointment had been made but later confirmed it had not, resulting in the resident not receiving the needed care.
Two residents with severe cognitive impairment experienced significant weight loss due to the facility's failure to provide timely nutritional interventions. Despite low meal intake and fluctuating appetites, the Clinical Dietitian and Registered Dietician delayed addressing the weight loss. Observations revealed inadequate assistance during meals, contributing to ongoing nutritional deficiencies.
A resident with a history of Hemiplegia and Chronic Kidney Disease experienced significant weight loss due to the facility's failure to follow physician's orders for tube feeding. Observations showed discrepancies in the administered formula amount, and staff reported a malfunctioning pump. The resident's behavior of pulling out the feeding tube was mentioned but not documented.
A facility failed to assess and provide psychosocial services for a resident with PTSD. The resident, a veteran, was not screened for PTSD upon admission, and staff were unaware of his triggers. The MDS Coordinator did not create a care plan, and the resident was not seen by a psychiatrist until a month later. The facility's PTSD policy was not followed, leading to a delay in addressing the resident's needs.
A facility failed to provide necessary psychosocial services for a resident with PTSD. The resident, a veteran, was admitted with PTSD but was not screened or provided with an individualized care plan as required by the facility's policy. The Social Service Director was unaware of her responsibilities regarding PTSD care, and the facility lacked a PTSD screening tool, leading to inadequate care for the resident's condition.
The facility failed to maintain accurate records for controlled medications for two residents. One resident's Tramadol administration was not documented in the MAR despite being given, and another resident's Oxycodone was signed out without date or time documentation. Staff acknowledged the oversight, citing distractions as a reason for incomplete records.
The facility failed to provide the correct diet consistency for two residents on a mechanical soft diet. Observations revealed that residents were served cooked red cabbage in pieces too large and tough for the diet's requirements, leading to one resident coughing. The Speech Language Pathologist confirmed the inconsistency and discussed it with the dietary team.
The facility failed to maintain food safety and hygiene standards in the Main Kitchen. Issues included flying insects near an open dumpster, disconnected drainage treatment, and improper temperature control in refrigeration units. Additionally, food storage practices were inadequate, with unlabeled and opened packages found. An Activity Coordinator was observed not washing hands after touching personal items before feeding a resident.
The facility failed to accurately document high-risk medication use in MDS assessments for two residents. One resident was incorrectly noted as taking an anticoagulant instead of an antiplatelet, while another was mistakenly documented as receiving an anticoagulant due to confusion with Procrit injections. The MDS Coordinator acknowledged the errors, attributing them to being overwhelmed and confused about medication classifications.
LPNs Administered IV Antibiotics Without Required Certification
Penalty
Summary
Licensed Practical Nurses (LPNs) at the facility were found to lack the required competencies and certifications to administer intravenous (IV) antibiotics, as evidenced by record reviews and staff interviews. Specifically, one LPN administered IV antibiotics and performed IV line flushing for a resident without having completed the mandated IV therapy certification and post-graduation training, which includes 30 hours of IV hydration training and 4 hours dedicated to central line care. The facility's professional standards require these certifications for LPNs performing such tasks, but documentation of the required certification for the LPN in question was not provided to the surveyor, despite requests. The resident involved had complex medical needs, including a recent admission with diagnoses such as sepsis following a hospital procedure, acute respiratory failure, alkalosis, and osteomyelitis. The resident was receiving multiple medications, including IV antibiotics, anticoagulants, and opioids. Interviews with staff revealed that LPNs were administering IV medications without the necessary certification, and there was a lack of awareness among some staff and consultants regarding the certification requirements. The Director of Nursing stated that LPNs providing IV care had the required certifications but was unable to produce documentation to verify this for the LPN who administered care to the resident.
Failure to Ensure Dignified Dining and ADL Assistance
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner during dining, affecting eight of the sampled residents. Observations revealed that several residents were left waiting for their meals while others at the same table were already eating. For instance, Resident #19 and Resident #90 were observed waiting for their lunch meals while their tablemates were already eating. Similarly, Resident #73 was observed waiting for her lunch meal while her tablemate was eating. Additionally, Resident #83 did not receive her lunch tray until 35 minutes after her roommate had started eating. Interviews with staff indicated that they were educated on serving meals with dignity, yet the practice of serving one table at a time was not consistently followed. The facility also failed to provide necessary assistance with Activities of Daily Living (ADLs) for Resident #73, who has severe cognitive impairment and requires substantial maximum assistance for eating. Observations showed that Resident #73's breakfast and lunch trays were left untouched, indicating a lack of assistance from staff. Despite the care plan highlighting Resident #73's need for significant help during meals, staff interviews revealed inconsistent assistance, with some days Resident #73 eating only 40% of her meals. The MDS Coordinator confirmed that residents coded for substantial maximum assistance require staff to be present to assist them throughout mealtimes.
Inaccessible Emergency Call Lights in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the bathroom emergency call light system was accessible and within easy reach for residents and staff members in a secure, locked unit. This deficiency was observed in the bathrooms of seven residents, where the emergency call cords were either tied around bathroom bars, wrapped around handrails, or missing entirely. These observations were made over a three-day period, and photographic evidence was obtained to document the inaccessibility of the emergency call systems. The residents affected by this deficiency had various medical conditions, including dementia, diabetes, hypertension, schizophrenia, and other cognitive impairments. Their Brief Interview Mental Status (BIMS) scores ranged from severe cognitive impairment to being cognitively intact. Despite their varying levels of cognitive function, all residents were observed to self-propel in their wheelchairs in and out of their bathrooms throughout the day, highlighting the importance of having accessible emergency call systems. Interviews with facility staff, including the Maintenance Director, Housekeeping Director, Director of Nursing, Regional Nurse, Regional Maintenance Director, and the Administrator, confirmed that the emergency call lights should be readily accessible. However, three of the four resident bathrooms remained non-compliant until surveyor intervention. Even after multiple observations, one bathroom's emergency call light remained inaccessible, indicating a persistent failure to address the deficiency.
Failure to Implement Care Plans for PTSD and Anticoagulant Use
Penalty
Summary
The facility failed to implement a care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD) and on anticoagulant medication. The resident, who was admitted post-hospitalization with diagnoses including Unspecified Cirrhosis of Liver, Coronary Artery Disease, Non-Alzheimer's Dementia, and PTSD, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. Despite these conditions, the facility did not have a care plan addressing the resident's PTSD, as confirmed by the MDS Coordinator during an interview. Additionally, the resident was prescribed Eliquis (Apixaban) for Atrial Fibrillation, with physician's orders to monitor for signs of bleeding due to the anticoagulant. However, the facility did not have a care plan in place to address the anticoagulant use or the associated risk of bleeding. The MDS Coordinator acknowledged the necessity of such a care plan during an interview, highlighting the oversight in care planning for this resident.
Failure to Assist Resident with Vision Services
Penalty
Summary
The facility failed to assist a resident, identified as Resident #89, in obtaining necessary vision services. Resident #89, who was admitted with diagnoses including unspecified dementia with severe cognitive impairment, was noted to require corrective lenses. Despite a family member's request for an eye doctor appointment approximately two months prior, the facility did not arrange for the resident to be seen by an eye doctor. The family member had temporarily provided over-the-counter reading glasses for the resident. Interviews revealed that the Social Service Director (SSD) initially believed the resident had been seen by an eye doctor, but later confirmed that no appointment had been made. The SSD acknowledged the oversight and admitted to not following up with the family member after speaking with the resident, who had severe cognitive impairment. This lack of action resulted in the resident not receiving the necessary vision care as requested by the family member.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to identify and address significant weight loss and provide timely nutritional intervention for two residents, leading to a deficiency in maintaining their nutritional health. Resident #32, who had severe cognitive impairment and multiple diagnoses including muscle wasting and anemia, experienced a weight loss of 8.9% over three months. Despite the resident's low meal intake, averaging 46% from 08/13/24 to 08/30/24, the Clinical Dietitian did not address the weight loss until 24 days after it was identified, delaying necessary nutritional interventions. Resident #7, also with severe cognitive impairment and multiple health conditions, showed a weight loss of 6.55% over six months. The resident's meal consumption varied significantly, with some meals entirely untouched. Despite the resident's fluctuating appetite and low protein levels, the Registered Dietician did not consider the weight loss significant enough to trigger immediate action. The resident's nutritional supplement was only increased after a continued trend of weight loss was observed. Both residents were observed to have inadequate assistance and encouragement during meals, with staff failing to offer alternative food options or ensure the consumption of prescribed nutritional supplements. These inactions contributed to the residents' ongoing nutritional deficiencies, highlighting a lack of timely and effective intervention by the facility's staff and dietitians.
Failure to Follow Tube Feeding Orders
Penalty
Summary
The facility failed to adhere to the physician's orders for tube feeding for a resident with a history of Hemiplegia, History of falling, Muscle Weakness, and Chronic Kidney Disease. The resident was readmitted to the facility with specific orders for enteral feeding using Jevity 1.5 at a rate of 75 ml per hour for 20 hours. However, observations on multiple occasions revealed discrepancies in the amount of formula administered compared to the expected amount based on the prescribed rate. For instance, on one occasion, the feeding bottle was observed to be at the 850 ml mark when it should have been at the 700 ml mark, indicating an over-administration of the formula. The resident experienced a significant weight loss of 9.8% over three months, which was noted by the Clinical Dietitian, who adjusted the feeding orders to continuous feedings due to the weight loss. Interviews with staff revealed that there was a malfunctioning of the tube feeding pump, and bolus feedings were administered to compensate for the feeding needs. The Director of Nursing mentioned that the resident had a behavior of pulling out the feeding tube, which might have contributed to the weight loss, but no documentation was provided to support this claim.
Failure to Assess and Provide Services for PTSD
Penalty
Summary
The facility failed to timely assess and provide appropriate psychosocial services to a resident diagnosed with Post Traumatic Stress Disorder (PTSD). Upon admission, the resident, a veteran with PTSD, was not screened using a standardized tool as per the facility's policy. The resident expressed that loud noises triggered flashbacks related to his wartime experiences. Despite this, the staff, including a Registered Nurse and the Social Service Director, were unaware of the resident's specific triggers and did not engage in discussions about his PTSD. The MDS Coordinator, responsible for care planning, had not initiated a care plan for PTSD, and the resident had not been seen by a psychiatrist until a month after admission. The facility's PTSD policy, which mandates screening and individualized care plans for residents with PTSD, was not followed. The Regional Nurse Consultant confirmed that the facility was not using the PTSD checklist tool, and no residents had been screened for PTSD. The Psychiatrist, who assessed the resident only after the surveyor's inquiry, noted the resident's hallucinations and initiated treatment with Seroquel. The lack of communication and adherence to the facility's policy resulted in a delay in addressing the resident's PTSD needs, highlighting a deficiency in the facility's care processes.
Failure to Provide PTSD Services
Penalty
Summary
The facility failed to provide necessary psychosocial services for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy required that all residents be screened for PTSD upon admission using a standardized tool, and those identified with PTSD should receive individualized care plans. However, the facility did not have a PTSD screening tool in use, and the Social Service Director was unaware of her responsibilities regarding PTSD care planning. The resident, a veteran with PTSD, was admitted with a history of flashbacks triggered by loud noises, but his social services evaluation did not include his PTSD diagnosis, and a relevant question on the assessment was marked as not applicable. Interviews with the Social Service Director revealed a lack of understanding and action regarding the resident's PTSD needs. The Director stated she did not handle PTSD cases and incorrectly marked the assessment question about traumatic experiences as not applicable, rather than noting the resident's refusal to answer. The Regional Nurse Consultant confirmed that no PTSD screenings had been conducted due to the absence of a tool, indicating a failure to adhere to the facility's policy and provide appropriate care for the resident's PTSD diagnosis.
Failure to Maintain Accurate Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate drug records and ensure proper documentation for controlled medications for two residents. Resident #19, who was admitted with diagnoses including obesity and muscle weakness, had a physician's order for Tramadol HCL 50mg to be administered as needed for pain. However, the Medication Administration Record (MAR) for July and August 2024 did not document the administration of Tramadol on specific dates, despite the Medication Monitoring / Control Record indicating it was given. Interviews with staff revealed lapses in documenting the date and time on the Medication Monitoring / Control Record, with staff acknowledging the oversight. Similarly, for Resident #306, who was admitted with conditions such as hemiplegia and type 2 diabetes, there was an order for Oxycodone HCL 5mg to be given as needed. The Medication Monitoring / Control Record showed the medication was signed out without indicating the date or time, although the MAR documented its administration on a specific date in September 2024. Staff interviews confirmed the failure to complete the Medication Monitoring / Control Record accurately, citing distractions as a possible reason for the incomplete documentation.
Inappropriate Diet Consistency for Mechanical Soft Diet
Penalty
Summary
The facility failed to provide the appropriate diet consistency for residents on a mechanical soft diet, specifically affecting two residents during dining observations. The facility's 'National Dysphagia Diet Level 3 Advanced' guidelines require that food be served moist and in bite-size pieces less than 1 inch long, avoiding hard, sticky, or crunchy foods. However, during a dining observation, Resident #73, who had severe cognitive impairment, was served cooked red cabbage in strips of approximately 2-3 inches, which was difficult to cut and not suitable for the mechanical soft diet. This resulted in the resident coughing after consuming the cabbage. Similarly, Resident #41, who had moderate cognitive impairment, was observed eating a meal in his room without staff supervision, which included cooked red cabbage pieces of 2-3 inches long, inconsistent with the mechanical soft diet requirements. The Speech Language Pathologist confirmed that the red cabbage served was inappropriate for the diet consistency and discussed the issue with the Clinical Dietitian and Dietary Manager, noting that the cabbage was not cooked enough to meet the dietary guidelines.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during a survey of the Main Kitchen. During the inspection, small flying insects were observed in the dishwashing area near an open garbage dumpster, and a drainage treatment system was found disconnected. The Kitchen Manager acknowledged the presence of insects and attempted to connect the treatment system. Additionally, the walk-in refrigerator was found to have an internal temperature of 55 degrees Fahrenheit, above the recommended 40 degrees Fahrenheit or below, with water condensation present and carton boxes feeling wet. The Kitchen Manager removed the internal thermometer, suspecting it was faulty. Similarly, a reach-in freezer in the Dry Storage Room showed a temperature of 38 degrees Fahrenheit instead of the recommended 0 degrees Fahrenheit or below, leading the Kitchen Manager to remove its thermometer as well. Further deficiencies were noted in food storage practices. An opened package of frozen tortillas in the walk-in freezer was not labeled or dated for expiration. In the Dry Storage Room, an opened package of cheesecake filling was found at the bottom of a box, which the Dietary Manager discarded and cleaned. Additionally, an incident involving Staff D, an Activity Coordinator, was observed where she failed to wash her hands after touching personal items before continuing to feed a resident, compromising food safety and hygiene standards.
Inaccurate MDS Assessments for High-Risk Medications
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents regarding their use of high-risk medications. For one resident, the MDS assessment incorrectly documented the use of an anticoagulant, despite the resident only being prescribed aspirin 81 mg for coronary artery disease, which should have been classified as an antiplatelet. The MDS Coordinator acknowledged the error, stating that aspirin at this dosage was not considered an antiplatelet, which led to the incorrect classification. For the second resident, the MDS assessment inaccurately indicated the use of an anticoagulant, although the resident had no orders for anticoagulants or antiplatelets. The resident was receiving Procrit injections for anemia, which the MDS Coordinator mistakenly associated with anticoagulant use. The MDS Coordinator admitted to being overwhelmed and confused about the medication classifications, leading to the errors in the MDS documentation for both residents.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
