Nspire Healthcare Tamarac
Inspection history, citations, penalties and survey trends for this long-term care facility in Tamarac, Florida.
- Location
- 5901 Nw 79th Avenue, Tamarac, Florida 33321
- CMS Provider Number
- 105609
- Inspections on file
- 23
- Latest survey
- June 12, 2024
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Nspire Healthcare Tamarac during CMS and state inspections, most recent first.
Surveyors identified that the facility did not maintain required documentation for 1.5-hour load bank testing, monthly generator load testing, weekly voltage checks, or monthly conductance testing for generator batteries. These omissions were confirmed during a record review and acknowledged by facility leadership.
Surveyors identified that the facility's Emergency Preparedness Program lacked required contact information for all staff and residents' physicians in its communication plan. The Administrator acknowledged these omissions during the review, and the findings were discussed with facility leadership.
Surveyors found that the facility's Emergency Preparedness Program listed satellite phones as an alternate means of communication, but the facility was unable to produce a satellite phone for inspection when requested. The Administrator confirmed that the alternate communication device was not available as required.
Surveyors found that two delayed egress exit doors lacked the required signage with a contrasting background, and one door in the Service Hallway automatically reset when tested, both in violation of NFPA 101 standards. These deficiencies were observed during a fire safety tour and acknowledged by facility leadership.
A resident with significant self-care limitations due to recent surgery and left-sided impairment reported long delays in call-light response and dissatisfaction with ADL care. Despite communicating these concerns to staff and family members reporting issues to the Administrator, no grievance documentation was found, and the facility failed to demonstrate a response to the resident's complaints as required by regulation.
A resident was found to have a vascular access device in place for eleven days without any physician orders for its care, maintenance, or removal. Nursing staff did not document or communicate the presence of the device, and no orders were obtained until prompted by surveyors. The device remained unused, and the resident was unaware of its purpose during their stay.
A resident had a line in place in the left upper arm for eleven days without a physician's order for its removal or care, and staff failed to notify the DON or physician or document the line in the care plan or progress notes. The line remained in place and unused, with visible discoloration at the site, and an order for removal was only obtained after surveyor inquiry.
Two residents did not receive meals consistent with their prescribed therapeutic diets due to the facility's failure to follow menu guidelines and ensure alignment between diet orders and meal preparation. One resident on a mechanical soft diet was served diced meats instead of ground, while another on a CHO-controlled, high-protein diet received incorrect portions and restricted items. Dietary staff and the dietitian confirmed confusion and lack of communication regarding menu breakdowns and diet order matching.
A resident with complex medical needs, including diabetes and a history of amputation, did not receive the physician-ordered CHO controlled, high-protein diet. Observations showed the resident was served meals inconsistent with the prescribed diet, and the CDM admitted to substituting menu items and not following the specific dietary order due to lack of guidance and communication with the dietitian. The resident was unaware of any special diet, and the facility's menu did not align with the required dietary restrictions.
Surveyors found that cooked chicken intended for resident meals was not maintained at the required hot-holding temperature on the steam table, with measured temperatures ranging from 107°F to 127°F instead of the required 165°F. The facility's food temperature log reflected only the post-oven temperature, not the holding temperature, and the Food Service Director acknowledged the discrepancy. This issue had the potential to affect all residents who received the alternate lunch meal containing chicken.
The facility did not complete required sensitivity testing for all smoke and duct detectors as mandated by NFPA 101 and NFPA 72. Record review revealed that 11 smoke detectors and two duct detectors were not tested, and inspection reports lacked documentation of sensitivity testing results. The Regional Maintenance Director acknowledged these findings during the survey.
Surveyors found that the Main Lobby had mixed sprinkler coverage, with two quick response and two standard sprinklers, which does not comply with NFPA requirements. The Regional Maintenance Director acknowledged the issue during the inspection, and the deficiency was documented with photographic evidence.
Surveyors found that a medication refrigerator was not connected to a distinctly marked receptacle powered by the critical branch of the EES, as required by NFPA 99. Additionally, the facility failed to provide documentation for required maintenance and testing of the EES, including generator inspections and load exercises. These deficiencies were confirmed through observation, staff interviews, and record review, affecting all residents receiving refrigerated medications and those dependent on emergency power systems.
A resident with significant self-care limitations following recent surgeries reported long delays in call-light response and dissatisfaction with ADL care. Despite voicing concerns to nursing staff and having her family report issues to the Administrator, no formal grievance documentation was submitted or addressed according to facility policy. Staff interviews confirmed the absence of grievance records for these complaints.
A resident had a vascular access device in place for eleven days without any physician orders for its care, maintenance, or removal, despite facility policy requiring such orders. The device was not in use, and staff failed to document or communicate its presence or need for removal, resulting in the device remaining in place until surveyor intervention.
Surveyors found that the facility did not provide prescribed therapeutic diets or follow the approved menu for two residents on specialized diets. One resident on a mechanical soft diet received chopped meats instead of ground, while another with diabetes and CKD received meals inconsistent with their diet order, including excess bread and bacon. Dietary staff confirmed discrepancies between diet orders and menu spreadsheets, leading to substitutions and mismatched diets.
A resident's complaints about delays in care and disturbances were communicated to staff but were not formally documented or submitted as grievances, despite facility policy requiring such action. The Social Worker and DON confirmed no grievance forms or documentation existed for these concerns, indicating a failure to follow the established grievance procedure.
The facility was found to have multiple deficiencies in maintaining a sanitary and comfortable environment for residents. Surveyors observed issues such as non-functional sinks, soiled floors, broken tiles, and privacy curtains that were too short, compromising resident privacy. Pervasive odors and damaged walls were also noted. The Corporate Maintenance Director acknowledged the problems and indicated that staff were not effectively using the computerized TELS system for reporting maintenance issues.
The facility failed to manage and dispose of controlled medications for two discharged residents, leaving them in storage instead of removing them for disposal. Emergency crash carts were found unsecured, containing expired supplies, and medication storage was poorly managed, with loose pills and expired medications found. Over-the-counter medications were left unattended, accessible to residents and staff, indicating lapses in following security protocols.
The facility failed to provide a nourishing diet due to broken refrigeration units, leading to the use of an emergency menu with non-perishable foods. Residents expressed dissatisfaction with the lack of fresh and hot meals, while staff consumed catered meals. The administration did not explore alternative refrigeration options or address residents' complaints effectively.
The facility failed to maintain the nutritional value of foods for 117 residents by preparing lunch items, including chicken and vegetables, too early and holding them hot for over two hours. Staff confirmed the early preparation, and the Dietary Director acknowledged concerns about the extended hot holding time. The facility's recipes did not address this issue.
The facility failed to adhere to food safety and hygiene standards, with issues such as improper food temperatures, inadequate sanitizer levels, and unsanitary food handling practices. Staff did not consistently perform hand hygiene, and there were storage and cleanliness issues in the kitchen and pantry areas.
The facility failed to implement Enhanced Barrier Precautions (EBP) for all sampled residents, with PPE not available at room entrances as required. A CNA did not follow proper infection control during Foley catheter care, leading to cross-contamination. In the dialysis suite, uncovered trash cans and improper storage of materials were observed, indicating broader infection control issues.
The facility failed to repair essential kitchen equipment, including a walk-in cooler and pellet warmer, leading to deficiencies in food service. The cooler had been out of order for over a week, and the warmer was incompatible with existing plates, resulting in resident complaints about cold food. Despite ongoing discussions since February, there was no evidence of a compatible warmer being ordered.
A resident with COPD, chronic bronchitis, depression, and a left BKA was not provided a wheelchair, hindering his mobility and participation in activities. Despite orders for activity participation and a care plan for wheelchair management, the facility failed to accommodate the resident's needs. Staff were unaware of the wheelchair's location, and documentation of care plan implementation was lacking.
A resident with multiple sclerosis and muscle weakness did not receive scheduled showers as per his preferences, due to miscommunication among staff at the LTC facility. Despite the facility's policy requiring assistance with bathing twice a week, the resident received only one shower over a two-week period. The care plan lacked specific ADL care instructions, leading to confusion between day and evening staff about who was responsible for the resident's showers. The issue was only addressed after surveyor intervention.
A resident with a Foley catheter did not receive appropriate care as observed during a survey. The CNA failed to follow proper procedures, such as wearing a gown, changing gloves, and performing hand hygiene. The CNA also left the resident's room door open, placed the catheter above the resident's chest, and did not use a catheter strap and anchor. Interviews confirmed the CNA's lack of preparation and failure to follow procedures.
A facility failed to ensure proper documentation and communication for a resident receiving dialysis care. Despite the resident's independence in ADLs and no cognitive impairment, the facility did not document critical information such as transfer times, medications, and shunt site observations. The dialysis center also failed to record pre and post dialysis weights, lab values, and finish times, indicating a systemic issue confirmed by the Corporate Nurse Consultant.
A facility's medication error rate was found to be 14.70%, exceeding the acceptable limit of 5%. An RN failed to administer all prescribed medications to two residents, one with COPD and diabetes, and another with multiple sclerosis and anemia. The RN omitted medications due to unfamiliarity with a new admission's regimen and nervousness during observation. The DON was informed of these errors.
The facility failed to address residents' food concerns and timely repair kitchen equipment, leading to the use of an emergency food menu due to a broken walk-in cooler. Residents expressed dissatisfaction with repetitive and non-substantial meals, while the administration was unaware of ongoing refrigeration issues. Additionally, meals were served cold due to the non-use of a pellet warmer, with no evidence of efforts to remedy the situation.
The facility failed to ensure call lights were within reach for three residents, impacting their ability to request assistance. One resident with cognitive impairment and multiple health issues had the call light out of reach, while another found it inside a nightstand and later on the floor. A third resident, dependent on assistance, had the call light stuck under the bed, compounded by visual impairment and a short overhead light string. Staff were either unaware or unable to promptly resolve these issues.
Failure to Maintain and Document Essential Electrical System Testing
Penalty
Summary
The facility failed to maintain the Essential Electrical System (EES) in accordance with NFPA 99 requirements, as evidenced by missing documentation and incomplete testing records. During a record review with the Regional Director of Plant Operations, surveyors found that there was no documentation for the required 1.5-hour load bank testing for 2024, nor was there evidence of monthly testing under a thirty percent load. This testing is necessary to ensure the generator can supply emergency power as required by regulation. Additionally, the facility did not provide documentation of weekly voltage checks for the two generator batteries. Regular monitoring of battery voltage is essential to confirm that the generator will function properly in the event of a power outage. The absence of these records indicates that the facility did not consistently monitor the generator batteries as required. Furthermore, there was no documentation of monthly conductance testing for the generator's two sealed batteries prior to 2025. Conductance testing is a standard procedure to assess the health and reliability of the batteries that support the emergency power system. The Regional Maintenance Director acknowledged these findings during the survey, and the deficiencies were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. An unannounced Fire & Life Safety Recertification survey was conducted on at Nspire Healthcare Tamarac, a nursing home in Tamarac, Florida. Nspire Healthcare Tamarac is not in compliance with 42 CFR 483 Subpart B, 42 CFR 488.307, and National Fire Protection Association (NFPA) 101 (2012 Edition), NFPA 99 (2012 Edition) requirements for nursing homes. Initial Plan Review. 1994 Existing NFPA 220 Construction Type: II (111) Number of beds: 151 Census: 122 The following is a description of the noncompliance. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. [Repeated sections with placeholders such as [R] and incomplete dates are included as in the original text.]
Incomplete Emergency Preparedness Communication Plan
Penalty
Summary
During a review of the facility's Emergency Preparedness Program (EP), surveyors found that the facility did not maintain a complete communication plan as required by federal regulations. Specifically, the communication plan was missing contact information for all staff members and for residents' physicians. This omission was identified during a record review conducted with the facility Administrator. The deficiency was confirmed through both documentation review and an interview with the Administrator, who acknowledged the absence of the required contact information in the EP. The findings were also discussed with the Regional Maintenance Director during the exit conference. No information was provided in the report regarding specific residents or their medical conditions at the time of the deficiency. The focus of the deficiency was solely on the incomplete communication plan within the facility's emergency preparedness documentation.
Plan Of Correction
Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030 Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030
Failure to Provide Alternate Communication Device Listed in Emergency Plan
Penalty
Summary
During a Fire & Life Safety re-licensure survey, surveyors reviewed the facility's Emergency Preparedness Program (EP) and found that the facility had listed satellite phones as an alternate means of communication in their emergency plan. However, when requested, the facility was unable to produce a satellite phone for inspection. This deficiency was identified through both record review and staff interview, where the absence of the listed communication device was confirmed. The Administrator acknowledged the findings during the interview and at the exit conference, confirming that the alternate communication method described in the EP was not available as required by federal regulations. The deficiency specifically relates to the facility's failure to ensure that the alternate means of communication, as outlined in their emergency preparedness plan, was present and accessible for inspection.
Plan Of Correction
Corrective Action for Affected Residents: The administrator added an updated list of primary and alternate means of communication. The facility does not use satellite phones. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: The administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure primary and alternate means of communication for the facility are listed. Monitoring/Quality Assurance: The Emergency Preparedness Manual will be reviewed annually, and findings will be submitted to QAPI.
Deficient Delayed Egress Door Signage and Function
Penalty
Summary
Surveyors observed that the facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 requirements. During a fire safety tour, it was found that two delayed egress exit doors—the first floor West Wing Rehabilitation Room door and the Service Hallway door—did not have the required signage with a contrasting background. This signage is necessary to comply with fire safety codes and to ensure that the doors are easily identifiable in an emergency. Additionally, the Service Hallway delayed egress exit door exhibited a malfunction during testing. Specifically, the door automatically reset when it was tested, which is not in accordance with the required operation for delayed egress doors. This issue could potentially interfere with the proper function of the delayed egress system, which is designed to allow safe evacuation during emergencies. The findings were confirmed through direct observation by surveyors and acknowledged by the Regional Maintenance Director during the inspection. The deficiency was reviewed with both the Administrator and the Regional Maintenance Director at the exit conference. Photographic evidence was obtained to document the observed issues. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.
Failure to Document and Respond to Resident Grievances Regarding Care Delays
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of documented grievances submitted by a resident regarding delays in call-light response and concerns related to activities of daily living (ADL) care. The resident, who was alert, oriented, and verbally responsive, had significant self-care limitations due to left-sided impairment and recent right-sided surgery. Her care plan required assistance with bathing, eating, hygiene, mobility, toileting, transfers, skin assessments, and the use of a call bell for help. Despite these needs, the resident reported waiting approximately four hours for assistance after activating her call light during nighttime hours and expressed dissatisfaction with the quality of care received upon admission. The resident stated that she communicated her concerns to nursing staff, but no improvements were observed. She also reported that certified nursing assistants (CNAs) told her they were responsible for 16 residents and did not have adequate time to provide timely care. The resident's family reported concerns to the Administrator but perceived the response as indifferent. Additionally, when the resident requested to receive ADL care before other residents due to her functional limitations, staff reportedly told her that permanent residents were prioritized over her. The administration did not address her complaints, and no documentation of her grievances was found. Interviews with staff revealed that while the resident's complaints were communicated to the Director of Nursing (DON) and documented in the facility's electronic system for other residents, no grievance documentation was submitted for this resident. The social worker confirmed that no grievance submissions were received from the resident and that there was no documentation indicating staff had submitted grievances on her behalf. The DON also stated that she had not received complaints from the resident or her family and described the facility's grievance procedure, which requires documentation and resolution within three days. However, no documentation existed for the resident's grievance, resulting in noncompliance with regulatory requirements.
Plan Of Correction
Resident #75 - grievances regarding ADL care and call light response were documented and addressed. A quality audit of current residents was conducted to ensure there are no undocumented grievances regarding delay in call light response and concerns related to activities of daily living (ADL) care. The Director of Nursing will educate the nursing staff on ensuring that grievances with residents' concerns are documented and addressed. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that staff is documenting grievances with residents' concerns. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly for 3 months or until substantial compliance has been met. per physician orders.
Failure to Obtain Physician Orders for Vascular Access Device Care and Removal
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician orders for the care, maintenance, or removal of a vascular access device in a resident. Upon re-admission, the resident had a vascular access device in the left upper arm, which was observed to remain in place for eleven days without any documented physician orders for its care or discontinuance. The facility's policy required nurses to obtain and verify physician orders for such devices, including their removal, care, and maintenance, but this was not followed. Multiple observations confirmed the device remained in place, with visible brownish discoloration and a small, darkened area at the site. The resident reported not receiving any medication through the device since admission and was unaware of the reason for its continued presence. Review of the resident's medical records, including physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR), revealed no orders for the device's care, maintenance, or removal during the resident's stay. Interviews with nursing staff indicated a lack of awareness regarding the device's presence and the absence of any action to obtain necessary physician orders. The nurse who changed the dressing admitted to not notifying the oncoming nurse, the DON, or the physician about the device, stating she had forgotten to do so. There was no documentation in the nursing progress notes, baseline care plan, or comprehensive care plan regarding the device, and the physician was not contacted for orders until prompted by the surveyor.
Plan Of Correction
A quality audit of current residents was conducted to ensure that no ([R]) were noted without a physician order in place. The Director of Nursing educated licensed nurses on ensuring that a physician order is obtained for residents with ([R]) lines. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that a physician order is obtained for ([R]) residents with [R] lines. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Obtain Physician's Order and Document Care for Unused Line
Penalty
Summary
A resident had a line in place in the left upper arm for eleven days without a current physician's order for its discontinuance or for its care and maintenance. Multiple observations confirmed the line remained in place and was not in use, with the site showing brownish discoloration and a small, darkened area noted in the tubing. The physician's orders for the resident only included two oral medications, with no order for the line during the facility stay. Staff who identified the line did not notify the oncoming nurse, the DON, or the resident's physician to obtain appropriate orders for removal or care, stating she had forgotten to do so. There was no documentation in the nursing admission progress notes, ongoing nursing progress, baseline care plan, or comprehensive care plan regarding the identification or existence of the line. The physician's order to remove the line was only obtained after surveyor inquiry.
Failure to Follow Prescribed Menus and Therapeutic Diet Orders
Penalty
Summary
The facility failed to follow prescribed menus and therapeutic diet orders for two residents, resulting in noncompliance with federal regulations regarding menu preparation, nutritional adequacy, and adherence to physician-ordered diets. For one resident on a mechanical soft diet, observations revealed that meals provided included diced or chopped meats rather than the ground meats specified in the facility's menu spreadsheet. The Certified Dietary Manager (CDM) and Speech Language Pathologist (SLP) confirmed that the menu breakdown called for ground meats, but the facility was serving bite-sized or chopped meats instead, citing their interpretation of the International Diet Standardization Initiative (IDDSI) guidelines. The CDM stated that the facility did not offer ground diets, despite the menu indicating otherwise. Another resident with a diet order for a carbohydrate-controlled, high-protein diet with regular texture and thin consistency was observed receiving meals that did not match the prescribed diet. The resident received two slices of bread and two strips of bacon for breakfast, and two rolls for lunch, which exceeded the menu's specified portions and included items not permitted on certain therapeutic diets, such as bacon for a CKD5 diet. The CDM admitted to substituting rolls for breadsticks and providing more bread than allowed, acknowledging these as mistakes. Additionally, the diet orders in the electronic health record (EHR) did not match the food service supplier's menu spreadsheets, leading to confusion and inconsistency in meal preparation. Interviews with dietary staff, including the CDM, Dietetic Technician (DTR), and the facility's Dietitian, revealed a lack of communication and review of the new menu spreadsheets. The CDM and DTR were not fully aware of the menu breakdowns or how to match them to resident diet orders, and the Dietitian confirmed that discrepancies between the EHR and menu spreadsheets had occurred previously. The facility's process for reviewing and updating menus, as well as ensuring that staff were trained on new menu guidelines, was insufficient, resulting in residents not consistently receiving meals that met their prescribed dietary needs.
Plan Of Correction
The Registered Dietician reviewed and updated the facility's menu to ensure a therapeutic diet is being provided for Resident #45 and Resident #1. A quality audit of current residents on a therapeutic diet was conducted to ensure the facility is following the menu for residents on a therapeutic diet. The Administrator educated the CDM (Certified Dietary Manager) on ensuring the menu is being followed for residents on a therapeutic diet. Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure the menu is being followed for residents on a therapeutic diet. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Follow Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when the facility failed to follow the prescribed therapeutic diet for a resident with multiple medical diagnoses, including Type 2 diabetes and a history of amputation. The resident had a physician's order for a carbohydrate (CHO) controlled, high-protein (Hi Pro) diet with regular texture and thin consistency. Despite this order, direct observation of the resident's meals revealed that the food provided did not match the prescribed diet. For breakfast, the resident received two slices of wheat bread and two strips of bacon, while the lunch meal included two rolls and no cauliflower, deviating from the intended dietary restrictions. Interviews with facility staff, including the Certified Dietary Manager (CDM), revealed a lack of understanding and implementation of the specific diet order. The CDM admitted to not having a CHO controlled diet on the spreadsheet and instead used a Hi-Pro diet as a substitute. The CDM also acknowledged that the number of bread servings provided was incorrect and that substitutions were made without proper guidance. Furthermore, the CDM stated that there was no review of the diets with him and only limited discussion with the facility's dietitian regarding discrepancies between the menu and the electronic health record (EHR) diet orders. The resident was unaware of being on a special diet and reported receiving the same meals as other residents. Review of the facility's menu and the "Nutritional Care Manual" indicated that certain foods, such as salty processed meats, should not have been included in the resident's diet, particularly for those with chronic kidney disease stage 5 (CKD5). The failure to provide the correct therapeutic diet as prescribed by the physician, and the lack of communication and oversight in dietary management, led to the cited deficiency.
Plan Of Correction
Resident #1 prescribed therapeutic diet order was reviewed and updated per physician order. A quality audit of current residents on a therapeutic diet was conducted to ensure the prescribed order is being followed. The Administrator educated the CDM (Certified Dietary Manager) on ensuring that prescribed therapeutic diet orders are being followed. Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that prescribed therapeutic diet orders are being followed. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Maintain Proper Hot-Holding Temperature for Cooked Chicken
Penalty
Summary
During a survey, it was observed that the facility failed to maintain cooked chicken at the required hot-holding temperature on the steam table prior to serving it to residents. Specifically, after two plates of chicken were prepared and placed on the food cart for distribution, the surveyor measured the temperature of the remaining chicken in the steam table pan. The pieces on the top registered at 107°F and those at the bottom at 127°F, both of which are below the required minimum hot-holding temperature of 165°F. Upon request, the chicken was reheated to the proper temperature before being served. A review of the facility's Prepared Food Temperature record revealed a discrepancy between the logged and observed temperatures. The log indicated a temperature of 162°F for the chicken, which the Food Service Director confirmed was the temperature when the meat was removed from the oven, not while it was being held on the steam table. The surveyor's direct measurement showed significantly lower temperatures at the point of service, indicating that the food was not maintained at safe temperatures during holding. The Food Service Director acknowledged that the temperature recorded in the log did not reflect the actual holding temperature and agreed that the temperature may have dropped while the chicken was on the steam table. This deficiency had the potential to affect all 12 sampled residents who received the alternate lunch meal containing chicken, with a total facility census of 121 at the time of the survey.
Plan Of Correction
Meat was reheated to the proper temperature. A quality audit of meat prepared and ready to be served was conducted to ensure it is maintained at the proper hot-holding temperature on the steam table. The Administrator educated the CDM (Certified Dietary Manager), and the Food Service Assistant on ensuring meat prepared and ready to serve is maintained at the proper hot-holding temperature on the steam table. The Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure meat prepared and ready to serve is maintained at the proper hot-holding temperature on the steam table. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Complete Required Fire Alarm System Sensitivity Testing
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 101 and NFPA 72 standards. During a record review with the Regional Maintenance Director, it was found that the biennial smoke detector sensitivity testing did not include 11 out of 73 smoke detectors. Additionally, the repairs inspection report did not indicate that the smoke detectors were sensitivity tested, nor did it provide the results of such testing. The annual fire alarm report listed 23 duct detectors in the inventory, but the duct detector differential pressure testing documented 24 duct detectors tested, and the smoke detector sensitivity testing only included 22 duct detectors, leaving two duct detectors untested for sensitivity. These discrepancies were identified through a combination of record review and staff interviews. The Regional Maintenance Director acknowledged the findings during the review. The records failed to demonstrate that all required smoke and duct detectors underwent the necessary sensitivity testing as mandated by the applicable codes and standards. The deficiency affects all residents and staff in the affected smoke compartments, as the fire alarm system is a critical component of the facility's safety infrastructure. The findings were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference, and photographic evidence was obtained to support the observations.
Plan Of Correction
Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically, the two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected. Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews.
Deficiency in Sprinkler System Compliance
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system (AFSS) in accordance with NFPA 101 and related standards for one of twelve sampled smoke compartments. During a fire safety tour, surveyors observed that the Main Lobby contained mixed sprinkler coverage, with two of the four sprinklers being quick response and the other two being standard sprinklers. This observation was made in the presence of the Regional Maintenance Director, who acknowledged the findings at the time. The deficiency was identified through a combination of direct observation, record review, and staff interviews. The surveyors specifically noted the inconsistency in the type of sprinkler heads installed within the same area, which does not comply with the requirements set forth by NFPA 13 and NFPA 25. The issue was discussed with both the Administrator and the Regional Maintenance Director during the exit conference, and photographic evidence was obtained to document the condition. No information was provided in the report regarding any residents' medical history or their condition at the time of the deficiency. The deficiency was limited to the fire protection system in the Main Lobby smoke compartment, and the report did not mention any immediate consequences or incidents resulting from the mixed sprinkler coverage. The focus of the findings was on the facility's failure to ensure uniform and compliant sprinkler system installation and maintenance as required by applicable fire safety codes.
Plan Of Correction
Continued from page 4 By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI.
Medication Refrigerator Not Connected to Critical Branch and EES Maintenance Documentation Lacking
Penalty
Summary
The facility failed to ensure that electrical receptacles serving medication preparation areas, specifically those used for medication refrigerators, were connected to the critical branch of the Essential Electrical System (EES) and were not distinctly marked as required by NFPA 99. During a fire safety tour, it was observed that a medication refrigerator was not plugged into a receptacle powered by the critical branch, and the required distinctive color or marking was absent. This deficiency was acknowledged by the Regional Maintenance Director during the observation and was reviewed with facility leadership at the exit conference. Photographic evidence was obtained to document the finding. Additionally, the facility did not maintain proper documentation for the maintenance and testing of the EES, including the generator and associated equipment. Required records for weekly inspections, monthly load exercises, and other scheduled maintenance activities were not provided during the record review with the Regional Director of Plant Operations. The lack of documentation means that the facility could not demonstrate compliance with NFPA 99, NFPA 110, and related standards for ensuring the reliability of emergency power systems. These deficiencies affect all residents who receive refrigerated medications from the affected medication room, as well as all residents and staff who rely on the facility's emergency electrical systems. The findings were based on direct observation, staff interviews, and record reviews conducted by surveyors during the inspection.
Plan Of Correction
Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: Weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in [date] and will be conducted annually, with the next test due [date], and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due [date], and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.
Failure to Document and Address Resident Grievances Regarding Call-Light Delays and ADL Care
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of documented grievances for a resident who reported significant delays in call-light response and concerns related to activities of daily living (ADL) care. The resident, who was alert, oriented, and verbally responsive, had been admitted with left-sided and recent right-sided surgery, resulting in significant self-care limitations. Her care plan required assistance with all ADLs, including bathing, eating, hygiene, mobility, toileting, transfers, and skin assessments, and she relied on the call bell for help. The resident reported waiting approximately four hours for assistance after activating her call light during nighttime hours and expressed dissatisfaction with the quality of care received. She stated that she communicated these concerns to nursing staff, but no improvements were observed. The resident also indicated that CNAs told her they were responsible for 16 residents and did not have adequate time to provide timely care. Additionally, her family reported concerns to the Administrator but perceived the response as indifferent. The resident further stated that when she requested to receive ADL care before other residents due to her functional limitations, staff responded that permanent residents were prioritized over her, and her complaints were not addressed by Administration. Interviews with staff revealed that while the resident's complaints were communicated to the Director of Nursing and documented in the facility's electronic system, no formal grievance documentation was submitted on her behalf. The Social Worker confirmed that no grievance forms had been received from the resident or staff, and the Director of Nursing stated that no complaints had been received from the resident or her family. The facility's grievance procedure requires documentation and resolution within three days, but no documentation existed for this resident's grievances.
Plan Of Correction
Resident #75- grievances regarding ADL care and call light response was documented and addressed. A quality review of current residents was conducted to ensure there is no undocumented grievances regarding delay in call light response and concerns related to activities of daily living (ADL) care. The Director of Nursing will educate the Nursing staff on ensuring that grievances with resident's concerns are documented and addressed. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that staff is documenting grievances with resident's concerns. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Obtain Physician Orders for Vascular Access Device Management
Penalty
Summary
The facility failed to obtain physician orders for the care, maintenance, or removal of a vascular access device for a resident. Upon review of the facility's policy and procedure, it was found that the policy requires nurses to obtain and/or verify physician orders for the type of solution or medication, dose, rate, length of treatment, and for the removal of such devices. However, for this particular resident, there were no physician orders documented for the discontinuance, care, or maintenance of the device, despite it being in place for an extended period without use. Observations revealed that the resident had a vascular access device in the left upper arm, which had not been used for medication administration since admission. The site was noted to have brownish discoloration and a small, darkened area in the tubing. The resident reported not knowing why the device was still in place, as she had not received any medication through it since admission. Record reviews, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), confirmed the absence of any orders related to the device's care or removal. Interviews with nursing staff indicated a lack of awareness regarding the presence and management of the device. One RN admitted she did not recall if the resident was admitted with the device in place and acknowledged that only oral medications had been administered. Another staff member who had changed the device dressing failed to notify the oncoming nurse, the DON, or the physician to obtain appropriate orders, stating she had forgotten to do so. There was no documentation in the nursing admission progress notes, ongoing nursing progress, baseline care plan, or comprehensive care plan regarding the existence or management of the device. The device remained in place and unused for eleven days, with no physician order for its removal until prompted by surveyor inquiry.
Plan Of Correction
Resident #111 was removed /2026 per physician orders. A quality audit of current residents was conducted to ensure that no [R] noted without a physician order place. The Director of Nursing educated licensed nurses on ensuring that a physician order is obtained for residents with [R] lines. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that a physician order is obtained for residents with [R] lines. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Provide Prescribed Therapeutic Diets and Follow Approved Menu
Penalty
Summary
Surveyors identified that the facility failed to provide prescribed therapeutic diets and did not follow the approved menu for residents requiring specialized diets. Specifically, one resident on a mechanical soft diet was observed receiving roast beef cut into pieces or chunks approximately 0.5 inches in size, rather than the ground meat specified in the facility's menu spreadsheet. Additionally, this resident was served diced or chopped chicken instead of ground meat, as required. The Certified Dietary Manager (CDM) and Speech Language Pathologist (SLP) both confirmed that the menu breakdown called for ground meats, but the facility did not offer ground diets, instead providing bite-sized or chopped meats for mechanical soft diets. Another resident with diagnoses including Type 2 diabetes and chronic kidney disease was prescribed a carbohydrate-controlled, high-protein diet with regular texture and thin consistency. Observations revealed that this resident received meals inconsistent with the prescribed diet, such as two slices of wheat bread and two strips of bacon for breakfast, and two rolls for lunch instead of the specified breadstick and cauliflower. The CDM acknowledged that the resident received too much bread and bacon, and that bacon is not permitted on the CKD5 diet. The CDM also stated that he substituted rolls for breadsticks due to unavailability and used a high-protein diet in place of the specific CKD5 diet, as the menu and electronic health record (EHR) did not match. Interviews with dietary staff, including the CDM, Dietetic Technician (DTR), and the facility's Dietitian, revealed a lack of alignment between the EHR diet orders and the food service supplier's menu spreadsheets. Staff admitted to not having reviewed the new menu breakdowns and to making substitutions or using alternative diets when the prescribed diet was not available or did not match the menu. The Dietitian confirmed that this mismatch had occurred previously and required customization, but there was no clear process to ensure residents consistently received the correct therapeutic diets as ordered by their physicians.
Plan Of Correction
Resident #1 prescribed therapeutic diet order was reviewed and updated per physician order. The Registered Dietician reviewed and updated the facility's menu to ensure a therapeutic diet is being provided for Resident #45 and Resident #1. A quality audit of current residents on a therapeutic diet was conducted to ensure the prescribed order is being followed, and to ensure the facility is following the menu for residents on a therapeutic diet. The Administrator educated the CDM (Certified Dietary Manager) on ensuring that prescribed therapeutic diet orders are being followed and ensuring the menu is being followed for residents on a therapeutic diet. The Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that prescribed therapeutic diet orders are being followed and that the menu is being followed for residents on a therapeutic diet. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Document and Address Resident Grievance
Penalty
Summary
A resident expressed frustration regarding delays in having her sanitary brief changed and reported these concerns to a staff member, who stated she communicated the issues to the Director of Nursing (DON) and documented them in the facility's electronic system. However, the staff member did not submit any formal grievance documentation for this resident, despite having done so for others. Another CNA, with long tenure at the facility, was aware of the resident's complaints about noise and other residents entering her room but did not report these issues to administration, as she did not consider them dangerous. The Social Worker confirmed that no grievance forms had been submitted by or on behalf of the resident, and the DON stated she had not received any complaints from the resident or her family. The facility's grievance procedure requires documentation and resolution within three days, but no documentation existed for this resident's concerns. This sequence of events demonstrates a failure to follow the facility's grievance policy, resulting in the resident's complaints not being formally documented or addressed as required.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for residents, as observed during a survey conducted by surveyors. The deficiencies were noted across multiple areas, including residential rooms, community shower rooms, activity rooms, and common areas on the First Floor West, Second Floor East, and Second Floor West. Specific issues included non-functional hand wash sinks, soiled and stained floors, broken wall tiles, and privacy curtains that were too short to ensure resident privacy. Additionally, there were reports of pervasive odors, damaged walls, and rust-laden portable commode seats. The surveyors observed that many rooms had privacy curtains that were too short, compromising resident privacy during personal care activities. Several rooms had soiled and stained floors, broken dresser drawers, and walls in disrepair. In some cases, there were pervasive odors, such as urine, which further contributed to the uncomfortable living conditions. The community shower rooms and nurse stations also exhibited significant cleanliness and maintenance issues, including dust accumulation, broken tiles, and non-functional faucets. The Corporate Maintenance Director acknowledged the issues and mentioned that the facility uses a computerized TELS system for reporting housekeeping and maintenance concerns. However, it was noted that staff were not utilizing this system effectively, leading to unresolved maintenance and housekeeping issues. The surveyor requested that all environmental concerns identified during the tours be reviewed with the Administrator, highlighting the need for improved reporting and maintenance practices within the facility.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to properly manage and dispose of controlled medications for two discharged residents. Resident #497, who had been prescribed Lacosamide for seizures, was discharged, yet the medication remained in the controlled substance drawer instead of being removed and given to the Director of Nursing (DON) for disposal. Similarly, Resident #496's controlled medication, Lorazepam Intensol, was found in a locked box in the refrigerator after the resident had been discharged. Staff interviews confirmed that these medications should have been removed and disposed of according to the facility's policy. The facility also failed to secure emergency crash carts and medications properly. During an observational tour, it was noted that the emergency crash cart on the first floor was unlocked and unattended, containing both sterile and non-sterile supplies, including syringes and normal saline with expired dates. Similar unsecured conditions were observed with the emergency crash carts at the 2-East and 2-West Nurse's stations. Staff interviews revealed uncertainty about whether the carts had been properly secured, indicating a lapse in following security protocols. Additionally, the facility did not manage medication storage effectively. Loose, unidentified pills were found in the medication cart drawers, and expired topical medications were stored in the wound treatment cart. Over-the-counter medications were left unattended and unsecured on a medication cart, accessible to residents, employees, and visitors. These observations highlight a failure to adhere to the facility's policies on medication storage and security, as acknowledged by the DON during interviews.
Failure to Provide Adequate Nutrition Due to Refrigeration Issues
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs. This deficiency was identified during a survey where it was found that the facility's walk-in and reach-in refrigerators had stopped working, leading to the implementation of an emergency menu consisting of non-perishable foods. The refrigeration issues began on 05/31/24 and 06/04/24, respectively, and despite attempts to repair the units, the facility was unable to store and prepare fresh foods, resulting in the use of canned and non-perishable items for meals. Residents expressed dissatisfaction with the meals, noting the lack of hot foods for breakfast and the poor taste of canned foods served for lunch and dinner. Interviews with residents revealed that they were aware of the refrigeration issues and felt that there had been ample time to address the problem and resume serving fresh meals. Additionally, residents observed staff eating catered meals, which exacerbated their dissatisfaction with the emergency menu. The facility administration acknowledged that they failed to explore alternative refrigeration options, such as utilizing existing refrigerators within the facility or arranging for a refrigerated truck from their grocery vendor. The administration was also unaware of the residents' complaints and the impact of the situation on their dining experience. The facility recognized that the refrigeration issues could have been managed more effectively to prevent the implementation of the emergency menu.
Deficiency in Food Preparation and Hot Holding
Penalty
Summary
The facility failed to prepare foods in a manner that maintains their nutritional value for potentially 117 residents. During an initial kitchen tour, it was observed that the hot holding unit was set up for the lunch meal, which included various dishes such as chicken, mechanically altered chicken, chicken and dumplings, mashed potatoes, rice, pureed chicken, pureed peas, mechanical soft peas, gravy, and carrots. Staff R confirmed that these items were prepared for lunch and stated that cooking began after breakfast was completed at about 8:30 AM. The carrots, which were canned, took approximately 20 minutes to prepare. However, there was no response from Staff R regarding the facility's policy for preparing foods prior to serving. The Dietary Director acknowledged concerns about the extended hot holding time, which exceeded two hours from cooking to serving. Additionally, the facility's recipe for canned carrots and peas did not address hot holding for extended periods.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to maintain food safety standards during food preparation, storage, and service. During a kitchen tour, it was observed that canned carrots were being held at an unsafe temperature of 93 degrees Fahrenheit. The sanitizer concentration was below the required level, and employee drinks were improperly stored in the walk-in freezer. Additionally, there was uncovered dough, dust accumulation on fan guards and vents, and food residue on a can opener blade. Serving utensils were found to be worn and unable to be properly sanitized. The facility's thawing process for meat was not followed correctly, as raw chicken was left in a bucket without running water, and staff failed to perform hand hygiene before donning gloves. Further observations revealed unsanitary practices during meal preparation and service. Staff members were seen reaching over food with loose clothing, changing gloves without hand hygiene, and improperly handling utensils. A waste receptacle in the processing area was nearly full and uncovered. In the unit pantry, there was mold in the ice dispenser chute and a lack of a working thermometer in a refrigerator. During meal service to residents, staff did not perform hand hygiene between serving trays until prompted by a nurse. The Activity Director acknowledged awareness of infection control practices but failed to implement them consistently during meal distribution.
Infection Control Deficiencies in PPE and Dialysis Suite
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) according to CDC guidelines and its own policies for all 24 sampled residents on EBP. Observations revealed that personal protective equipment (PPE) such as gowns and gloves were not available at the entrance of residents' rooms, as required. Interviews with staff indicated a lack of understanding and adherence to the facility's EBP policy, with some staff incorrectly stating that PPE was only needed for certain conditions or that PPE was available in limited quantities per wing. During a specific observation of Foley catheter care for a resident, a Certified Nursing Assistant (CNA) failed to don a gown and used the same pair of gloves throughout the procedure, leading to cross-contamination of multiple surfaces. The CNA also handled the resident's Foley catheter improperly and touched various surfaces without changing gloves or sanitizing hands. The Director of Nursing acknowledged that proper infection control techniques were not followed during this procedure. In the in-house dialysis suite, several infection control concerns were noted, including uncovered trash cans containing soiled gloves and gowns, broken covers on infectious waste cans, and improper storage of essential dialysis components. These observations indicate a broader issue with infection control practices within the facility, as evidenced by the improper handling and storage of potentially infectious materials.
Failure to Repair Kitchen Equipment Affects Food Temperature
Penalty
Summary
The facility failed to promptly repair and replace essential kitchen equipment, leading to deficiencies in food service. During an initial kitchen tour, it was observed that the walk-in cooler was out of order, and the facility had been using a disaster emergency menu since the cooler had been non-functional for over a week. The Dietary Manager confirmed that the cooler had been down since the end of May and was not expected to be repaired until mid-June. This delay in repair affected the facility's ability to store food at appropriate temperatures. Additionally, during a follow-up kitchen tour, it was noted that the kitchen staff were not using the pellet warmer while plating meals, resulting in complaints from residents about cold food. The facility had ordered a warmer that was incompatible with their existing plates, and despite ongoing discussions since February, there was no evidence of a compatible warmer being ordered. Documentation from an external agency highlighted repeated concerns about food temperature during visits from February to June. The facility's invoices indicated that the warmer had been non-functional since September of the previous year.
Failure to Provide Wheelchair for Resident's Mobility and Activity Participation
Penalty
Summary
The facility failed to provide a wheelchair to a resident, identified as Resident #13, which hindered his mobility and participation in activities. Resident #13 was admitted with diagnoses including COPD, chronic bronchitis, depression, and a left below-the-knee amputation. The resident had a moderate cognitive impairment and was dependent on assistance for various functional abilities, including transferring from bed to wheelchair. Despite physician's orders for the resident to participate in activities twice weekly and to modify the treatment plan as needed, the facility did not provide the necessary equipment to facilitate this. Observations and interviews revealed that Resident #13 had been without a wheelchair for months, preventing him from attending activities outside his room. The resident expressed his concerns to both morning and evening staff, but received no response regarding the whereabouts of his wheelchair. Multiple staff members, including a Licensed Practical Nurse, Certified Nursing Assistant, and the MDS coordinator, were unaware of the wheelchair's location. The Director of Activities claimed the resident refused to participate in activities, but there was no documentation to support this claim. The facility's records, including the Electronic Health Record and Occupational Therapy notes, lacked evidence of following through on the resident's care plan, particularly regarding wheelchair management training. Despite a speech therapist eventually locating the wheelchair, there was no explanation provided for its absence. The Physical Therapist Director was unable to provide documentation of interventions and outcomes for the resident during the months of April, May, and June, further highlighting the facility's failure to accommodate the resident's needs and preferences as required.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide appropriate personal assistive care and services for a resident, specifically in the area of bathing and showering. The facility's policy required assistance with showering and bathing at least twice a week, with the resident's preferences reviewed quarterly. However, the care plan for the resident did not include specific ADL care related to bathing, despite the resident's expressed preference for showers on specific days and times. The resident, who had intact cognition and a history of multiple sclerosis and muscle weakness, reported not receiving a shower for over a week, contrary to his preferences and the facility's schedule. Interviews with staff revealed a lack of clarity and communication regarding the resident's shower schedule. The resident's care plan focused on his limited physical mobility but did not address his personal ADL care needs. Staff members were unclear about who was responsible for providing the resident's showers, with both day and evening staff assuming the other was fulfilling this duty. This miscommunication resulted in the resident receiving only one shower over a two-week period, despite being scheduled for three showers. The facility's Director of Nursing acknowledged the oversight and the importance of honoring and clarifying residents' preferences for ADL care. The resident's dissatisfaction with the change in his shower schedule and the lack of follow-through on his requests for assistance highlighted the deficiency in the facility's adherence to its own policies and procedures. The resident's needs were not met until after surveyor intervention, indicating a failure in the facility's system to ensure consistent and personalized care for its residents.
Deficient Foley Catheter and Peri-care Observed
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Foley catheter, as observed during a survey. The resident, who had a neurogenic bladder and other medical conditions, was observed receiving peri-care and Foley catheter care from a CNA. The CNA did not follow proper procedures, such as wearing a gown, changing gloves, and performing hand hygiene. Additionally, the CNA left the resident's room door open, compromising privacy, and placed the Foley catheter above the resident's chest, which is against the care plan instructions. During the observation, the CNA used the same pair of gloves to clean the resident's perineal area and then touched various surfaces in the room, leading to cross-contamination. The CNA also left the resident unattended in a high bed position while she went to get additional supplies, further compromising the resident's safety. The CNA did not use a Foley catheter strap and anchor, which was not present in the resident's room, and there was no physician's order for it. Interviews with the resident and staff confirmed the deficiencies in care. The resident stated she had never used a Foley catheter strap and anchor. Both the RN and CNA acknowledged the CNA's lack of preparation and failure to follow appropriate procedures. The DON also recognized the CNA's failure to utilize proper infection control techniques during the procedure.
Inadequate Documentation and Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure proper communication and documentation for a resident receiving dialysis care. The resident, who was re-admitted with Chronic Kidney Disease and Altered Mental Status, was receiving in-house dialysis three times a week. Despite having no cognitive impairment and being independent in Activities of Daily Living, the facility did not maintain adequate records of the dialysis process. The Hemodialysis Communication Record lacked documentation of critical information such as the time of transfer to and from the dialysis center, medications administered prior to dialysis, and shunt site observations. The dialysis center also failed to document essential details, including pre and post dialysis weights, lab values, and dialysis finish times. This lack of documentation was consistent across multiple dates, indicating a systemic issue in maintaining proper records for dialysis care. The Corporate Nurse Consultant confirmed these findings, highlighting the facility's failure to ensure ongoing communication and collaboration with the dialysis center for the resident's care.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 14.70%. During a medication administration observation, a registered nurse (RN) prepared medications for a resident with multiple diagnoses, including COPD, diabetes, and end-stage renal disease. The RN initially prepared a medication labeled for a different resident but corrected this before administration. However, the RN omitted two medications, Cyanocobalamin and Pantoprazole Sodium, from the resident's morning regimen. The RN admitted to not contacting the pharmacy for the undelivered Pantoprazole and was unfamiliar with the new admission's medication regimen, leading to the omission of the Vitamin B12 tablet. In another instance, the same RN prepared and administered six out of eight prescribed medications to a resident with multiple sclerosis and anemia. The RN omitted Ferrous Sulfate and Magnesium Oxide, which were part of the resident's morning medications. The resident reported feeling tired and weak, symptoms associated with her condition. The RN acknowledged not recalling the administration of the omitted medications and attributed her oversight to nervousness due to the surveyor's presence. The Director of Nurses was informed of these observations and acknowledged the findings.
Deficiency in Addressing Food Concerns and Equipment Repairs
Penalty
Summary
The facility failed to develop and implement an effective Quality and Performance Improvement Plan (QAPI) to address residents' food concerns and timely repair of kitchen equipment. The walk-in cooler had been out of order since May 31, 2024, leading the facility to unnecessarily resort to serving the emergency food menu. Despite the availability of other refrigeration options within the facility, such as using refrigerators or renting a refrigerated truck, these alternatives were not utilized, resulting in the continued use of the emergency menu. Residents expressed dissatisfaction with the meals provided, noting a lack of variety and palatability. Interviews with residents revealed that they were served repetitive and non-substantial meals, such as peanut butter and jelly with cereal, instead of their preferred options like eggs and bacon. The facility administration was unaware of the residents' complaints and the ongoing refrigeration issues, which had been affecting meal quality and acceptance. Additionally, the facility failed to address the issue of cold meals being served to residents. The pellet warmer was not used during meal plating, and meals were delivered in carts without a heat source, resulting in food being served at ambient temperatures. Despite ongoing complaints and awareness of the issue since February, there was no evidence of efforts to remedy the situation, such as ordering compatible warmers or utilizing microwaves to reheat food upon request.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to maintain call lights within reach of residents, affecting three sampled residents. Resident #23, who has a moderate cognitive impairment and multiple health issues, was observed with the call light out of reach on multiple occasions. Despite the care plan indicating the need for the call light to be within reach due to the resident's high risk of falls, the call light was found clipped to the wall and on the floor, making it inaccessible. Staff were unaware of the issue, indicating a lack of attention to the resident's needs. Resident #481 also experienced issues with the call light being inaccessible. During a facility tour, the resident reported needing assistance but was unable to find the call light, which was discovered inside a nightstand and later on the floor. This indicates a failure to ensure the call light was consistently within reach, preventing the resident from calling for help when needed. Resident #13, who has moderate cognitive impairment and is dependent on assistance for daily activities, was found with the call light stuck under the bed, making it impossible to use. Despite the resident's repeated attempts to call for help, staff were either unaware or unable to resolve the issue promptly. The resident's inability to access the call light was compounded by visual impairment and a short overhead light string, further limiting their ability to communicate with staff. Maintenance was eventually called to address the issue, but the call light remained inaccessible for an extended period.
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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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