Oak Haven Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburndale, Florida.
- Location
- 919 Old Winter Haven Rd, Auburndale, Florida 33823
- CMS Provider Number
- 105302
- Inspections on file
- 19
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Oak Haven Rehab And Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure complete documentation of ADL care for three residents with significant care needs, resulting in missing records for essential tasks such as bed mobility, toileting, bathing, dressing, and incontinence care. Despite care plans indicating the need for extensive staff assistance, the required documentation was not present on multiple dates, as confirmed by the DON.
The facility failed to perform weekly skin assessments for eight residents and wound care assessments for two residents with non-pressure wounds. This deficiency was identified through observations, interviews, and record reviews. For instance, a resident did not have documented weekly skin checks for several weeks, despite being at risk for skin impairment due to multiple health conditions. Similarly, another resident's wound care was inadequately documented, with missing weekly skin checks and incomplete wound assessments, despite having a significant leg injury.
The facility failed to provide consistent pressure ulcer care and documentation for three residents, leading to deficiencies. A resident with a stage 4 ulcer had inconsistent wound evaluations, while another with diabetes and a foot ulcer experienced discrepancies in wound care documentation. A third resident with an ankle injury lacked documented wound evaluations, with the LPN citing personal notes and external care involvement. The DON confirmed the expectation for weekly documentation, highlighting lapses in adherence to care plans.
The facility failed to maintain ongoing communication with the dialysis center for three residents requiring dialysis services. Despite having care plans in place, communication books were missing, and dialysis communication forms were often incomplete. Staff interviews revealed inconsistent follow-up with the dialysis center, and there was no documentation of communication in the residents' progress notes, leading to a deficiency in providing safe and appropriate dialysis care.
The facility failed to ensure proper hand hygiene and equipment disinfection during medication administration and blood glucose monitoring. Staff did not sanitize hands or clean equipment between residents, and PPE protocols were not followed for residents on droplet precautions. Observations and interviews revealed multiple instances of non-compliance with infection control measures.
A facility failed to accurately code the MDS at discharge for a resident who was hospitalized. The resident, with multiple diagnoses, was sent to the hospital following a change in condition. However, the MDS incorrectly marked the discharge status as 'Home/Community'. The MDS Director confirmed the error during an interview.
The facility failed to ensure accurate PASRR documentation for two residents. One resident's PASRR did not mark a diagnosis of Depressive Disorder, while another's did not mark Epilepsy under Intellectual Disability. PASRRs were reviewed post-admission by the clinical team, leading to inaccuracies.
A facility failed to update a resident's care plan after discontinuing an antipsychotic medication. Despite the medication being stopped, the care plan still included interventions related to its use. The DON acknowledged the oversight, and the facility lacked a specific care plan policy, relying on the RAI manual instead.
A resident with multiple medical conditions experienced constipation and requested a suppository, which was delayed and not documented by the facility staff. The resident's care plan included monitoring for bowel irregularity, but there was no physician order or documentation of the medication administration. The LPN admitted to administering the suppository without proper documentation, leading to a deficiency in pharmaceutical services.
Two instances of improper medication storage were observed in the facility. An LPN left a resident's inhaler unattended on a medication cart while washing hands, and another LPN left an insulin bottle on a cart while administering an injection. Both actions violated the facility's policy requiring medications to be stored in locked compartments.
A resident requested a snack after breakfast, but it was not provided due to a communication breakdown among staff. A CNA acknowledged the request but did not fulfill it, claiming to have informed the assigned CNA, who was unaware of the request. The RN and DON confirmed that any CNA could provide snacks after consulting with a nurse, as per facility policy.
The facility failed to maintain accurate and complete documentation of Skilled Nursing Documentation Notes for three residents, resulting in missing records on several dates. A resident with chronic conditions had incomplete documentation despite receiving therapy services. Another resident had missing documentation and an undocumented bruise, while a third resident experienced delays in care and had incomplete records. The facility's policy requires comprehensive documentation, which was not met.
Failure to Document ADL Care and Services in Resident Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation of Activities of Daily Living (ADLs) for three sampled residents. For one resident with diagnoses including Parkinson’s, dementia, anemia, and hypotension, review of the medical record revealed missing documentation for multiple ADL tasks such as bed mobility, toileting, bathing, dressing, and incontinence care on several dates. The care plan indicated the resident required assistance with all ADLs, but the records did not reflect that care was provided or documented as required. The Director of Nursing (DON) confirmed that documentation was missing for the specified dates and acknowledged that she expected to see records of tasks performed. Another resident, with a history of diabetes, Alzheimer’s disease, hypertension, and dementia, was also found to have incomplete documentation regarding incontinence care and toileting. The care plan specified that the resident was dependent on staff for these tasks, yet the ADL records showed only one or two instances of incontinence care documented on several days, and no documentation at all on one date. The DON verified the absence of documentation for incontinence care and stated that staff were expected to document these services. A third resident, with multiple chronic conditions including diabetes with foot ulcer, hyperthyroidism, and peripheral vascular disease, had missing ADL documentation for bed mobility, toileting, transfers, and other care activities during both day and evening shifts on several dates. The care plan indicated the resident required extensive assistance for these activities. The DON confirmed that documentation was not completed for the identified dates. Facility policies reviewed required that all care and services provided be documented in the resident’s medical record, including details such as date, time, and the name and title of the individual providing care.
Failure to Perform Weekly Skin and Wound Assessments
Penalty
Summary
The facility failed to perform weekly skin assessments for eight residents and wound care assessments for two residents with non-pressure wounds. This deficiency was identified through observations, interviews, and record reviews. For instance, Resident #19 did not have documented weekly skin checks for several weeks, despite being at risk for skin impairment due to multiple health conditions. Similarly, Resident #90's wound care was inadequately documented, with missing weekly skin checks and incomplete wound assessments, despite having a significant leg injury. Resident #8 also experienced a lack of consistent skin assessments, with missing documentation for weekly skin checks and incomplete records of observed bruises. Resident #267 had multiple wounds, including a diabetic ulcer and a pressure ulcer, but lacked documented wound sizes and assessments since admission. The facility's wound care nurse and floor nurses were responsible for these assessments, but there were lapses in documentation and follow-up. Additional residents, such as Resident #362, #58, and #5, also had incomplete or missing skin and wound assessments. The facility's Director of Nursing and wound care nurse acknowledged these deficiencies, citing issues such as staff absences and lack of documentation. The facility's policies required comprehensive skin assessments and documentation, but these were not consistently followed, leading to the identified deficiencies.
Inconsistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure consistent treatment and services for pressure ulcers in three residents, leading to deficiencies in care. Resident #362, who was admitted with a stage 4 pressure ulcer on the coccyx, had a care plan that included weekly skin checks and wound assessments. However, the facility's records showed inconsistencies in the documentation of weekly wound evaluations, with only three evaluations recorded over a month-long period. The Director of Nursing (DON) confirmed that weekly wound assessments should be conducted by both the bedside nurse and the wound care nurse, indicating a lapse in adherence to the care plan. Resident #58, diagnosed with type 2 diabetes and a foot ulcer, also experienced deficiencies in wound care documentation. The resident's care plan required weekly skin checks, but the wound evaluations showed discrepancies in the frequency and detail of assessments. The evaluations revealed changes in the wound's size and stage, yet the documentation did not consistently reflect these changes. This inconsistency suggests a failure to accurately monitor and document the resident's condition, as required by the facility's policies. Resident #5, with a diagnosis of a superficial injury to the right ankle, had a care plan that included monitoring for skin impairments and weekly skin checks. However, the facility's records lacked weekly wound evaluations for a month, and the Licensed Practical Nurse (LPN) responsible for wound care admitted to not documenting current assessments. The LPN cited personal notes and external wound care involvement as reasons for the lack of documentation. The DON acknowledged the expectation for weekly documentation and noted that the absence of uploaded notes hindered the bedside nurses' ability to access necessary information. This failure to document and communicate wound care assessments contributed to the deficiency in care for Resident #5.
Lack of Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication between the facility and the dialysis center for three residents who required dialysis services. Resident #33, who was admitted with diagnoses including end-stage renal disease and hemiplegia, had a care plan that outlined specific interventions for dialysis care. However, the facility did not maintain a communication book, and the dialysis communication forms were often incomplete, lacking input from the dialysis nurse. Interviews with staff revealed that communication with the dialysis center was inconsistent, and there was no documentation of ongoing communication in the resident's progress notes. Resident #35, with diagnoses including end-stage renal disease and type 2 diabetes mellitus, also experienced a lack of communication between the facility and the dialysis center. The dialysis communication forms for this resident were consistently left blank by the dialysis nurse, and there was no documentation of communication in the progress notes. Staff interviews indicated that the facility did not routinely follow up with the dialysis center when communication forms were incomplete, relying instead on monthly calls to obtain treatment notes. Resident #268, diagnosed with chronic kidney disease stage four and other conditions, faced similar issues with incomplete dialysis communication forms and a lack of documented communication in progress notes. Staff interviews highlighted that communication with the dialysis center was sporadic, and there was no consistent follow-up when forms were incomplete. The facility's policy on dialysis care required correspondence from the dialysis center to be recorded in the plan of care, but this was not consistently done, leading to a deficiency in ensuring safe and appropriate dialysis care for the residents.
Infection Control and PPE Lapses
Penalty
Summary
The facility failed to ensure proper hand hygiene and equipment disinfection during medication administration and blood glucose monitoring. Observations revealed that several staff members, including RNs and LPNs, did not perform hand sanitizing before or after medication passes, nor did they clean blood pressure cuffs and blood glucose monitors between resident uses. For instance, one RN was observed not sanitizing hands before administering medications and not cleaning the blood pressure machine after use. Similarly, an LPN was seen handling medication and equipment without hand sanitizing, and another LPN did not clean the blood pressure cuff between residents. Additionally, the facility did not adhere to proper PPE protocols for residents on droplet precautions. Staff members were observed exiting rooms with face shields and masks still donned, contrary to the signage instructions that required removal of face protection before room exit. Interviews with staff confirmed these lapses, with admissions of forgetting to remove PPE as required. The Director of Nursing acknowledged the expectation for staff to follow PPE instructions and the need for proper infection control practices. The facility's policies on medication administration, hand hygiene, and disinfecting were not followed, contributing to the deficiencies. The policies required hand hygiene before and after resident contact, medication administration, and glove changes, as well as cleaning and disinfecting equipment between uses. However, these procedures were not consistently implemented, as evidenced by the observations and staff interviews. The failure to adhere to these standards resulted in multiple instances of non-compliance with infection prevention and control measures.
Inaccurate MDS Coding at Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) at discharge for a resident, leading to a deficiency. Resident #111, who had been admitted with multiple diagnoses including malignant neoplasm of the lung, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, and generalized muscle weakness, was sent to the hospital for treatment and evaluation following a change in condition. Despite being hospitalized, the Discharge Return Anticipated /End of PPS Part A Stay MDS inaccurately marked the resident's discharge status as 'Home/Community'. During an interview, the MDS Director confirmed the error, acknowledging that the resident was indeed hospitalized at discharge, not sent home.
Inaccurate PASRR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Level I Preadmission Screening and Resident Review (PASRR) for two residents. Resident #19 was admitted with diagnoses including Anxiety Disorder and Major Depressive Disorder. However, the Level I PASRR did not mark the diagnosis of Depressive Disorder in the relevant section, and it indicated that no serious mental illness or intellectual disability was present, thus not requiring a Level II PASRR evaluation. Similarly, Resident #7 was admitted with diagnoses including Bipolar Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, and Epilepsy. The PASRR for this resident marked Bipolar and Depressive Disorders but failed to mark the related condition of Epilepsy under Intellectual Disability, again indicating no need for a Level II evaluation. The deficiency was identified through record reviews and staff interviews, revealing that the PASRRs were not reviewed pre-admission. The Admissions Director stated that PASRRs are received from the hospital and uploaded into the system, with the clinical team reviewing them only after the resident is admitted. The Nursing Home Administrator confirmed that the clinical team, which includes the Director of Nursing, Assistant Director of Nursing, Unit Managers, and Social Services, reviews PASRRs during daily clinical meetings. This process led to inaccuracies in the PASRR documentation for the two residents, as the reviews were not conducted before admission.
Failure to Revise Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to revise the care plan for a resident after a medication was discontinued, which was identified during a review of records and interviews. The resident, who was admitted with diagnoses including unspecified dementia and other behavioral disturbances, had been prescribed Olanzapine for a psychotic disorder. This medication was discontinued on a specified date, but the care plan was not updated to reflect this change. The care plan still included interventions related to the administration and monitoring of antipsychotic medications, despite the discontinuation. During interviews, the Director of Nursing acknowledged that the care plan should have been revised to reflect the discontinued use of antipsychotic medication. The facility did not have a specific policy for care plans, instead following the Resident Assessment Instrument (RAI) manual. The RAI manual emphasizes the importance of updating care plans to reflect changes in residents' preferences and goals. This oversight in updating the care plan represents a deficiency in the facility's adherence to care planning protocols.
Failure to Document and Administer Medication for Constipation
Penalty
Summary
The facility failed to ensure the Plan of Care was followed for a resident concerning the administration and documentation of a medication for constipation. The resident, who had multiple medical conditions including a right above-knee amputation, diabetes, and dementia, was admitted to the facility with a care plan that included monitoring for bowel irregularity. However, there was no physician order for a bowel regimen or documentation of a Dulcolax suppository being administered on the specified date, despite the resident experiencing constipation and requesting relief. Interviews revealed that the resident's family had informed staff of the resident's pain due to constipation and requested a suppository. The nurse delayed the administration of the suppository, and there was no documentation of the order or administration in the resident's medical record. The Director of Nursing confirmed the absence of a bowel regimen order and stated that staff could contact the medical provider at any time for medication orders. The Advanced Practice Registered Nurse (APRN) stated that a verbal order for a suppository was given, but it was not documented by the nurse who administered it. The facility's policies on medication administration and physician orders require that medications be administered safely and as prescribed, with proper documentation of orders and administration. The Licensed Practical Nurse (LPN) involved admitted to administering the suppository without documenting the order or the results, citing a busy day as the reason for the oversight. This lack of documentation and adherence to the facility's policies led to the deficiency in providing pharmaceutical services to meet the resident's needs.
Improper Medication Storage Observed
Penalty
Summary
The facility failed to ensure proper storage of medications during two separate medication administration observations. In the first instance, a Licensed Practical Nurse (LPN) was observed administering medication to a resident and then leaving the resident's inhaler unattended on the medication cart while she went to wash her hands in the bathroom, where she could not see the medication. In the second instance, another LPN placed an insulin bottle on the computer keyboard of the medication cart and left it unattended while administering an insulin injection to a resident in their room. Both instances involved medications being left out of a locked compartment, contrary to the facility's policy that requires all drugs and biologicals to be stored in locked compartments under proper conditions. The Director of Nursing (DON) confirmed that the expectation is for medications not to be left unattended outside of a locked medication cart.
Failure to Provide Requested Snack to Resident
Penalty
Summary
The facility failed to provide a requested snack to a resident, leading to a deficiency in meeting the nutritional needs of the resident. On the morning of July 15, 2024, a resident expressed hunger after receiving two eggs for breakfast and requested a snack. Despite the request being communicated to a Certified Nursing Assistant (CNA), the snack was not provided. The CNA, who was not assigned to the resident, acknowledged the request but did not fulfill it, instead claiming to have informed the assigned CNA. Further interviews revealed a breakdown in communication among staff members. The assigned CNA stated she was not informed of the resident's request, and the Registered Nurse (RN) confirmed that any CNA could have provided the snack, regardless of assignment. The Director of Nursing (DON) reiterated that any CNA could fulfill snack requests after consulting with a nurse to ensure the appropriate snack is given. The facility's policy indicated that snacks should be available upon request, but this was not adhered to in this instance.
Incomplete Skilled Nursing Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation of Skilled Nursing Documentation Notes for three residents. Resident #19, who has multiple chronic conditions including chronic respiratory failure and congestive heart failure, was observed with missing documentation on several dates in June and July 2024. Despite receiving various therapy services, the skilled documentation notes were not recorded on specific dates, indicating a lapse in maintaining accurate medical records. Resident #8, who also has multiple health issues such as chronic obstructive pulmonary disease and chronic kidney disease, was found to have incomplete documentation of skilled services. The resident's records lacked documentation on several dates in July 2024. Additionally, a bruise was noted on the resident's hand, but the location was not documented, and the weekly skin check was not performed as required. The Director of Nursing confirmed these documentation gaps during an interview. Resident #267, with a history of surgical amputation and other health conditions, also had missing skilled documentation notes for several days in July 2024. The resident's family reported delays in receiving care for constipation, and the resident had a wound on the head and an ulcer on the bottom. The facility's policy requires comprehensive documentation of services provided, but the records for these residents were incomplete, failing to meet the standards set by the facility's guidelines.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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