Ocala Oaks Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ocala, Florida.
- Location
- 3930 E Silver Springs Blvd, Ocala, Florida 34470
- CMS Provider Number
- 105724
- Inspections on file
- 23
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Ocala Oaks Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) to two residents within the mandated two-day timeframe before the end of their Medicare Part A coverage. In one case, the form was signed only one day prior to coverage ending, and in another, it was signed after coverage had ended. Staff interviews confirmed the forms were not delivered as required by policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to follow physician orders for two residents: one did not receive wound care as prescribed, with improper dressing application and lack of documentation, while another did not receive IV antibiotics at the ordered every-8-hour intervals, instead receiving them on a TID schedule. The DON and staff confirmed the deviations from prescribed care.
Surveyors found that two residents were administered oxygen at rates higher than ordered by their physicians, and a third resident's nebulizer mask was not stored in a plastic bag when not in use, contrary to facility policy. The DON and unit manager confirmed that these practices did not follow established procedures.
Surveyors found that kitchen equipment, including can openers and stove drawers, had significant buildups of dirt and food debris, and that cleaning schedules were not followed as required by facility policy. The Food Service Director confirmed the lack of completed cleaning checklists and acknowledged that cleaning assignments were not being completed.
The facility failed to maintain a plan that outlines the process for conducting QAPI and QAA activities, as required. Surveyors found no documentation or description of how these quality assurance activities are implemented.
Multiple live insects, including cockroaches, were observed in the kitchen area during a tour with the ADM and FSD. Documentation from the pest control company confirmed repeated pest activity in various kitchen locations over several months. Despite a policy requiring routine inspections and reporting, pests continued to be present, demonstrating a failure to maintain an effective pest control program.
The facility failed to provide timely Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms to two residents. The Social Services Director confirmed that the signed copies for the residents were missing and were only signed months later, outside the required timeframe.
A facility failed to implement physician orders following pharmacist recommendations for a resident with multiple diagnoses. Despite the physician accepting the pharmacist's recommendations to discontinue Cyclobenzaprine and Prednisone, the orders were not processed, and the resident continued to receive the medications. The DON admitted that consultation reports were not reviewed, and the facility's policy was not followed.
The facility failed to ensure complete and accurate medical records for several residents, particularly in insulin administration and PICC dressing changes. Staff did not document missed insulin doses or notify physicians, and there were inconsistencies in following protocols for medication administration and documentation.
The facility failed to transmit resident assessment data within 14 days after completion for two residents. One resident, admitted with multiple diagnoses, was discharged home, and their MDS Discharge Return Not Anticipated Assessment was not submitted to CMS. Another resident, also admitted with multiple diagnoses, was discharged home, and their MDS Discharge Return Not Anticipated Assessment was not submitted to CMS. The MDS Coordinator confirmed the failure, and the Administrator acknowledged the absence of a policy on submitting MDS Assessments.
A resident with cerebral infarction and hemiplegia did not receive the required restorative services to maintain or improve range of motion. Despite a care plan indicating the need for an Active Assistive Range of Motion Program, there were significant gaps in the documentation and provision of these services, as confirmed by the Director of Clinical Services and the Director of Rehabilitation Services.
A resident with COPD and other conditions was observed receiving oxygen at 3.5 L/min instead of the prescribed 2 L/min. Staff confirmed the discrepancy, and the facility's policy on oxygen administration was not followed.
The facility failed to ensure the posted nurse staffing data included the required information. The nursing staffing data did not contain the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This deficiency was confirmed by the Administrator, DON, and Staff Development Coordinator, who stated that the night shift charge nurse is responsible for filling out and posting the data before the end of her shift, using the midnight census total.
The facility failed to ensure staff used appropriate PPE during direct care for three residents under transmission-based precautions and did not follow infection control practices for another resident during dining. An LPN did not wear a gown while discontinuing an IV catheter, a CNA provided direct care without a gown, and another CNA was unaware of a resident's need for enhanced barrier precautions. Additionally, a resident had a urinal with drops of urine on his meal table, and a CNA placed the food tray next to it.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to two residents within the required two-day timeframe prior to the end of their Medicare Part A coverage. For one resident, the NOMNC form indicated the last covered day as 6/17/2025, but the form was signed on 6/16/2025, only one day prior. For the second resident, the last covered day was 3/4/2025, but the form was signed by the resident's representative on 3/5/2025, after the coverage had already ended. The facility was unable to provide documentation of the email sent to the representative for signature. Interviews with the Social Services Director (SSD) and the Administrator confirmed that the NOMNC forms were not delivered 48 hours before the last covered day as required by policy. The SSD acknowledged responsibility for reviewing, obtaining signatures, and filing the NOMNC forms, and confirmed the forms for both residents were not provided within the mandated timeframe. Review of facility policy reiterated the requirement to deliver the NOMNC at least two calendar days before Medicare-covered services end.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Follow Physician Orders for Wound Care and IV Antibiotic Administration
Penalty
Summary
The facility failed to follow physician orders for two residents regarding wound care and intravenous antibiotic administration. For one resident with a wound on the lower left leg, observation revealed that the dressing was not dated or initialed, and part of it was peeling off. The resident reported not having received wound care for four days. Review of the physician's order specified a detailed wound care regimen, including cleansing, application of collagen powder and calcium alginate, covering with an ABD pad, wrapping with kerlix and an ACE bandage, and offering pain medication prior to treatment, to be performed every shift. The Wound Care Nurse confirmed the dressing was incorrect and not applied as ordered, and the DON stated that dressings should be applied per order and dated. For another resident readmitted with multiple serious diagnoses, including sepsis and malignancies, the facility failed to administer the intravenous antibiotic Meropenem as prescribed. The physician ordered Meropenem 1 gram IV every 8 hours for four doses, but the medication was instead scheduled and administered according to the facility's standard three times daily (TID) schedule, not at the prescribed intervals. The DON acknowledged that the every-8-hour schedule was not discussed with the physician and the medication was entered into the system as TID. Both the pharmacy consultant and the physician confirmed that the medication should have been administered every 8 hours as ordered.
Failure to Follow Physician Orders for Oxygen Therapy and Proper Storage of Nebulizer Equipment
Penalty
Summary
Surveyors observed that two residents were not receiving oxygen therapy in accordance with their physician orders. One resident was administered oxygen at 3 liters per minute (lpm) via nasal cannula, while the physician order specified 2 lpm continuously. This resident had a medical history including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, non-ST elevation myocardial infarction, and dependence on supplemental oxygen. Another resident was observed receiving oxygen at 4 lpm via nasal cannula, despite a physician order for 2 lpm continuously. This resident's diagnoses included dependence on supplemental oxygen and shortness of breath. In both cases, the Director of Nursing confirmed that physician orders should be followed for oxygen administration, and facility policy required checking the physician’s order and setting the correct flow rate. Additionally, a third resident’s nebulizer mask was found resting on top of the nebulizer machine and not stored in a plastic storage bag when not in use, as required by facility policy. The resident had a physician order for Ipratropium-Albuterol inhalation solution to be administered as needed for shortness of breath or wheezing, with the last administration documented the previous day. Both the unit manager and the Director of Nursing confirmed that nebulizer masks should be stored in a plastic bag when not in use, in accordance with the facility’s aerosol therapy policy.
Failure to Maintain Cleanliness and Follow Cleaning Schedules in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain kitchen equipment in a safe and clean condition and did not follow established cleaning schedules for the kitchen and food service equipment. During multiple kitchen inspections, significant buildups of dirt, food debris, and discoloration were found on equipment such as table-mounted and counter can openers, the stove's catch drawer, prep tables, and stainless-steel counters. The Food Service Director (FSD) confirmed the presence of these buildups and acknowledged that the stove catch-drawer and other equipment should have been cleaned. A review of facility documentation revealed that the cleaning schedule was not being followed, as no completed checklists were available for review. The FSD confirmed that cleaning assignments were not being completed as required. The facility's own policy required daily cleaning duties to be listed, cleaning assignments to be posted, and schedules to be initialed and dated upon completion, but these procedures were not adhered to, resulting in unsanitary kitchen conditions.
Lack of Documented QAPI/QAA Process
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or a described process outlining how QAPI and QAA activities are to be carried out within the facility.
Failure to Maintain Effective Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple live insect sightings in the kitchen area during a tour with the Administrator and Food Service Director. Observations included live insects around the blade of a counter-mounted can opener, on a utility cart, on the coffee counter, and on the ceiling strip of the exterior back wall. Both the Administrator and Food Service Director confirmed these pest sightings in the dietary department/kitchen, and the Food Service Director reported that roaches had been seen on numerous occasions in the past few weeks, with notifications documented in the pest log. Review of pest control documentation from the contracted pest control company revealed that cockroaches were noted during services in both May and July, with findings in the kitchen above the drop ceiling, in the steam table, behind ovens, and in the dish area. The facility's pest control policy requires routine inspections, documentation of sightings, and communication with the maintenance supervisor, as well as staff training and regular cleaning measures. Despite these procedures, the presence of pests persisted, indicating a failure to ensure the effectiveness of the pest control program.
Failure to Provide Timely SNF ABN Forms
Penalty
Summary
The facility failed to ensure that residents received the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) within the required time frame for two residents. For Resident #18, the Medicare Part A Skilled Services Episode started on 11/27/2023, and the last covered day was 1/4/2024. However, the signed SNF ABN form could not be located for the January 2024 discharge date. The resident eventually signed the form on 5/15/2024, which was not within the acceptable period. Similarly, for Resident #25, the Medicare Part A Skilled Services Episode started on 3/20/2024, and the last covered day was 4/23/2024. The signed SNF ABN form for the April 2024 discharge date was also missing and was only signed on 5/15/2024 by the resident's representative, which was again outside the required timeframe. During an interview, the Social Services Director, who started on 1/22/2024, confirmed that they were responsible for reviewing the SNF ABN and Notice of Medicare Non-Coverage (NOMNC) forms with residents and their representatives, obtaining signatures, and filing the forms appropriately. The director admitted that the signed copies for the two residents could not be located and were only signed on 5/15/2024, which was not within the acceptable period. The facility's policy, last reviewed in 8/2023, mandates that Medicare denial letters must be used to notify residents of non-coverage at the time of admission or for termination of benefits following a covered Part A stay. The policy also specifies that the SNF ABN form should be provided to residents before the termination of current services under Medicare or before receiving specific items/services that Medicare probably will not cover.
Failure to Implement Physician Orders Following Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that physician orders following the pharmacist's recommendations were implemented for a resident reviewed for unnecessary medications. The resident, who had multiple diagnoses including heart failure, dementia, and chronic pain, was prescribed Cyclobenzaprine and Prednisone. The pharmacist recommended discontinuing these medications due to their potential adverse effects, and the physician accepted these recommendations. However, the orders to discontinue the medications were not processed, and the resident continued to receive Prednisone daily and Cyclobenzaprine on specific dates from February to May 2024. The Director of Nursing (DON) stated that the responsibility for reviewing the consultation reports was transferred to the Assistant Director of Nursing (ADON) in February 2024. The DON admitted that the consultation reports for March and April 2024 were not reviewed, and the changes recommended by the pharmacist were not implemented. The facility's policy requires that the attending physician document any action taken in response to the pharmacist's recommendations and that the Medical Director be alerted if recommendations are not addressed in a timely manner. This policy was not followed, leading to the deficiency.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for several residents, specifically in the administration of insulin and PICC dressing changes. For Resident #39, the Medication Administration Record (MAR) showed multiple instances where insulin was not administered as required, and there was no documentation in the progress notes regarding the missed doses or notification of the physician. Similarly, Resident #62's MAR indicated several instances of missed insulin administration without corresponding documentation or physician notification. Resident #46's MAR also showed discrepancies in insulin administration, with staff failing to document communication with the physician when insulin was held due to low blood sugar levels. Additionally, the facility failed to follow physician orders for PICC dressing changes for Resident #107. The resident's MAR indicated daily dressing changes, contrary to the physician's order for a one-time change 24 hours post-insertion and then every seven days. Interviews with staff, including RNs, LPNs, the ADON, and the DON, revealed inconsistencies in following protocols for insulin administration and documentation. Staff admitted to not documenting communications with physicians and not adhering to the facility's policy for medication administration. The Medical Director and physicians confirmed that while they were notified of insulin holds, the nursing staff failed to document these communications properly. The DON acknowledged that all communication between nurses and providers should be documented, and the lack of documentation indicated non-compliance with the facility's policies. The ADON and other staff members also highlighted the importance of documenting all actions and communications related to medication administration to ensure resident safety and compliance with professional standards.
Failure to Transmit Resident Assessment Data
Penalty
Summary
The facility failed to transmit resident assessment data within 14 days after completion of assessment for two residents. Resident #99 was admitted with multiple diagnoses including arthritis, postprocedural septic shock, type 2 diabetes mellitus, hypertension, atrial fibrillation, chronic kidney disease, and ileostomy status, and was discharged home on 12/15/2023. The MDS Discharge Return Not Anticipated Assessment for Resident #99, completed on 12/21/2023, was not submitted to CMS. Similarly, Resident #71, admitted with diagnoses including anemia, congestive heart failure, atrial fibrillation, and acute cholecystitis, was discharged home on 1/5/2024. The MDS Discharge Return Not Anticipated Assessment for Resident #71, completed on 1/8/2024, was also not submitted to CMS. The MDS Coordinator confirmed the failure to submit these assessments, and the Administrator acknowledged the absence of a policy on submitting MDS Assessments, stating that they follow the RAI guidelines.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate restorative services to maintain or improve range of motion. Resident #86, who had diagnoses including cerebral infarction, hemiplegia, and reduced mobility, was observed lying in bed with her left arm in a bent position against her chest. The resident expressed a desire for therapy, stating she had not received it in months and wanted to go home. Interviews with staff revealed that while the resident was receiving occupational therapy until early February 2024, the services were supposed to transition to a Restorative Nursing Program (RNP) afterward. However, there were significant gaps in the documentation and provision of these restorative services as evidenced by missing entries in the task tracking sheets for April and May 2024. The Director of Clinical Services acknowledged the gaps in documentation and confirmed that the resident had not received the restorative services as required. The care plan for the resident indicated a need for an Active Assistive Range of Motion Program for the left upper extremity, but the task tracking sheets showed multiple dates with no documented entries, indicating a failure to provide the necessary services. The Director of Rehabilitation Services stated that the frequency of services should have been determined by the therapist and included in the Restorative Nursing Services Evaluation, but this was not consistently done, leading to the deficiency in care for Resident #86.
Failure to Follow Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Resident #51 received respiratory care services as prescribed. Observations on multiple occasions revealed that the resident's oxygen concentrator was set to 3.5 liters per minute (L/min), despite the physician's order specifying 2 L/min as needed for shortness of breath. The resident was observed with the nasal cannula intact and the oxygen concentrator running at the incorrect setting on three separate occasions over two days. The resident's medical history includes Chronic Obstructive Pulmonary Disease (COPD), chronic peripheral venous insufficiency, shortness of breath, and dementia. Interviews with staff confirmed the discrepancy between the prescribed oxygen flow rate and the actual setting. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) both acknowledged that the oxygen concentrator was not set according to the physician's order. The facility's policy on oxygen administration, which includes checking the physician's orders and monitoring the resident's response to oxygen therapy, was not followed. This failure to adhere to prescribed respiratory care protocols led to the deficiency noted in the report.
Failure to Post Complete Nurse Staffing Data
Penalty
Summary
The facility failed to ensure the posted nurse staffing data included the required information. During an observation on 5/13/2024 at 9:00 AM, the nursing staffing data for that day did not contain the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This deficiency was confirmed by the Administrator on 5/15/2024 at 8:00 AM, who stated that the night shift is responsible for the federal posting for staffing, and the Staff Coordinator would review the posting for accuracy upon arrival. The Director of Nursing (DON) and the Staff Development Coordinator also confirmed that the night shift charge nurse is responsible for filling out and posting the nursing staffing data before the end of her shift at 7 AM, using the midnight census total. The facility's policy and procedures titled Nursing Scheduling/Staffing/Posting, last revised in 8/2023, require that the center post specific nurse staffing information daily, including the center name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, as well as the resident census. The policy also mandates that this data be posted at the beginning of each shift in a clear and readable format in a prominent place accessible to residents and visitors. The failure to include the required information in the posted nurse staffing data indicates non-compliance with the facility's own policies and federal requirements.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure staff used appropriate PPE during direct care for three residents under transmission-based precautions and did not follow infection control practices for another resident during dining. Specifically, a Licensed Practical Nurse (LPN) did not wear a gown while discontinuing an intravenous catheter for a resident with enhanced barrier precautions due to a wound. Another Certified Nursing Assistant (CNA) entered a resident's room without a gown and provided direct care, despite the resident being on enhanced barrier precautions for a wound. Additionally, a CNA was unaware of a resident's need for enhanced barrier precautions due to a dialysis port, and no signage or PPE was available outside the resident's room. The Infection Preventionist confirmed the need for enhanced barrier precautions for residents with indwelling devices to prevent MDROs, but the resident was not listed on the infection control line listing, and no orders were in place for enhanced barrier precautions for this resident. Furthermore, during a dining observation, a resident had a urinal with drops of urine on his meal table, and a CNA placed the resident's food tray next to the urinal. The resident mentioned that the urinal had fallen on the floor, and he had placed it on the table. A Licensed Practical Nurse (LPN) later stated that the urinal should not be on a table next to a food tray and would have taken steps to clean the table and provide a new tray if observed. These actions and inactions led to deficiencies in infection prevention and control practices within the facility.
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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