Palm Beach Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Worth, Florida.
- Location
- 4405 Lakewood Road, Lake Worth, Florida 33461
- CMS Provider Number
- 105466
- Inspections on file
- 22
- Latest survey
- October 28, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Palm Beach Nursing Center during CMS and state inspections, most recent first.
A resident with diabetes, a left foot ulcer, and a recent amputation did not receive timely podiatrist-ordered care due to missed transportation for a follow-up appointment and failure to update wound care orders in the medical record. Staff interviews revealed inconsistent processes for reviewing and implementing new orders after outside appointments, leading to delays in necessary treatment.
The facility failed to maintain resident privacy, with incidents including a resident left exposed during care due to inadequate curtain coverage, staff entering rooms without permission, and loud discussions of medical information in hallways. These actions affected residents' privacy and confidentiality, causing stress and discomfort.
The facility failed to provide adequate staffing, leading to care deficiencies such as delayed incontinence care and unresponsive staff, particularly during night shifts and weekends. Residents reported long wait times for assistance and cold food service, with staffing levels notably lower on weekends.
A resident with cognitive impairment and on medications for insomnia, depression, and anxiety voiced concerns about her roommate's disruptive behavior, but the facility failed to document or address the grievance. The Social Services Assistant acknowledged the complaint but did not inform the Social Services Director, resulting in no follow-up or resolution.
The facility failed to ensure timely, accurate, and complete PASSAR documentation for three residents with mental disorders or intellectual disabilities. One resident's PASSAR was missing, another's was incomplete with no Level II PASSAR despite indications, and a third had several sections left blank. The Social Services Director acknowledged issues with incomplete PASSARs from the hospital and later provided completed forms.
The facility failed to follow physician orders for two residents regarding blood pressure parameters and vital sign documentation, and did not provide prescribed medication to a resident with heart failure and COPD. One resident received Midodrine despite high blood pressure, and another had incomplete vital sign records. A third resident reported not receiving Bumetanide, affecting his breathing and causing swelling, despite the MAR indicating administration. The DON confirmed the medication was missing.
A resident who underwent cataract surgery did not receive her prescribed eyeglasses, resulting in her inability to read. Despite being aware of the issue, the facility failed to track or document the missing eyeglasses effectively. Substitute glasses provided were ineffective, and the facility's policy lacked a process for handling such situations, leading to a prolonged delay in resolving the issue.
A resident with a history of UTIs received improper incontinence care, as observed when a CNA cleaned the resident's back side incorrectly, causing discomfort. The resident's medical records showed a recent UTI and uncompleted urinalysis orders. The resident's son noted frequent UTIs at the facility, and a rash was observed during care. The CNA admitted to not following the correct procedure, and the Unit Manager was unaware of the resident's condition.
The facility failed to provide adequate respiratory care for four residents, with issues including dirty oxygen equipment, misplaced nasal cannulas, missing Ambu bags, and failure to change oxygen tubing and humidifiers as ordered. These deficiencies indicate lapses in staff adherence to care protocols and physician orders, potentially compromising resident safety.
Two medication administration errors were identified, resulting in a 7.69% error rate. An LPN administered incorrect doses to two residents: one received fewer Methocarbamol tablets than prescribed, and another received Losartan prematurely due to a MAR discrepancy.
The facility failed to obtain and document laboratory services for two residents, resulting in deficiencies. One resident, who was cognitively impaired and incontinent, had three unfulfilled urinalysis orders with no follow-up actions. Another resident's blood work was marked as completed, but no results were documented. The facility's staff did not provide further information despite being informed of the issues.
The facility failed to serve meals at palatable temperatures, as reported by several residents who experienced cold meals. Cognitively intact residents noted that food trays often sat in carts before distribution, leading to inconsistent meal temperatures. Grievance logs confirmed multiple complaints about cold food over the past six months.
The facility failed to accommodate dietary preferences and needs for several residents, leading to dissatisfaction and potential health concerns. A diabetic resident was served inappropriate foods, a vegetarian received meals with meat, and residents requiring double portions or specific preferences were not consistently accommodated. The dietary management process was inadequate, with residents not receiving menus to select their choices and meal tickets not accurately reflecting preferences.
A facility failed to follow infection control practices during a blood sugar check and did not properly implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter and pressure injuries. An LPN used non-disinfecting wipes on a glucometer, and a CNA did not wear a protective gown during high-contact care activities, compromising infection control measures. Staff interviews revealed a lack of awareness about the necessity of gowns as part of PPE for EBP.
The facility failed to ensure a clean and homelike environment, with issues such as damaged furniture, stained curtains, and persistent urine odor across three units. Interviews revealed communication gaps and unclear responsibilities among staff regarding maintenance and cleanliness.
A facility failed to provide adequate ADL care for three residents, leading to deficiencies in incontinence care, personal hygiene, and grooming. One resident with hemiplegia was left in soiled briefs for extended periods, resulting in skin redness. Another resident reported not having his hair shampooed for six months and infrequent perineal care. A third resident with cognitive impairment had dirty fingernails despite needing assistance. Staff were slow to respond to care needs, and personal hygiene was neglected.
Failure to Coordinate and Implement Podiatrist-Ordered Care
Penalty
Summary
A deficiency occurred when the facility failed to coordinate and implement care as ordered by a podiatrist for a resident with a complex medical history, including Type 2 diabetes, a left foot ulcer, chronic osteomyelitis, and a right below-knee amputation. The resident was scheduled for a follow-up podiatry appointment for surgical debridement, but missed the appointment because nursing staff did not arrange transportation. Additionally, the facility did not ensure that updated wound care orders from the podiatrist were entered into the resident's record, and there was a lack of documentation of podiatry visit notes in the resident's chart. Interviews with facility staff revealed that neither the Unit Manager nor the Assistant Director of Nursing were aware of new orders or scripts for medical clearance and antibiotics provided by the podiatrist. The process for reviewing and implementing new orders after outside appointments was inconsistently followed, resulting in the resident not receiving timely care as ordered. The resident's daughter expressed concern about the delay in care and the lack of coordination for necessary medical follow-up.
Privacy Violations in Resident Care and Information Disclosure
Penalty
Summary
The facility failed to ensure the privacy of residents' personal and medical records, affecting several residents. Resident #9, who was cognitively intact, expressed significant stress due to privacy violations during care. He reported that staff often did not close privacy curtains fully during personal care, leaving him exposed. Additionally, staff entered his room without knocking or waiting for permission, exacerbating his stress. During an interview with Resident #9, a CNA entered the room without knocking, further demonstrating the lack of privacy. The resident also expressed concern about his roommate's visitors potentially seeing him exposed due to inadequate curtain coverage. Another incident involved staff discussing a resident's HIV medication loudly in the hallway, where other staff and potentially residents could overhear. This breach of confidentiality was acknowledged by the unit manager present at the time. Such actions compromise the privacy of residents' medical information, which is a critical aspect of their rights. Resident #77 was found lying naked on his bed with the door open and the privacy curtain not drawn, while the CNA attending to him left the room. The resident indicated that sometimes staff did not pull the curtain for privacy, although he seemed resigned to this lack of privacy. These incidents collectively highlight the facility's failure to maintain the privacy and confidentiality of residents, both in terms of personal exposure and medical information disclosure.
Staffing Deficiencies Lead to Care Issues
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple care issues identified during the survey. Observations and interviews revealed that residents experienced delays in receiving incontinence care, repositioning, and other necessary assistance, particularly during evening and night shifts. Specific instances included residents waiting for extended periods for care, with some reporting that staff were unresponsive or absent. The facility's staffing levels were notably lower on weekends compared to weekdays, contributing to these deficiencies. Residents voiced significant concerns about the lack of staff responsiveness, particularly during night shifts and weekends. Several residents reported waiting for hours for assistance, with some indicating that staff would turn off call lights without providing care. The Resident Council meeting further highlighted these issues, with attendees confirming that call light response times were poor, and incontinence care was often delayed. Additionally, residents reported that food was frequently served cold and not according to their preferences, with trays left sitting in carts for extended periods. The staffing coordinator acknowledged that the facility was understaffed on Sundays and agreed that weekend staffing should match weekday levels. Despite these acknowledgments, the facility consistently operated with fewer CNAs on weekends, exacerbating the care deficiencies. The survey findings underscore the facility's failure to maintain adequate staffing levels, resulting in unmet resident needs and dissatisfaction with care quality.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to respond to a grievance voiced by a resident regarding her roommate's disruptive behavior. Resident #38, who has some cognitive impairment and is on medications for insomnia, depression, and anxiety, expressed her distress about her roommate, Resident #40, who exhibited agitated behavior such as yelling, crying, and throwing objects. Despite Resident #38's repeated complaints about the ongoing disturbances, no action was taken by the staff to address her concerns. The Social Services Assistant (SSA) acknowledged the complaint but did not document it or inform the Social Services Director (SSD), resulting in a lack of follow-up or resolution. The facility's grievance policy requires that grievances be documented and routed to the Grievance Coordinator, but this procedure was not followed in this case. The SSA's failure to report the grievance to the SSD meant that the issue was not addressed, leaving Resident #38's concerns unresolved. The SSD confirmed during an interview that she was unaware of any issues between the two residents, highlighting a breakdown in communication and adherence to the facility's grievance process.
Incomplete PASSAR Documentation for Residents
Penalty
Summary
The facility failed to ensure timely, accurate, and complete PreAdmission Screening and Resident Record Review (PASSARs) for three of four sampled residents. Resident #64 was admitted with diagnoses including Psychosis and Dementia, but no completed Level 1 PASSAR was found in the electronic record until a request was made, and a new PASSAR was completed by the Social Services Director. Resident #78, admitted with Parkinsonism and Psychosis, had an incomplete Level I PASSAR with missing information and no Level II PASSAR, despite indications that one might be required. The Social Services Director acknowledged the inaccuracies in the previous PASSAR completed by the hospital and provided a newly completed Level I PASSAR. Resident #93, admitted with Unspecified Psychosis, Anxiety, Depression, and Dementia, had a Level I PASSAR with several sections left blank, including critical information such as Social Security Number and Medicaid Identification Number. The Social Services Director noted that the PASSARs received from the hospital were often incomplete, sometimes containing only the resident's first name. A fully completed Level I PASSAR was later provided by the Social Services Director. These deficiencies highlight the facility's failure to maintain accurate and complete PASSAR documentation for residents with mental disorders or intellectual disabilities.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to adhere to physician orders regarding blood pressure parameters and medication administration for two residents. Resident #40 was prescribed Midodrine to be held if systolic blood pressure exceeded 130. However, the medication was administered on multiple occasions when the resident's blood pressure was above this threshold, including readings of 131/76, 138/79, and 135/69. Additionally, the medication was inappropriately held when the blood pressure was 108/65. The Unit Manager was informed of these discrepancies but did not provide further information by the time of the Exit Conference. For Resident #73, the facility did not consistently document vital signs as ordered. The resident's care plan required blood pressure and pulse to be recorded twice daily, yet the MAR only showed checkmarks without actual values, and the pulse was documented only 13 out of 127 times. The Unit Manager acknowledged the issue but did not provide additional information before the Exit Conference. Resident #82, who had heart failure and COPD, reported not receiving his prescribed Bumetanide for five days, which he stated affected his breathing and caused swelling. Despite the MAR indicating administration, the resident insisted he did not receive the medication. An LPN confirmed the medication was not available and administered a substitute, Lasix, after consulting the pharmacist and physician. The DON was unable to locate the missing medication in the storage cart, confirming the resident's complaint.
Failure to Provide Prescribed Eyeglasses
Penalty
Summary
The facility failed to provide timely access to prescribed eyeglasses for a resident who had undergone cataract surgery. The resident, who was admitted with diagnoses including congestive heart failure and type 2 diabetes, had been waiting for her prescribed eyeglasses since the surgery in May 2023. Despite having good cognitive function and adequate vision with corrective lenses, the resident reported being unable to read due to not receiving the prescribed eyeglasses. Interviews with the resident and staff revealed that the eyeglasses were reportedly sent to the facility but were lost, and the facility had not effectively tracked or documented the whereabouts of the eyeglasses. The Social Services Director and other staff members were aware of the missing eyeglasses but failed to provide a satisfactory resolution. The facility attempted to provide substitute reading glasses, which were not effective for the resident, and there was a lack of communication with the eye doctor regarding the missing eyeglasses. The facility's policy on visually impaired residents did not include a process for tracking undelivered or missing eyeglasses, contributing to the delay in resolving the issue. Interviews with various staff members, including the Director of Social Services and an LPN, indicated that the resident's complaints about her missing eyeglasses were known but not adequately addressed. The facility's documentation was insufficient, with no progress notes on the resident's complaints until prompted by the surveyor. The lack of a systematic approach to tracking and resolving the issue of the missing eyeglasses resulted in the resident being unable to read for an extended period, highlighting a deficiency in the facility's provision of vision services.
Improper Incontinence Care Leads to Resident Discomfort and Potential UTI
Penalty
Summary
The facility failed to provide proper incontinence care for a resident with a history of urinary tract infections (UTIs). The resident, who was totally dependent on staff for toileting and always incontinent of bowel and bladder, was observed receiving inappropriate care. During an observation, a Certified Nursing Assistant (CNA) was seen cleaning the resident's back side by wiping from the buttock toward the front, contrary to the facility's policy of wiping from front to back. This improper technique was noted despite the resident's visible discomfort and grimacing, which the CNA initially did not acknowledge. The resident's medical records indicated a history of UTIs, with a recent infection caused by E. Coli, suggesting poor incontinence care. Additionally, there were uncompleted orders for urinalysis related to UTI symptoms. The resident's son reported that the resident frequently experienced UTIs at the facility, unlike at home. A skin evaluation revealed a rash on the resident's sacrum, and during the observed care, a diffuse red rash was noted on the resident's upper buttock and lower back. The CNA admitted to not following the correct procedure when questioned, and the Unit Manager was unaware of the resident's condition during the care.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents, as evidenced by several deficiencies in oxygen care and services. Resident #78 was observed with a dirty oxygen concentrator and a nasal cannula misplaced under the resident's eye. The maintenance and housekeeping departments were unclear about their responsibilities regarding the cleaning and maintenance of the oxygen equipment, leading to the equipment remaining in poor condition over several days. Resident #51, who had a tracheostomy, was supposed to have an Ambu bag at the bedside as per physician orders. However, during an interview, the resident was unaware of its location, and neither the surveyor nor the Director of Nursing could initially find it. It was later discovered that the Ambu bag was stored in a different location, indicating a lack of adherence to the physician's order and potential risk in an emergency situation. Resident #31, diagnosed with COPD and other respiratory issues, was observed with oxygen tubing and a nasal cannula wrapped around his wrist, indicating he was not receiving the prescribed oxygen therapy. Despite multiple observations, staff failed to address the issue or ensure the resident was receiving the necessary oxygen therapy. Similarly, Resident #82's oxygen tubing and humidifier were not changed as ordered, and the resident reported that staff did not have the necessary equipment to provide proper care. These failures highlight significant lapses in the facility's respiratory care protocols and staff's adherence to physician orders.
Medication Administration Errors Identified
Penalty
Summary
The medication error rate at the facility was found to be 7.69 percent, exceeding the acceptable threshold of 5 percent. This was identified during a medication administration observation involving two residents. For the first resident, the LPN administered only one 500 mg Methocarbamol tablet instead of the prescribed two tablets. The LPN acknowledged the error upon reviewing the medication order. For the second resident, the LPN administered three medications, including Losartan, which was not due until later in the evening. The error was attributed to the medication appearing on the electronic MAR due to a failure by the morning nurse to either administer or sign off the medication. The Assistant Director of Nursing confirmed this discrepancy upon reviewing the MAR.
Failure to Obtain and Document Laboratory Services
Penalty
Summary
The facility failed to provide timely and appropriate laboratory services for two residents, leading to deficiencies in care. Resident #66, who was cognitively impaired and always incontinent of urine, had three separate physician orders for urinalysis that were not fulfilled. On each occasion, the facility's records lacked documentation of the urinalysis results, and there was no evidence of follow-up actions or communication with the physician to address the inability to collect the urine samples. The Assistant Director of Nursing confirmed the absence of results and documentation during a review, indicating a failure in the facility's process for obtaining and documenting laboratory tests. Similarly, Resident #73 had an order for a comprehensive metabolic panel and complete blood count, which was marked as completed in the Treatment Administration Record. However, the facility's records did not contain any results or further documentation regarding the laboratory services. Despite being informed of the missing blood work, the Second Floor Unit Manager did not provide any additional information by the time of the exit conference, highlighting a lapse in the facility's follow-through on ordered laboratory tests.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that residents were served food at a palatable temperature, affecting several residents who voiced concerns about the temperature of their meals. Resident #82 reported that his meals were sometimes cold, estimating that this occurred about half the time. Resident #89 also mentioned that her meals were sometimes cold. Resident #77, who eats in his room, stated that his food was always cold and noted that the food cart often sat in the hallway before trays were distributed. These residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. Additionally, a review of the grievance log revealed multiple complaints about cold food over the past six months, with resolutions involving reheating meals and staff in-service training. During a special Resident Council meeting, four residents, all cognitively intact, confirmed that food was consistently served cold and that trays often sat in carts for extended periods before being distributed. Despite some recent improvements, the residents noted that these improvements were not consistent.
Failure to Accommodate Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide food according to the preferences and dietary needs of several residents, leading to dissatisfaction and potential health concerns. Resident #104, who is diabetic, reported being served orange juice and foods she dislikes, such as green beans and carrots, without being offered alternatives. Resident #63, who requires double portions due to increased nutritional needs, was served single portions and left the dining room without eating, as no alternative was offered. Resident #107, a vegetarian with specific dietary restrictions, was served a salad containing turkey, contrary to his dietary preferences and physician's orders. The facility's dietary management process was also found lacking. The Dietary Manager stated that food preferences are communicated through a form from nursing and discussed with residents within the first 24 hours of admission. However, Resident #73 reported not receiving a menu to select his choices and expressed frustration when his meal preferences were not honored, such as receiving gravy on his hamburger steak despite his meal ticket specifying no gravy. Resident #77, who prefers double portions, reported that this preference was rarely honored, although it was provided during the survey week. These deficiencies highlight a systemic issue in the facility's ability to accommodate residents' dietary preferences and needs. The dietary staff, including the Dietary Manager, failed to ensure that meal tickets accurately reflected residents' preferences and that alternative options were offered when necessary. This lack of adherence to dietary preferences and orders resulted in dissatisfaction among residents and potential health risks, particularly for those with specific dietary restrictions or increased nutritional needs.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to adhere to proper infection control practices during a blood sugar check for a resident. The Licensed Practical Nurse (LPN) used FitRight Wet Wipes, which are intended for hand hygiene and do not contain disinfecting agents, to clean the glucometer after use. The LPN was unaware of the manufacturer's instructions for the MicroKill Bleach wipes, which require a three-minute wet time to effectively disinfect the glucometer. This oversight in following the correct disinfection procedure was confirmed during an interview with the LPN. Additionally, the facility did not properly implement Enhanced Barrier Precautions (EBP) for a resident with multiple health conditions, including an indwelling urinary catheter and unhealed pressure injuries. The resident was observed to be under EBP, but the Certified Nursing Assistant (CNA) failed to wear a protective gown while performing high-contact care activities, such as perineal care and handling the urinary catheter. The CNA also wore multiple pairs of gloves without changing them between tasks, which compromised the infection control measures. Interviews with other staff members, including another CNA and a Registered Nurse (RN), revealed a lack of awareness regarding the requirement to use gowns as part of the PPE for residents under EBP. The staff emphasized hand washing and glove use but did not mention the necessity of gowns, indicating a gap in the facility's adherence to its own EBP policy. The resident later experienced discomfort and was sent to the hospital due to complications with the urinary catheter.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents across three of its four units. During an initial tour, several deficiencies were observed, including damaged furniture, such as a footboard with jagged edges and a missing nightstand replaced by a plastic bin. Additionally, there were issues with room cleanliness, such as stained privacy curtains, dust accumulation in air-conditioning vents, and brown residue on tube feeding equipment and floors. A strong urine odor was noted in one room, persisting over several days, and a small roach was observed entering a vent. Interviews with the Maintenance Director and Housekeeping Manager revealed communication gaps and unclear responsibilities regarding maintenance and cleanliness. The Maintenance Director, recently hired, indicated that repairs and missing items should be reported by nursing staff through a work order system. The Housekeeping Manager, also new to the position, was unaware of the urine odor issue and stated that CNAs were responsible for cleaning certain equipment during turnover, while housekeeping was responsible during regular cleaning. The environmental tour confirmed these issues, highlighting a lack of awareness and coordination among staff regarding the facility's environmental conditions.
Deficiencies in ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for three residents, leading to deficiencies in incontinence care, personal hygiene, and grooming. Resident #45, who has a history of cerebral vascular accident and hemiplegia, reported being left in soiled adult briefs for extended periods, resulting in severe redness in her groin and gluteal area. Despite her cognitive impairment, she was able to communicate her discomfort and the delay in receiving care. Observations confirmed that staff were slow to respond to her needs, with significant delays in changing her soiled briefs. Resident #74, with diagnoses including dorsalgia and muscle weakness, expressed dissatisfaction with the lack of personal grooming, specifically mentioning that his hair had not been shampooed for six months. He also reported infrequent perineal care, often sitting in a wet brief for hours. Despite having good cognitive function, he felt unable to request assistance due to staff being busy. Observations noted his unkempt appearance, with uncombed hair and dirty fingernails, indicating a lack of regular personal hygiene care. Resident #8, who has cognitive impairment and requires assistance with personal hygiene, was observed with dirty fingernails despite having been shaved. His care plan indicated a need for moderate assistance, yet staff failed to routinely clean his nails. The CNA responsible for his care acknowledged the need for cleaning but did not provide a reason for the oversight. This pattern of neglect in personal hygiene and grooming was consistent over several days, as evidenced by staff assignments and observations.
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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