Palm Garden Of Clearwater
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearwater, Florida.
- Location
- 3480 Mcmullen Booth Rd, Clearwater, Florida 33761
- CMS Provider Number
- 105581
- Inspections on file
- 17
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at Palm Garden Of Clearwater during CMS and state inspections, most recent first.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of care needs.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment was not maintained to minimize risks, and supervision was insufficient to prevent incidents.
The facility failed to ensure accurate PASRR assessments for twelve residents, leading to deficiencies in the screening process. The PASRR Level I assessments contained inaccuracies, such as unchecked diagnoses of mental illnesses like anxiety disorder, depressive disorder, and psychotic disorder, despite these conditions being present in the residents' medical records. Additionally, the facility lacked a policy and procedures for PASRR, contributing to the inaccuracies observed in the screenings.
The facility failed to provide sufficient staffing to ensure timely meal service, resulting in residents receiving cold meals. Multiple residents reported concerns about food temperature, and observations showed delays in meal service on two units. Staff interviews revealed high resident-to-staff ratios, with staffing decisions based on census numbers rather than resident needs. The facility lacked a clear staffing policy, contributing to the deficiency.
The facility failed to maintain professional standards for food service safety, with staff not wearing proper hair restraints, inadequate labeling of food items, and poor cleanliness in the kitchen and nourishment rooms. Staff did not perform hand hygiene or sanitize thermometer probes between food items, and food temperatures were not maintained at safe levels. The facility's policies on personal hygiene, food labeling, and temperature recording were not followed, leading to deficiencies in food service safety.
The facility failed to maintain resident dignity by requiring residents to wear informational wristbands without consent and failed to ensure the privacy of a resident's catheter bag, which was visible from the hallway. Residents expressed discomfort with the wristbands, and staff did not promptly address the visibility of the catheter bag, violating residents' rights to dignity and privacy.
The facility failed to follow physician orders for wound care for three residents, leading to deficiencies in care. A resident with a terminal prognosis had a wound dressing that was not changed as ordered. Another resident with diabetes and dementia had an undated bandage on her shin, with staff unsure of who was responsible for care. A third resident with a surgical wound lacked an active order for wound care, leading to confusion among staff. These issues highlight a failure to adhere to wound care protocols.
The facility failed to provide bedtime snacks to several residents, resulting in a gap of at least 15 hours between dinner and breakfast. Despite the Dietary Manager's claim that snacks are sent to units, residents reported not receiving them or being offered inadequate options. The Registered Dietitian confirmed the extended time between meals, which violates the facility's policy requiring snacks to be offered at bedtime.
Two residents expressed concerns about meals, care, and food temperatures, but the facility failed to document and resolve these grievances promptly. Despite communicating their issues to various staff members, including the Dietary Manager and Unit Manager, the grievances were not recorded in the logs, and no changes were made. The facility's grievance policy outlines the process for handling grievances, but inconsistencies in documentation and follow-up were evident.
A resident at risk for pressure ulcers was not provided with the prescribed offloading boot, as staff were unaware of the order and the resident's care needs. Despite documentation indicating the boot was offered, observations and interviews revealed it was not, leading to a failure in preventing pressure ulcers.
A facility failed to follow a contracture maintenance program for a resident with right-sided weakness, resulting in the resident not wearing a prescribed hand splint over several days. The care plan required the splint to be worn as tolerated, but staff were unaware of this requirement, and there was no documentation in the MAR or TAR to support the splint's use. Interviews with staff confirmed a lack of awareness and documentation regarding the splint, despite the resident's cognitive intactness and ability to make decisions.
The facility failed to ensure accurate documentation in the medical records for three residents, leading to discrepancies in dietary restrictions and physician orders. One resident was incorrectly documented as taking nutrition orally despite being on an NPO diet with a gastrostomy tube. Two other residents on NPO diets were documented as having been provided snacks.
A resident with severe medical conditions was given ice cream by an activity aide despite having an NPO order, leading to severe respiratory distress and hospital transfer. The facility failed to report the incident within the required timeframe.
The facility failed to develop an accurate care plan for a resident who was NPO and exhibited non-compliant behaviors. Despite the resident's dependence on a gastric tube for nutrition, the care plan did not reflect his NPO status and lacked specific interventions for his behaviors. Interviews revealed that the facility was aware of the issues but did not adequately address them in the care plan.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not meet regulatory standards for comprehensive and measurable care planning.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding specific residents, their medical history, or the exact nature of the hazards or accidents were provided in the report.
Inaccurate PASRR Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) assessments for twelve residents, leading to deficiencies in the screening process. The PASRR Level I assessments for these residents contained inaccuracies, such as unchecked diagnoses of mental illnesses like anxiety disorder, depressive disorder, and psychotic disorder, despite these conditions being present in the residents' medical records. For instance, Resident #1's PASRR indicated no diagnosis or suspicion of serious mental illness, despite having major depressive disorder and anxiety disorder. The report highlights several instances where the PASRR Level I screenings did not reflect the residents' actual diagnoses. For example, Resident #126's PASRR failed to check anxiety disorder, even though it was part of the resident's medical history. Similarly, Resident #44's PASRR marked no suspicion of serious mental illness, despite the presence of anxiety disorder, depressive disorder, and psychotic disorder. These discrepancies indicate a lack of thoroughness in the PASRR screening process, which is crucial for determining the need for a Level II evaluation. Additionally, the facility lacked a policy and procedures for PASRR, as confirmed by the Nursing Home Administrator. This absence of a structured approach to PASRR assessments likely contributed to the inaccuracies observed in the screenings. The failure to accurately complete PASRR assessments could lead to inappropriate admissions and inadequate care planning for residents with serious mental illnesses or intellectual disabilities.
Inadequate Staffing Leads to Cold Meals for Residents
Penalty
Summary
The facility failed to ensure sufficient staffing to provide timely meal service to residents on two units, B and D, out of four units in the facility. Multiple residents expressed concerns about the temperature of their meals, consistently reporting that the food was cold. Observations revealed delays in meal service, with meal carts arriving and being served over extended periods, contributing to the cold food issue. The staff available for meal service varied, with some instances having only two CNAs and one nurse to serve meals, which may have contributed to the delays. Interviews with staff indicated that CNAs were responsible for a high number of residents, often exceeding ten, which they reported made it difficult to provide quality care. The facility's staffing decisions were based on census numbers, with no adjustments made for weekends. The Nursing Home Administrator and Director of Nursing stated that staffing was based on resident acuity and needs, but there was no clear policy or procedure for staffing, and the facility did not provide one when requested. This lack of a formal staffing policy may have contributed to the inadequate staffing levels observed.
Deficiencies in Food Service Safety and Hygiene
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the kitchen, staff were found not wearing proper hair restraints, with hair exposed beyond the acceptable limit. Additionally, food items in the walk-in fridge were not labeled correctly, and some were in poor condition, such as wrinkled peppers with dark spots. The walk-in freezer had scattered food particles and debris on the floor, indicating a lack of cleanliness. Furthermore, the kitchen hood was observed to have a brown rusted color and areas of oxidation, suggesting inadequate cleaning. In the nourishment rooms, the microwave was found with dried food particles, and staff were observed using cell phones while handling clean kitchen items, which is against the facility's policy. During meal service, staff failed to perform hand hygiene before taking food temperatures and did not sanitize the thermometer probe between different food items. The temperature of the ribs was recorded below the required safe level, and cold food items were not maintained at the appropriate temperature, indicating a failure in monitoring and maintaining food safety standards. The facility's policies on personal hygiene, food labeling, and temperature recording were not followed, as evidenced by the lack of handwashing, improper use of hair restraints, and failure to label and date food items correctly. The Certified Dietary Manager (CDM) acknowledged these deficiencies and stated that staff should not be using cell phones in the kitchen and that the dietary team is responsible for maintaining cleanliness. However, the observations during the survey revealed significant lapses in adhering to these policies, contributing to the overall deficiency in food service safety.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity by requiring residents to wear plastic informational wristbands without their consent or understanding. Observations over several days revealed that multiple residents were wearing these wristbands, which contained personal information such as photos, numbers, and barcodes. Interviews with residents indicated that many did not understand the purpose of the wristbands and expressed discomfort and a desire not to wear them. The facility's Director of Nursing (DON) and Registered Nurse/Unit Manager (RN UM) confirmed the use of wristbands for resident identification but were unable to provide consent forms for the residents involved. Additionally, the facility failed to ensure the privacy of a resident using an indwelling catheter. On multiple occasions, the catheter bag was observed hanging in a manner that made it visible from the hallway and nurses' station, without being placed in a privacy bag. This was contrary to the facility's catheter care policy, which requires the use of a privacy bag to maintain resident dignity and privacy. Staff members, including a Certified Nursing Assistant (CNA) and the RN UM, were observed not addressing the visibility of the catheter bag promptly. The facility's failure to obtain consent for wristbands and to maintain the privacy of catheter bags violated residents' rights to dignity and privacy. The Nursing Home Administrator (NHA) acknowledged the lack of specific policies and procedures related to privacy and dignity, relying instead on general guidelines in the resident rights section of the admission packet. The absence of consent forms and the improper handling of catheter bags highlight deficiencies in the facility's adherence to resident rights and care standards.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for three residents, leading to deficiencies in care. Resident #5, who was admitted with a terminal prognosis and at risk for skin integrity issues, had a wound dressing on her forehead that was not changed as per the physician's orders. The dressing was supposed to be changed every other day, but it was observed to be dated two days prior, and staff admitted to documenting the change without actually performing it. Resident #138, who has multiple diagnoses including diabetes and dementia, was observed with an undated bandage on her left shin. The facility's records showed that the wound care orders were not consistently followed, and there was confusion among staff about who was responsible for changing and documenting the dressing. The wound care nurse and floor nurses had conflicting accounts of the care provided, and the bandage was found to be undated, which is against the facility's policy. Resident #266, admitted with a surgical wound on the left knee, did not have an active order for wound care until several days after admission. The hospital discharge summary specified that the dressing should remain until a certain postoperative day unless saturated, but this order was not transcribed into the facility's records. Staff interviews revealed a lack of clarity on the need for physician orders for dressing changes, and the Director of Nursing confirmed the absence of an active order for the resident's wound care.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to offer a nourishing snack at bedtime for five out of six residents sampled for dining. Interviews with residents revealed that they were not offered evening snacks, and when they requested snacks, the staff either did not have any available or provided inadequate options. One resident mentioned that the kitchen was closed when they attempted to request a snack, while another resident was given a moon pie after expressing their desire for a snack. The residents expressed their dissatisfaction with the lack of snacks, indicating a preference for having something to eat before bedtime. The Dietary Manager stated that snacks are sent to the units each evening for residents who have requested them, along with a variety of other snacks for those who might request them. However, the Registered Dietitian noted that there was at least a 15-hour gap between dinner and breakfast, which exceeds the facility's policy of no more than 14 hours between meals unless a nourishing snack is provided. The facility's policy requires that snacks be offered at bedtime and that there be no more than 14 hours between the evening meal and breakfast unless a nourishing snack is served, which was not adhered to in this case.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident #109 expressed repeated concerns about meals and care, stating that the facility did not listen to her. Despite these concerns being communicated to various staff members, including the Dietary Manager and the Unit Manager, there was no documentation of these grievances in the facility's grievance logs from November 2024 to February 2025. The Dietary Manager acknowledged receiving concerns from residents but admitted to not documenting them consistently. Resident #268 also reported concerns about care and food temperatures since admission, stating that these issues were communicated to multiple staff members, including CNAs, nurses, and the Unit Manager, but no changes were made. The grievance logs from January 2025 to February 2025 did not reflect any grievances for Resident #268. Staff members, including a CNA and an RN, confirmed that grievances could be filed by anyone, but there was a lack of documentation and follow-up on these concerns. The facility's grievance policy, revised in March 2024, outlines the process for handling grievances, including the roles of the Grievance Official and Social Services personnel. However, interviews with staff revealed inconsistencies in the documentation and resolution of grievances. The Social Services Director, responsible for overseeing the grievance process, confirmed that grievances are discussed in daily meetings and tracked for trends, but there was no follow-up with residents unless the issues were related to Social Services. The Nursing Home Administrator stated that grievances are logged and discussed in manager meetings, but the process failed to ensure timely resolution and documentation of the residents' concerns.
Failure to Provide Pressure Ulcer Prevention Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with a known risk for pressure ulcers. The resident, who was admitted with diagnoses including palliative care, weakness, and reduced mobility, had orders to wear a right offloading boot when in bed to prevent pressure ulcers. However, observations over several days revealed that the resident was not wearing the prescribed boot, and staff were unaware of the resident's need for the boot or the associated doctor's orders. Interviews with multiple CNAs assigned to the resident indicated a lack of awareness regarding the resident's need for the offloading boot. The CNAs, who regularly cared for the resident, were not informed about the resident's upper or lower extremity weaknesses or the requirement for the boot. The resident herself could not recall being offered the boot recently and mentioned that it hurt her foot, but there was no documentation of refusal or any behavior issues related to the boot in her care plan. The facility's records, including the February 2025 MAR, inaccurately documented that the resident was offered and assisted with the boot, despite observations and interviews indicating otherwise. The Rehabilitation Department was not involved in the resident's care concerning the boot, as it was ordered by the physician for pressure ulcer prevention. The lack of proper communication and documentation led to the resident not receiving the necessary care to prevent pressure ulcers, as per professional standards of practice.
Failure to Implement Contracture Maintenance Program
Penalty
Summary
The facility failed to adhere to the contracture maintenance program for a resident, resulting in the resident not being assisted with the donning and doffing of their splint device over a four-day observation period. The resident, who has a history of right-sided weakness due to a cerebrovascular accident, was observed without the prescribed right hand splint on multiple occasions. Interviews with the assigned CNAs revealed they were unaware of the resident's need for a splint, indicating a lack of communication and training regarding the resident's care plan. The resident's care plan and physician's orders specified the use of a right resting hand splint to be worn as tolerated, with specific instructions for application and removal during evening and morning care. However, there was no documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to support that the splint was offered, worn, or refused, suggesting a failure in record-keeping and adherence to the care plan. Interviews with nursing staff, including an LPN and RN Unit Manager, confirmed the absence of documentation regarding the splint's use and any refusals by the resident. The Rehabilitation Director was unaware that the splint was not being applied as per the care plan and acknowledged that the responsibility for applying the splint lay with the night shift aides. Despite the resident's cognitive intactness and ability to make decisions, there was no evidence of documented refusals of the splint, further highlighting the facility's failure to implement and monitor the prescribed contracture maintenance program effectively.
Documentation Errors in Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for three residents. Resident #1, who had multiple diagnoses including pneumonia and severe protein-calorie malnutrition, was documented as taking nutrition and medication orally despite having a gastrostomy tube and being on an NPO diet. The LPN responsible for the documentation admitted to the error, stating it was careless charting and that the resident was actually receiving everything via the g-tube. The Director of Nursing acknowledged the documentation errors and expressed concern over the accuracy of the records. Resident #2, who was on an NPO diet due to pneumonitis from inhalation of food and vomit, was documented by certified nursing assistants as having been provided snacks on multiple occasions. This was contrary to the physician's orders and the resident's dietary restrictions. An observation of Resident #2 showed that he was alert but non-verbal, and he acknowledged questions by nodding. Resident #3, who had diagnoses including pleural effusion and dysphagia, was also on an NPO diet. However, the certified nursing assistants documented that he had been provided a snack on one occasion. An observation of Resident #3 showed that he was in bed and did not respond when spoken to. These documentation errors indicate a failure to adhere to the residents' dietary restrictions and physician orders, compromising the accuracy of the medical records and potentially the residents' care.
Failure to Timely Report Incident Leading to Hospital Transfer
Penalty
Summary
The facility failed to report an event that led to the transfer of a resident to a higher level of care within the specified timeframe. The resident, who had a history of severe medical conditions including pneumonia, urinary tract infection, severe protein-calorie malnutrition, and others, was admitted to the facility and later discharged to the hospital. The resident was cognitively intact and required partial assistance for daily activities. On the day of the incident, the resident attended an ice cream social and was given ice cream by an activity aide, despite having a medical order for nothing by mouth (NPO) and being on enteral feeding via a peg tube. The resident began experiencing severe respiratory distress during the social event, with oxygen saturation levels dropping significantly. The resident was placed on portable oxygen and a rebreather mask but showed minimal improvement. The decision was made to transfer the resident to the emergency room, and 911 was called. The incident was initially reported to the Director of Quality Assurance/Risk Manager (DOQA/RM) by the weekend supervisor, who stated that the resident had grabbed the ice cream. However, further investigation revealed that the ice cream was handed to the resident by the activity aide, who had access to the dietary list indicating the resident's NPO status. The DOQA/RM initiated an investigation on the following day and discovered the full details of the incident. The activity aide was removed from the schedule and later terminated. The facility reported the incident to the appropriate authorities, including the State Survey Agency, Adult Protective Services, and local law enforcement, but not within the required timeframe. The delay in reporting and the failure to follow the resident's medical orders led to the deficiency noted in the report.
Inadequate Care Plan for NPO Resident with Non-Compliant Behaviors
Penalty
Summary
The facility failed to ensure the Comprehensive Patient-Centered Care Plan was developed and accurate for a resident who was NPO (nothing by mouth) and exhibited non-compliant behaviors. The resident, who had multiple diagnoses including pneumonia, severe protein-calorie malnutrition, and dysphagia, was dependent on a gastric tube for nutrition and hydration. Despite this, the care plan did not accurately reflect the resident's NPO status and failed to address his non-compliant behaviors, such as drinking tap water and eating unauthorized food items. The MDS coordinator confirmed that the behavior care plan did not indicate the resident was NPO and acknowledged that the interventions could have been personalized but were not. Interviews with the Director of Quality Assurance/Risk Manager (DOQA/RM) and the Director of Nursing (DON) revealed that the facility was aware of the resident's non-compliant behaviors but did not adequately address them in the care plan. The DOQA/RM discovered an unopened package of snacks in the resident's room, and the DON confirmed that the care plan interventions were basic and needed to be more focused on the resident's specific behaviors. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but the care plan for this resident did not meet the required standards for addressing dietary orders and specific health and safety concerns.
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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