Palm Garden Of Sun City
Inspection history, citations, penalties and survey trends for this long-term care facility in Sun City Center, Florida.
- Location
- 3850 Upper Creek Dr, Sun City Center, Florida 33573
- CMS Provider Number
- 105736
- Inspections on file
- 21
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Palm Garden Of Sun City during CMS and state inspections, most recent first.
A resident with bilateral above-knee amputations, impaired gait, and coordination deficits, who was care planned as total assist x2 for bed mobility and incontinent care, fell from bed during incontinent care when only one CNA provided assistance. The resident became agitated, pulled on the privacy curtain, and rolled out of bed, sustaining a small forehead abrasion. The CNA reported she was unaware that two-person assistance was required and believed, based on prior information from nurses, that the resident was a one-person assist, despite the Kardex specifying total assist x2.
A resident who was dependent on staff for transfers due to significant mobility impairments was injured when two CNAs failed to properly secure the sling straps during a mechanical lift transfer from wheelchair to bed. As a result, the resident fell from the lift, sustained a head laceration, and required hospital treatment. The incident occurred despite clear care plan instructions and facility procedures requiring two-person assistance and proper sling attachment.
A resident with multiple medical conditions, including contractures and significant pain, was neglected in a facility. The resident was not provided with necessary pain management, supportive devices, or adequate ADL care. Despite family concerns and staff awareness, the resident's pain and therapy needs were not addressed, and she remained confined to bed without a wheelchair or special chair. The facility's policies on neglect and nail care were not followed, leading to the resident's physical harm and pain.
A resident with significant medical conditions, including contractures, experienced inadequate pain management and care. Despite expressing pain and needing assistance, the resident only received Tylenol, which was insufficient. Communication failures led to the resident not receiving prescribed Tramadol, and therapy evaluations were not completed due to pain. The resident's hygiene and positioning needs were also neglected, contributing to her discomfort.
The facility failed to ensure proper food safety and storage practices, including staff not wearing hairnets, unlabeled and improperly stored food items, and incomplete temperature logs. These deficiencies were observed in the kitchen, dining room, nourishment room, and activity room, with photographic evidence supporting the findings.
The facility failed to accurately complete PASRR forms for several residents, leading to deficiencies in documenting mental disorders or intellectual disabilities. A resident with Major Depressive Disorder and Dementia had incorrect PASRR documentation, while another with multiple mental health diagnoses was not marked for dementia. Additionally, a resident's PASRR form did not reflect their anxiety and major depressive disorder, and another's form incorrectly marked the absence of dementia. The Care Plan Specialist confirmed these inaccuracies, and the facility lacked a PASRR policy.
The facility failed to properly store and label medications, with pills found on bedside tables and loose in medication carts. Expired medications and non-medication items were stored improperly, contrary to facility policy. Staff interviews revealed lapses in cleaning and monitoring responsibilities, and the DON was unaware of these issues.
The facility failed to maintain proper infection control practices, including incorrect precaution signage, inadequate hand hygiene, and improper PPE usage. Respiratory masks were left uncovered, and staff entered rooms with contact precautions without PPE. Confusion among staff regarding PPE protocols and inconsistent adherence to facility policies contributed to these deficiencies.
A resident was left to sleep on an unmade bed after a CNA failed to return to remake it following a urinal spill. The resident, who required assistance with personal care, was found on a bare mattress by another CNA. The facility lacked a specific policy on dignity, as confirmed by the DON.
The facility failed to develop care plans for two residents, one requiring splint management and another with impaired vision. A resident with a physician's order for a palm protector was often found without it, and staff did not assist in its application. Another resident with vision impairment struggled to find her glasses and could not read facility materials, yet had no care plan addressing her vision needs. The deficiencies were acknowledged by staff but not rectified at the time of the survey.
A resident with a right-hand contracture did not receive physician-ordered splint management, as the palm guard was not consistently applied. Despite the order for the palm guard to be worn at all times except for hygiene, staff were confused about the resident's orthotic device, and there was no documentation in the care plan or administration records. The DON acknowledged the need for an updated care plan, highlighting a gap in adherence to the facility's restorative nursing policy.
A resident on a vegetarian diet, who prefers fish, was not provided with balanced meals, lacking protein options. Observations revealed that selected meal items were altered by staff, and the resident expressed dissatisfaction with limited vegetarian options, often feeling hungry after meals. The care plan indicated a nutritional risk, but menu selections lacked protein, leading to inadequate meal offerings.
The facility was found to have falsified documentation related to refrigerator temperature logs and inaccurately documented services for a resident with significant medical conditions. The temperature logs were retroactively completed, and the resident's records inaccurately reflected frequent transfers and locomotion activities, despite the resident remaining in bed without a wheelchair. These actions violated the facility's Code of Conduct, which requires accurate and complete records.
Failure to Provide Required Two-Person Assist During Incontinent Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for bed mobility and incontinent care was protected from a fall during care. The resident had a history of other abnormalities of gait and mobility, lack of coordination, and bilateral above-knee amputations, and was care planned as total assist x2 for bed mobility, transfers with mechanical lift, and incontinent care. During an episode of incontinent care, a CNA provided care alone. The resident became agitated and combative, and when the CNA turned to clean the resident, the resident pulled on the privacy curtain and rolled out of the bed, resulting in a fall and a small skin tear/abrasion to the forehead. The CNA reported she had routinely cared for this resident and was not aware that two-person assistance was required for bed mobility and incontinent care. She stated she had previously asked nurses whether the resident required two-person assistance and was told the resident was a one-person assist, though she could not recall which nurse provided this information. The CNA later reviewed the chart and saw the resident was documented as an extensive assist, meaning one- or two-person assistance, while the care plan and Kardex specified total assist x2 for bed mobility and incontinent care. The DON stated her expectation was that CNAs review and follow the Kardex prior to providing care and indicated that, in this incident, the Kardex directions for two-person assistance were not followed.
Failure to Ensure Safe Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer of a resident who required a mechanical lift and two-person assistance for transfers. The resident, who was dependent on staff for activities of daily living due to impairments in both upper and lower extremities, was being transferred from a wheelchair to a bed. During the transfer, two CNAs were present; one positioned the sling straps over the front hooks, but the other failed to properly secure the back sling straps to the lift. As the lift was operated and the resident was raised approximately two feet, the unsecured straps led to the resident sliding forward and falling from the sling to the floor. The incident resulted in the resident sustaining a head laceration and crying out in pain, with blood observed on the face and floor. The LPN on duty was notified and, upon assessment, called for emergency medical assistance. The resident was subsequently transferred to a hospital for evaluation and treatment and did not return to the facility. The facility's investigation confirmed that the mechanical lift and sling were not faulty, and the failure was attributed to staff not following the standard operating procedure for mechanical lift transfers. The resident's care plan specified the use of a mechanical lift with two-person assistance for all transfers due to a history of multiple falls and fractures. Facility policy and manufacturer instructions both required that all sling straps be properly secured before lifting a resident. Staff interviews confirmed that the standard practice was to have two staff members present and all four straps hooked appropriately to prevent such incidents. The failure to adhere to these procedures directly led to the resident's fall and injury.
Neglect in Pain and Contracture Management
Penalty
Summary
The facility failed to protect a resident from neglect related to pain management, contracture management, activities of daily living (ADL) care, and seating systems. The resident, who was admitted with multiple medical conditions including nontraumatic intracerebral hemorrhage, moyamoya disease, and contractures, was observed in bed with significant pain and without necessary supportive devices such as palm guards or splints. The resident's care plan did not address contractures of the upper extremities, and the resident was not provided with adequate pain management, as only Tylenol was ordered despite the resident's significant pain during movement. Interviews with staff revealed a lack of communication and follow-up regarding the resident's pain and therapy needs. The resident's primary care nurse practitioner was unaware of the resident's pain issues and therapy status, and a previously ordered pain medication, Tramadol, was not administered due to a system error. The resident's family expressed concerns about the resident's pain, lack of therapy, and inadequate nail care, which were not addressed by the facility. The resident was also not provided with a wheelchair or special chair, resulting in her being confined to bed. The facility's policies on abuse, neglect, and nail care were not followed, as evidenced by the resident's untrimmed and dirty nails and the lack of appropriate interventions for her contractures and pain. The Director of Nursing and other staff members acknowledged the deficiencies in communication and care, but no corrective actions were documented in the report. The facility's failure to provide necessary goods and services resulted in the resident experiencing physical harm and pain.
Inadequate Pain Management and Care for Resident with Contractures
Penalty
Summary
The facility failed to provide adequate pain management for a resident with significant medical conditions, including nontraumatic intracerebral hemorrhage, moyamoya disease, and contractures of the upper and lower extremities. The resident was observed in pain, particularly when moved, and expressed a desire for assistance with her contracted hands. Despite these observations, the resident's care plan did not address the contractures of the upper extremities, and the only pain medication ordered was Tylenol, which was insufficient for her level of pain. Interviews with staff revealed a lack of communication and follow-up regarding the resident's pain management needs. The resident's primary care NP was unaware of the resident's pain issues and believed the resident was receiving physical therapy, which was not the case. The NP had ordered Tramadol for pain management, but this order was not reflected in the facility's system, and the medication was never administered. Additionally, the therapy department did not communicate with nursing about the resident's inability to tolerate therapy due to pain, and no alternative pain management strategies were implemented. The resident's condition was further exacerbated by inadequate hygiene and positioning. Her fingernails were long and dirty, and she was not provided with a wheelchair or appropriate seating system, resulting in her being confined to bed. Staff reported difficulty in cleaning the resident's hands due to her contractures, and her feet were observed to be in poor condition with dry, cracked skin and significant edema. The facility's failure to address these issues contributed to the resident's ongoing pain and discomfort.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety services, as observed in various areas including the kitchen, dining room, nourishment room, and activity room. Dietary staff were not wearing hairnets, as required, and food items were improperly stored. Specifically, a box of bananas was found on the floor in the dry storage area, and several food items in the walk-in refrigerator were not labeled or dated. Additionally, some food items were improperly stored with other items placed on top, breaking the seal and exposing them to potential contamination. Temperature logs for refrigerators and freezers were incomplete, with multiple missing dates in the dining room and activity room. The Certified Dietary Manager confirmed that all food items should be labeled and dated, and temperature logs should be completed daily. The facility's policies on food labeling, dating, and temperature monitoring were not followed, leading to these deficiencies. Photographic evidence supported these findings, and the Certified Dietary Manager acknowledged the issues and the unethical practice of completing temperature logs retroactively.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to complete accurate Preadmission Screening and Resident Review (PASRR) forms for four residents, leading to deficiencies in the documentation of mental disorders or intellectual disabilities. Resident #19 was admitted with diagnoses of Major Depressive Disorder and Dementia, but the PASRR Level I Screen did not mark these diagnoses correctly. Similarly, Resident #15's PASRR form failed to indicate dementia, despite the resident having multiple mental health diagnoses, including post-traumatic stress disorder and bipolar disorder. Resident #59's PASRR form did not reflect any mental illness, even though the resident had been diagnosed with anxiety disorder and major depressive disorder. Additionally, Resident #24's PASRR form incorrectly marked the absence of a primary diagnosis of dementia, despite the resident's severe cognitive impairment and behavioral issues related to dementia. The deficiencies were confirmed during an interview with Staff T, the Care Plan Specialist, who acknowledged the inaccuracies in the PASRR forms for the residents mentioned. Staff T explained her process of checking new admissions and updating PASRR forms with new diagnoses but admitted to the errors in the current cases. Furthermore, the Director of Nursing revealed that the facility did not have a PASRR policy in place, which may have contributed to the oversight and inaccuracies in the PASRR documentation for the residents.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. On two out of three units and in all three medication carts, medications were not stored properly. Pills were found in medication cups on bedside tables in two rooms, and loose pills were discovered in the drawers of medication carts. Expired medications, such as Acetaminophen suppositories and Ibuprofen, were found in the carts, and some medications lacked expiration dates. Additionally, non-medication items like a blood pressure monitor, pulse oximeter, and other miscellaneous items were stored with medications, which is against the facility's policy. Interviews with staff, including RNs and LPNs, revealed that the night shift was responsible for cleaning the medication carts and ensuring no expired or loose medications were present. However, this was not done, leading to the deficiencies observed. The Director of Nursing was unaware of these issues and confirmed that medications should not be left at the bedside unless a resident is approved to self-administer, which was not the case for the residents involved. The facility's policy requires medications to be stored in an orderly manner and expired or discontinued medications to be destroyed or returned, which was not adhered to in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices across two out of three units, as observed through incorrect transmission-based precaution signs, lack of hand hygiene during tray pass, improper storage of respiratory masks, and improper personal protective equipment (PPE) usage. On multiple occasions, respiratory masks were left uncovered on bedside tables for extended periods, indicating a lapse in infection control protocols. Additionally, there was a failure to post appropriate isolation precaution signage in a timely manner for a resident with multiple cancer diagnoses and a pending stool sample for enteric pathogen PCR. The report highlights several instances where staff did not adhere to proper PPE protocols. For example, a CNA entered a resident's room with a contact precaution sign without wearing PPE and failed to perform hand hygiene between resident interactions. This resident had a current diagnosis of a urinary tract infection and was on antibiotics, necessitating contact precautions. Another CNA entered a different resident's room, who was on contact precautions for C-Diff and MRSA, without donning PPE, and used alcohol-based hand sanitizer instead of soap and water, contrary to the requirements for C-Diff precautions. Interviews with staff revealed confusion and misunderstanding regarding the appropriate use of PPE and the specific requirements for contact precautions versus enhanced barrier precautions. The Infection Preventionist and Director of Nurses acknowledged discrepancies in the signage and the need for proper storage of respiratory equipment. The facility's policy on transmission-based precautions was not consistently followed, contributing to the deficiencies observed during the survey.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #257, who reported having to sleep on an unmade bed after an incident involving a full urinal. The resident stated that they had to use an almost full urinal, which spilled, and when the CNA arrived, she expressed frustration and indicated that she would have to shower the resident. The resident refused the shower, wanting to return to bed, but the CNA stripped the bed and did not return to remake it. Consequently, the resident had to sleep on a bare mattress, wearing a large sweater for warmth. The incident was corroborated by the resident's roommate and another CNA, Staff K, who found the resident on the bare mattress. The resident's admission record indicated recent admission with diagnoses including benign prostatic hyperplasia and a need for assistance with personal care. The Director of Nursing acknowledged that the situation was unacceptable and stated that the facility lacked a specific policy on dignity or resident rights, although they claimed to follow regulations.
Failure to Develop Care Plans for Splint Management and Vision Impairment
Penalty
Summary
The facility failed to develop a care plan for splint management for Resident #9, who was observed multiple times without the required palm guard on their right hand. Despite a physician's order for the resident to wear the palm protector at all times, it was frequently found on the bedside table or elsewhere in the bed, and the resident reported that staff did not assist in putting it on. The Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's refusal or non-compliance with wearing the splint, but it was not. Additionally, the facility lacked a specific care plan policy, relying solely on the Resident Assessment Instrument manual. Resident #59, who had moderately impaired vision, also lacked a care plan addressing her vision needs. She was observed struggling to locate her glasses and expressed difficulty in reading materials such as newsletters and menus. Although her vision care plan had been marked as resolved in April 2023, it was confirmed by the MDS Coordinator that the resident still had vision loss and no current care plan was in place. The oversight was acknowledged, and the care plan was subsequently updated, but the deficiency remained at the time of the survey.
Failure to Provide Physician-Ordered Splint Management
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered splint management to prevent the worsening of a contracture. Resident #9, who was admitted with multiple diagnoses including a contracture of the right hand, was observed multiple times without the required palm guard. The resident reported that staff removed the palm guard and did not assist in putting it back on, despite the physician's order for it to be worn at all times except for hygiene. Interviews with staff revealed confusion regarding the resident's orthotic device, with some staff believing the resident used a carrot splint instead of the palm guard. The occupational therapy notes indicated that the palm guard was deemed more beneficial than the carrot splint, and the resident was instructed to wear it consistently. However, there was no documentation in the Medication Administration Record, Treatment Administration Record, or care plan regarding the palm guard or splint management. The Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's needs and any refusals to wear the splint. The facility's policy on restorative nursing programming includes splint or brace assistance, but there was a lack of adherence to this policy in the case of Resident #9. The absence of a care plan policy and reliance solely on the Resident Assessment Instrument manual contributed to the oversight in managing the resident's contracture care.
Failure to Provide Balanced Vegetarian Diet
Penalty
Summary
The facility failed to provide a well-balanced special diet for a resident on a vegetarian diet, who prefers fish, and was on a select menu. On multiple occasions, the resident's meal trays lacked protein options, which is a critical component of a balanced diet. For instance, during a lunch observation, the resident's selected seasoned pasta was struck out by staff, and no protein was provided, leaving the resident with only vegetables and carbohydrates. The resident expressed dissatisfaction with the limited vegetarian options, stating that she often felt hungry after meals and had to rely on snacks and food brought by her family. The resident's care plan indicated a nutritional risk related to her diagnoses and required serving the diet as ordered. However, the menu selection sheets for a specific week showed no protein options for lunch and dinner meals. Interviews with the resident confirmed her ongoing hunger and lack of sufficient meal options, particularly protein. The Senior Director of Culinary Operations acknowledged the deficiency, noting that the resident's meals should have included a protein option and that the current offerings were inadequate.
Falsification of Documentation and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure ethical conduct by staff, as evidenced by the falsification of documentation related to the dining room reach-in refrigerator temperature log. On multiple occasions, the temperature log was found incomplete, with missing entries for several days. However, upon a subsequent observation, the log was filled in with temperatures for the previously missing dates, suggesting that someone had retroactively completed the log. The Certified Dietary Manager acknowledged that this practice was unethical and could lead to inaccurate temperature documentation, which is against the facility's policy requiring daily temperature checks and logs. Additionally, the facility failed to provide accurate documentation of services for a resident with significant medical conditions, including dementia and diabetes. The resident's records inaccurately documented frequent transfers and locomotion activities, despite interviews with staff and family indicating that the resident remained in bed and did not have a wheelchair. The Director of Nursing confirmed that the resident could not tolerate being out of bed and had not been evaluated for a wheelchair, contradicting the documented care activities. The facility's Code of Conduct policy emphasizes the importance of maintaining accurate and complete records, which was not adhered to in these instances. The discrepancies in documentation and the lack of ethical conduct in record-keeping highlight significant deficiencies in the facility's compliance with its own policies and procedures.
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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