Pearl At Fort Lauderdale Rehabilitation And Nursin
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Lauderdale, Florida.
- Location
- 1701 Ne 26th St, Fort Lauderdale, Florida 33305
- CMS Provider Number
- 105089
- Inspections on file
- 19
- Latest survey
- December 12, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pearl At Fort Lauderdale Rehabilitation And Nursin during CMS and state inspections, most recent first.
The facility failed to maintain food safety and sanitation standards, affecting 187 residents. Observations included unclean kitchen equipment, improper food labeling, and a dietary aide preparing food without a beard covering. The dishwasher temperature exceeded the manufacturer's recommended limit, and a stock pot had residue buildup. These issues indicate non-compliance with professional food service standards.
The facility's QAPI/QAA failed to implement an effective plan to correct deficiencies in Resident Rights (F550), Nutrition (F692), Pharmacy Services (F755), Meal Frequency (F809), and Infection Control (F880). These issues were previously cited and identified again, potentially affecting all 196 residents. No effective corrective plan was evident during the QAPI review.
The facility failed to maintain resident dignity during dining by referring to residents as 'feeders' and standing while feeding them. Staff were observed using disrespectful terminology and not sitting at eye level when assisting residents with meals, contrary to the facility's policy on dignity.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting medications and diagnoses. A resident with nicotine dependence was observed smoking despite having a nicotine patch, which was not coded as a psychotropic medication. Another resident's MDS was incorrectly coded for Schizophrenia instead of Schizoaffective Disorder, Bipolar Type. A third resident's MDS was inaccurately coded for anticoagulant use, despite no physician order, and failed to document other medications administered.
The facility failed to implement comprehensive care plans for residents on psychotropic medications and antibiotic therapy, leading to deficiencies in monitoring and addressing their needs. A resident on Trazodone lacked orders for side effect monitoring, while another on Meropenem had inadequate IV site maintenance. Other residents on psychotropic medications also had care plan deficiencies, indicating systemic issues in care planning and monitoring.
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in care. A resident with cognitive impairment was left without assistance during meals, consuming only a small portion of food. Another resident with multiple health issues received inadequate oral care, resulting in dry and cracked lips. A third resident expressed dissatisfaction with grooming, while two others struggled to eat without staff support. These incidents highlight the facility's failure to adhere to care plans and provide necessary support.
A resident with a urinary catheter experienced blood-tinged urine, but the facility failed to document or address the issue. Observations showed improper infection control practices, such as placing the urinary bag on the floor and not changing gloves between tasks. Interviews revealed a lack of communication and documentation by staff, contributing to the deficiency.
The facility failed to calibrate scales and provide timely nutritional supplements, leading to significant weight loss in two residents. One resident with chronic kidney disease lost 17% of their weight over two months, and another with multiple diagnoses lost 13.6% over less than six months. The dietitian delayed increasing supplements, and scales had outdated or missing calibration stickers, potentially affecting weight accuracy.
The facility failed to obtain current physician's orders and maintain proper documentation for the care of IV/PICC lines for three residents. One resident had a PICC line with a stained, peeling dressing and no maintenance orders. Another resident's PICC line lacked specific orders for dressing changes and flushing, with no care plan in place. A third resident had an IV catheter left in place after antibiotic therapy completion, with loose dressing and no documentation of care. Staff interviews revealed a lack of knowledge and communication regarding the care and maintenance of these lines.
A facility failed to obtain current physician's orders for oxygen therapy for a resident with COPD and did not properly monitor another resident receiving nebulizer treatments. The resident receiving oxygen therapy was observed without a current physician's order, and documentation was lacking in the MAR and TAR. The resident receiving nebulizer treatments was not monitored according to standards, with no staff present during treatment and no assessment of vital signs or breath sounds. Interviews revealed inconsistencies in monitoring practices, despite guidelines stating nurses should stay with residents during treatments.
The facility failed to follow physician-ordered fluid restrictions for two residents requiring dialysis. One resident received excessive fluids due to unclear instructions and lack of staff awareness, while another's meal tickets lacked fluid restriction information, leading to overconsumption. This indicates a deficiency in managing care for dialysis patients.
The facility failed to accurately reconcile controlled substances for four residents, leading to discrepancies between the Controlled Drug Disposition sheets and Medication Administration Records (MAR). Interviews with staff, including LPNs and the DON, revealed a lack of documentation for medications like Alprazolam, Tramadol, and Percocet, despite being dispensed. The DON and Consultant Pharmacist acknowledged the need for better education on documentation and reconciliation processes.
The facility failed to monitor medication side effects and efficacy for several residents, including those on psychotropic, antipsychotic, and hypoglycemic medications. This lack of monitoring was evident in the absence of documentation and care plan adherence, affecting residents with conditions such as diabetes, depression, and schizoaffective disorder. The consultant pharmacist and nursing staff acknowledged these deficiencies, indicating a systemic issue in medication management practices.
The facility failed to maintain sanitary storage of glucometers, secure medication storage rooms, and prevent residents from keeping medications at their bedside. A glucometer was improperly stored, the medication room door was left open, and a resident had an unsecured insulin pen accessible to others. Staff interviews revealed lapses in following protocols for medication storage and handling.
The facility did not follow their menu for the regular diet during a kitchen observation, affecting 117 residents. The menu specified 3 ounces of apple butter pork loin, but a lunch tray contained a slice weighing only 2.25 ounces. The Food Service Director stated that the cook should have pre-cut and weighed each slice to ensure it met the 3-ounce requirement, which was not done.
Two residents with severe cognitive impairments were served meals that did not meet the required pureed diet consistency, as observed during dining. The facility's policy mandates a smooth, pudding-like texture for pureed foods to ensure safe swallowing and minimize aspiration risk. However, meals served to these residents contained lumps and grainy textures, indicating non-compliance with the policy.
The facility failed to meet the dietary needs and preferences of three residents, leading to deficiencies in care. A resident with severe cognitive impairment did not receive a nutritional supplement, another with moderate impairment and multiple diagnoses did not receive a high-calorie pudding, and a third resident on a fortified food regimen did not receive the required fortified mashed potatoes. These oversights were confirmed by staff and highlight a failure to adhere to dietary plans.
A facility failed to maintain hospice documentation for a resident with severe cognitive impairment receiving hospice care. Despite an agreement requiring weekly discussions and medication reconciliation, the hospice nurse's progress notes were not kept in the facility, leading to a deficiency in documentation.
The facility failed to follow Enhanced Barrier Precautions (EBP) for several residents, with staff not consistently using gloves or performing hand hygiene. A CNA was observed touching surfaces without washing hands, and an LPN had long artificial nails, contrary to policy. Additionally, a resident's nebulizer mask was not stored properly, and EBP signage and supplies were inadequate.
The facility did not complete baseline care plans within the required 48-hour timeframe for three residents. The MDS Director and DON mistakenly believed the timeframe was 72 hours, leading to delays in finalizing care plans.
A resident with multiple health conditions did not receive a snack when the time between dinner and breakfast exceeded 14 hours, highlighting a deficiency in the facility's meal service. The resident, along with others, expressed dissatisfaction with the timing of meals and snacks, particularly noting late breakfast service and lack of timely coffee delivery.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food service safety and sanitary conditions, impacting 187 of 196 residents. During a tour of the main kitchen, several deficiencies were observed. The handwashing station near the entry door had a dark substance on the grout above the sink. The exterior side walls of the Vulcan ovens were covered with a thick, burnt-yellow residue. In the Arctic walk-in refrigerator, brown debris was splattered on the tiles, and a yellow food substance was found on the floor. Additionally, a prepared food cart had salads with a sticker indicating dates that the Dietary Manager could not explain, requiring clarification from another staff member. Further observations revealed a crumpled ball of brown paper and a small, dark brown substance on the floor of the dry foods storage area. A dietary aide was seen preparing food without a beard covering. The dishwasher temperature was recorded at 170 degrees Fahrenheit, exceeding the manufacturer's recommended maximum of 140 degrees. A double handle stock pot had dark brown residue on its exterior and around the bolts securing the handles. These findings indicate a lack of adherence to professional standards for food storage, preparation, and service, potentially compromising food safety and sanitation.
Repeated Deficiencies in Resident Rights, Nutrition, Pharmacy, Meals, and Infection Control
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to implement an effective plan of action to correct identified quality deficiencies. These deficiencies were observed in areas such as Resident Rights / Exercise of Rights (F550), Nutrition / Hydration Status Maintenance (F692), Pharmacy Services / Procedures / Pharmacist / Record (F755), Frequency of Meals / Snacks at Bedtime (F809), and Infection Prevention and Control (F880). The facility had been previously cited for these deficiencies during a recertification survey with an exit date of 08/31/23, and they were identified again in the current survey. The repeated deficient practices have the potential to affect all 196 residents residing in the facility at the time of the survey. During the QAPI review, there was no evidence of an effective plan to address these cited deficiencies.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to treat residents with dignity during dining observations, as evidenced by staff referring to residents as 'feeders' and standing while feeding them. During observations, a registered nurse and certified nursing assistants were noted using the term 'feeder' when referring to residents who required assistance with meals. This terminology was used in the presence of other staff and residents, which is contrary to the facility's policy on dignity that emphasizes respectful communication and avoiding labels based on care needs. Additionally, staff were observed standing over residents while assisting them with meals, rather than sitting at eye level, which is necessary to maintain dignity and respect. Specific instances included staff standing while feeding residents with cognitive impairments and failing to promptly assist residents with their meals, leaving them waiting for extended periods. These actions were inconsistent with the facility's policy and the expectations for treating residents with dignity and respect.
Inaccurate MDS Assessments for Medications and Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in documenting medications and diagnoses. Resident #77 was admitted with multiple diagnoses, including nicotine dependence, and had a physician order for a nicotine patch. However, the resident was observed smoking, and the nicotine patch was not coded as a psychotropic medication in the MDS assessment. The Consultant Pharmacist was unaware of the resident's smoking and had not performed a Gradual Dose Reduction (GDR) as required. The MDS Director acknowledged the oversight but stated that a psychiatry consult had approved the concurrent use of the nicotine patch and smoking. Resident #167's clinical record showed a diagnosis of Schizoaffective Disorder, Bipolar Type, but the MDS assessment was incorrectly coded for Schizophrenia. The MDS Director and Coordinator admitted the error, noting that the diagnosis of Schizoaffective Disorder was always present in the resident's records, and the miscode occurred due to reliance on an incorrect diagnosis list. Resident #168's MDS assessment was inaccurately coded for anticoagulant use, despite no physician order for such medication. The resident was prescribed Aspirin as an antiplatelet, but the MDS Director mistakenly coded it as an anticoagulant. Additionally, the assessment failed to document the use of antibiotics, antidepressants, and hypoglycemic medications administered during the review period. The MDS Director attributed the errors to a 'click on error' and acknowledged the need for modification of the assessment.
Deficiencies in Care Plan Implementation for Psychotropic Medications and Antibiotic Therapy
Penalty
Summary
The facility failed to implement comprehensive care plans for residents on psychotropic medications and antibiotic therapy, leading to deficiencies in monitoring and addressing the medical, physical, mental, and psychosocial needs of the residents. For Resident #145, who was on Trazodone for depression, the care plan included goals to be free of drug-related complications and interventions to monitor side effects. However, there were no physician orders to monitor these side effects, and the staff was unaware of the need for such monitoring. Interviews with staff revealed a lack of understanding and communication regarding the necessity of monitoring side effects for psychotropic medications. Resident #198, who was on antibiotic therapy with Meropenem, had a care plan that included interventions for IV site monitoring and dressing changes. However, the MAR indicated that the required checks and dressing changes were not documented, and observations showed that the IV site was not properly maintained, with loose dressings and signs of drainage. The DON was aware that the antibiotic was discontinued but did not have information on why the IV catheter was still in place, indicating a lack of communication and follow-up with the physician. Other residents, such as Resident #73, #77, and #86, also had deficiencies in their care plans related to psychotropic medications. Resident #73 was on Sertraline without orders to monitor side effects, and Resident #77 was using a nicotine patch without proper monitoring for side effects or behavior changes. Resident #86, who was on Quetiapine for psychosis, did not have a care plan to monitor side effects of antipsychotic medications. These deficiencies highlight a systemic issue in the facility's approach to care planning and monitoring for residents on psychotropic medications.
Deficiencies in ADL Support and Care in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in care. Resident #311, who has type 2 Diabetes and Dementia with a BIMS score indicating moderate to severe cognitive impairment, was observed with an untouched breakfast tray for 20 minutes without staff assistance. Despite needing partial to moderate assistance with eating, staff did not provide timely help, resulting in the resident consuming only 25% of the meal. Resident #40, diagnosed with multiple conditions including Cerebral Atherosclerosis and Dementia, was found to have inadequate oral care. Observations over several days showed the resident's mouth, lips, teeth, tongue, and gums were dry and cracked, with no water or Glycerin moisture sticks available at the bedside. Interviews with staff revealed a lack of adherence to the care plan, which required regular mouth care and hydration support, contributing to the resident's discomfort and potential dehydration. Resident #36, with severe cognitive impairment, expressed dissatisfaction with his grooming, specifically his facial hair, which was not maintained according to his preferences. Despite a care plan that included personal hygiene assistance, the resident's facial hair was unkempt, affecting his self-esteem. Additionally, Residents #144 and #59, both requiring assistance during dining, were observed struggling to eat without staff support, leading to food spillage and distress. These incidents highlight the facility's failure to provide necessary support for residents' ADLs, as outlined in their care plans.
Deficiency in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, leading to a deficiency in care. The resident, who had a history of Atrial Fibrillation, Type I Diabetes Mellitus, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Chronic Kidney Disease, was observed with blood-tinged urine in the catheter tubing. Despite the resident's complaints of blood-tinged urine from the night of December 8th until the evening of December 10th, there was no documentation of urinary catheter care being performed during this period. Additionally, the urinary drainage bag was not changed, and the catheter was not irrigated, even though the resident reported these issues to the nursing staff. Observations revealed that the resident's urinary tubing had a blood-tinged color, and the urinary bag was improperly placed on the floor without privacy protection. Staff K, a Certified Nursing Assistant (CNA), was observed performing perineal care without changing gloves between tasks, which included touching various surfaces and the resident's personal items. This improper infection control practice was noted during the survey, and the urinary bag was placed on the floor, contrary to the facility's policy. Interviews with staff members, including CNAs and Registered Nurses (RNs), indicated a lack of communication and documentation regarding the resident's condition. Staff P, a CNA, stated that she frequently checks the urinary catheter but noted that there was no way to document cloudy or bloody urine in the facility's computer system. Staff N, an RN, admitted to not observing or documenting the resident's red-colored urine and not reviewing the care plan or MAR. The Director of Nursing (DON) confirmed that CNAs are responsible for urinary catheter care and should report any abnormalities to the nurse, who is then responsible for documenting these findings. However, this process was not followed, leading to the deficiency.
Failure to Calibrate Scales and Provide Timely Nutritional Supplements
Penalty
Summary
The facility failed to ensure accurate calibration of scales and timely provision of nutritional supplements for two residents, leading to significant weight loss. Resident #100, with chronic kidney disease and anemia, experienced a 17% weight loss over two months. Despite the dietary progress note indicating decreased meal intake and weight loss, the dietitian delayed increasing nutritional supplements, opting first to liberalize the diet. The supplements were only increased 40 days after the initial weight loss was identified. Resident #311, with type 2 diabetes, acute neurologic dysphagia, anemia, subdural hemorrhage, and dementia, experienced a 13.6% weight loss over less than six months. A possible weight discrepancy was noted, but no reweight was obtained, and the significant weight loss was not addressed after it was identified. The dietitian did not provide an explanation for the lack of action regarding the weight loss. Additionally, the facility's scales were not calibrated as required. Observations revealed that several scales and Hoyer lifts had outdated or missing calibration stickers. The Director of Plant Operations stated that an outside company was responsible for calibration, but there was no evidence of a recent inspection, and the director could not provide a contract with the company. This lack of calibration could have contributed to inaccurate weight measurements, impacting the residents' nutritional management.
Deficiencies in IV/PICC Line Management and Documentation
Penalty
Summary
The facility failed to obtain current specified physician's orders for the care and maintenance of IV/PICC lines for three residents, leading to deficiencies in the administration and documentation of IV therapy. Resident #308, who had a moderate cognitive impairment, was observed with a PICC line that lacked a date and time on the dressing, which was stained, peeling, and not securely attached. There were no physician's orders for the maintenance of the PICC line, and no documentation in the resident's care plan or medical records regarding the presence or care of the PICC line. Resident #185, with intact cognition, was admitted with a PICC line but lacked specific physician's orders for dressing changes and line flushing. Observations revealed the PICC line dressing was old, stained, and not securely attached, with no date or time noted. Interviews with staff indicated a lack of knowledge about the dressing change schedule, and there was no care plan or documentation of care performance for the PICC line in the resident's records. Resident #198, with mild cognitive impairment, had an IV catheter in place despite the completion of IV antibiotic therapy weeks prior. The dressing was loose, with reddish fluid drainage and a blood-like smell, and lacked date and nurse's initials. The resident was unaware of the reason for the continued presence of the IV catheter, and staff interviews revealed a lack of communication and documentation regarding the discontinuation of the IV catheter. The DON acknowledged the deficiencies in documentation and physician orders for the care and maintenance of the IV lines for all three residents.
Deficiencies in Oxygen and Nebulizer Therapy Administration
Penalty
Summary
The facility failed to obtain current physician's orders for oxygen therapy administration for a resident with chronic obstructive pulmonary disease, hypertension, and atherosclerotic heart disease. The resident was observed receiving continuous oxygen therapy at three to four liters via an oxygen concentrator without a current physician's order. Despite multiple observations over several days, no documentation was found in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to indicate that the oxygen therapy was being administered as per a physician's order. Interviews with staff confirmed the absence of a current order, and a physician's order was only obtained after surveyor intervention. Additionally, the facility failed to monitor a resident receiving nebulizer treatments according to standards of care. The resident, who had a history of chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypercapnia, atrial fibrillation, and sleep apnea, was observed receiving nebulizer treatment without proper monitoring. The resident's head was not elevated to the recommended semi-Fowler's position, and no staff nurse was present in the room during the treatment. The nurse did not assess the resident's breath sounds or take vital signs before, during, or after the treatment, and there was no documentation of the resident's toleration of the treatment or respiratory evaluation in the MAR. Interviews with staff revealed inconsistencies in the monitoring process for nebulizer treatments. While the unit manager and DON stated that nurses should stay with residents during nebulizer treatments to monitor changes, the observed practice did not align with this protocol. The respiratory therapist confirmed that it is recommended for nurses to stay with residents during the entire duration of nebulizer treatments to respond promptly to any breathing difficulties, such as bronchospasms, that may occur during the treatment.
Failure to Adhere to Fluid Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to adhere to physician-ordered fluid restrictions for two residents requiring dialysis, leading to deficiencies in their care. Resident #123, who has End-Stage Renal Disease and receives dialysis three times a week, was observed to have received 829 ml of fluids in one meal, exceeding the prescribed daily fluid restriction of 1500 ml. The resident was not adequately educated on her fluid restrictions, and staff members, including a CNA and a Registered Nurse, were unclear about the specific fluid limits, leading to inconsistencies in the resident's care. Similarly, Resident #89, who has multiple diagnoses including Acute Kidney Failure and Chronic Kidney Disease, was subject to a daily fluid restriction of 1200 ml. However, observations revealed that the resident's meal tickets did not include information about fluid restrictions, and the dietary services provided fluids exceeding the prescribed limits. Staff members, including a CNA and the Kitchen Manager, were unaware of the resident's fluid restrictions, resulting in the resident receiving more fluids than allowed. The lack of communication and documentation regarding fluid restrictions for both residents highlights a systemic issue within the facility. The failure to provide clear instructions and ensure staff awareness of fluid restrictions led to the residents receiving excessive fluids, which could potentially impact their health. The facility's oversight in managing these restrictions indicates a deficiency in the care provided to residents requiring dialysis.
Controlled Substance Reconciliation Failures
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substance medications for four residents, leading to discrepancies in medication administration records. For Resident #14, there was a lack of documentation for the administration of Alprazolam on specific dates, despite the medication being dispensed and removed from the controlled substance box. This discrepancy was confirmed during an interview with a Licensed Practical Nurse (LPN) and the South wing Unit Manager, who were unable to explain the inconsistencies. Resident #168 experienced similar issues with Tramadol HCl, where the Controlled Drug Disposition sheet indicated administration on certain dates, but the Medication Administration Record (MAR) lacked corresponding documentation. The LPN responsible for administering the medication could not account for the missing entries during a review with the Unit Manager. For Resident #186, the Controlled Drug Disposition sheets for Percocet showed discrepancies between the documented administration and the MAR. The LPN involved acknowledged signing the MAR but not the disposition sheet for certain dates. Additionally, Resident #201's records showed Tramadol HCl was dispensed without corresponding MAR documentation. The Director of Nursing and the Consultant Pharmacist recognized the need for improved education on controlled substance documentation and reconciliation after reviewing the discrepancies.
Failure to Monitor Medication Side Effects and Efficacy
Penalty
Summary
The facility failed to ensure proper monitoring of residents' medication regimens, particularly for psychotropic, antipsychotic, antiplatelet, and hypoglycemic medications. This was evidenced by the lack of written documentation of medication side effects, efficacy, and behavior monitoring for several residents. For instance, Resident #77, who had multiple diagnoses including Type 2 Diabetes Mellitus and Major Depressive Disorder, was not monitored for side effects of psychotropic medications or for signs of hypoglycemia and hyperglycemia as per the care plan. The consultant pharmacist acknowledged the lack of monitoring and the absence of a Gradual Dose Reduction (GDR) for the resident's medications. Resident #167, diagnosed with Schizoaffective Disorder and other conditions, was also not monitored for side effects of psychotropic, antianxiety, and opioid medications. Despite care plan interventions requiring such monitoring, the December 2024 Medication Administration Record (MAR) showed no evidence of it. The consultant pharmacist had previously recommended tracking adverse effects, but this was not implemented. An attempt to interview the resident revealed agitation and cursing, indicating potential unmanaged symptoms. Other residents, such as Resident #73 and Resident #145, were similarly affected by the facility's failure to monitor medication side effects and behaviors. Resident #73, on Sertraline for depression, had no orders for monitoring side effects, and the Director of Nursing confirmed the lack of monitoring. Resident #145, on Trazodone for depression, also lacked monitoring orders, and the consultant pharmacist admitted to missing this requirement. These deficiencies highlight a systemic issue in the facility's medication management practices, affecting the well-being of multiple residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store residents' glucometers in a sanitary manner, as observed in the North wing medication storage room. A glucometer was found on top of the medication cart without being contained in a plastic wrap, directly touching sterile lancets. This was confirmed by a Registered Nurse who acknowledged the requirement for glucometers to be wrapped but did not provide an explanation for the oversight. Additionally, the facility lacked a specific policy for glucometer storage, although the Director of Nursing stated that nurses are educated on proper storage during orientation. The North wing medication storage room door was found halfway open without staff supervision, allowing potential unauthorized access to medications. The key to the storage room was also left hanging outside on a desk, further compromising security. This situation persisted for at least ten minutes before being addressed by a staff member. The Director of Nursing confirmed that there is no specific policy for glucometer storage but emphasized that staff are educated on proper procedures. Resident #407 had an unsecured insulin pen on her nightstand, accessible to others. The resident, who has Type 2 Diabetes Mellitus and other conditions, stated she brought the pen from home and believed it was empty. Staff interviews revealed that medications brought from home should be collected and returned to family members, but this protocol was not followed in this case. The Director of Nursing acknowledged the oversight but noted that staff cannot search through residents' belongings.
Menu Adherence Failure in Kitchen Observation
Penalty
Summary
The facility failed to adhere to their menu for the regular diet during an observation in the main kitchen, which could potentially affect 117 residents on a regular diet. The facility's fall/winter 2024 diet guide specified that the regular diet should include 3 ounces of apple butter pork loin. However, during an observation, a lunch tray was found to contain a pre-sliced piece of pork loin weighing only 2.25 ounces, which did not meet the specified menu requirement. An interview with the Food Service Director revealed that the cook was responsible for pre-cutting and weighing each slice of pork to ensure it met the 3-ounce requirement, which was not done in this instance.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
The facility failed to provide food in a form designed to meet individual needs for residents on a pureed diet, specifically affecting two residents observed during dining. Resident #22, who has severe cognitive impairment due to cerebral atherosclerosis and hypertension, was observed eating a breakfast meal that included pureed pancakes with lumps, contrary to the facility's policy requiring a smooth, pudding-like consistency for pureed diets. Similarly, Resident #48, diagnosed with dementia and depressive disorder, was observed consuming meals that did not meet the required pureed consistency. During breakfast, the pureed breakfast meat and pancakes were noted to be grainy and lumpy. At lunch, the pureed turkey was also observed to be lumpy. The facility's policy, which aims to promote safe swallowing and minimize aspiration risk, was not adhered to, as confirmed by the speech therapist who stated that pureed foods should have a cohesive, smooth texture without particles or lumps.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to accommodate the dietary needs and preferences of three residents, leading to deficiencies in their care. Resident #32, who has severe cognitive impairment and is diagnosed with protein-calorie malnutrition and dementia, did not receive a Mighty Shake nutritional supplement as indicated on their lunch tray. Despite the presence of staff members responsible for ensuring the correct food items and supplements are provided, the supplement was missing from the tray. Resident #100, with moderate cognitive impairment and multiple diagnoses including chronic kidney disease and anemia, did not receive a high-calorie pudding as per their dietary plan. The resident expressed dissatisfaction with the missing item, which was confirmed by multiple staff members, including the Certified Dietary Manager and Registered Dieticians, who acknowledged the oversight. The resident's care plan specifically included fortified foods to address their nutritional needs, yet the high-calorie pudding was absent from their meal tray. Resident #144, with severe cognitive impairment and a diagnosis of epilepsy and hypothyroidism, was on a fortified food regimen. However, during meal observations, the fortified mashed potatoes, which were supposed to be part of their diet, were not included on their tray. The Food Director confirmed the absence of the fortified food item, which was supposed to be provided according to the resident's dietary plan. These incidents highlight the facility's failure to adhere to its policy of accommodating resident food preferences and dietary needs.
Failure to Maintain Hospice Documentation
Penalty
Summary
The facility failed to meet professional standards by not ensuring that hospice documentation was readily available for a resident receiving hospice care. The facility had an agreement with a hospice company, which required the facility to maintain medical records, including progress notes and clinical notes for each hospice patient. However, during a review, it was found that the hospice binder for a resident did not contain any progress notes from the hospice nurse, despite the resident being on hospice care since May 2024 and having had ten visitations by the hospice nurse from June to December 2024. The resident in question was admitted with a diagnosis of age-related physical debility and had a severe cognitive impairment, as indicated by a BIMS score of 6. The facility's agreement with the hospice company also required weekly discussions between the hospice nurse and the facility's staff, as well as medication reconciliation at each visit. Despite these requirements, the RN Manager acknowledged that the hospice nurse's progress notes were sent to the hospice company and not kept in the facility, leading to the deficiency in maintaining proper documentation.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to the Enhanced Barrier Precautions (EBP) guidelines for four residents, leading to multiple instances of improper infection control practices. For Resident #26, staff members did not consistently use gloves or perform hand hygiene when providing care, such as changing socks and handling bed controls. Staff J, a CNA, was observed touching various surfaces and equipment without washing hands between tasks, increasing the risk of cross-contamination. Similarly, for Resident #139, Staff J did not clean the Hoyer lift after use, further compromising infection control measures. Resident #465's care was also compromised as staff did not wear the required personal protective equipment (PPE) while providing care, despite the presence of an EBP sign. This oversight indicates a lack of compliance with established guidelines meant to protect both residents and staff from potential infections. Additionally, Resident #460's room lacked proper EBP signage and supplies, which were observed to be located several doors away, indicating a systemic issue in maintaining infection control protocols. The facility also failed to ensure proper hygiene practices concerning fingernail length and cleanliness among staff. Staff U, an LPN, was observed with long artificial nails, which are known to harbor bacteria and compromise hand hygiene. Despite the facility's policy against artificial nails, both Staff U and Staff V, a Registered Nurse/Unit Manager, were found with long nails, indicating a disregard for infection control policies. Furthermore, the nebulizer mask for Resident #507 was not stored in a sanitary manner, as it was left uncovered on a bedside table, contrary to the facility's policy on respiratory equipment maintenance.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within the required 48-hour timeframe for three of five sampled residents. For Resident #36, the baseline care plan was initiated on November 1, 2024, but not completed until November 5, 2024. Similarly, Resident #508's care plan was started on November 29, 2024, and completed on December 2, 2024. Resident #189's care plan was initiated on October 18, 2024, and completed on October 21, 2024. An interview with the MDS Director revealed a misunderstanding of the required timeframe, as she believed the completion time was 72 hours instead of the mandated 48 hours. This misunderstanding was confirmed by the Director of Nurses, who also stated the incorrect timeframe.
Failure to Provide Timely Snacks and Meals
Penalty
Summary
The facility failed to provide a nourishing snack to residents when the time lapse between dinner and breakfast exceeded 14 hours. This deficiency was observed for a resident who did not receive a snack the previous evening, resulting in a time lapse of 14 hours and 34 minutes between dinner and breakfast. The resident, who has a diagnosis of Cancer, Anemia, Orthostatic Hypotension, Thyroid Disorder, and Depression, expressed dissatisfaction with the timing of meals and snacks, particularly noting that breakfast was served too late and coffee was not provided at the desired time. During a resident council meeting, multiple residents voiced concerns about difficulties in obtaining snacks at preferred times, indicating a broader issue within the facility's kitchen services. The resident in question, who has moderate cognitive impairment, specifically mentioned that breakfast trays are typically delivered around 9:30 AM, which he finds unsatisfactory. This situation highlights the facility's failure to meet the nutritional needs and preferences of its residents, potentially affecting 22 of 24 residents on oral diets in the same wing.
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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