Royal Palm Beach Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Royal Palm Beach, Florida.
- Location
- 600 Business Park Way, Royal Palm Beach, Florida 33411
- CMS Provider Number
- 105494
- Inspections on file
- 25
- Latest survey
- May 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Royal Palm Beach Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that 12 out of 18 portable fire extinguishers were installed with the top of the handle positioned above the sixty-inch maximum height allowed by NFPA 101 and NFPA 10, with some as high as sixty-three inches. In one case, a trash can obstructed access to a fire extinguisher cabinet. The Maintenance Director acknowledged these findings during the inspection.
Surveyors found that two smoking areas were not maintained according to NFPA 101 requirements, with large numbers of cigarette butts littered in both the Courtyard and the area near Rehabilitation. No ashtrays or metal cans with self-closing lids were present, and the deficiency was acknowledged by facility leadership.
Surveyors found that medical gas cylinders were improperly stored next to flammable liquid cans in the outdoor oxygen storage area, violating NFPA 99 requirements. Additionally, the facility did not have a current, approved Comprehensive Emergency Management Plan, as required by state regulations. Both deficiencies were acknowledged by facility leadership during the survey.
Surveyors found that two delayed egress exits were not properly maintained: one exit failed to operate when tested, and another required excessive force to open. These issues were confirmed by the Maintenance Director during the inspection and discussed with facility leadership.
Surveyors found that staff failed to consistently use required PPE, such as gowns and gloves, during high-contact care activities for residents on Enhanced Barrier Precautions, did not always perform hand hygiene, and did not follow proper procedures for cleaning equipment or disposing of used PPE. These deficiencies were observed during care for several residents, including those on isolation for COVID-19, and were confirmed through staff interviews and direct observation.
Multiple residents experienced delays in obtaining lab cultures, specialist consults, and timely medication administration, with some medications given up to three hours late. One resident used a CPAP machine daily without a physician's order or care plan until surveyor intervention. These deficiencies were confirmed through record review, observation, and staff and resident interviews.
The facility failed to timely update and revise care plans for two residents following changes in condition, incidents of falls, and medication regimen changes. One resident's care plan was not updated after multiple falls and issues with wheelchair safety, while another resident's care plans did not reflect current diagnoses or medication changes, and lacked a care plan for a specific medical condition. Staff interviews confirmed inconsistencies and omissions in care plan documentation and updates.
The facility failed to obtain timely culture results for a resident with a wound, resulting in a 22-day delay from collection to lab receipt and a delay in effective treatment for a multi-drug resistant organism. Additionally, another resident did not receive medications within the required time frame on multiple occasions, with some doses administered more than three hours late, despite staff awareness of the facility's medication timing policy.
A resident with mild cognitive impairment and partial dependence in ADLs did not receive a timely urology consult or urine culture as ordered. Despite care planning and physician orders for specialist evaluation and lab work, there was no documented follow-up to ensure a referral was completed, and there was an unexplained delay in obtaining a urine specimen. These lapses resulted in the resident not receiving timely assessment and intervention.
A resident who used a CPAP machine daily did not have a physician's order or a care plan addressing CPAP therapy. The resident's medical record and care plan lacked documentation and interventions for CPAP, despite observations confirming the device's presence and use. The physician's order was only obtained after surveyor intervention.
A resident with multiple medical conditions and on hospice care was found using full side bed rails without proper assessment, informed consent, or physician order, despite documentation indicating bed rails were not to be used and consent had been declined. Staff were unaware of the assessment status, and the care plan did not address side rail use.
Surveyors found that staff did not consistently document or monitor behaviors for three residents prescribed psychotropic medications, as required by facility policy and physician orders. Staff interviews revealed confusion and gaps in documentation practices, and reviews of medical records showed missing or incomplete entries regarding behavior monitoring and interventions.
A resident with orders for adaptive eating equipment did not consistently receive a two-handled cup with lid for each beverage, as required by their care plan and physician orders. Observations showed the resident was sometimes provided with only a Styrofoam cup or a single adaptive cup for multiple drinks, and staff interviews revealed inconsistent practices in providing and rotating the adaptive equipment.
A resident's bathroom call light was found wrapped around a grab bar, making it inaccessible and nonfunctional. The Director of Maintenance confirmed the issue during an observation, and a staff member responsible for daily checks reported only verifying the presence and condition of the call light, not its accessibility or functionality.
The facility did not timely update or revise care plans for two residents after significant changes in condition and medication orders. One resident experienced a fall and injury during a wheelchair transfer, but the care plan was not updated to address the incident. Another resident's care plan did not reflect changes in diagnoses or medication regimen, and a care plan for a new condition was not developed. Staff interviews confirmed gaps in care plan updates and documentation.
Improper Installation and Accessibility of Portable Fire Extinguishers
Penalty
Summary
Surveyors observed that the facility failed to install and maintain portable fire extinguishers in accordance with NFPA 101 and NFPA 10 standards. Specifically, 12 out of 18 sampled fire extinguishers were found to be mounted in cabinets with the top of the handle positioned more than sixty inches above the finished floor, with measurements ranging from sixty and a half inches to sixty-three inches. This was noted in multiple locations throughout the facility, including the kitchen, various corridors, near the nurses' station, the rehabilitation suite, and near the maintenance office. In one instance, a trash can was placed in front of a fire extinguisher cabinet, initially obstructing the cabinet door from opening until it was moved. The observations were made during a fire safety tour conducted with the Maintenance Director, who acknowledged the findings at the time. The issue was also reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during the exit conference. The report does not mention any specific residents or staff being directly affected at the time of the deficiency, nor does it provide details about any medical history or conditions related to the deficiency. Additionally, the report notes that the facility failed to maintain smoking areas in accordance with NFPA 101 for both of its designated smoking areas. However, the detailed findings and observations in the report focus primarily on the improper installation height and accessibility of portable fire extinguishers, as well as the temporary obstruction of access to one extinguisher by a trash can.
Plan Of Correction
Corrective Actions On 6/9/2025, the following locations' fire extinguishers were replaced with a shorter extinguisher so that the top of the new extinguisher is less than 60 inches from the floor: A. Kitchen. Two extinguishers. B. East Corridor. Near the Staff Development Office. C. East Corridor. Near the kitchen entrance. D. SE Corridor. Near room 100. E. South Corridor. Near room 100. F. SW Corridor. Near the Nurses Station. G. West Corridor. Near room 126. H. West Corridor. Near the Maintenance Office. I. Rehabilitation Suite. J. North Corridor. Near the exit. K. North Corridor. Near room 213. L. North Corridor. Near room 200. Identification of Others Potentially Affected All fire extinguishers in cabinets were accounted for, so no further evaluation was needed. Systemic Changes The Maintenance Director, or designee, will perform documented monthly inspections for three months of the facility fire extinguishers placed in cabinets to ensure the top of the extinguisher is less than 60 inches from the floor. Quality Assurance Results of the monthly inspections will be presented at the monthly QA meetings for three months. If substantial compliance is not met after three months, results of the ongoing monthly inspections will be brought to QA meetings until substantial compliance is met. K 355 Immediate Corrective Action 1. The Courtyard was cleaned of cigarette butts on the ground on 5/28/2025. 2. The designated smoking area near the
Failure to Maintain Smoking Areas per NFPA 101
Penalty
Summary
Surveyors observed that the facility failed to maintain its designated smoking areas in accordance with NFPA 101 regulations. During a fire safety tour, it was found that the Courtyard, which is used as a smoking area during rain, had more than eighty cigarette butts scattered throughout, and the screened-in porch area contained nine additional cigarette butts. There were no ashtrays, metal cans with self-closing lids, or fire extinguishers present in these areas, as required by the standard. The Administrator confirmed that the Courtyard serves as a smoking area when it rains. Additionally, the designated smoking area near Rehabilitation was found to have more than one hundred cigarette butts littered throughout the area. Both the Administrator and the Maintenance Director acknowledged these findings during the survey. The lack of proper disposal containers and the accumulation of cigarette butts in both smoking areas were documented, and photographic evidence was obtained by the surveyors.
Plan Of Correction
Rehabilitation was cleaned of cigarette butts on the ground on 5/28/2025. Method to Assess Others The Maintenance Director, or designee, performed documented inspections of the facility's other smoking areas to ensure there were no cigarette butts on the ground. Systematic Process The Maintenance Director, or designee, will perform weekly inspections X 8 weeks of all smokers areas of the facility to ensure there are no cigarette butts on the ground. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Documentation of the smokers areas inspections will be brought to the monthly QAPI meeting for review X 2 months. If substantial compliance is not met after 2 months, weekly inspections will continue and be brought to the monthly QAPI meeting until substantial compliance is met. K 741 Immediate Corrective Action 1. The Courtyard was cleaned of cigarette butts on the ground on 5/28/2025. 2. The designated smoking area near rehabilitation was cleaned of cigarette butts on the ground on 5/28/2025. Method to Assess Others The Maintenance Director, or designee, performed documented inspections of the facility's other smoking areas to ensure there were no cigarette butts on the ground. Systematic Process The Maintenance Director, or designee, will perform weekly inspections X 8 weeks of all smokers areas of the facility to ensure there are no cigarette butts on the ground. Quality Assurance Reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director at the exit conference on 05/27/2025 at 5:30 PM. NFPA 101 (2012 Edition) 19.7.4 (5-6) Photographic Evidence Obtained.
Improper Medical Gas Cylinder Storage and Lapsed Emergency Management Plan
Penalty
Summary
During a fire safety tour, surveyors observed that the facility failed to properly store medical gas cylinders in accordance with NFPA 99 standards. Specifically, in the outdoor oxygen storage area, which was detached from the main building by approximately twenty-five feet, six flammable liquid cans were found stored directly next to full oxygen cylinders. Among these cans, two contained a mixture of gasoline and oil, while the remaining four were empty. The oxygen storage area contained twenty-three full E-cylinders and one full H-cylinder. The presence of flammable liquids in close proximity to oxidizing gases is a direct violation of the required separation and storage protocols outlined in NFPA 99. Additionally, the facility was unable to produce a current, approved Comprehensive Emergency Management Plan (CEMP) during the record review. The last approved CEMP was dated over a year prior, and subsequent submissions had either expired or been rejected. The most recent resubmission was still pending approval at the time of the survey. This failure to maintain an up-to-date and approved emergency management plan is not in compliance with Florida Administrative Code requirements, which mandate annual review and approval of such plans. Both deficiencies were acknowledged by facility leadership, including the Maintenance Director and the Administrator, during interviews conducted at the time of the survey. The findings were reviewed with the relevant facility staff at the exit conference. Photographic evidence was obtained to document the improper storage of medical gas cylinders and the presence of flammable liquids in the oxygen storage area.
Plan Of Correction
Immediate Corrective Action The six flammable liquid cans were removed from the outdoor oxygen storage area on 5/27/2025, during the survey. Method to Assess Others The facility only has one oxygen storage area so no further evaluation was needed. Systematic Process The Maintenance Director, or designee, will perform weekly inspections X 8 weeks of the outside oxygen storage area to ensure there are no flammable liquids stored in the area. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Documentation of the outdoor oxygen storage area inspections will be brought to the monthly QAPI meeting for review X 2 months. If substantial compliance is not met after 2 months, weekly inspections will continue and be brought to the monthly QAPI meeting until substantial compliance is met. --- Immediate Corrective Action The Administrator reached out to the Palm Beach County Division of Emergency Management on 4/30/2025 for an update and was given a timeframe of 60 days until the CEMP would be reviewed and then approved. Method to Assess Others No other disaster preparedness documentation was identified for submission to the Palm Beach County Division of Emergency Management. Systematic Process The Administrator, or designee, will continue to ensure the facility's CEMP is submitted to the Palm Beach County Division of Emergency Management within 60 days of the previous year's approval date. Quality Assurance The Administrator is responsible for the oversight of this process. QAPI will be notified when the CEMP is submitted for annual approval until substantial compliance is made. --- Immediate Corrective Action The six flammable liquid cans were removed from the outdoor oxygen storage area on 5/27/2025, during the survey. Method to Assess Others The facility only has one oxygen storage area so no further evaluation was needed. Systematic Process The Maintenance Director, or designee, will perform weekly inspections X 8 weeks of the outside oxygen storage area to ensure there are no flammable liquids stored in the area. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Documentation of the outdoor oxygen storage area inspections will be brought to the monthly QAPI meeting for review X 2 months. If substantial compliance is not met after 2 months, weekly inspections will continue and be brought to the monthly QAPI meeting until substantial compliance is met.
Deficient Maintenance of Delayed Egress Doors
Penalty
Summary
During a fire safety tour of the facility, surveyors observed that two of seven sampled delayed egress exits were not maintained in accordance with NFPA 101 requirements. At 11:00 AM, the Southeast Corridor exit, which was equipped with a delayed egress locking arrangement, failed to operate when tested. Later, at 1:04 PM, the Northeast corridor exit near Central Supply, also equipped with a delayed egress locking arrangement, required more than fifteen pounds of force to open the door, exceeding the standard for ease of egress. These deficiencies were confirmed through direct observation and acknowledged by the Maintenance Director during the inspection. The findings were subsequently reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during the exit conference. No information regarding specific residents or their medical conditions was provided in relation to these deficiencies.
Plan Of Correction
Corrective Actions A. The SE corridor exits delayed egress locking arrangement was repaired on 5/28/2025. B. The NE corridor exits delayed egress locking arrangement was adjusted on 5/28/2025 so that it required less than 15 lbs. of force to open the door. Identification of Others Potentially Affected The Maintenance Director, or designee, evaluated all other egress doors with a delayed egress locking arrangement to ensure proper functionality and operating force. Systemic Changes On an ongoing basis as part of the facility's life safety program, the Maintenance Director, or designee, will perform monthly testing of all facility egress doors with a delayed egress locking arrangement to ensure proper functionality. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Results of the monthly testing will be reviewed at the monthly QAPI meetings X 3 months. If substantial compliance is not met after 3 months, results of the ongoing monthly inspections will be brought to QAPI meetings until substantial compliance is met. The statements made on this plan of correction are not an admission to and do not constitute an agreement with alleged deficiencies herein. To remain compliant with all federal and state regulations, the facility has taken actions set forth in the plan of correction. The plan of correction constitutes the facility's allegation of compliance such as the deficiencies cited have been corrected by the date certain. Corrective Actions A. The SE corridor exits delayed egress locking arrangement was repaired on 5/28/2025. B. The NE corridor exits delayed egress locking arrangement was adjusted on 5/28/2025 so that it required less than 15 lbs. of force to open the door. Identification of Others Potentially Affected The Maintenance Director, or designee, evaluated all other egress doors with a delayed egress locking arrangement to ensure proper functionality and operating force. Systemic Changes On an ongoing basis as part of the facility's life safety program, the Maintenance Director, or designee, will perform monthly testing of all facility egress doors with a delayed egress locking arrangement to ensure proper functionality. Quality Assurance The Administrator, or designee, is responsible for the oversight of this program. Results of the monthly testing will be reviewed at the monthly QAPI meetings X 3 months. If substantial compliance is not met after 3 months, results of the ongoing monthly inspections will be brought to QAPI meetings until substantial compliance is met.
Deficient Infection Control Practices and PPE Use
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices, specifically related to the use of personal protective equipment (PPE) and adherence to Enhanced Barrier Precautions (EBP). During care for two residents, staff failed to don required PPE gowns while performing high-contact care activities, such as changing briefs and providing perineal care. In one instance, a certified nursing assistant (CNA) entered a resident's room to answer a call light and performed care without wearing a gown, despite the presence of an EBP sign. The CNA also failed to change her mask after touching it with a gloved hand. Another CNA confirmed that gowns and gloves are required for care activities under EBP, but not for answering call lights, indicating inconsistent understanding and application of the policy. Further observations revealed that a registered nurse (RN) did not perform hand hygiene before entering a resident's room for a check, donned PPE, and then cleaned a piece of equipment with tissue paper soaked in sanitizer, contrary to facility policy. The facility's policy required the use of specific cleaning agents and procedures, which were not followed. Additionally, two certified nurse assistants performed care for another resident without wearing PPE gowns, and one of them changed gloves without performing hand hygiene between tasks. The survey also found that appropriate means for disposing of used PPE were not provided in a resident's room who was on isolation for COVID-19. The only waste receptacles available were small, uncovered containers, and there was no designated bin for PPE disposal as required by facility policy and CDC guidelines. Interviews with staff and the infection preventionist confirmed the lack of proper receptacles and inconsistent practices regarding PPE removal and disposal. These deficiencies were observed across multiple staff members and residents, indicating systemic issues with infection control protocols.
Plan Of Correction
On , the Staff Development Coordinator provided 1:1 education to Staff G on proper Enhanced Barrier Precautions. On , the Staff Development Coordinator provided 1:1 education for Staff I on Enhanced Barrier Precaution. On , the Staff Development Coordinator provided 1:1 education to Staff L on the proper procedure to and proper hygiene. On , Staff J was given 1:1 education on proper PPE uses for a resident on EBP and proper hygiene. On , Staff Q was given 1:1 education on proper PPE uses for a resident on EBP and proper hygiene. On , a receptacle with a lid was placed in room of resident #95. On , the Staff Development Coordinator conducted a quality review of residents on Enhanced Barrier Precautions to ensure staff are utilizing appropriate PPE and hygiene. On , the Staff Development Coordinator conducted a quality review of residents on transmission-based precautions to ensure that proper waste receptacles were present for staff to discard used PPE. No additional findings were noted. On , the preventionist conducted a quality review of in the center to ensure that they were properly. By , the Staff Development Coordinator educated the current staff on the components of F880 with an emphasis on Proper Donning and Doffing of PPE, Proper adherence to Enhanced Barrier Precautions, and Proper Hygiene. On , the DON educated the ADON/IP on the components of F880 with emphasis on placement of the proper waste receptacles for PPE disposal. By , licensed nurses were educated on the components of F880 with an emphasis on proper technique of by the Staff Development Coordinator. As a part of a systematic change, newly hired staff will be educated on the components of F880 with an emphasis on Proper Donning and Doffing of PPE, Proper adherence to Enhanced Barrier Precautions, and Proper Hygiene. As part of a systematic change, newly hired Preventionists will be educated on F880 with emphasis on placement of the proper waste receptacles for PPE disposal. As part of a systematic change, newly hired licensed nurses will be educated on the components of F880 with an emphasis on proper technique of . The DON/designee will conduct 5 random observations of gown donning and doffing x 4 weeks, then 10 random observations of gown donning and doffing monthly x 2 months to ensure that gowns are being properly worn during high contact care activities. DON/Designee will conduct 10 random hygiene observations weekly x 4 weeks and then 20 random hygiene observations monthly x 2 months to ensure that proper hygiene is performed. DON/designee will conduct 5 observations of cleaning weekly x 4 weeks then 10 observations of cleaning monthly x 2 months to ensure proper of equipment. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. F 880 F 880 F 880
Delays in Medical Interventions, Medication Administration, and Care Planning
Penalty
Summary
The facility failed to provide adequate and appropriate health care to several residents as evidenced by multiple deficiencies in timely medical interventions and documentation. For one resident, there was a significant delay of 22 days between the collection of a wound culture and its receipt by the laboratory, resulting in a delay in effective treatment for an infection with a drug-resistant organism. The Assistant Director of Nursing was unable to explain the cause of this delay, and the resident was started on an antibiotic to which the organism was resistant, further delaying appropriate care. Another resident did not receive a timely urology consult as ordered by the physician. Despite documentation of the need for a referral and follow-up, there was no evidence that the referral was completed before the resident was transferred to the hospital. The staff member responsible for referrals acknowledged the lack of follow-up. Additionally, there was a delay in obtaining a required culture for this resident, with no explanation provided by the Assistant Director of Nursing. Medication administration was also found to be deficient, with one resident receiving multiple medications outside the facility's policy of administering within one hour before or after the scheduled time. Some medications were administered as late as three hours after the scheduled time, and the resident confirmed receiving medications late on several occasions. Furthermore, another resident was observed using a CPAP machine daily without a physician's order or a care plan in place for its use until the last day of the survey, after surveyor intervention.
Plan Of Correction
On Resident #12 was assessed by the provider. On is healing without complications and no s/s of current . On resident #92 was evaluated by the provider with no acute findings noted. On the medical records/staff made the consult for resident #1. On resident #1 was reevaluated by the provider with no acute findings. On additional CPAP orders were obtained for Resident #304. On , the care plan for a CPAP was revised by the Regional Nurse Consultant. On , the Regional Nurse Consultant conducted a quality review of current residents with cultures ordered in the past 30 days to ensure that the culture was obtained within the appropriate time frame. No additional findings were noted. On , the Regional Nurse Consultant conducted a quality review of medication administrations for the past 24 hours. Follow up based on findings. On , the Regional Nurse Consultant conducted a quality review of current residents with to ensure physician orders for consults and cultures in the past 30 days have been followed timely. No additional findings were noted. On DON conducted a quality review of current residents who require the use of a CPAP to ensure proper physician orders and care plans were in place. No additional findings were noted. By licensed nurses were educated by the Staff Development Coordinator on the components of N201 with an emphasis on obtaining cultures timely and administering medications timely. As a systematic change, newly hired licensed nurses will be educated on the components of N201 with an emphasis on obtaining cultures timely and administering medications timely during orientation. By licensed nurses were educated by the Staff Development Coordinator on N201 with an emphasis on obtaining consults and cultures timely. As part of a systematic change, newly hired licensed nurses will be educated on N201 with an emphasis on obtaining consults and cultures timely. By licensed nurses were educated by the staff development coordinator on the components of N201 with an emphasis on obtaining appropriate physician orders for use of a CPAP as well as implementing a care plan for the CPAP. As part of a systematic change, newly hired licensed nurses will be educated on the components of N201 with an emphasis on obtaining appropriate physician orders for use of a CPAP as well as implementing a care plan for the CPAP during orientation. DON/Designee will conduct quality monitoring of order listing reports 5 times weekly x 4 weeks, then 5 monthly x 2 months to ensure that cultures ordered are obtained timely. DON/Designee will conduct quality monitoring of 5 random residents weekly x 4 weeks, then 10 random residents monthly x 2 months to ensure that medications are administered within the appropriate time frame. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. DON/Designee will conduct quality monitoring of order listing reports 5 times weekly x 4 weeks, then 10 order listing reports monthly x 2 months to ensure that cultures and consults are obtained timely. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. DON/Designee will conduct quality monitoring of 3 residents who require CPAPs weekly x 4 weeks and 5 residents who require CPAPs monthly x 2 months to ensure that proper physician orders and care plans are in place. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. N 201 N 201
Failure to Timely Update and Revise Care Plans Following Changes in Condition and Medication
Penalty
Summary
The facility failed to revise and update care plan interventions in a timely manner for multiple residents, as required by federal regulations. For one resident, who had a history of vision impairment, abnormal gait, and need for assistance with personal care, there were two incidents of falls, one of which was unwitnessed and another witnessed. Despite these incidents and a physician's order for regular monitoring, the resident's care plan was not updated to reflect the new fall events or to add interventions addressing the specific circumstances of the falls, such as issues with wheelchair safety and transfer assistance. Interviews with staff revealed confusion about who was responsible for updating care plans after such incidents, with some staff believing it was the responsibility of management or the MDS team, and others stating that interventions were updated but not always dated or reflected in the care plan documentation. Another resident, who was readmitted after a hospital transfer, had multiple medication orders, including psychotropic medications, some of which were discontinued. The care plans for this resident did not reflect current diagnoses or changes in medication regimens. Specifically, there were care plans referencing medications and diagnoses that were not present in the resident's medical record, and interventions were not updated to reflect the discontinuation of medications or the absence of certain diagnoses. Staff interviews confirmed that care plans were not consistently updated to match the resident's current medication orders and diagnoses, and there was acknowledgment from the Social Services Director and MDS staff that care plans were missing or not properly revised. Additionally, the same resident did not have a care plan developed to address and provide care for a specific medical condition present at the time of assessment. Both the Regional MDS Coordinator and the Assistant MDS Coordinator confirmed during interviews that there was no care plan in place for this condition. The lack of timely and accurate care plan updates and development for these residents demonstrates a failure to comply with regulatory requirements for comprehensive, person-centered care planning based on current assessments, diagnoses, and medication regimens.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with alleged deficiencies herein. To remain compliant with all federal and state regulations, the facility has taken actions set forth in the plan of correction. The plan of correction constitutes the facility's allegation of compliance such as the deficiencies cited have been corrected by the date certain. On , the DON updated the care plan and added the appropriate intervention for resident #92. On , the regional reimbursement coordinator revised and updated the care plans for the changes of diagnosis and medications for resident #76. On , the regional reimbursement coordinator initiated the care plan for resident #76. On , the Regional Nurse Consultant conducted a quality review of residents who have had a in the past 30 days to ensure that interventions are added to the care plan timely. Follow up based on findings. On , the Regional Reimbursement Coordinator conducted a quality review of residents with new active diagnosis or medication changes in the past two weeks to ensure that care plans were appropriately developed or updated. Follow up based on findings. On , the Regional Nurse Consultant conducted a quality review of current residents with the diagnosis of to ensure that appropriate care plans have been developed. No additional findings noted. By , the licensed nurses including the MDS nurses were educated by the Staff Development Coordinator on the components of F657 with an emphasis on accurate revisions and updating of care plans. As a systematic change, newly hired licensed nurses, including MDS nurses, will be educated on the components of F657 with an emphasis on accurate revisions and updating of care plans. DON/designee will conduct quality monitoring audits of 10 random residents weekly x 4 weeks then 10 random residents monthly x 2 months to ensure proper revision and updating of the care plans. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. F 657
Delayed Culture Results and Medication Administration
Penalty
Summary
The facility failed to obtain culture results in a timely manner for one resident. This resident was admitted with multiple diagnoses and required partial assistance with activities of daily living. The care plan included management of wounds on the right and left heels. A physician order was placed for a culture of the left heel, and progress notes indicated the culture was collected and stored for lab pickup. However, there was a delay of 22 days from the time of collection to when the culture was received in the lab. The culture ultimately tested positive for a multi-drug resistant organism requiring isolation, and there was a delay in effective treatment due to the delay in obtaining results. The facility also failed to administer medications in a timely manner for another resident. This resident had multiple medical conditions, including visual impairment, mobility issues, and required assistance with personal care. Physician orders included several scheduled and as-needed medications. Review of the medication administration audit report showed that medications were repeatedly administered outside the facility's policy window of one hour before or after the scheduled time. Some medications were given as late as over three hours past the scheduled time. The resident confirmed that morning medications were sometimes received hours late. Interviews with nursing staff, including an RN, LPN, and the DON, confirmed their understanding of the facility's policy regarding medication administration timing. Despite this, the audit report documented multiple instances of late medication administration, indicating a failure to follow established protocols for timely medication delivery.
Plan Of Correction
On , Resident #12 was assessed by the provider. The resident is healing without complications and shows no signs or symptoms of current provider issues. Resident #92 was evaluated by the provider with no acute findings noted. On , the Regional Nurse Consultant conducted a quality review of current residents with cultures ordered in the past 30 days to ensure that the culture was obtained within the appropriate time frame. No additional findings were noted. On , the Regional Nurse Consultant conducted a quality review of medication administrations for the past 24 hours. Follow-up was conducted based on findings. By , licensed nurses were educated by the Staff Development Coordinator on the components of F 684, with an emphasis on obtaining cultures timely and administering medications timely. As a systematic change, newly hired licensed nurses will be educated on the components of F 684 during orientation, with an emphasis on obtaining cultures timely and administering medications timely. The DON/Designee will conduct quality monitoring of order listing reports 5 times weekly for 4 weeks, then 5 times monthly for 2 months to ensure that cultures ordered are obtained timely. Additionally, the DON/Designee will conduct quality monitoring of 5 random residents weekly for 4 weeks, then 10 random residents monthly for 2 months to ensure that medications are administered within the appropriate time frame. The findings of these quality monitoring activities are to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met.
Failure to Obtain Timely Urology Consult and Urine Culture
Penalty
Summary
The facility failed to obtain a timely urology consult and urine culture for a resident with a history of mild cognitive impairment and partial dependence in activities of daily living. The resident was care planned as being at risk for complications related to their diagnosis and required regular care and laboratory monitoring. Physician orders were in place for a urologist consult and for results to be faxed to the urologist, with follow-up also ordered. However, documentation showed that the consult was dependent on a referral, and there was no evidence of follow-up to ensure the referral was completed. Medical Records staff confirmed that no follow-up occurred for the urologist consult prior to the resident's transfer to the hospital. Additionally, there was a delay in obtaining a urine culture and sensitivity (C&S) for the same resident. Although an order for the culture was present, the specimen was not collected and reported in a timely manner. The Assistant Director of Nursing was unable to explain the delay in obtaining the sample. These failures resulted in the resident not receiving timely assessment and intervention as required by their clinical condition and care plan.
Plan Of Correction
F 690 On , the medical staff made the records/ consult for resident #1. On , resident # 1 was reevaluated by the provider with no acute findings. On , the Regional Nurse Consultant conducted a quality review of current residents with to ensure physician orders for consults and cultures in the past 30 days have been followed timely. No additional findings were noted. By , licensed nurses were educated by the Staff Development Coordinator on F 690 with an emphasis on obtaining consults and cultures timely. As part of a systematic change, newly hired licensed nurses will be educated on F 690 with an emphasis on obtaining , consults and cultures timely. DON/Designee will conduct quality monitoring of order listing reports 5 times weekly x 4 weeks, then 10 order listing reports monthly x 2 months to ensure that cultures and consults are obtained timely. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. F 690
Failure to Obtain Physician Order and Care Plan for CPAP Therapy
Penalty
Summary
The facility failed to obtain a physician's order for CPAP (Continuous Positive Airway Pressure) therapy and did not develop or implement a care plan for its use for one resident. Record review showed that the resident had multiple diagnoses and was cognitively intact, as indicated by a Brief Interview of Mental Status score of 15. The Minimum Data Set assessment did not document CPAP use, and the resident's care plan lacked goals, plans, and interventions related to CPAP. Observations on multiple occasions revealed a CPAP machine and tubing at the resident's bedside, and the resident confirmed daily use of the device. The physician's order for CPAP was only obtained on the last day of the survey after surveyor intervention.
Plan Of Correction
On , additional CPAP orders were obtained for Resident # 304. On , the care plan for a CPAP was revised by the Regional Nurse Consultant. On , the DON conducted a quality review of current residents who require the use of a CPAP to ensure proper physician orders and care plans were in place. No additional findings were noted. By , licensed nurses were educated by the staff development coordinator on the components of F695 with an emphasis on obtaining appropriate physician orders for use of a CPAP as well as implementing a care plan for the CPAP. As part of a systematic change, newly hired licensed nurses will be educated on the components of F695 with an emphasis on obtaining appropriate physician orders for use of a CPAP as well as implementing a care plan for the CPAP during orientation. The DON/Designee will conduct quality monitoring of 3 residents who require CPAPs weekly x 4 weeks and 5 residents who require CPAPs monthly x 2 months to ensure that proper physician orders and care plans are in place. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
A deficiency occurred when a resident was found using full side bed rails without proper assessment, informed consent, or physician order, contrary to facility policy and federal regulations. The resident, who had diagnoses including Type 2 diabetes, lack of coordination, abnormal gait, and was on hospice care, had a documented refusal of bed rail use by their representative, and physician orders specifically indicated no side rails. The care plan did not address side rail use, and the Minimum Data Set (MDS) assessment also documented that bed rails were not used. Despite these records, multiple observations confirmed the resident was in a bed with full side rails up on both sides at various times. Interviews with staff revealed a lack of awareness regarding the resident's hospice status and the origin of the bed with full side rails, with some staff attributing the presence of side rails to the hospice-provided bed. The Director of Nursing and Administrator acknowledged the presence of full side rails and stated that their usual process involves assessment, consent, physician order, and care planning, none of which were completed for this resident. The resident was subsequently removed from the bed with full side rails after the deficiency was identified.
Plan Of Correction
F 700 On , the siderails for resident #45 were removed by the maintenance director. On , the Regional Nurse Consultant conducted a quality review of current residents with siderails to ensure that proper assessments and consents were in place. No additional findings were noted. By , current licensed nurses were educated by the Staff Development Coordinator on the components of F 700 with an emphasis on proper assessment and obtaining consent for bedrails. As part of a systematic change, newly hired licensed nurses will be educated on the components of F 700 with an emphasis on proper assessment and obtaining consent for bedrails. DON/Designee will conduct quality monitoring of 5 residents with siderails weekly x 4 weeks, then 10 residents with siderails monthly x 2 months to ensure that proper assessment and consents are in place. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. F 700
Failure to Ensure Adequate Behavior Monitoring for Residents on Psychotropic Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure proper behavior monitoring for three residents who were prescribed psychotropic medications. The facility's policy required that behaviors be clearly documented in the medical record, included in the care plan, and reviewed at least quarterly. However, for the residents reviewed, there were inconsistencies and omissions in the documentation of behavior monitoring, as well as a lack of adherence to physician orders regarding the observation and recording of behaviors associated with medication administration. For one resident with moderate cognitive impairment and diagnoses including psychiatric conditions, the care plan and physician orders specified that staff should monitor for behaviors and document findings in the Medication Administration Record (MAR) and progress notes. Review of the MAR revealed that staff often marked boxes with an 'X' or 'Y' without specifying the behaviors, and interviews with LPNs and an RN confirmed that behavior monitoring was not consistently documented as required. Staff acknowledged gaps in documentation and were unclear about the process for recording behaviors, especially during certain shifts. Another resident with severe cognitive impairment and multiple psychiatric diagnoses had several physician orders for behavior and side effect monitoring, requiring documentation every shift. However, review of the behavior monitoring records and progress notes showed missing documentation for behaviors, interventions, or outcomes, despite orders to do so. A third resident with moderate cognitive impairment and psychiatric diagnoses also had incomplete documentation in the MAR, with some entries marked but lacking identification of specific behaviors. Interviews with staff and the DON confirmed that behavior monitoring was not performed or documented according to policy and physician orders.
Plan Of Correction
On , resident #34 was discharged from the facility. On , resident #76 was evaluated by the psych provider. No recent behaviors noted and no new orders received. On , resident #14 was evaluated by the psych provider. No recent behaviors noted and no new orders received. On , the Director of Nursing conducted a quality review of current residents who require behavior monitoring. No additional findings were noted. By , the Staff Development Coordinator educated licensed nurses on the components of F757 with an emphasis on appropriate completion of the behavior monitoring. As part of a systematic change, licensed nurses will be educated on the components of F757 with an emphasis on appropriate completion of the behavior monitoring during orientation. DON/Designee will conduct an audit of residents who require behavior monitoring weekly x 4 weeks and then 10 residents who require behavior monitoring monthly x 2 months to ensure that the behavior monitoring orders are appropriately completed by the licensed nurses. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Provide Adaptive Drinking Equipment for Resident with Physician Orders
Penalty
Summary
The facility failed to provide required adaptive equipment for a resident with physician orders specifying the use of a scoop dish and a two-handled cup with lid to maximize intake and minimize spillage. Observations revealed that the resident, who had diagnoses including Non-ST Elevation Myocardial Infarction and required assistance with personal care, did not consistently receive the adaptive drinking equipment for each beverage. Specifically, the resident was observed with a Styrofoam cup of water on the overbed table without the prescribed two-handled cup, and at another time, only one two-handled cup was present for multiple beverages on the breakfast tray. Interviews with staff indicated that the process for providing adaptive equipment was inconsistent. A CNA reported that she would rotate the two-handled cup between different beverages, rinsing and refilling it as needed, and would obtain a clean cup for water only after breakfast. The Dietary Manager stated that a two-handled cup should be provided for each beverage, but also noted that nursing staff were responsible for obtaining and returning the cups for cleaning. These actions and inactions resulted in the resident not having the necessary adaptive equipment for all drinks as required by their care plan and physician orders.
Plan Of Correction
On the meal tracker tray cards for resident #19 were updated to include two handled cups for each beverage provided. On the CDM conducted a quality review of current residents who require adaptive equipment to ensure that the Meal Tracker Tray Card contains the appropriate adaptive equipment with no additional findings noted. On the Regional Director of Environmental and Food Services educated the Certified Dietary Manager on the components of F810 with an emphasis providing appropriate quantity of adaptive equipment on the meal tray. On the Certified Dietary Manager educated the dietary staff on the components of F810 with an emphasis on providing appropriate quantity of adaptive equipment on the meal tray. As part of a systematic change, newly hired dietary employees will be educated on the components of F810 with an emphasis on providing appropriate quantity of adaptive equipment on the meal tray during orientation. The administrator/designee will conduct 5 observations weekly x 4 weeks, then 10 observations monthly x 2 months to ensure that appropriate adaptive equipment is on the meal tray. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Inaccessible Call Light in Resident Bathroom
Penalty
Summary
The facility failed to ensure that each resident bathroom was adequately equipped with a functioning call system accessible to residents, as required by federal regulations. During observations, surveyors found that the call cords in a resident's bathroom were wrapped around the grab bar, rendering the call system inaccessible and nonfunctional in its current state. The Director of Maintenance confirmed that the call light would not function properly when wrapped around the grab bar and had to manually unwrap and test it to restore functionality. Interviews with staff revealed gaps in the facility's procedures for checking call lights. The Social Service Assistant, who was assigned as the Guardian Angel for the resident, stated that her checks only included verifying the presence and physical condition of the call light, not whether it was wrapped around the grab bar or if it was operational. This lack of thoroughness in daily checks contributed to the deficiency, as the inaccessibility and improper placement of the call cord went unaddressed until identified by surveyors.
Plan Of Correction
On , the call light in the bathroom of # was unwrapped from the grab bar and assessed to be functional by the maintenance director. On , the Maintenance Director conducted a quality review of the call lights in resident rooms and bathrooms to ensure that they were functioning properly. By , current staff were educated by the Staff Development Coordinator on F919 with an emphasis on ensuring call lights were unwrapped from the grab bar and appropriately functioning. As part of a systematic change, the Nursing Home Administrator updated the Angel Rounds form on to include proper call light functioning. NHA/designee will conduct quality monitoring of 10 call lights weekly x 4 weeks and then 20 call lights monthly x 2 months to ensure that call lights are properly functioning. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Timely Update and Revise Care Plans Following Changes in Resident Condition and Medication
Penalty
Summary
The facility failed to revise and update care plan interventions in a timely manner for multiple residents, as required by state regulations. For one resident, after experiencing a fall while attempting to transfer between wheelchairs, the care plan was not updated to reflect the incident or to address the new safety concerns. The resident, who had a history of vision impairment and mobility issues, reported that the fall occurred due to a malfunctioning wheelchair lock and confusion during the transfer process. Despite documentation of the incident and the resident's injuries, the care plan remained unchanged, and staff interviews revealed uncertainty about who was responsible for updating care plans following such events. Another resident's care plan was not revised to reflect changes in diagnoses and medication orders. The resident had multiple discontinued and current medication orders, including psychotropic drugs, but the care plan did not accurately address the resident's current medication regimen or associated diagnoses. Interviews with nursing and MDS staff confirmed that there was no documented diagnosis for some of the medications administered, and care plans were not consistently updated to reflect medication changes or discontinuations. The facility's policy required that information from ongoing evaluations be incorporated into the comprehensive care plan, but this was not consistently followed. Additionally, the same resident did not have a care plan developed or implemented to address a newly identified condition. Both the Regional MDS Coordinator and the Assistant MDS Coordinator acknowledged the absence of a care plan for this condition during interviews. The lack of timely and accurate updates to care plans, as well as the failure to develop care plans for new diagnoses, constituted noncompliance with regulatory requirements for comprehensive, person-centered care planning.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with alleged deficiencies herein. To remain compliant with all federal and state regulations, the facility has taken actions set forth in the plan of correction. The plan of correction constitutes the facility's allegation of compliance such as the deficiencies cited have been corrected by the date certain. On the DON updated the care plan and added the appropriate intervention for resident #92. On the regional reimbursement coordinator revised and updated the care plans for the changes of diagnosis and medications for resident #76. On the regional reimbursement coordinator initiated the care plan for resident #76. On [date], the Regional Nurse Consultant conducted a quality review of residents who have had a [specific event or condition] in the past 30 days to ensure that interventions are added to the care plan timely. Follow up based on findings. On [date], the Regional Reimbursement Coordinator conducted a quality review of residents with new active diagnosis or medication changes in the past two weeks to ensure that care plans were appropriately developed or updated. Follow up based on findings. On [date], the Regional Nurse Consultant conducted a quality review of current residents with the diagnosis of [diagnosis] to ensure that appropriate care plans have been developed. No additional findings noted. By [date], the licensed nurses including the MDS nurses were educated by the Staff Development Coordinator on the components of N071 with an emphasis on accurate revisions and updating of care plans. As a systematic change, newly hired licensed nurses, including MDS nurses, will be educated on the components of N071 with an emphasis on accurate revisions and updating of care plans. The DON/designee will conduct quality monitoring audits of 10 random residents weekly for 4 weeks, then 10 random residents monthly for 2 months to ensure proper revision and updating of the care plans. The findings of these quality monitoring audits are to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
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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