Shores Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Saint Joe, Florida.
- Location
- 220 Ninth Street, Port Saint Joe, Florida 32456
- CMS Provider Number
- 105435
- Inspections on file
- 27
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Shores Nursing And Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the Memory Care unit was not kept clean or comfortable, with food debris and sticky floors throughout, and a resident's room containing a dirty mattress and stained bedsheet. A PCA was performing housekeeping duties due to staff absences, and both the DON and an RN acknowledged the inadequate cleanliness.
Multiple residents voiced ongoing concerns about the repetitive menu and limited food options, filing a formal grievance through the Resident Council. Despite documentation of complaints and an investigation that involved sending evidence to corporate, the grievance remained unresolved, and staff interviews revealed a lack of awareness and follow-up regarding the issue, contrary to the facility's grievance policy.
A resident's room was found to have damaged baseboards held together with tape and a bed frame with extensive rust, while maintenance staff failed to identify or address these issues during routine checks. The maintenance log only reflected unrelated minor repairs, and no new beds had been ordered despite claims to the contrary.
Surveyors found that the facility did not develop or implement complete, person-centered care plans for several residents with complex medical and behavioral needs. For example, a resident with dementia and behavioral complaints had no care plan interventions addressing these issues, and other residents lacked care plans for conditions such as limited range of motion, safe smoking with oxygen, and disease-specific needs. The DON confirmed that care plans were missing or incomplete for multiple residents.
A resident who required moderate to maximum assistance with personal hygiene, dressing, grooming, and oral care was repeatedly observed with unkempt hair, stained clothing, visible food particles, and poor oral hygiene. Despite a care plan outlining the need for staff assistance with these activities, the resident was not provided adequate support, resulting in ongoing unmet needs.
A resident with a left hand contracture and history of CVA did not receive appropriate range of motion care, as repeated observations showed no splints or devices were applied and no restorative program was in place. Staff interviews confirmed that restorative care was inconsistent due to staffing issues, and record review showed the resident had significant functional limitations without a maintenance program.
A resident with a newly placed AV fistula for dialysis did not receive consistent monitoring of the fistula's bruit and thrill by nursing staff. Despite discharge instructions to check the site daily, documentation showed assessments occurred only on three occasions, and there were no physician's orders for monitoring until nearly a month after placement. The DON confirmed the lack of orders and ongoing assessment prior to that time.
A resident with hepatic encephalopathy and liver cirrhosis did not receive prescribed rifaximin on multiple days because the medication was not available from the pharmacy. After missing several doses, the resident experienced increased confusion, tremors, and a decline in self-care, resulting in transfer to a hospital for altered mental status. Facility records and staff interviews confirmed the medication was unavailable for several days prior to the resident's transfer.
The facility did not provide documentation that several residents received education or were offered the pneumococcal vaccine, as required by policy. Review of medical records and staff interviews confirmed that forms indicating education, consent, or declination were missing for these residents.
The facility did not provide documentation showing that several residents received education about and were offered the COVID-19 vaccine, as required by policy. Interviews with nursing leadership confirmed that such documentation should be present in the medical record, but it could not be located for the affected residents.
Two resident rooms were found to have privacy curtains that were too short in width to ensure full visual privacy between beds, as confirmed by facility staff during an observation. The Administrator acknowledged the expectation for each room to provide complete visual privacy.
The facility failed to conduct annual performance reviews and training for a CNA, identified as Staff Member D, who was unable to recall her last training on resident rights and working with cognitively impaired residents. The DON confirmed that evaluations and training were only completed recently, with no prior documentation available.
The facility failed to promote resident dignity and quality of life by not allowing residents to wear personal clothing, not providing enough clean clothes, and restricting movement at night. A resident was found unclothed and distressed over lack of assistance, while others reported issues with soiled linens and rude night staff. The DON acknowledged these concerns.
A linen shortage in the facility affected resident care, with several residents lacking clean clothing and bed linens. Staff reported difficulties in obtaining necessary linens, and observations confirmed poorly stocked linen rooms. The Maintenance Director acknowledged the issue, citing delays in linen orders due to administrative approval processes.
The facility failed to resolve grievances promptly for several residents, as required by their policy. Grievances included inappropriate staff behavior, lack of assistance, and issues with medication and personal care. These grievances were not documented or investigated, and the Social Services Director responsible was terminated for not performing these duties.
The facility failed to provide timely assistance with daily living activities, including hygiene and nail care, due to staffing shortages. Residents were found in soiled conditions, with some reporting infrequent baths and falls due to lack of assistance. Staff interviews confirmed inadequate staffing, particularly on evening and night shifts, impacting care quality.
The facility failed to provide sufficient staffing to meet residents' basic needs, resulting in inadequate assistance with daily living activities such as bathing, dressing, and oral hygiene. Residents reported long wait times for help, missed showers, and unsanitary conditions. Staffing shortages, particularly during evening and night shifts, led to unmet care needs and compromised hygiene, as corroborated by staff interviews.
A facility failed to develop a comprehensive care plan for a resident requiring wound care. Despite having a physician's order for wound treatment, the resident's care plan lacked goals and interventions for wound care. A review confirmed the oversight, which was against the facility's policy requiring comprehensive care plans with measurable objectives.
A facility failed to obtain lab results for a resident after a physician ordered tests for CBC, BMP, and Hemoglobin A1c. The Treatment Administration Record indicated the blood sample was collected, but no results were found in the medical records. The DON requested the results, but they were not provided, and an RN confirmed the absence of lab results despite the completed documentation.
Failure to Maintain Clean and Homelike Environment in Memory Care Unit
Penalty
Summary
Surveyors observed that the Memory Care unit (400 Hall) was not maintained in a clean, comfortable, and homelike condition. During a facility tour, floors throughout the unit, including the dining area and all resident rooms, were found to have food debris and were sticky. One resident room had a mattress on the floor with fall mats, and both the mattress and mats were dirty, with the bedsheet visibly stained. Staff interviews revealed that a Personal Care Assistant was performing housekeeping duties due to the absence of regular housekeeping and maintenance staff, who had called out sick. The Director of Nursing confirmed the staff shortage, and a Registered Nurse acknowledged that the cleanliness of the unit was inadequate, specifically noting the state of the floors and rooms. These observations and staff statements directly indicated a failure to provide a safe, clean, and homelike environment for residents in the Memory Care unit.
Failure to Address Resident Council Grievance Regarding Food Quality and Variety
Penalty
Summary
The facility failed to act upon a grievance filed by the Resident Council regarding the variety and quality of food served. During a meeting with Resident Council members, multiple residents expressed ongoing dissatisfaction with the food, citing repetitive menus, limited alternate meal options, and the discontinuation of certain preferred items such as fried chicken. Residents reported that their complaints about food quality and variety had been raised multiple times, including in council meeting minutes and a formal grievance, but the issues persisted. The grievance investigation noted that pictures of portion sizes and repetitive menu items were sent to corporate, and a plan was made to work with the contracted food service company to improve offerings, but the grievance remained unresolved and residents continued to express dissatisfaction. Interviews with facility staff revealed a lack of awareness and follow-through regarding the grievance. The Dietary Manager was unaware of the specific grievance and stated that menu changes were routine and not in response to resident concerns. The Social Services Director confirmed ongoing complaints and stated that the grievance was reported to corporate, but could not provide evidence of any measures taken to resolve the issue or follow-up with residents. The facility's grievance policy requires prompt efforts to resolve complaints and inform residents of progress, but there was no documentation showing that these steps were taken in response to the Resident Council's food-related grievance.
Failure to Maintain Safe and Sanitary Resident Equipment
Penalty
Summary
The facility failed to maintain resident equipment in a safe and sanitary manner in one of the resident rooms. During observation, the baseboards in the room were found to be damaged, cracked, and held together with blue painter's tape, while the bed frame of one resident was extensively rusted, covering more than half its length. Maintenance Employee A reported conducting daily rounds to check exit doors and hallways and reviewing the maintenance log at each nurse's station, but was unaware of the extent of the rust on the bed and the damaged baseboards. The maintenance log only noted a need for replacement light bulbs in the room, and although Employee A entered the room to replace the bulbs, he did not notice or document the other issues. The Administrator initially stated that beds were on order but later confirmed that no beds had actually been ordered.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all identified needs for multiple residents. For one resident with dementia, observations and interviews revealed complaints of not being treated with dignity and respect, and reports from the resident's daughter indicated that staff were sometimes rough. Despite these behavioral concerns and allegations, there were no care plan interventions in place to address the resident's behaviors or false allegations, even though the care plan included other risks such as falls and communication deficits. The Director of Nursing acknowledged that these behaviors should have been care planned but were not. For another resident with multiple diagnoses including COPD, dementia, schizophrenia, CVA, diabetes, epilepsy, and heart failure, a plan of care was initiated to review functional abilities, but no interventions were included. Additionally, there was no care plan in place for limited range of motion until after an interview with the DON. The facility only had a partial restorative program in place, limited to dining activities. Other residents with complex medical histories, such as those on hospice, with indwelling catheters, or at risk for elopement, also lacked care plans addressing key aspects of their care, such as safe smoking practices, oxygen therapy, dementia, communication deficits, and disease-specific interventions. Record reviews and staff interviews confirmed that care plans were either missing, incomplete, or not updated to reflect the residents' current needs and conditions. The DON acknowledged that the care plans did not directly address the residents' care needs, resulting in a failure to provide a comprehensive care plan process for six out of twenty-one residents reviewed.
Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living for a resident who was unable to perform these tasks independently. Multiple observations over several days revealed the resident in various states of poor hygiene and unkempt appearance, including tangled and messy hair, food particles in her lap and on her clothing, and stained, unclean shirts. The resident was also repeatedly observed with a thick yellowish substance around her teeth and gum line, indicating a lack of oral care. At times, her clothing was improperly positioned, such as a shirt pulled up to expose her abdomen, and her incontinent brief was visible above her pants. The resident was often seen slumped in her wheelchair or lying in bed, with little evidence of assistance provided to maintain her cleanliness or dignity. Record review indicated that the resident required moderate to maximum assistance with personal hygiene, showers, incontinent care, dressing, toileting, and transfers, as documented in her MDS assessment and care plan. The care plan specified that staff were to provide assistance with hygiene, mobility, dressing, grooming, oral care, and toileting needs. Despite these documented needs and interventions, the resident was consistently observed in a state that demonstrated a lack of appropriate care and assistance with activities of daily living.
Failure to Provide Range of Motion Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) for a resident with a left hand contracture. Multiple observations over several days showed that the resident consistently did not have any splints or devices applied to her left hand to address the contracture, despite a care plan indicating a history of CVA and left side hemiparesis with a left hand contracture. Staff interviews revealed that the facility had not maintained a restorative program for some time, and the designated restorative aide was also required to perform regular CNA duties, limiting her ability to provide consistent restorative care, including ROM exercises and application of splints or devices. Record review indicated that the resident had significant functional limitations and impairments to both upper and lower extremities, as documented in the MDS and therapy screenings. Although therapy discharge summaries recommended 24-hour care, there were no restorative or functional maintenance programs in place for the resident at the time of the deficiency. The lack of consistent application of splints or devices and absence of a restorative program contributed to the facility's failure to provide necessary care and services to address the resident's contracture and limited ROM.
Failure to Monitor AV Fistula for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a newly placed arteriovenous (AV) fistula required for dialysis. The resident reported that nursing staff did not touch, palpate, or assess the fistula. Medical record review showed the AV fistula was placed on 4/10/25, but there were no physician's orders to check the bruit and thrill until 5/7/25. Hospital discharge instructions specified that the fistula site should be checked daily to ensure the thrill remained the same. Documentation revealed that the thrill was only assessed by nursing staff on three occasions: 4/12/25, 4/13/25, and 4/20/25. The DON confirmed that there were no orders to monitor the bruit and thrill prior to 5/7/25, despite the need for ongoing assessment since the fistula was placed.
Failure to Provide Prescribed Medication for Hepatic Encephalopathy
Penalty
Summary
A deficiency occurred when a resident with hepatic encephalopathy and liver cirrhosis did not receive their prescribed rifaximin 550 mg twice daily on multiple occasions due to the medication not being available from the pharmacy. The medication administration record and progress notes documented missed doses on several specific dates. The package insert for rifaximin indicates its use in reducing the risk of overt hepatic encephalopathy recurrence, and the resident was admitted with this diagnosis. On one of the days following missed doses, the resident experienced a change in condition, including increased tremors, confusion, and a decline in self-care, which led to a transfer to an acute care hospital for altered mental status. Hospital records confirmed that the facility had been out of rifaximin for several days prior to the transfer. During an interview, the DON acknowledged the resident's increased confusion and emotional upset when not receiving liver medications and confirmed the pharmacy's practice of sending only a five-day supply due to the medication's high cost.
Failure to Document Pneumococcal Vaccine Education and Consent
Penalty
Summary
The facility failed to provide documentation that four out of six residents reviewed had received education and were offered the pneumococcal immunization. Upon review of the medical records for these residents, there was no evidence of education, consent, or declination regarding the pneumococcal vaccine. Both paper and electronic records were checked, and interviews with the ADON and DON confirmed that such documentation should be present if a resident declines the vaccine. However, the required forms could not be located for the affected residents. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon or prior to admission, and the vaccine should be offered within 30 days unless contraindicated or previously administered. The policy also requires documentation of education and any refusal in the resident's medical record. The absence of this documentation for the four residents reviewed constitutes a failure to follow established procedures for immunization education and consent.
Failure to Document COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to provide documentation that five out of six residents reviewed had received education and were offered the COVID-19 immunization, as required by facility policy. Upon review of both paper and electronic medical records, there was missing documentation regarding education and consent or declination of the COVID-19 vaccine for these residents. Interviews with the ADON and DON confirmed that education and the offer of immunization should occur on admission, and that a signed declination form should be present if a resident refuses the vaccine. Despite attempts to locate the required forms, the facility was unable to provide documentation for the affected residents. The facility's admission packet specifies that all residents are to be educated and offered the COVID-19 vaccine, with a signature required to indicate acceptance or declination.
Insufficient Privacy Curtains Compromise Resident Visual Privacy
Penalty
Summary
During an observation of two resident rooms, it was found that the privacy curtains between the occupied beds were insufficient in width to provide full visual privacy. In one room, the curtain was measured and found to be approximately two feet too short, while in another room, the curtain was about eighteen inches too short. These findings were confirmed by both the Maintenance Director and the Administrator during the walkthrough. The Administrator acknowledged that each room is expected to be equipped to provide full visual privacy to each resident. Photographic evidence was obtained to document the deficiency.
Failure to Conduct Timely Performance Reviews and Training
Penalty
Summary
The facility failed to ensure that employee performance reviews were completed every 12 months for one of the six sampled Certified Nursing Assistant (CNA) staff members, identified as Staff Member D. During an interview, Staff Member D was unable to recall when her last training on resident rights, abuse prevention, and working with cognitively impaired residents with difficult behaviors occurred. A review of her employee file revealed that she was hired on 10/20/22, but there were no records of any performance evaluations or training in responding to cognitively impaired residents with difficult behaviors prior to 10/30/24. The Director of Nursing (DON) confirmed that the performance evaluation and training for Staff Member D were only completed on 10/30/24, the day before the interview. The DON was unable to provide any documentation of previous training or evaluations for Staff Member D before this date. This indicates a lapse in the facility's adherence to the requirement for annual performance evaluations and training for staff members, particularly in handling cognitively impaired residents with difficult behaviors.
Failure to Promote Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to uphold the dignity and quality of life for several residents by not allowing them to wear their personal clothing, not providing enough clean clothes, and restricting movement at night. Specifically, four residents were not allowed to wear their own clothes, and two residents did not receive enough clean clothes. One resident was restricted from leaving his room at night, which he expressed was due to staff citing it as a fire hazard. Additionally, there were issues with the availability of incontinence care supplies, leading to a resident wearing the same pull-up since the previous evening. Observations revealed that one resident was found unclothed in her bed with a strong smell of urine in the room, and she expressed distress over not receiving assistance for bathing. Another resident was using soiled bed linens and had unsuccessfully requested clean sheets. Multiple residents were observed wearing gowns despite preferring their own clothes, and one resident reported that night shift staff were rude and unaccommodating. The Director of Nursing acknowledged the concerns and mentioned efforts to provide clothing to residents in need.
Linen Shortage Affects Resident Care
Penalty
Summary
The facility failed to provide adequate supplies of clean laundry in four out of five linen storage areas, affecting eight of the 32 residents sampled. This deficiency was observed through resident and staff interviews, as well as direct observations by the surveyor. Residents reported issues such as wearing soiled or inappropriate clothing, lack of bed linens, and prolonged use of the same clothing without being washed. For instance, one resident was found wearing a patient gown and expressed a preference for regular clothes, while another resident had been using the same sheets for several days without them being changed. Staff interviews revealed that the facility often experiences shortages in linen supplies, with CNAs describing the situation as "horrible" and noting that linen rooms are poorly stocked. The lack of fitted sheets and other essential linens was a recurring issue, with staff reporting that they sometimes have to wait until the end of the day shift to obtain necessary items. The surveyor's tour of the laundry rooms confirmed these shortages, with many shelves completely empty or minimally stocked with essential items like sheets, pillowcases, and gowns. The Maintenance Director, who oversees laundry services, acknowledged the shortage of linens and indicated that there was a stock of linens in plastic bags designated as emergency supplies. However, these were not being circulated for regular use. The director mentioned that he had ordered more linens, but the order was pending approval from the administrator, who was currently on leave. This delay in processing orders further contributed to the deficiency in providing a safe, clean, and comfortable environment for the residents.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances for several residents, as required by their grievance policy. From May to July 2024, seven out of ten grievances sampled were not properly documented or investigated. Specific grievances included a resident reporting a night nurse's inappropriate behavior, another resident complaining about staff refusing to heat water, and a resident lacking clothes and being unable to eat in the dining hall. Additionally, a family member reported issues with medication administration and incontinence care for two residents. None of these grievances had documented investigations or resolutions. Resident #16 reported a grievance about neglectful behavior by a CNA, which was not documented or investigated. The resident provided text messages with the DON as evidence of the grievance. The DON acknowledged awareness of the grievance but stated that the grievance was never filed by the weekend supervisor. The facility's grievance policy requires prompt resolution and documentation of grievances, which was not adhered to in these cases. The Social Services Director responsible for handling grievances was terminated for failing to perform these duties.
Inadequate Resident Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely assistance to residents in performing activities of daily living, including oral care, nail care, podiatry care, and general hygiene. Observations and interviews revealed that multiple residents were left in soiled conditions, with strong odors of urine present in their rooms, indicating a lack of adequate incontinence care. Residents reported not receiving regular baths or showers, with some unable to recall their last bath. Additionally, residents expressed frustration over the lack of assistance with dressing, transfers, and other personal hygiene tasks. Resident #6 was found unclothed in bed with long toenails and a strong smell of urine in the room. She expressed distress over not receiving help with bathing and nail care. Resident #1 was observed with dry, cracked lips, long fingernails with debris, and long toenails, indicating neglect in oral and nail care. He reported not being assisted out of bed frequently and had only received oral hygiene assistance on a few occasions over several weeks. Other residents, such as Resident #8, reported falls and a lack of assistance during the night, leading to increased pain and difficulty in performing daily tasks. Staff interviews confirmed that the facility was experiencing staffing shortages, particularly on evening and night shifts, which impacted the ability to provide adequate care. Certified Nursing Assistants (CNAs) and Patient Care Assistants (PCAs) reported being overwhelmed with the number of residents they were responsible for, leading to missed care tasks such as turning residents, providing showers, and changing linens. The facility's reliance on PCAs, who are not yet certified, further exacerbated the issue, as they were unable to perform all necessary care tasks independently.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the basic needs of residents, as evidenced by observations, resident interviews, staff interviews, and record reviews. Residents reported inadequate assistance with daily living activities, such as bathing, dressing, and oral hygiene. Many residents were found in unsanitary conditions, with long nails, soiled linens, and strong odors of urine in their rooms. The lack of staff resulted in residents not receiving timely assistance, leading to unmet care needs and compromised hygiene. Several residents expressed dissatisfaction with the care provided, citing long wait times for assistance, missed showers, and infrequent checks by staff. Some residents reported incidents of neglect, such as being left in soiled briefs for extended periods and not receiving help with transfers or mobility. The facility's staffing shortages were particularly pronounced during evening and night shifts, with insufficient numbers of CNAs and an over-reliance on less experienced PCAs, who were unable to perform all necessary care tasks independently. Staff interviews corroborated the residents' accounts, highlighting the challenges faced due to inadequate staffing levels. CNAs and nurses reported being overwhelmed by the high acuity of residents and the demands of enhanced supervision for certain individuals. The facility's inability to maintain adequate staffing levels resulted in residents not being repositioned, bathed, or provided with necessary care in a timely manner, contributing to the overall deficiency in meeting residents' care needs.
Failure to Develop Comprehensive Wound Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who required wound care. The resident, who had been admitted with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, hypertension, and chronic kidney disease, had a physician's order for wound care on the right scapula. This order, dated 5/30/24, specified cleansing the open area with wound cleanser and applying Duoderm every three nights and as needed. However, a review of the resident's most recent care plan, dated 6/6/24, revealed that it did not include any goals or interventions related to wound care, despite the resident having wounds prior to that date. An interview with a Registered Nurse and the facility's MDS coordinator confirmed that the resident should have been care planned for wounds during the most recent review. The facility's policy on comprehensive care plans, dated 9/1/2022, requires that each resident's care plan includes measurable objectives and timetables to meet their medical, nursing, mental, and psychological needs, and identifies the professional services responsible for each element of care. This policy was not adhered to in the case of the resident in question.
Failure to Obtain Laboratory Results for a Resident
Penalty
Summary
The facility failed to obtain laboratory results for a resident who was sampled for blood testing. A physician ordered laboratory tests for a Complete Blood Count (CBC), Basic Metabolic Panel (BMP), and Hemoglobin A1c on 7/22/24. The Treatment Administration Record (TAR) indicated that the blood sample collection was completed on the same date. However, upon review of the resident's medical records, no laboratory results were found on file. The Director of Nursing (DON) requested the results, but they were not provided. A Registered Nurse (RN) confirmed the absence of lab results despite the physician's order and the documentation indicating the collection was completed.
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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