Springs At Boca Ciega Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in South Pasadena, Florida.
- Location
- 1255 Pasadena Ave S, Suite C, South Pasadena, Florida 33707
- CMS Provider Number
- 105537
- Inspections on file
- 16
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 5 (4 serious)
Citation history
Health deficiencies cited at Springs At Boca Ciega Bay during CMS and state inspections, most recent first.
A resident with multiple serious conditions, documented decision-making capacity, and a signed Florida DNR order had clear physician orders and care plan entries indicating DNR status. During an episode of respiratory distress and severe hypoxia, the assigned LPN obtained orders to transfer the resident to the ER and left to prepare paperwork, while an RN responded with a crash cart, directed suctioning and oxygen, and then ordered staff to lower the resident to the floor and begin chest compressions without verifying code status. Multiple LPNs rotated performing CPR under the RN’s direction, no overhead code was called, and staff assumed someone had checked the code status; the assigned LPN later discovered the DNR while preparing transfer documents. EMS arrived and continued CPR until the yellow DNR form was printed and provided, at which point compressions were stopped after approximately 20 minutes, despite facility policies requiring staff to refer to the DNR form and physician orders before initiating CPR.
A resident with multiple serious diagnoses had clearly documented DNR status, including a signed state DNR form, care plan entries, and advance care planning notes confirming the wish not to be resuscitated. During an episode of respiratory distress and severe hypoxia, an RN led the emergency response, directing staff to bring the crash cart, suction the resident, move the resident to the floor, and initiate chest compressions without verifying code status. Several LPNs performed CPR in succession, EMS was called and took over compressions, and a code blue was not called overhead. Staff later realized the resident was a DNR only after CPR had been in progress and EMS was present; DNR documentation was then provided and compressions were stopped, but CPR had already been performed for about 20 minutes in direct conflict with the resident’s documented wishes.
A resident with multiple serious diagnoses and clearly documented DNR status, including a signed Florida DNR form and care plan entries, experienced respiratory distress and severe hypoxia. After a provider ordered transfer to the ER, the assigned LPN left to prepare paperwork while an RN responded with a crash cart, suctioned the resident, and directed that the resident be lowered to the floor and CPR started. Several nurses rotated performing chest compressions without verifying code status, assuming the resident was full code. Only after EMS arrived and CPR had been ongoing for about 20 minutes was the resident’s DNR status confirmed via the yellow DNR form, at which point compressions were stopped and the resident was pronounced deceased. Surveyors found that staff failed to honor the resident’s DNR order and advance directive, resulting in an Immediate Jeopardy deficiency.
A resident with multiple chronic conditions and a documented DNR order, including a signed state yellow DNR form and corresponding physician orders in the EHR, developed respiratory distress and low O2 saturation. Nursing staff obtained orders to transfer the resident to the hospital, but as his condition worsened, an RN and several LPNs initiated a code response with a crash cart, suction, and a non-rebreather mask, then lowered the resident to the floor and performed chest compressions without first verifying code status. Staff interviews showed that no one checked the EHR or yellow DNR form before starting CPR, the code was not called overhead, and the code blue worksheet/timeline was not completed. Another RN later confirmed in the EHR that the resident was DNR and provided documentation to EMS, who then stopped compressions after about 20 minutes of CPR. Surveyors found that staff failed to follow facility policies on CPR, advance directives, admission/readmission, and resident rights by not honoring the resident’s DNR order, resulting in an Immediate Jeopardy deficiency.
A resident with a documented DNR order experienced a change in condition, during which an RN, LPNs, and a CNA initiated CPR without verifying the resident’s code status, despite hospital and facility records indicating Do Not Resuscitate. Staff demonstrated confusion about whether CNAs were permitted to perform CPR and were inconsistent in their understanding and use of code blue documentation tools that were supposed to be on the crash cart. Interviews showed that some nurses had never seen the code log, others believed a code timeline was standard but not present, and CNAs were unsure of their CPR role, revealing a lack of clear education and implementation of the facility’s QAPI-driven processes for code response and documentation.
Failure to Honor DNR Order During Code Event
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) order and advance directive during a cardiopulmonary arrest. The resident had multiple significant diagnoses, including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, history of TIA and cerebral infarction, and adult failure to thrive. The medical record contained physician orders documenting DNR status on multiple occasions, and the care plan stated the resident had capacity to make health care decisions and had signed a DNR, with the signed Florida DNR form scanned into the electronic health record. A hospitalist progress note also documented that the resident was DNR and had declined invasive measures such as a PEG tube, opting for comfort-focused care and liberalized diet for quality of life. On the day of the incident, the resident complained of shortness of breath and was noted to be hypoxic, with oxygen saturation documented as low as 55%. The assigned LPN assessed the resident, contacted the NP, and obtained orders to transfer the resident to the ER. While the assigned LPN left the room to prepare transfer paperwork, another RN (the nurse manager) was notified and went to the resident’s room with the crash cart. According to interviews and the facility’s internal timeline, the RN found the resident in respiratory distress, drooling, and directed staff to obtain towels, oxygen equipment, suction, and a non-rebreather mask. The resident was suctioned, placed on a non-rebreather, and then lowered to the floor. The RN did not verify the resident’s code status before directing staff to initiate chest compressions. Multiple nurses, including several LPNs, participated in performing chest compressions, rotating as directed by the RN who was leading the code. Staff reported that a code blue was not called overhead and that they assumed someone had checked the resident’s code status. The assigned LPN later stated he did not realize the resident was a DNR because this was not indicated on the face sheet. Another LPN discovered the resident’s DNR status while preparing transfer paperwork and questioned why CPR was being performed. EMS arrived and instructed staff to continue compressions until they could review documentation; compressions continued until the yellow Florida DNR form was produced and provided to paramedics. The facility’s investigation and timeline showed that chest compressions were performed for approximately 20 minutes before being discontinued, despite the presence of a physician-signed DNR order and a scanned Florida DNR form in the record, resulting in the facility’s failure to follow the resident’s advance directive and physician orders. The facility’s own policies on Emergency Care (CPR) and Advance Directives required staff to identify and honor each resident’s choice for treatment, to use the yellow DNR form as the physician order concerning CPR, and to refer to the presence of the yellow form and/or physician orders to determine if CPR should be performed in a cardiac emergency. Interviews with the Nursing Home Administrator and regional clinical leadership confirmed that, prior to this event, the process relied on the nurse to verify code status in the electronic health record and dashboard, and that in this incident the resident’s code status was not verified before CPR was initiated. The surveyors determined that this failure to honor the resident’s DNR and advance directive caused unnecessary physical harm and pain and denied the resident a peaceful death, and that it created a situation resulting in a worsened condition and likelihood for serious injury and/or death, leading to an Immediate Jeopardy determination.
Removal Plan
- Initiated disciplinary action and suspension for two nurses.
- Terminated an RN and reported the RN to the Board of Nursing.
- Reviewed nurse files to confirm CPR certification, licensure, skills checklists, and background checks were present for all nurses.
- Held ad hoc QAPI meetings to discuss the concern and correction plan.
- Held an ad hoc meeting to provide additional education and reinforce prior education on code status and abuse, neglect, and exploitation (ANE), and to review and approve a code blue worksheet and an abuse posttest.
- Held an ad hoc meeting to review, revise, and approve the code blue worksheet.
- Implemented staff review of the revised code blue worksheet on the units and allowed any staff member to complete the code blue worksheet.
- Educated all nurses on advance directives, resident right to make decisions, emergency care (CPR), and ANE.
- Educated new licensed staff on abuse and code status upon hire.
- Reviewed all resident medical records to verify code status orders.
- Audited residents who expired in the facility to confirm code status was honored.
- Initiated and continued mock code drills on varying shifts and days.
- Reviewed and verified code status for all new admissions.
- Provided reinforcement education to nurses to verify and document code status orders.
- Implemented the code drill worksheet and revised it to include a checkbox for full code/DNR.
- Provided additional education to non-licensed staff to reinforce prior education on code status, who can perform CPR and emergency care, advance directives, ANE, and their role during a code blue.
- Continued reinforcement education and required staff to complete it prior to working their next shift.
Failure to Honor DNR Resulting in CPR Performed Against Resident’s Wishes
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) status and right to refuse CPR, resulting in CPR being performed against the resident’s documented wishes. The resident had multiple serious medical diagnoses, including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, prior TIA, cerebral infarction without residual deficits, and adult failure to thrive. The medical record contained multiple physician orders documenting DNR status, including a State of Florida yellow DNR form signed by the resident and physician and scanned into the electronic health record. The resident’s care plan documented that the resident had capacity to make health care decisions and had signed a DNR, and advance care planning notes and a hospitalist progress note also confirmed DNR status and the resident’s preference for comfort-focused care. On the day of the event, the resident complained of shortness of breath and was noted to be hypoxic, with oxygen saturation documented as low as 55%. Nursing staff contacted the provider, who ordered transfer to the ER. While the assigned LPN left the room to prepare transfer paperwork, another RN responded to the room after being told assistance was needed. That RN brought the crash cart, suctioned the resident for drooling, and observed agonal breathing followed by cessation of breathing. Multiple witnesses reported that this RN directed the response in the room, instructing staff to obtain oxygen equipment and suction, to place the resident on the floor with a backboard, and to initiate chest compressions. Several LPNs took turns performing chest compressions, and paramedics were called and took over CPR when they arrived. Staff reported that a code blue was not called overhead and that the resident’s code status was not verified before CPR was started. Interviews and record review showed that staff performing and directing CPR either did not check the resident’s code status or assumed someone else had done so. The assigned LPN stated he did not realize the resident was a DNR because the face sheet showed full code, and another LPN stated she began compressions based on the RN’s direction without confirming code status. The RN leading the response did not verify the code status prior to initiating compressions, and staff reported that the resident’s DNR status was only recognized after CPR had been in progress and EMS was already on scene. A timeline from the facility’s investigation documented that chest compressions began at 3:18 p.m., EMS arrived at 3:23 p.m., the DNR status was identified at 3:35 p.m., and DNR documentation was provided to EMS at 3:38 p.m., at which time compressions were discontinued. In total, chest compressions were performed for approximately 20 minutes on a resident who had an active DNR order and documented wishes not to be resuscitated. The surveyors determined that this failure resulted in a situation that created a worsened condition and the likelihood for serious injury and/or death and constituted Immediate Jeopardy. The report also notes that the facility’s policies required staff to identify and follow each resident’s advance directives, including referring to the yellow DNR form and physician orders before initiating CPR. Staff interviews revealed inconsistent understanding and use of tools to verify code status, such as a code status book or code blue sheets, and multiple staff stated they had not seen or used code blue logs or worksheets prior to this event. The Nursing Home Administrator acknowledged that the expectation was for staff to assess a resident and determine code status before initiating CPR, and that if a resident had DNR orders, chest compressions should not be performed. Despite these policies and expectations, the resident’s clearly documented DNR status was not checked or followed before CPR was initiated and continued for an extended period.
Removal Plan
- Disciplinary action/suspension was initiated for two nurses
- RN was terminated and reported to Board of Nursing
- Nurse files were reviewed and it confirmed CPR certification, license, skills checklists and backgrounds were present for 100% of nurses
- Ad hoc QAPI meetings were held to discuss concern and correction plan
- Ad hoc meeting was held to review IJ citations
- Ad hoc meeting was held to provide additional education to evaluate and reinforce education previously provided on code status, abuse, neglect, and exploitation (ANE); reviewed and approved a code blue worksheet; reviewed and approved an abuse posttest to reinforce prior education
- Ad hoc meeting was held to review, revise and approve code blue worksheet
- Revised code blue worksheet was taken to units and staff review of the worksheet was initiated
- Implemented that anyone can complete the code blue worksheet
- Educated 100% of nurses on advance directives, resident right to make a decision, emergency care (CPR), and ANE
- New licensed staff were educated on abuse and code status upon hire
Failure to Honor DNR Order During CPR Event
Penalty
Summary
Facility staff failed to honor a resident’s physician-ordered Do Not Resuscitate (DNR) status when the resident was found unresponsive and staff initiated Cardiopulmonary Resuscitation (CPR), including chest compressions, without first confirming code status. The resident had a documented history of serious medical conditions including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, prior TIA, cerebral infarction without residual deficits, and adult failure to thrive. The medical record contained multiple physician orders documenting DNR status, including a State of Florida DNR form signed by the resident and physician and scanned into the electronic health record, as well as care plan entries and advance care planning notes confirming the resident’s wish to be DNR and to avoid aggressive interventions such as feeding tubes. On the day of the event, the resident complained of shortness of breath and was noted to be hypoxic, with oxygen saturation documented as low as 55%. Nursing staff contacted the provider, who ordered transfer to the ER. While the assigned nurse left the room to prepare transfer paperwork, another RN responded to the resident’s respiratory distress, brought the crash cart, and began directing the emergency response. Staff reported that the resident was drooling, appeared to be in respiratory distress, and was suctioned and placed on a non-rebreather mask. During this process, the resident developed agonal breathing and then stopped breathing. At the direction of the RN leading the event, the resident was lowered to the floor and chest compressions were initiated by an LPN, with subsequent rotation of multiple nurses performing compressions. Multiple staff involved in the code, including LPNs and RNs, acknowledged that the resident’s code status was not verified before CPR was started. Staff assumed the resident was a full code, and one LPN stated she did not check code status because she was specifically called by the RN to start compressions. Another LPN later discovered in the electronic record that the resident was DNR while CPR was ongoing. Paramedics arrived and instructed staff to continue compressions until they could review documentation; CPR continued for approximately 20 minutes until the yellow State of Florida DNR form was produced, at which point EMS stopped compressions and the resident expired. The surveyors determined that by providing CPR, staff failed to honor the resident’s advance directive and signed DNR order, causing unnecessary physical harm and pain and denying the resident a peaceful death, and this failure resulted in a determination of Immediate Jeopardy. Interviews with the Nursing Home Administrator and regional clinical leadership confirmed that the facility’s policy required staff to determine a resident’s code status, including reference to the yellow DNR form and physician orders, before initiating CPR. The NHA stated that if a resident had DNR orders, the expectation was that staff would not perform chest compressions and would instead focus on comfort. The facility’s policies on emergency care (CPR), advance directives, and resident rights all emphasized honoring the resident’s treatment choices and using the signed yellow DNR form as the physician order concerning CPR. Despite these policies and the presence of clear DNR documentation in the record and care plan, staff did not verify code status prior to initiating CPR, leading to the Immediate Jeopardy finding.
Removal Plan
- Disciplinary action/suspension was initiated for two nurses.
- The RN involved was terminated and reported to the Board of Nursing.
- Nurse files were reviewed and confirmed CPR certification, license, skills checklists, and background checks were present for 100% of nurses.
- Ad hoc QAPI meetings were held to discuss the concern and correction plan.
- An ad hoc meeting was held to review IJ citations and to plan additional education on code status and abuse/neglect/exploitation (ANE), approve a code blue worksheet, and approve an abuse posttest to reinforce prior education.
- An ad hoc meeting was held to review, revise, and approve the code blue worksheet.
- The revised code blue worksheet was taken to units and staff review of the worksheet was initiated.
- Education was provided to 100% of nurses on advance directives, resident right to make decisions, emergency care (CPR), and ANE.
- New licensed staff were educated on abuse and code status upon hire.
- A 100% review of resident medical records was completed to verify code status orders.
- An audit of residents who expired in the facility in the past 90 days was conducted with no concerns found related to honoring code status.
- Mock code drills were initiated and continued on varying shifts and days.
- Code status for all new admissions was reviewed and verified.
- All nurses received reinforcement education to verify and document code status orders.
- Implementation of the code drill worksheet began and feedback was incorporated to add a checkbox for full code/DNR.
- Additional education was provided to non-licensed staff to reinforce prior education on code status, who can perform CPR and emergency care, advance directives, ANE, and their role during a code blue.
- Reinforcement education was ongoing and staff were to complete it prior to working their next shift.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff were competent in identifying and honoring a resident’s code status and following physician orders for Do Not Resuscitate (DNR). A resident was admitted and later re-admitted with multiple diagnoses including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, history of TIA and cerebral infarction without residual deficits, and adult failure to thrive. The resident had a State of Florida yellow DNR order signed by the resident and physician and scanned into the electronic health record, and there were physician orders in the record reflecting DNR status, including orders that had been changed from full CPR to DNR. On the day of the event, the resident experienced respiratory distress, with staff noting shortness of breath, low oxygen saturation, congestion, and drooling. Nursing staff contacted the provider and obtained orders to transfer the resident to the hospital. As the resident’s condition worsened, multiple staff responded to the room. A crash cart was brought, suction and oxygen equipment were set up, and the resident was suctioned and placed on a non-rebreather mask. The resident was then lowered to the floor and chest compressions were initiated. Staff interviews consistently indicated that no one verified the resident’s code status in the electronic health record or by locating the yellow DNR form before starting CPR. Staff reported that the nurse manager in the room directed the response, including instructing an LPN and CNA to move the resident to the floor and instructing the LPN to begin chest compressions. Several LPNs took turns performing compressions, and staff stated they assumed someone had checked the code status or believed the resident was a full code. The code blue was not called overhead, and the code blue worksheet/timeline on the crash cart was not completed during the event. During the ongoing CPR, another RN arrived, questioned the resident’s code status, and checked the electronic record, confirming the resident had DNR orders. Staff then informed EMS personnel that the resident was DNR and provided the yellow DNR documentation, at which point paramedics discontinued compressions. Facility investigation and timelines showed that chest compressions were initiated at approximately 3:18 p.m., EMS arrived shortly thereafter, and compressions continued until about 3:38 p.m., totaling roughly 20 minutes of CPR on a resident with an active DNR order. Interviews with facility leadership and regional clinical staff confirmed that the process in place at the time relied on staff checking the electronic health record or the presence of the yellow DNR form to determine whether CPR should be performed, but in this incident, staff did not verify the code status before initiating resuscitation. The facility’s own policies on emergency care (CPR), advance directives, admission/readmission, and resident rights required verification and implementation of the resident’s DNR orders, which did not occur in this case. The surveyors determined that this failure to verify and honor the resident’s DNR order resulted in CPR being performed contrary to the resident’s documented wishes and physician orders. The report states that the CPR provided denied the resident the right to a peaceful death and caused unnecessary physical harm and pain. This situation was determined to have created a worsened condition and the likelihood for serious injury and/or death to the resident and led to a finding of Immediate Jeopardy. Cross-references were made to deficiencies related to resident rights, freedom from abuse/neglect, and quality of life (F578, F600, and F678).
Removal Plan
- Initiated disciplinary action/suspension for two nurses; terminated the RN involved and reported the RN to the Board of Nursing.
- Reviewed nurse personnel files and confirmed all nurses had current CPR certification, active license, skills checklists, and background documentation.
- Held ad hoc QAPI meetings to discuss the concern and develop the correction plan, including review of IJ citations.
- Conducted an ad hoc QAPI meeting to plan additional education reinforcing prior education on code status; reviewed and approved a code blue worksheet; reviewed and approved an abuse post-test to reinforce prior education.
- Conducted an ad hoc QAPI meeting to review, revise, and approve the code blue worksheet.
- Deployed the revised code blue worksheet to units and initiated staff review of the worksheet; allowed any staff member to complete the code blue worksheet.
- Provided education to all nurses on advance directives, resident right to make decisions, emergency care (CPR), and abuse/neglect/ANE.
- Educated newly licensed staff upon hire on abuse and code status.
- Completed a review of resident medical records to verify code status orders.
- Audited residents who expired in the facility and found no concerns related to honoring code status.
- Initiated mock code drills on varying shifts and days.
- Reviewed and verified code status for all new admissions.
- Provided reinforcement education to all nurses to verify and document code status orders.
- Implemented the code drill worksheet and added a checkbox for Full Code/DNR based on feedback.
- Provided additional education to non-licensed staff reinforcing prior education on code status, who can perform CPR and emergency care, advance directives, and abuse/neglect/exploitation (ANE) and their role during a code blue.
- Continued ongoing education so staff complete reinforcement education prior to working their next shift.
Failure to Verify DNR Status and Inconsistent Code Response Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were educated and equipped to respond appropriately to a resident’s change in condition, specifically regarding verification of code status, CNA involvement in CPR, and use of code documentation tools. Record review showed that Resident #1 had a signed Do Not Resuscitate Order (DNRO) on file, and hospital records uploaded into the facility’s system documented the resident’s code status as Do Not Resuscitate on two separate dates, with no evidence that this order had been rescinded. The facility’s own physician orders also showed a DNR order initiated for this resident. Progress notes documented that Resident #1 experienced a change in condition at the facility, during which an RN assessed the resident, who then stopped breathing and was reported to have no pulse. The RN directed an LPN and a CNA to place the resident on the floor and begin chest compressions. The CNA stated that CNAs were not allowed to perform CPR at the facility, and LPN staff continued CPR until EMS arrived and took over. Interviews with the Nursing Home Administrator and regional leadership confirmed that the involved staff did not verify the resident’s code status prior to initiating CPR, despite the resident’s documented wishes not to be resuscitated. Multiple staff interviews revealed inconsistent understanding of the facility’s code procedures, the role of CNAs in CPR, and the use and availability of code blue forms or timelines. The NHA stated that CNAs were not allowed to perform CPR and that if CPR was started, the code should be documented using paper attached to the crash cart, but acknowledged that staff did not use this documentation during the event. Some LPNs reported that code sheets or timelines were supposed to be on the crash cart, while others stated they had never seen a code blue log or were unaware that a code timeline was used. CNAs expressed uncertainty about whether they were allowed to perform CPR, and one CNA referenced a book at the desk listing residents’ code statuses. Review of the facility’s Quality Management/QAPI policy showed that the facility’s QAPI program was intended to use data and systemic analysis to improve care, but the events described demonstrated that staff were not consistently following or aware of established processes related to code status verification and code response documentation.
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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