St Johns Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lauderdale Lakes, Florida.
- Location
- 3075 Nw 35th Ave, Lauderdale Lakes, Florida 33311
- CMS Provider Number
- 105371
- Inspections on file
- 19
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at St Johns Nursing Center during CMS and state inspections, most recent first.
Surveyors identified widespread unsanitary conditions and improper food handling in the kitchen and storage areas, potentially affecting 154 residents. Observations included open and improperly placed garbage bins, sanitizer buckets with no active sanitizing agent, and visibly soiled food containers such as a banana bin with debris and hair. Expired and visibly spoiled items were found in the walk‑in refrigerator, including ricotta cheese, chocolate frosting, pureed pumpkin, and ice cream toppings, along with undated leftover beef and a case of Mighty Shakes stored unfrozen despite "Keep Frozen" labeling. Kitchen equipment such as the juice machine, tilt skillet, grill, oven, toaster, and microwave had accumulated food residue and grease, while muffin pans and shelving showed rust‑colored and stuck‑on debris. In the dry storage area, cans had white granules, a dented can was not segregated, floors and shelves were dirty, pasta was on the floor, and a slicer stored with other pans had a dead roach on it, with disinfectant spray stored next to food equipment. Personal instant coffee was also stored in the food production area, and bulk ingredient containers were sticky and soiled on the exterior.
A resident admitted after right knee surgery with a history of AKI, A-fib, and HTN had sacral redness/rashes and a Stage I pressure injury documented on admission, but staff failed to complete and record the required weekly monitoring and measurements of this sacral skin condition. Initial nursing notes described sacral redness/rashes present on admission, yet subsequent documentation focused only on the right knee surgical site. CNAs and RNs reported performing skin assessments and believed that any changes were reported and that weekly assessments occurred, but the RN stated she did not monitor or measure the sacral area after admission, assuming the wound care nurse was responsible. The wound care nurse, in turn, stated she did not monitor or document the sacral area, believing the staff nurses were doing so. Despite a care plan directing weekly monitoring, measuring, and documentation of the sacral area until healed, no such weekly documentation was found in the record.
The facility failed to maintain dignity during mealtimes, referring to residents needing assistance as 'feeders' and delaying meal service. A resident waited 35 minutes for a meal, while another with severe mental impairment had a meal tray left unattended for 10 minutes. Staff stood over a resident with moderate cognitive impairment while feeding, rather than sitting at eye level.
The facility failed to ensure that call lights were within reach for three residents, despite policy requirements. A resident with severe cognitive impairment and two residents with moderate cognitive impairment and upper extremity impairments were observed with call lights wrapped around bed rails, making them inaccessible. Staff interviews confirmed awareness of the policy, yet the deficiency persisted.
A resident was transferred to a nursing home from an ALF due to renovations and financial reasons, with an expected return in two months. However, after three months, the resident had not been informed about his return and felt his concerns were ignored. Facility staff provided inconsistent information about the necessity of the nursing home stay, and the resident expressed dissatisfaction with the lack of communication and services received. The Administrator acknowledged the resident's complaints and facilitated his return to the ALF after surveyor intervention.
A resident with severe cognitive impairment and physical limitations was observed with overgrown facial hair, indicating a failure by the facility to provide necessary grooming assistance. Despite the CNA's awareness of the issue, no action was taken initially. The facial hair was later removed, but staff interviews did not reveal who provided the care, highlighting deficiencies in care provision and documentation.
A facility failed to follow physician orders for a resident's urinary care, leading to a deficiency. The resident, with multiple health issues, was to receive Foley catheter care every shift, but nursing notes lacked documentation of this care. Observations showed reddish tinged urine with sediments in the tubing and drainage bag, and the bag often lacked a privacy cover. An LPN was aware of procedures for red-colored urine but did not document or notify the physician, contributing to the deficiency.
A facility failed to follow fluid restriction orders for a dialysis resident, leading to excessive fluid intake. The resident, with End Stage Renal Disease, was supposed to have a daily fluid limit of 1200 ml, but records showed nursing staff often exceeded this limit. Observations revealed a lack of awareness among staff about the fluid restriction, and inconsistent documentation further complicated adherence to the physician's orders.
A resident's personal items, including cash and a gate card, went missing in an LTC facility. Despite communication with the social worker and photographic evidence, the facility failed to follow its policy on handling valuables, resulting in a deficiency. The Director of Social Services and the DON were not informed, and no grievance was filed. The Administrator was unaware of the issue until the survey.
The facility failed to secure medications and treatment carts, leaving them unattended and accessible. An LPN left medication cups on a cart, and a resident had pills left at her bedside without being assessed for self-administration. A wound care nurse left a treatment cart unlocked, and a medication cart was found unattended. Staff acknowledged these lapses, which violated facility policies.
The facility failed to honor the food preferences of several residents during a lunch meal. A resident with GERD was served a different meal than indicated on the meal ticket. Another resident with heart and kidney issues received only mashed potatoes instead of the specified sandwich and tots. A third resident received a beef sandwich instead of a peanut butter and jelly sandwich. Staff interviews confirmed these discrepancies, and the DON acknowledged the issues.
The facility failed to maintain food safety and proper portion control in the kitchen. Observations revealed the Food Service Director without a facial hair covering, a dirty rag on the counter, and several food items past their used-by dates. Additionally, a meal was served with incorrect portion size, weighing only 2 ounces instead of the required 3 ounces. These deficiencies highlight issues in food service safety and sanitary conditions.
A facility failed to disinfect a vital signs machine between uses for multiple residents and did not follow droplet precaution protocols for a COVID-19 positive resident. A CNA used the machine on several residents without cleaning it and did not consistently perform hand hygiene. Another CNA entered a COVID-19 isolation room without proper PPE, touching surfaces and the resident's items with bare hands, contrary to the facility's infection control guidelines.
Widespread Unsanitary Food Storage, Preparation, and Equipment Conditions in Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to procure, store, prepare, and serve food in a safe and sanitary manner in the kitchen and food storage areas, with the potential to affect 154 residents. During a kitchen tour with the Kitchen Supervisor, Kitchen Manager, and Director of Food and Nutrition Services, surveyors observed an open tall gray garbage bin near the Vulcan stove, with no garbage bin near the handwashing area. Two red buckets identified as sanitizing solution were tested and showed no active quaternary ammonium sanitizer, as the test strips remained yellow instead of turning green-blue. A plastic bin holding bananas contained small round beige debris, a piece of white paper, brown/black debris, and a hair. In the pot washing room, a garbage bin was located very close to the mixer, which should be maintained in a clean area away from garbage. Three AC vents above the tray line had caked-on dark gray matter extending onto the surrounding ceiling. Multiple issues were identified in the walk-in refrigerator and other cold storage. Ricotta cheese with a manufacturer’s expiration date of 02/01/26 had expired and had clusters of dark black-green spots on the exterior top of the container. An open 12‑pound container of chocolate frosting with an expiration date of 01/31/26 was also expired and had thick green substance and clusters of green matter on the exterior grooves. A plastic container of pureed pumpkin labeled as prepared on 02/04/26 with a use‑by date of 02/11/26 had visible spherical matter with spore-like projections on the top layer. A plastic container with a piece of beef in the walk‑in refrigerator had no date, and the Kitchen Manager did not know how long it had been stored. A case of Mighty Shakes labeled “Keep Frozen” and dated 01/31/26 was found in a reach‑in refrigerator in an unfrozen state, and neither the Director of Food and Nutrition Services nor the Kitchen Supervisor knew how long it had been there. Two plastic containers of ice cream toppings with handwritten expiration dates of 10/20/25 were expired, and one opened container of beige, crunchy topping remained in storage. Additional unsanitary conditions and improper storage were observed throughout the kitchen and dry storage areas. The juice machine had a buildup of pink and yellow‑orange residue. The Vulcan tilt skillet handle and oven temperature knob had thick yellow‑brown residue in grooves, with particles on the skillet surface; the adjacent grill had yellow and yellow‑brown food remnants on the cooking surface, borders, and backsplash, and food remnants were present on the counter between the counter and grill. The Vulcan oven had dried yellow‑brown liquid on the ledge, brown residue on the interior door, and black buildup on the oven floor, despite being reported as cleaned weekly. In the dry goods room, cans had white granules on top, one can of evaporated milk was dented and not separated, the floor had stuck‑on brown‑black residue, pasta was on the floor near shelving wheels, and shelves showed yellow‑brown stuck‑on residue and dried drippings. Muffin pans had rust‑colored debris, white residue, and food particles. A slicing machine stored on a shelf had a dead roach on it, with a bottle of disinfectant spray stored next to it. Rubbermaid containers of sugar, lentils, and dried peas were sticky with yellow and brown residue on the exterior; the top of a rolling toaster had dried dark brown greasy spills; the interior of an Amana microwave had yellow‑brown buildup; and a plastic bag of personal instant coffee was stored on a lower shelf in the food production area.
Failure to Document Ongoing Assessment of Sacral Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring evaluation and documentation of identified skin changes in the weekly skin check section of the electronic medical record. The facility’s Wound Prevention, Skin Observation policy stated that nurses must evaluate and document identified changes weekly. Resident #1, admitted after right knee surgery with a history of Vancomycin-induced acute kidney injury, atrial fibrillation, and hypertension, had a documented Stage I pressure ulcer or injury on the admission MDS and nursing notes indicating sacral redness/rashes present on admission. After two initial nursing progress notes describing the sacral redness/rashes with no signs of infection, there were no further nursing progress notes addressing this sacral skin condition, despite ongoing daily skin assessments that focused on the right knee surgical site. Interviews with staff revealed inconsistent understanding of responsibility for monitoring and documenting the sacral area. A CNA reported that she performs ongoing skin checks during daily care and reports changes to nurses, and an RN stated that she performs head-to-toe assessments on admission, documents findings, and notifies the physician. The RN also stated that weekly skin assessments were performed for the resident’s sacral redness but acknowledged she did not monitor or measure the area after admission, believing the wound care nurse was responsible. The wound care nurse reported seeing the sacral redness on admission, with a cream ordered and applied and a turning schedule in place, but stated she did not monitor the sacral area and only monitored and documented the right knee surgical site, assuming the staff nurses were monitoring and documenting the sacral redness/rashes. The resident’s care plan required weekly monitoring, measuring, and documentation of the sacral wound status until healed, but record review showed no such weekly documentation in the nursing progress notes, and the ADON confirmed that, despite staff training, the nurses had not documented according to policy.
Undignified Mealtime Practices and Delayed Meal Service
Penalty
Summary
The facility failed to treat residents in a dignified manner during mealtime observations and did not provide adequate grooming for one resident. During mealtime on the 2nd floor South unit, staff members referred to residents as 'feeders,' which is considered undignified. Resident #140 experienced a delay in receiving her lunch tray, waiting approximately 35 minutes after her roommate had finished eating. Additionally, Resident #75, who has moderate cognitive impairment, was fed while staff stood over him, rather than sitting at eye level, which is the recommended practice for maintaining dignity. Resident #100, who has severe mental impairment and primarily receives nutrition through a PEG tube, was also referred to as a 'feeder' by staff. His dinner tray was left in front of him for 10 minutes without assistance, despite his need for help with eating. These observations indicate a pattern of undignified treatment and inadequate assistance during mealtimes for residents requiring help, as well as a lack of timely meal service for some residents.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that residents' call devices were within reach, affecting three residents. The facility's policy mandates that call bells be accessible to facilitate care and enhance safety. However, during observations, it was noted that the call light cords for Residents #85, #153, and #51 were wrapped around bed rails, leaving the call buttons dangling and out of reach. This was confirmed through interviews with staff and photographic evidence. Resident #85, who has severe cognitive impairment and is dependent on staff for activities of daily living, was observed unable to reach his call light. Despite having no upper extremity impairment, the call light was not accessible, and the resident could not indicate its location. Similarly, Resident #153, with moderate cognitive impairment and upper extremity impairment on one side, reported that his call light was often unreachable. Observations confirmed that his call light was not within reach, and he expressed difficulty in accessing it. Resident #51, also with moderate cognitive impairment and upper extremity impairment, stated that he could never find his call light and resorted to using his cell phone to contact his daughter for assistance. Observations showed that his call light was not accessible, corroborating his statement. Interviews with various staff members, including the Nurse Manager and CNAs, revealed an awareness of the policy to keep call lights within reach, yet the deficiency persisted, indicating a lapse in adherence to the facility's procedures.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not facilitating his return to an assisted living facility (ALF) after his temporary stay at the nursing home. The resident, who was cognitively intact with a BIMS score of 15/15, was initially transferred to the nursing home due to renovations at his ALF apartment and was expected to return in two months. However, three months later, the resident had not received any communication regarding his return and felt his concerns were ignored. Interviews with facility staff revealed inconsistencies and lack of documentation regarding the resident's admission to the nursing home. The Social Services Director and a Social Worker indicated that the resident was transferred due to financial reasons and pending Medicaid approval, but neither could provide documentation supporting the necessity of the nursing home stay. The Director of Nursing and a Resident Navigator provided conflicting information about the resident's need for nursing home care, with the DON unaware of a physician's assessment indicating the resident did not require such services. The resident expressed dissatisfaction with his stay, stating he had not received rehabilitation services and was only given medications. He was concerned about the financial implications of his stay and felt restricted in handling his personal affairs compared to his previous autonomy at the ALF. The Business Office Manager confirmed the resident's Medicaid application was approved, but the delay resulted in unexpected costs. The facility's Administrator acknowledged the resident's complaints and the lack of communication regarding his return to the ALF, which was eventually facilitated after surveyor intervention.
Failure to Assist Resident with Personal Grooming
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident, identified as Resident #139, who was unable to perform self-care due to severe cognitive impairment and physical limitations following a cerebrovascular aneurysm. The resident required total assistance for most ADLs, including personal grooming. On a specific date, the resident was observed with overgrown facial hair, indicating a lack of grooming assistance. Despite being aware of the resident's condition, the assigned Certified Nursing Assistant (CNA) did not take action to address the overgrown facial hair. Subsequent observations revealed that the resident's facial hair was eventually removed, but there was no documentation or staff acknowledgment of who provided the grooming care. Interviews with the staff, including the Unit Manager, failed to identify who attended to the resident's grooming needs. This lack of documentation and accountability highlights a deficiency in the facility's care provision and record-keeping practices, as the resident's grooming needs were not consistently met or recorded.
Failure to Follow Physician Orders for Urinary Care
Penalty
Summary
The facility failed to follow physician orders for urinary care for a resident with an indwelling catheter, leading to a deficiency in care. The resident, who had multiple diagnoses including chronic urinary retention and obstructive uropathy, was supposed to receive Foley catheter care every shift as per physician orders. However, nursing notes from multiple shifts lacked documentation of catheter care, and observations revealed that the resident's urinary tubing and drainage bag contained reddish tinged urine with sediments, indicating a potential urinary tract infection. Additionally, the urinary drainage bag was observed without a privacy cover on several occasions. Interviews with staff revealed that the LPN responsible for the resident's care was aware of the procedures to follow if red-colored urine was observed, including documenting the findings and notifying the physician. Despite this, there was no documentation of such actions being taken in the nursing notes. The lack of proper catheter care and documentation, as well as the failure to notify the physician of changes in the resident's urine, contributed to the deficiency in care for the resident.
Failure to Adhere to Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The facility failed to adhere to physician orders for fluid restriction for a resident undergoing dialysis, identified as Resident #42. The resident, who has diagnoses including End Stage Renal Disease, Anxiety Disorder, Anemia, and Hypertension, was supposed to have a daily fluid intake limited to 1200 ml, divided between nursing and dietary departments. However, records revealed that the nursing staff frequently exceeded the prescribed fluid limit, providing amounts ranging from 360 ml to 960 ml, which surpassed the 480 ml limit set for nursing. Additionally, the dietary department was providing an average of 780 ml daily, which also exceeded the intended 720 ml. This discrepancy in fluid management was further compounded by the lack of consistent documentation and communication between the nursing and dietary departments regarding the resident's actual fluid consumption. Observations and interviews highlighted a lack of awareness and adherence to the fluid restriction protocol among staff. The resident was observed with a water pitcher at her bedside, and when questioned, she indicated a lack of understanding of her fluid restrictions. Interviews with staff members revealed inconsistencies in their understanding and execution of the fluid restriction orders. The CNA responsible for the resident's care mentioned general practices for managing fluid intake but did not demonstrate a clear understanding of the specific fluid restriction order. The regional dietician acknowledged the dietary department's role in providing fluids but noted that they did not maintain records of the resident's total fluid consumption, relying instead on nursing documentation, which was inconsistent and incomplete.
Failure to Address Missing Personal Items and Clothing
Penalty
Summary
The facility failed to address social services responsibilities regarding missing personal items and clothing for a resident, leading to a deficiency. The resident, who had a history of multiple medical conditions including diabetes, anxiety disorder, and hypertension, was admitted to the facility. The resident's son reported missing personal items, including cash and a gate card, which were not addressed by the facility staff. Despite photographic evidence and communication with the facility's social worker, the missing items were not located or resolved. The facility's policy on handling valuables was not followed, as there was no documentation of efforts to locate the missing items or to inform pertinent staff members. The social worker, Staff V, acknowledged receiving emails from the resident's family regarding the missing items but did not document any further actions or communication with the family. The Director of Social Services and the Director of Nursing were not informed of the missing items, and no grievance was filed as per the facility's protocol. The facility's storage areas for personal items were not regularly checked, and there was no master inventory list for residents' belongings. The Administrator was unaware of the missing items until the survey. The lack of communication and documentation, along with the failure to follow established procedures, contributed to the deficiency in addressing the resident's missing personal items and clothing.
Medication and Treatment Cart Security Lapses
Penalty
Summary
The facility failed to secure dispensed medications, which were left unattended on a medication cart and at a resident's bedside. During an initial tour, a Licensed Practical Nurse (LPN) was observed leaving two small medication cups on top of a locked medication cart. The LPN confirmed that the cups contained medications for a resident who had refused them, and she intended to administer them later. This action was against the facility's policy, which requires that dispensed medications be discarded if refused and not stored for later administration. Additionally, a resident was found with a small medication cup containing four unidentified pills on her over-bed-side table. The resident stated that the nurse left the medications for her to take, which was a recurring practice. The resident had not been evaluated for self-administration of medications, as required by the facility's policy. The policy mandates that medications should not be left at the bedside unless the resident is assessed and approved for self-administration, with medications stored in a locked cabinet or drawer. The facility also failed to secure a treatment cart during a wound care observation. A wound care nurse left the treatment cart unlocked and unattended in the hallway while attending to a resident. The cart contained ointments, creams, and other supplies, posing a risk of unauthorized access. Furthermore, a medication cart on the South Wing was observed unlocked and unattended, accessible to residents, staff, and visitors. Staff members acknowledged these lapses, which were contrary to the facility's policy requiring medication carts to be locked when not attended.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of several residents during a lunch meal, as observed in the cases of four residents. Resident #14, who has a diagnosis of Gastroesophageal Reflux Disease (GERD) and moderate cognitive impairment, was served a mechanical soft diet of chicken chunks and rice, despite the meal ticket indicating chopped chicken with rice. Staff interviews confirmed the discrepancy between the meal served and the resident's preferences. Resident #151, with diagnoses including Acute Systolic Heart Failure, Atherosclerotic Heart Disease, and Chronic Kidney Disease, was supposed to receive an Italian Beef Sandwich with potato tots according to the meal ticket. However, the resident was only served mashed potatoes and gravy, with no meat or bread. The resident expressed dissatisfaction with the repetitive and unappealing meals, and staff interviews corroborated the inconsistency between the meal ticket and the food served. Resident #133, who has intact cognition and diagnoses including Metabolic Encephalopathy and Vitamin Deficiency, was supposed to receive a peanut butter and jelly sandwich but was instead served a beef sandwich with tater tots, fruit, and soup. The resident expressed dissatisfaction with the taste and quality of the food, noting that the sandwich was dry and tough. Staff interviews confirmed the discrepancy between the meal ticket and the food served. The Director of Nursing acknowledged the discrepancies in meal service for these residents.
Food Safety and Portion Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitary conditions, as observed during a survey of the main kitchen. The Food Service Director was noted to be without a facial hair covering in the food production area, and a dirty used rag was left on the food production counter instead of being placed in a sanitation bucket. Additionally, one of the three lights under the hood was not functioning, and a private plastic drinking cup was found under the food production area. Several food items in the walk-in refrigerator were past their used-by dates, including cooked pork, [NAME] sauce, marinara sauce, cooked eggs, and raw fish and chicken. Notably, a container of cream of broccoli soup had an unusually long used-by date, which the Food Service Director could not explain. During a tray line observation, the facility failed to serve the correct portion size as per the menu for a Regular diet. A large tray of pre-sliced pork pieces was noted, and the Food Service Director plated a meal with sliced pork and salsa sauce that weighed only 2 ounces instead of the required 3 ounces. An interview with a cook revealed that pork pieces were pre-sliced to 4 ounces each, indicating a discrepancy in portioning. These observations highlight the facility's failure to maintain food safety and proper portion control, potentially leading to foodborne illnesses and inadequate nutrition for residents.
Infection Control Deficiencies in Equipment Disinfection and PPE Use
Penalty
Summary
The facility failed to properly disinfect a vital signs machine between resident uses, as observed with three residents. A Certified Nursing Assistant (CNA), identified as Staff O, was seen using a vital signs machine on multiple residents without cleaning or disinfecting it between uses. This included not sanitizing the machine after use with Resident #137, Resident #428, and another resident. Staff O also failed to perform hand hygiene consistently between resident interactions, which is a critical step in preventing the transmission of infections. Additionally, the facility did not adhere to droplet precaution protocols for a resident diagnosed with COVID-19. Resident #375, who was on droplet isolation due to a positive COVID-19 diagnosis, was visited by Staff A, a CNA, who entered the room without wearing the required personal protective equipment (PPE) such as a gown and gloves. Staff A also failed to sanitize her hands before entering the room and touched various surfaces and the resident's items with bare hands, which could potentially lead to the spread of infection. The facility's infection control policies, as outlined in their guidelines, were not followed in these instances. The guidelines specify the need for proper hand hygiene, the use of PPE, and the disinfection of equipment between uses to prevent the transmission of infections. The failure to adhere to these protocols was confirmed through interviews with staff members, who acknowledged the requirements for PPE and hand hygiene in isolation situations.
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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