Sunset Lake Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Venice, Florida.
- Location
- 832 Sunset Lake Boulevard, Venice, Florida 34292
- CMS Provider Number
- 105761
- Inspections on file
- 27
- Latest survey
- April 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sunset Lake Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors observed dietary staff using unsanitary practices, including using a cut glove stored in a back pocket without proper cleaning, applying hand sanitizer to the glove instead of cleaning it, and performing hand hygiene for less than the required time. Staff also used the dishwashing sink for handwashing and demonstrated a lack of understanding of proper hand hygiene standards.
Two residents with severe cognitive and physical impairments did not receive necessary assistance with hygiene, dressing, and incontinence care. Staff were observed leaving one resident in food-stained clothing and soiled bedding for extended periods, while another resident's family member had to change a saturated brief after staff failed to respond to repeated requests for help. Documentation and interviews confirmed that required ADL support was not provided.
Two residents with documented preferences for music, religious services, and group activities were not consistently offered or assisted to participate in these activities, despite care plans and facility policy requiring individualized engagement. Both residents were frequently observed alone in their rooms without access to preferred activities, and activity logs showed minimal participation or one-on-one engagement.
A resident with a history of falls and cognitive impairment experienced multiple unwitnessed and witnessed falls over several months, despite various care plan interventions. The resident was housed in a room far from the nurses' station, left unsupervised, and exposed to environmental hazards such as a broken fan on the floor. Staff were aware of the frequent falls and cognitive issues but did not implement increased supervision or frequent checks, and safety equipment was not consistently used.
Multiple residents reported prolonged wait times for call light responses, with some waiting up to an hour for assistance and experiencing discomfort or unmet care needs. Staff interviews confirmed expectations for prompt response, but residents consistently cited staffing shortages as the reason for delays. Documentation of call light audits was withheld from surveyors by the administrator.
Staff did not follow infection prevention protocols for two residents with PICC lines, failing to change dressings as ordered and lacking proper documentation of dressing changes. Additionally, staff providing care to a resident on enhanced barrier precautions did not wear required PPE, such as gowns, during high-contact care activities, despite being aware of the protocols and signage. The DON acknowledged that PPE supply location may have contributed to staff non-compliance.
A newly admitted resident with diabetes, a recent fall, and a history of wounds did not receive a resident-centered baseline care plan within 48 hours of admission. The baseline care plan incorrectly documented no wounds, as a full skin assessment was not performed due to the resident's refusal to remove dressings. Staff and family later identified and addressed wounds that were not initially care planned, and the DON acknowledged the care plan's lack of resident-specific information.
A resident with left-sided contracture and hemiplegia did not consistently receive prescribed splinting for the hand and knee, as required by physician orders. Observations showed the resident was often without the necessary splints, and when applied, the hand splint was frequently positioned incorrectly. Staff interviews revealed confusion about the orders and inconsistent knowledge of proper application, and there were no written instructions available for staff. This resulted in a failure to provide appropriate care to maintain or improve the resident's range of motion.
During an emergency evacuation for a hurricane, a facility failed to protect residents from neglect, resulting in serious harm. Residents were transported without necessary medications, food, or hydration, and staff support was inadequate. The facility's emergency plan was not effectively implemented, leading to widespread neglect and immediate jeopardy to residents' health and safety.
During an emergency evacuation due to a hurricane, the facility failed to ensure the safety and proper care of residents, resulting in serious harm. A resident with fractures was laid across bus seats, causing severe pain; another wheelchair-bound resident sustained an ankle fracture during improper transport; and an oxygen-dependent resident experienced respiratory distress due to lack of a CPAP machine. The facility's emergency plan was not effectively implemented, and necessary medications were not provided.
The facility failed to effectively utilize resources and implement an emergency plan during a hurricane evacuation, resulting in serious harm to residents. A resident suffered fractures due to improper transport, another was evacuated without necessary medical equipment, and many residents missed medications. The facility lacked contingency plans and adequate staff training, leading to a chaotic evacuation process.
The facility failed to implement corrective actions for deficiencies in staff training and competency during an emergency evacuation ahead of a hurricane. Inadequate transportation and lack of nursing staff on transport vehicles led to multiple residents suffering harm, including severe pain, fractures, and respiratory distress. The facility's Emergency Preparedness Plan was not effectively implemented, and no corrective actions were discussed in QAPI meetings following the incident.
The facility's assessment was incomplete, lacking input from listed contributors, including key staff and a resident. Interviews revealed that the Activities Director, Director of Housekeeping, and others were unaware of the assessment process. Additionally, the assessment did not document how staff were informed about the Comprehensive Emergency Management Plan (CEMP), as confirmed by the Administrator.
A facility failed to ensure that three nurses were trained and competent in checking the function of wander alert bands, leading to a resident with cognitive impairment being found outside the facility. The resident was wearing a wander alert bracelet, but staff only checked its placement, not its functionality. Documentation showed inaccurate records of functionality checks, and there was no training or competency documentation for the staff involved.
A resident was injured during an evacuation when therapy staff physically lifted them off a bus without a mechanical lift, resulting in a fracture. The facility failed to report the incident to the appropriate authorities as required by state law.
Improper Sanitation and Food Handling Practices Observed in Kitchen
Penalty
Summary
Multiple instances of improper sanitation and food handling practices were observed in the facility's kitchen. Dietary staff were seen using a cut-resistant glove that was stored in a back pocket and not sanitized before use, with hand sanitizer being applied to the glove instead of proper cleaning. Staff also performed hand hygiene for less than the required duration, with some using the 3-compartment sink intended for dishwashing rather than the designated handwashing sink. These actions were directly observed during food preparation and after handling garbage. Interviews with dietary staff revealed a lack of understanding regarding the correct handwashing duration, with one staff member stating that 10 seconds was sufficient. The culinary manager acknowledged that the use of hand sanitizer on gloves and improper handwashing practices were not in accordance with professional standards and facility policy. The observations and staff interviews indicate that the facility failed to ensure food was prepared and handled in accordance with professional standards for food service safety.
Failure to Provide Adequate ADL Support and Hygiene
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living (ADLs) for two residents who required substantial help due to severe cognitive and physical impairments. One resident, admitted with diagnoses including stroke, hemiplegia, aphasia, and muscle weakness, was observed multiple times over two days wearing the same food-stained blouse and lying in soiled bedding. Staff were seen attempting to feed the resident while she was not fully alert, resulting in food spilling onto her clothing and bedding, which were not changed afterward. Incontinence care was provided without changing the soiled linens, and staff admitted unfamiliarity with the residents due to being assigned to a different unit. Another resident with severe dementia, pneumonia, spinal fracture, and atrial fibrillation was found by his daughter in a completely soaked incontinent brief, which she had to change herself after multiple unsuccessful attempts to get staff assistance. The resident was also observed wearing the same shirt over several days, with documentation indicating no staff assistance was provided for dressing or toileting, despite care plans identifying a need for hands-on help. Staff interviews revealed a lack of knowledge about the residents' care needs, with some staff stating they did not usually work in the assigned hallway and were unsure if residents' clothing or bedding had been changed. Documentation and direct observations confirmed that both residents did not receive necessary hygiene, dressing, and incontinence care as required by their conditions and care plans. The facility's failure to provide appropriate ADL support resulted in residents remaining in soiled clothing and bedding, and in one case, a family member having to intervene to address basic care needs.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of two residents, as required by their own policy and federal regulations. Both residents had documented preferences and care plan interventions indicating the importance of activities such as music, religious services, group events, and social interaction. Despite these documented needs, observations over several days showed that both residents spent extended periods in their rooms, often in bed, with no music, television, or engagement in preferred activities. Activity calendars indicated that relevant group activities were scheduled, but the residents were not consistently offered assistance to attend or participate. One resident, with a history of major depressive disorder and moderately impaired cognitive skills, expressed a strong interest in music, religious activities, and group events. However, he reported that staff did not routinely invite him to activities or assist him in getting out of bed, and he was observed missing several activities he had identified as important. Documentation showed limited participation in activities over a period of weeks, with only a few conversation visits and minimal engagement in group or preferred activities. The second resident, who was on hospice and had severe cognitive impairment, primarily spoke Polish and required assistance and cues to participate in activities. Her care plan noted a preference for music and religious activities, but she was observed alone in her room with the television off during scheduled activities. Activity logs indicated infrequent and brief one-on-one visits, and no group activity participation was documented in the previous month. Staff interviews confirmed language barriers and limited engagement, despite the resident's expressed preferences for certain activities.
Failure to Provide Adequate Supervision and Safe Environment for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision to prevent multiple falls for a resident with a significant history of falls and cognitive impairment. The resident, who had previously been hospitalized for multiple falls following a craniotomy, continued to experience frequent unwitnessed and witnessed falls after admission to the facility. Despite the implementation of various care plan interventions such as reminders to use the call light, placement of signs, medication reviews, and environmental adjustments, the resident sustained 14 falls over several months. Many of these falls were unwitnessed, and the interventions did not include increased supervision or frequent checks, even though the resident was known to be non-compliant with safety reminders and had memory deficits. Observations revealed that the resident was housed in a room located at the far end of the hallway, away from the nurses' station and staff visibility, and was often left unsupervised. The resident did not participate in therapy sessions, group activities, or supervised outdoor time, and typically remained in the room with a roommate. Environmental hazards, such as a broken fan on the floor, were present in the resident's room for several days and were not removed despite being identified as a tripping hazard. Additionally, safety equipment such as fall mats and side rails were not consistently in use, and required signage was missing from the room. Interviews with staff confirmed awareness of the resident's frequent falls and cognitive challenges, but no interventions to increase supervision were implemented until after the survey observations. Staff acknowledged that the resident was not listed for frequent checks and that the room location was not optimal for monitoring. The DON confirmed that interventions had not been effective in preventing falls and that incident reporting for the resident's falls had ceased. The lack of increased supervision and failure to address environmental hazards contributed to the ongoing risk and occurrence of falls for the resident.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and observations. Several residents reported extended wait times for call light responses, with some waiting 15 to 60 minutes for assistance. One resident described being left on a bedpan for over an hour, resulting in numbness and discomfort, while another reported having to keep a partially filled urinal at the bedside due to delayed staff response. Residents consistently stated that staff told them the facility was short-staffed, and that call light response times varied depending on the day and staff present. Photographic evidence was obtained to support these claims. Staff interviews confirmed that call lights should be answered within 3 to 5 minutes, and the DON stated that the facility staffs based on census and acuity, never going below certain staffing thresholds. Despite this, residents continued to experience delays. The DON also indicated that all staff, including non-nursing departments, are expected to answer call lights, and that call light audits and ambassador rounds are conducted. However, when surveyors requested documentation of these audits, the administrator withheld the forms, stating the survey team was not permitted access.
Failure to Follow Infection Control Protocols for PICC Lines and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols for residents with peripherally inserted central catheters (PICCs) and those on enhanced barrier precautions (EBP). For one resident with a PICC line, the dressing was not changed as ordered, with the dressing remaining in place since hospital admission and not being changed by facility staff, despite ongoing intravenous antibiotic administration. Documentation indicated the dressing had been changed, but the nurse later admitted this was not accurate. The Director of Nursing confirmed that the facility policy requires dressing changes every 5-7 days, and that documentation should not be completed before the task is performed. Another resident with a PICC line for antibiotic infusion also did not have dressing changes documented as required by physician orders. Observation revealed the dressing was outdated, and the Unit Manager stated she could not determine when it was last changed due to lack of documentation. The Unit Manager subsequently changed the dressing and implemented a plan to perform all PICC dressing changes on the same day to avoid confusion, but prior to this, the required infection control interventions were not followed. Additionally, staff did not adhere to EBP protocols for a resident with a suprapubic catheter and multiple chronic wounds. Staff were observed providing high-contact care activities, such as toileting, dressing, and transferring the resident, without donning the required gown, despite EBP signage and available PPE supplies. Both the CNA and LPN involved acknowledged they did not wear gowns as required. The DON noted that staff had been educated on EBP but recognized that the location of PPE supplies may have contributed to non-compliance.
Failure to Develop and Communicate Resident-Centered Baseline Care Plan
Penalty
Summary
The facility failed to develop and communicate a resident-centered baseline care plan to address the immediate needs of a newly admitted resident within 48 hours of admission, as required by policy. The resident, who had a history of a recent fall, adjustment disorder, type 2 diabetes, and congestive heart failure, was admitted with intact cognition and no skin conditions noted on the initial evaluation. However, the baseline care plan incorrectly indicated that the resident did not have any wounds, despite the presence of dressings on the coccyx and bilateral heels. Staff interviews revealed that the admitting nurse did not perform a full skin assessment due to the resident's refusal to remove hospital dressings after a long commute, and documented 'no wounds' on the baseline care plan because the form did not allow for additional comments. Further review showed that the resident and family expressed concerns about the lack of preparation for the resident's diabetic dietary needs and wound care. The wound care nurse later identified and treated wounds on the coccyx and heels, including a deep tissue injury and excoriation, which were not initially care planned. Staff interviews confirmed that the baseline care plan was not updated to reflect the resident's actual condition, and the DON acknowledged the limitation of the form and the need for resident-specific care planning, particularly regarding wounds.
Failure to Provide Proper Splint Application and ROM Care
Penalty
Summary
A deficiency was identified when a resident with a history of left hand contracture, hemiplegia, hemiparesis, and left knee stiffness did not receive appropriate care and services to maintain or improve range of motion (ROM) as ordered. Physician orders specified the use of a knee extension splint for the left knee and a resting hand splint for the left hand, with clear instructions on application times and monitoring of skin integrity. Despite these orders, multiple observations revealed that the resident was frequently not wearing the prescribed splints, and when the hand splint was applied, it was often done incorrectly, with the hand roll positioned at the wrist instead of the palm. Staff interviews indicated a lack of awareness and understanding regarding the resident's splint orders. Some staff members were unaware of the need for a knee splint, and others did not know the current status of the orders. The Director of Therapy confirmed that staff are instructed and demonstrated on how to apply the devices, but there were no written instructions or photos available for this resident. The Director of Therapy also noted that the resident experienced discomfort with the leg splint, but the physician's order remained active and was not updated until therapy was completed. Documentation review showed that the CNA Kardex included instructions for both splints, yet these were not consistently followed. Observations over several days confirmed repeated failures to apply the splints as ordered, and when applied, the devices were not positioned correctly. This lack of adherence to physician orders and improper application of splints contributed to the facility's failure to provide appropriate care and services to prevent a decline in the resident's range of motion.
Neglect During Emergency Evacuation
Penalty
Summary
The facility failed to protect residents from neglect during an emergency evacuation ahead of a major hurricane. The evacuation involved 112 residents, with 96 traveling approximately 197 miles over eight hours to two receiving facilities. During this transfer, the facility neglected to ensure that residents received necessary medications, food, or hydration, and failed to provide adequate staff support during transport. This resulted in several residents suffering serious harm, including a resident with multiple fractures who was improperly laid across two seats on a bus without access to pain medication, and another resident who sustained an open ankle fracture when being carried off the bus. The facility's Comprehensive Emergency Management Plan (CEMP) was not effectively implemented, as evidenced by the lack of contingency planning for transportation and the failure to ensure staff accompanied residents during the evacuation. The plan required that medications travel with residents and that staff remain with them throughout the evacuation process, but these protocols were not followed. The facility's contracted transport companies were unable to provide the necessary equipment, such as mechanical lifts, and the facility did not have a backup plan in place. As a result, residents were transported inappropriately, and many did not receive their prescribed medications, including insulin, antibiotics, and pain management drugs. Interviews with staff and residents revealed a chaotic evacuation process, with insufficient staff to provide care and administer medications. Residents reported being left without food, water, or necessary medical equipment, such as CPAP machines and oxygen, leading to severe health complications. The facility's administration failed to ensure that the evacuation was conducted safely and in accordance with the CEMP, resulting in widespread neglect and immediate jeopardy to the residents' health and safety.
Inadequate Emergency Evacuation Procedures Lead to Resident Harm
Penalty
Summary
The facility failed to ensure the safety and proper care of residents during an emergency evacuation due to a hurricane. This deficiency affected all 112 residents evacuated, with specific incidents involving three residents who suffered due to inadequate transportation and supervision. The facility did not have appropriate processes in place to manage the evacuation, resulting in serious harm to the residents. One resident with multiple fractures and a neck brace was inappropriately laid across two seats on a coach bus for a long journey, causing severe pain. Another resident, who was wheelchair-bound and required a full body mechanical lift, was improperly transported on a coach bus and sustained an open ankle fracture when staff physically carried her off the bus. Additionally, a resident who was oxygen-dependent and required a CPAP machine was laid flat on a mattress on the floor, leading to respiratory distress and an emergency hospital transfer. The facility's emergency plan was not effectively implemented, as evidenced by the lack of appropriate transportation and medical equipment for the residents. The Medical Director was not consulted about the safety of transporting certain residents, and there was a failure to ensure that residents received their necessary medications during the evacuation. The Administrator acknowledged the challenges faced during the evacuation but did not identify any concerns warranting discussion in the Quality Assurance and Performance Improvement (QAPI) program.
Inadequate Emergency Evacuation Planning and Execution
Penalty
Summary
The facility's administration failed to effectively utilize its resources to prevent the neglect of residents during an emergency evacuation ahead of a category 3 hurricane. The facility did not develop and implement an effective emergency plan, including contingency planning for evacuation transportation, nor did it adequately train and verify the competency of staff to respond to natural disasters. This resulted in avoidable serious harm to several residents and created a likelihood of serious injury to many others during the evacuation process. Resident #19 suffered multiple fractures and excruciating pain when staff inappropriately laid her across two seats for a long transport. Resident #7, who required a full body mechanical lift for transfers, was evacuated in a coach bus instead of necessary transportation equipped with a lift, resulting in a fractured ankle when she was physically carried off the bus. Resident #9, who had Chronic Obstructive Pulmonary Disease and required a CPAP machine, was evacuated without it and was improperly laid flat, leading to her becoming unresponsive and requiring emergency hospital transfer. The facility's emergency plan lacked contingency planning for when contracted transport companies could not fulfill their agreements. Staff interviews revealed a lack of training and preparedness, with many staff members driving their own vehicles to the receiving facility instead of accompanying residents on transport. The Administrator was unable to provide documentation of staff assignments or care provided during the evacuation, and there was no evidence of staff or resident training prior to hurricane season. The chaotic evacuation process resulted in residents missing medications, experiencing distress, and suffering from inadequate care during transport.
Deficient Emergency Evacuation Procedures During Hurricane
Penalty
Summary
The facility failed to implement corrective actions for identified quality deficiencies related to staff training and competency in responding to natural disasters, which led to the neglect of residents during an emergency evacuation ahead of a category 3 hurricane. The facility did not ensure appropriate transportation for wheelchair and stretcher-bound residents and failed to staff each transport vehicle with nursing staff to ensure residents' safety, provision of care, and administration of necessary medications. This resulted in multiple residents suffering harm during the evacuation process. One resident with multiple fractures was inappropriately laid across two seats for approximately 197 miles and seven hours during transport, causing severe pain. Another resident, who required a mechanical lift for transfers, was evacuated in a coach bus without a lift, resulting in a fractured ankle when staff physically carried her off the bus. A third resident with Chronic Obstructive Pulmonary Disease was not evacuated with her CPAP machine and was improperly laid flat, leading to serious harm and an emergency hospital transfer. The facility's failure to have an effective Quality Assurance and Performance Improvement program to identify and address these deficiencies created a likelihood of serious harm, injury, or death for other residents. The facility's Emergency Preparedness Plan was not effectively implemented, as evidenced by the lack of staff training on the evacuation process and the absence of nursing staff on transport vehicles to provide necessary care. The Administrator was unaware of the residents not receiving care, food, hydration, or medications during the evacuation, and no corrective actions were discussed in the facility's QAPI meetings following the incident.
Incomplete Facility Assessment and Lack of Staff Involvement
Penalty
Summary
The facility failed to ensure a comprehensive and complete Facility Assessment, which is necessary to determine the resources required for competent resident care during regular operations and emergencies. The assessment, last updated on January 11, 2024, listed several staff members and a resident as contributors. However, interviews revealed that the Activities Director, Director of Housekeeping, Assistant Director of Housekeeping, and Admissions Director were not familiar with the assessment and did not participate in its development. Additionally, the resident mentioned as a contributor stated she had no involvement or awareness of the planning process. Furthermore, the assessment lacked documentation on how staff were informed about the Comprehensive Emergency Management Plan (CEMP). The Administrator confirmed that the current assessment did not include instructions for staff regarding the CEMP.
Failure to Ensure Competency in Wander Alert Device Functionality
Penalty
Summary
The facility failed to ensure that three of five sampled nurses were trained and competent in checking the function of wander alert bands, which are designed to alert staff when a resident leaves a designated safe area. This deficiency was identified through observations, record reviews, and interviews. Specifically, Resident #16, who was at high risk for elopement due to cognitive impairment, was found outside the facility despite wearing a wander alert bracelet. The bracelet was supposed to be checked every shift for placement and functionality, but the investigation revealed that the bracelet was sounding when the resident was brought back inside, indicating a failure in monitoring its function. Further investigation showed that Registered Nurse Staff N and Staff HH were not aware of how to check the functionality of the wander alert bracelets, only verifying their placement. Documentation showed that these staff members had inaccurately recorded that they had checked the function of the bracelets. The Assistant Director of Nursing confirmed there was no documentation of training or competency for these staff members regarding the wander alert devices. Additionally, the Director of Nursing admitted that the facility lacked a policy and procedure for checking the function of the wander alert bracelets.
Failure to Report Resident Injury During Evacuation
Penalty
Summary
The facility failed to immediately report an alleged violation involving neglect for a resident who was injured during an evacuation ahead of a hurricane. The incident occurred when the facility had to evacuate residents due to an impending hurricane, and the available transportation did not have the necessary mechanical lifts for wheelchair-bound residents. As a result, the resident, who required a full body mechanical lift for transfers, was physically lifted by therapy staff from the receiving facility, leading to an injury when the resident's foot came in contact with the ground. The facility Administrator initiated an investigation into the incident but did not report the injury, which resulted in a fracture, to the State Survey Agency and Adult Protective Services as required by state law. The Administrator acknowledged that the resident did not evacuate on a stretcher transportation due to space constraints and confirmed that the injury occurred during the physical transfer off the bus. Despite recognizing the incident as an accident, the Administrator did not classify it as a reportable event, thus failing to comply with mandatory reporting requirements.
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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