Tarpon Bayou Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tarpon Springs, Florida.
- Location
- 515 Chesapeake Dr, Tarpon Springs, Florida 34689
- CMS Provider Number
- 105280
- Inspections on file
- 19
- Latest survey
- April 11, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Tarpon Bayou Center during CMS and state inspections, most recent first.
The facility failed to ensure proper hand hygiene practices before and after meal service across all units, including the Melody-secured unit. Staff did not provide hand hygiene to residents before delivering hydration or meal trays, and residents reported not receiving hand hygiene before meals. Additionally, the Melody-secured unit had issues with hand hygiene availability after toileting, with a resident reporting the lack of towels in the shared bathroom.
The facility failed to ensure the kitchen's low temperature dishwashing machine was operating effectively, with observations revealing that the machine was dispensing sanitizer at a concentration well over the required 50-100 PPM. Despite being inserviced on correct procedures, staff did not test the sanitizer concentration that morning, leading to the discovery of the excessive levels.
The facility failed to maintain a homelike environment and improperly used a resident patio for storage of housekeeping equipment and other items. Observations revealed cluttered and broken furniture in a resident's room and a cold unit. The Environmental Director acknowledged the issues and cited a lack of storage space as a contributing factor.
The facility failed to ensure timely and accurate Level 1 PASRR screens for eight residents, resulting in incomplete or delayed assessments of mental illness diagnoses. The administration confirmed the responsibility for PASRR accuracy and acknowledged the need for updates.
The facility failed to provide appropriate and stimulating activities for residents in the secured memory care unit. Observations revealed residents were often left sitting with minimal engagement, and staff did not interact with them as expected. Interviews confirmed the absence of the activity person on certain days, leading to a lack of structured activities for residents with severe cognitive impairments.
The facility failed to treat residents with dignity and respect by spraying cleaner directly onto tables in front of them and dressing a male resident in another resident's socks. The DON confirmed the inappropriate actions and demonstrated the correct procedure for cleaning tables.
A resident with multiple diagnoses was prescribed Doxycycline for a suspected UTI without a confirmed urinalysis. Despite multiple attempts to collect a urine sample, the physician decided to prescribe the antibiotic based on the resident's pale appearance and increased weakness. No change of condition assessment was documented, and the facility lacked a specific UTI protocol.
The facility failed to ensure accurate MDS assessments for a resident with schizophrenia. Despite clear documentation of the diagnosis in the resident's medical records, multiple MDS assessments incorrectly marked the diagnosis as 'No'. This discrepancy was confirmed through record reviews and staff interviews.
The facility failed to revise care plans for three residents, leading to discrepancies in Advance Directives, elopement risk management, and PTSD diagnosis. These oversights were identified during a survey, revealing lapses in updating care plans to reflect current resident needs and conditions.
A resident experienced discomfort and pain due to the facility's failure to provide adequate foot and toenail care. Despite repeated requests for assistance, staff did not address the issue, and the facility lacked a specific policy for ADL or nail care maintenance.
A facility failed to ensure proper infection control for a resident with a urinary catheter, as the catheter tubing and drainage bag were repeatedly found lying on the floor. Despite daily and as-needed catheter care being documented, the facility lacked a specific policy on the proper storage of urinary catheters.
The facility failed to document and monitor the behaviors of two residents, leading to the administration of additional as-needed psychotropic medications without proper documentation. Observations and interviews revealed that staff did not consistently document behaviors, non-pharmaceutical interventions, or notify responsible parties, and the facility lacked specific policies on psychotropic medication use and behavior documentation.
The facility failed to maintain a medication error rate below 5.00%, resulting in a 7.41% error rate. Observations revealed discrepancies in medication administration and documentation for two residents, including incorrect documentation of a refused nasal spray and an unobserved administration of Metoprolol. The facility's policy on accurate medication administration and documentation was not followed.
The facility failed to maintain accurate records for two residents, leading to deficiencies in documenting medication administration and obtaining daily vital signs. One resident's records showed repeated entries of the same vital signs over several days, while another resident's refusal of a nasal spray medication was incorrectly documented as administered. The DON confirmed that refusals should be documented as such, not as administered.
A resident was prescribed Doxycycline for a UTI without a confirmed diagnosis through urinalysis. Despite attempts to collect a urine sample, the physician decided to prescribe the antibiotic based on the resident's appearance. The facility lacked a UTI protocol, and the Infection Preventionist was not consulted, leading to a deficiency in antibiotic stewardship.
Failure to Ensure Proper Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices before and after meal service across all four units, including the Melody-secured unit. Observations revealed that staff did not provide hand hygiene to residents before delivering hydration or meal trays. Interviews with staff members indicated a lack of consistent understanding and implementation of hand hygiene protocols, with some staff believing that hand hygiene was only necessary during morning care or after meals. Residents also reported not receiving hand hygiene before meals, confirming the observations made by surveyors. In the main dining room, staff were observed passing hydration to residents without providing hand hygiene. Two residents were seen using their hands to eat independently without any hand hygiene assistance. The facility's policy on dining services did not include instructions for encouraging or assisting residents with hand hygiene before or after meals, contributing to the deficiency. Additionally, the Melody-secured unit had issues with hand hygiene availability after toileting. A resident reported the lack of towels in the shared bathroom, leading to the use of clothing for drying hands. Observations confirmed the absence of towels and the presence of toilet paper on the sink edge. Staff interviews revealed that the issue was known but not adequately addressed. The facility's hand hygiene policy emphasized the importance of hand hygiene but did not specify when residents should be encouraged or assisted with it, further contributing to the deficiency.
Failure to Ensure Proper Operation of Dishwashing Machine
Penalty
Summary
The facility failed to ensure the kitchen's low temperature dishwashing machine was operating effectively, specifically in providing the correct chemical sanitizer concentration. During a tour of the main kitchen, the Dietary Manager and Staff A confirmed that the dishwashing machine should operate with a wash and rinse temperature of 120 degrees Fahrenheit and a chemical sanitizer concentration between 50 and 100 parts per million (PPM). However, observations revealed that the machine was dispensing sanitizer at a concentration well over 100 PPM, as indicated by the dark blue/purple color of the test strips used during the inspection. Staff A demonstrated the operation of the dishwashing machine, showing that the wash and rinse cycles met the temperature requirements. However, the chemical sanitizer concentration was consistently too high, as confirmed by the Dietary Manager using litmus paper test strips. Despite being inserviced on the correct operation and testing procedures, Staff A admitted that she had not tested the sanitizer concentration that morning, which led to the discovery of the excessive sanitizer levels. The facility's records, including the dish machine temperature log and chemical sanitizer log for the previous two months, did not indicate any issues with the machine's operation. The Dietary Manager confirmed that the machine was allocating too much chemical sanitizer and took immediate steps to address the issue by contacting the dish machine maintenance company. The facility's policy and procedure for monitoring dish machine temperatures and chemical saturation levels were reviewed, revealing that staff are required to test and document these parameters at each meal prior to dishwashing, which was not followed in this instance.
Failure to Maintain a Homelike Environment and Improper Use of Resident Patio
Penalty
Summary
The facility failed to maintain a homelike environment on one of its units and did not ensure that a resident patio was free from storage of facility housekeeping equipment and other items. Observations revealed that a resident's room had a broken dresser used as a television stand, broken window blinds, and a malfunctioning toilet paper holder. Additionally, the unit was reported to be cold, with the hallway thermostat reading 71°F. The patio outside the main dining room was cluttered with rolled mattresses, an industrial floor scrubber, a rusty fan, and other items, which were not appropriate for a resident area. The Environmental Director acknowledged these issues and mentioned the lack of storage space in the building as a contributing factor. The Environmental Director confirmed that residents and their families used the patio area, despite it being used for storage. During an activity on the patio, residents were observed amidst the clutter, which included a bed frame with a mattress, an extension ladder, and various housekeeping equipment. The facility did not have a policy regarding maintaining a homelike environment, as confirmed by the returned request list. The Environmental Director admitted that the floor equipment should not be stored on the resident's patio and acknowledged the need for a more suitable storage solution.
Failure to Ensure Timely and Accurate PASRR Screens
Penalty
Summary
The facility failed to ensure residents received timely and accurate Level 1 Pre-Admission Screening & Resident Review (PASRR) for eight of thirty-eight sampled residents. Resident #96 was admitted for long-term care services with a diagnosis of Anoxic Brain Disorder but did not have a Level 1 PASRR screen until several months later. Similarly, Resident #163 was admitted with multiple mental illness diagnoses, but the PASRR screen was completed seven days after admission. Resident #28 had a PASRR screen from 2016 that did not include updated diagnoses of Bipolar, OCD, and Anxiety, and there was no evidence of a corrected or updated screen. Resident #1 was admitted with multiple mental illness diagnoses, but the PASRR screen was completed three years after admission and did not include all relevant diagnoses. Resident #32 had a PASRR screen from 2013 that did not include the diagnosis of Psychosis. Resident #31 had a PASRR screen from 2021 that did not include diagnoses of Parkinsonism, PTSD, and Major Depression. The facility's administration confirmed that it is their responsibility to ensure the accuracy of all Level 1 PASRR screens and that they perform weekly and quarterly audits to ensure compliance. The facility's policy and procedure for PASRR screening, effective from 2021, require preadmission screening to be conducted prior to admission. However, the facility did not have a Quality Assurance Performance Improvement Plan in place regarding PASRR screen accuracy and submission timeframe. The facility staff confirmed that the listed residents' PASRR screens were not reflective of all current mental illness diagnoses and needed to be updated. Additionally, Resident #85's PASRR assessment did not include a diagnosis of schizophrenia, and Resident #25's PASRR did not include diagnoses of Traumatic Brain Injury or unspecified mood disorder.
Failure to Provide Appropriate Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide activities in an appropriate and stimulating manner on the secured memory care unit. Observations on multiple occasions revealed that residents were often left sitting in the common area with minimal engagement or interaction from staff. For instance, on April 8th, residents were observed sitting at tables with magazines and a muted television, with no active participation in scheduled activities such as 'Morning Social' or 'Move and Groove'. Staff members were either administering medications or not present, and the activity person was reportedly off on Mondays, leading to a lack of structured activities for the residents. Interviews with staff members, including a Registered Nurse (RN) and the Activity Director (AD), confirmed that the activity person was not present on certain days, and there was an expectation for other staff to interact with residents in their absence. However, this expectation was not met, as evidenced by the lack of engagement observed. The AD admitted that sometimes planned activities were not executed due to resident preferences, and the assistant was often assigned to other units, leaving the secured memory care unit without adequate activity coverage. The residents involved, such as Resident #24, Resident #52, and Resident #107, had documented preferences and needs for specific types of activities, which were not met during the observed periods. These residents required assistance with activity pursuit and had severe cognitive impairments, making it crucial for staff to provide appropriate and stimulating activities. The facility's policy on activities emphasized the need for programs that meet individual needs and promote physical, cognitive, and emotional health, which was not adhered to in this case.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that four residents sitting at one of four tables were treated with dignity and respect. Staff members were observed spraying a cleaner directly onto the table in front of the residents. On two separate occasions, a CNA and a housekeeper sprayed a liquid disinfectant onto tables where residents were seated, and then wiped the liquid away. The Director of Nursing confirmed that it was inappropriate to spray cleaner directly in front of residents and demonstrated the correct procedure of spraying the cleaner onto a towel first. Additionally, the facility failed to dress a male resident in clothing belonging to him. The resident was observed wearing socks labeled with another resident's name. A CNA confirmed that the resident was wearing another resident's socks and reported not being the resident's aide on that day.
Failure to Complete Significant Change in Condition Assessment
Penalty
Summary
The facility failed to ensure a significant change in condition assessment was completed for a resident prior to the use of antibiotics. Resident #12, who had diagnoses including traumatic brain injury, major depressive disorder, seizures, schizophrenia, and anxiety disorder, was prescribed Doxycycline for a suspected urinary tract infection (UTI) without a confirmed urinalysis. Despite multiple attempts to collect a urine sample, the staff were unsuccessful, and the physician decided to prescribe the antibiotic based on the resident's pale appearance and increased weakness. No change of condition assessment was documented for the resident's weakness and antibiotic use. The facility's policy titled 'Physician Notification' requires licensed nurses to notify physicians of changes in diagnostic results, including changes in condition, laboratory results, and diagnostic results. However, the Director of Nursing confirmed that there was no specific policy or procedure for UTI protocol. The Infection Preventionist also confirmed that no change of condition assessment was completed, which was expected in such cases. Progress notes indicated that the resident was continued on the antibiotic without adverse reactions, but the initial decision to prescribe the antibiotic was made without confirming the UTI through a urinalysis.
Inaccurate MDS Assessments for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the diagnoses of a resident. Specifically, Resident #85, who had been admitted with diagnoses including schizophrenia, had this diagnosis incorrectly marked as 'No' in multiple MDS assessments. This discrepancy was identified through a review of the resident's medical records and confirmed by interviews with the Regional Nurse Consultant, MDS Coordinator, and Director of Nursing. The error was present in the Admission MDS, Quarterly MDS, and an in-progress Quarterly MDS, all of which failed to accurately document the resident's schizophrenia diagnosis. The issue was further corroborated by the Clinical Reimbursement Director, who acknowledged that the diagnosis of schizophrenia was missed in the MDS assessments. The resident's medical records, including an admission document from a local hospital, clearly indicated a history of schizophrenia. Despite this, the MDS assessments did not reflect the accurate diagnosis, leading to a failure in ensuring an accurate assessment for the resident.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plan for Resident #52 regarding the Advance Directive of code status. Despite having a Do Not Resuscitate Order signed by the resident's Power of Attorney on 3/13/24 and by the physician on 3/18/24, the care plan still indicated a FULL CODE status. This discrepancy was not corrected until 4/11/24, after it was identified during the survey. The Clinical Reimbursement Director (CRD) acknowledged the oversight and updated the care plan accordingly. Resident #107's care plan was not revised to reflect the absence of an electronic wander bracelet, despite the resident being at risk for elopement. The care plan, initiated on 3/10/24, included interventions to apply and check the function of the wander bracelet. However, multiple observations between 4/8/24 and 4/11/24 showed the resident was not wearing the bracelet. The CRD admitted that the care plan should have been updated and suggested that the error might have occurred during the Admission Elopement Risk evaluation. Resident #15's care plan included a diagnosis of Post-Traumatic Stress Disorder (PTSD), but staff members were unable to recall the resident's triggers related to PTSD. The diagnosis was found to be erroneously placed in the resident's medical records, as confirmed by the Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant. The Clinical Reimbursement Director/Registered Nurse (CRD/RN) also reviewed the resident's chart and found no clinical documentation supporting the PTSD diagnosis. The care plan was initially driven by this incorrect diagnosis, leading to inappropriate interventions being implemented.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically foot and toenail care, for a resident who had been at the facility for about two weeks. The resident was observed multiple times with swollen, red feet and elongated, yellowed toenails that were causing her discomfort. Despite the resident's repeated requests to night shift aides for assistance with cutting her toenails, no action was taken. The resident had to modify her footwear by cutting slits in her shoes to alleviate the pressure caused by her long toenails. Interviews with various staff members, including CNAs, the Social Service Director, and an LPN, revealed a lack of awareness and responsibility regarding the resident's nail care. The CNAs and the Social Service Director were either unaware of the resident's needs or did not know who was responsible for providing nail care. The LPN confirmed that either a CNA or a nurse could clip the resident's nails, as she was not diabetic, but acknowledged that this had not been done. The Unit Manager attempted to assist with the resident's nail care but found that the facility lacked the appropriate clippers for the task. Both the Unit Manager and the Nursing Home Administrator confirmed that the facility did not have a specific policy or procedure for ADL or nail care maintenance. This lack of a structured approach contributed to the oversight and neglect of the resident's toenail care needs, resulting in her continued discomfort and pain.
Failure to Ensure Proper Infection Control for Urinary Catheter
Penalty
Summary
The facility failed to ensure proper infection control for a resident with a urinary catheter. Observations over several days revealed that the resident's catheter tubing and drainage bag were repeatedly found lying on the floor in the common area of the secured memory care unit. The tubing was observed on the floor under the resident's wheelchair, and at times, the drainage bag was seen dragging on the floor. Staff confirmed that the catheter tubing and drainage bag should not be on the floor, but the facility did not have a specific policy addressing the proper storage of urinary catheters, only a competency guide that did not cover this aspect. The resident involved had a medical history that included metabolic encephalopathy, unspecified altered mental status, and generalized muscle weakness. The resident was being treated for benign prostatic hyperplasia (BPH) with medications such as Finasteride and Tamsulosin. Despite the resident's Treatment Administration Record (TAR) indicating that staff were performing daily and as-needed urinary catheter care, the observations showed a consistent failure to maintain proper infection control practices. The Nursing Home Administrator and Director of Nursing acknowledged the issue but could not provide a specific policy on urinary catheter care.
Failure to Document and Monitor Behaviors Leading to Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to document and monitor the behaviors of two residents, leading to the administration of additional as-needed psychotropic medications without proper documentation. Resident #24 was observed multiple times engaging in various activities such as sitting in the common area, coloring, and drinking coffee. Despite these observations, the facility did not document behaviors associated with the resident's use of multiple psychotropic medications, including Alprazolam, Duloxetine, Mirtazapine, Quetiapine, Trazodone, Buspirone, Lithium, and Risperdal. The facility also failed to provide data from the electronic Behavior Monitoring Form (BMF) and did not document non-pharmaceutical interventions or notify the resident's representative about the behavior that led to the as-needed Alprazolam order on 4/9/24. Interviews with staff revealed that the as-needed Alprazolam was administered due to the resident screaming and being agitated, but this was not documented properly in the progress notes or care plan. Similarly, Resident #83 was observed multiple times sitting on the patio with no activity or appearing to be asleep. The facility obtained an order for Diazepam for anxiety on 4/9/24, but the Medication Administration Record (MAR) did not show that licensed nursing staff were monitoring for target behaviors associated with the use of the resident's psychotropic medications. The facility also failed to provide the April Behavior Monitoring Flowsheet (BMF) and did not document behaviors requiring the necessity for the as-needed Diazepam order. Interviews with staff revealed that the resident exhibited behaviors such as yelling and grabbing chairs, but these were not documented properly in the progress notes or care plan. A late entry note was made after a conversation with staff, but it did not include details about notifying the resident's responsible party or the outcome of non-pharmaceutical interventions. The facility's care plans for both residents included goals and interventions related to managing behaviors and psychotropic medication use, but these were not followed. The Director of Nursing (DON) and other staff members acknowledged that the expectation was for nurses to document behaviors and reasons for administering as-needed psychotropic medications, but this was not done consistently. The facility also lacked specific policies regarding the use of psychotropic medications and behavior documentation, further contributing to the deficiencies observed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5.00%, resulting in a 7.41% error rate. During an observation of medication administration with a Registered Nurse/Unit Manager (RN/UM) for a resident, the nurse dispensed multiple medications, including chewable Aspirin and Carbamazepine, which the resident swallowed instead of chewing. Additionally, the resident refused the Fluticasone nasal spray, but the nurse documented it as administered. The nurse confirmed the error and intended to notify the doctor about the refusal of the nasal spray. The Medication Administration Record (MAR) showed the nasal spray as administered, contrary to the actual event. The Director of Nursing (DON) confirmed that the refusal should have been documented correctly as a refusal, not as administered. In another instance, an observation of medication administration with a Licensed Practical Nurse (LPN) for a different resident revealed that the nurse dispensed six tablets and one patch. However, the MAR indicated that a 25 mg tablet of Metoprolol Tartrate was also administered, which was not observed during the medication administration. The LPN confirmed giving all medications, including the narcotic, but the documentation did not match the observed administration. The DON reviewed the Audit Report and confirmed the discrepancy in the documentation. The facility's policy on Medication Administration, dated 9/18, requires that medications be administered as prescribed and documented accurately. The policy also mandates that any refusal or withholding of medication be documented correctly, with explanatory notes if necessary. The observed discrepancies in medication administration and documentation for both residents indicate a failure to adhere to these policies, leading to a medication error rate above the acceptable threshold of 5.00%.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate records for two residents, leading to deficiencies in documenting medication administration and obtaining daily vital signs. Resident #107's records showed repeated entries of the same vital signs over several days, indicating that the vital signs were not updated daily as required. The Director of Nursing (DON) confirmed that vital signs should be updated daily in the skilled notes, but the facility did not have a policy for Daily Skilled notes, as stated by the Assistant Director of Nursing (ADON) and Regional Nurse Consultant (RNC). Resident #31 was observed refusing a nasal spray medication, but the staff member documented it as administered in the Medication Administration Record (MAR). The DON reviewed the MAR and confirmed that refusals should be documented as such, not as administered. The facility's policy on Medication Administration, dated 9/18, specifies that refusals should be circled and an explanatory note should be entered on the reverse side of the record. These deficiencies highlight the facility's failure to maintain accurate and up-to-date medical records, which is crucial for ensuring proper care and treatment of residents. The lack of a policy for Daily Skilled notes and the incorrect documentation of medication refusals are significant issues that need to be addressed to improve the quality of care provided to residents.
Failure to Appropriately Assess Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed for the use of an antibiotic. Resident #12 was admitted with multiple diagnoses, including unspecified focal traumatic brain injury, major depressive disorder, other seizures, schizophrenia, and anxiety disorder. A physician ordered Doxycycline for a urinary tract infection (UTI) without confirming the infection through a urinalysis. Despite attempts to collect a urine sample, the staff was unsuccessful, and the physician decided to prescribe the antibiotic based on the resident's appearance of paleness and weakness. The resident's care plan included monitoring for adverse reactions and symptoms related to antibiotic therapy, but no urinalysis was conducted to confirm the UTI before starting the antibiotic treatment. Progress notes indicated that the resident was continued on the antibiotic without any adverse reactions noted, but there was no documentation of a change of condition assessment. The Infection Preventionist confirmed that the situation did not meet the McGreer Criteria for antibiotic use, as there was no urinalysis to assess for antibiotic resistance. Interviews with staff revealed that there was no facility policy or procedure for UTI protocol, and the decision to start the antibiotic was made without consulting the Infection Preventionist. The facility's policies on antibiotic stewardship emphasized the importance of tracking antibiotic use and resistance patterns, but these protocols were not followed in this case. The lack of a confirmed diagnosis and proper assessment before administering the antibiotic led to the deficiency identified in the report.
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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