The Terrace Of Delray Beach Nursing And Rehabilita
Inspection history, citations, penalties and survey trends for this long-term care facility in Delray Beach, Florida.
- Location
- 5430 Linton Blvd, Delray Beach, Florida 33484
- CMS Provider Number
- 105475
- Inspections on file
- 21
- Latest survey
- August 1, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Terrace Of Delray Beach Nursing And Rehabilita during CMS and state inspections, most recent first.
The facility failed to provide privacy curtains for residents in 14 rooms, specifically for Bed A, which is closest to the door. This deficiency affected two residents. During a tour, it was observed that residents residing nearest the door did not have privacy curtains. A nurse confirmed the absence of privacy curtains while providing care to a resident. The spouse of a resident reported that the curtain had been missing for many months. A subsequent tour with the Maintenance Director confirmed the absence of privacy curtains in the specified rooms and noted that the existing curtains between beds were too short to provide complete privacy.
A resident was discharged from a facility without the necessary Home Health Services, despite physician orders for RN evaluation, PT, OT, and HHA. The Social Worker Director claimed to have sent documents to the Home Health Agency, but there was no evidence of this, and the agency did not receive any documentation. Consequently, the resident did not receive the required services upon discharge.
A resident with minimal cognitive impairment did not receive showers as per the facility's schedule. Despite instructions to contact the resident's significant other if he refused, there was no documentation of refusals or attempts to contact. Interviews revealed the resident and his significant other were dissatisfied with the care, and staff were confused about the shower schedule. The ADON confirmed documentation issues since a company change.
A facility failed to implement a resident's DNR status, resulting in a deficiency. The resident's electronic medical record and physician's orders indicated a Full Code, while a DNR document was present but not updated in the system. An LPN was unaware of the DNR status, and the resident's son, who requested the DNR, noted a delay in its implementation. This reflects a breakdown in communication and documentation of the resident's advance directive.
The facility failed to maintain a clean and homelike environment, with issues such as peeling paint, stained furniture, broken carts, and wheelchairs with torn armrests. The Maintenance Director acknowledged these deficiencies and plans to audit wheelchairs, having been in the role for only a few months.
A facility failed to provide adequate restorative services to a resident, as required by their policy. The resident, who was cognitively intact, had a physician order for AROM and bed mobility services, but the order lacked specified frequency and duration. Documentation showed the resident received services only twice in a month, contrary to the standard of three times a week. Interviews revealed a lack of documentation for service provision and resident refusals.
A resident requiring substantial assistance with ADLs did not receive timely nail care, despite facility policy and CNA documentation indicating otherwise. The resident's care plan lacked nail care details, and observations showed long, dirty nails over several days. The Activity Assistant confirmed the delay in providing care, despite the resident's requests.
A resident with a BIMS score of 15 was observed with a skin tear on her right forearm, but the facility failed to document the incident, notify the physician, or create a care plan. The Infection Control Preventionist applied a dressing without obtaining a physician's order, and the RN was unaware of the bandage, highlighting a lack of communication and documentation.
The facility failed to provide proper urinary catheter care for two residents. One resident received improper cleaning of the catheter tubing, contrary to the facility's policy, and had a history of UTIs with MDROs. Another resident's catheter was not secured with an anchoring device as ordered, risking urethral traction, and also had a history of UTIs. The ADON was informed of these issues.
The facility failed to provide adequate pain management for a resident with chest wall pain and did not administer medications as per physician orders for two other residents. Despite complaints, pain management was delayed, and medications were marked unavailable without proper documentation or monitoring. The pharmacy confirmed delivery, highlighting issues in medication management.
The facility failed to document pain levels for two residents at risk for pain, blood glucose levels for a diabetic resident, and meal consumption percentages for another resident. Additionally, a resident's care plan lacked nail care information, and another resident's care plan incorrectly included peritoneal dialysis. The Director of Nursing and other staff confirmed these documentation deficiencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) effectively, as observed in several residents with wounds, indwelling devices, and infections. There was a lack of appropriate signage and PPE availability, and staff demonstrated confusion about EBP protocols, such as when to wear gowns during care. The Infection Control Preventionist acknowledged these issues, despite prior in-service training, leading to the deficiency identified by surveyors.
The facility's Admission Agreement improperly required residents to waive their right to a jury trial as a condition for admission and care, affecting all 88 residents. The agreement failed to inform residents that arbitration was not mandatory and did not allow them to rescind the agreement within 30 days, contrary to federal regulations.
The facility failed to provide the required CMS Form 10055 (SNF ABN) to two residents discharged from Medicare Part A services, despite having skilled benefit days remaining. The Social Services Director was unaware of the form's requirement, leading to a deficiency noted by surveyors.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to provide privacy curtains for residents in 14 rooms, specifically for Bed A, which is closest to the door. This deficiency affected two sampled residents. During an initial tour, it was observed that residents residing nearest the door did not have privacy curtains. A registered nurse confirmed the absence of privacy curtains while providing care to one of the residents. The spouse of one resident reported that the curtain had been missing for many months. A subsequent tour with the Maintenance Director and Regional Maintenance Director confirmed the absence of privacy curtains in the specified rooms and noted that the existing curtains between beds were too short to provide complete privacy.
Failure to Arrange Home Health Services for Discharged Resident
Penalty
Summary
The facility failed to ensure adequate discharge documentation and follow physician orders for a resident's discharge home. The resident, who had multiple diagnoses including a fracture, pain, difficulty walking, hypertension, diabetes, depression, and anxiety, was discharged without the necessary arrangements for Home Health Services. The physician's orders specified that the resident should be discharged with RN evaluation, PT, OT, and HHA, and a follow-up with the PCP within a week. However, the discharge notes only mentioned that the resident was discharged in stable condition with instructions to visit the PCP in 3-5 days, without any mention of the Home Health Services setup. Interviews conducted with the resident and the Social Worker Director revealed that the facility did not arrange for the required Home Health Services. The Social Worker Director claimed to have sent the necessary documents to the Home Health Agency, but there was no evidence to support this claim. The Home Health Care Coordinator confirmed that they did not receive any documentation from the facility, as the resident's name was not in their system. This lack of documentation and communication resulted in the resident not receiving the prescribed Home Health Services upon discharge.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure the provision of showers according to the facility schedule for a resident with minimal cognitive impairment. The resident was admitted to the facility and had a care plan indicating he rejected care, including showers, but lacked an intervention to contact his significant other if he refused. Despite a progress note instructing staff to call the resident's significant other if he refused a shower, there was no documentation of such refusals or attempts to contact the significant other, except for a generic statement during a care plan meeting. Interviews revealed that the resident expressed dissatisfaction with the care provided, specifically mentioning the lack of showers. The resident's significant other, who attended care plan meetings, also voiced concerns about the lack of showers, stating that the resident would accept showers if offered. Staff interviews indicated confusion about the shower schedule, with some staff unable to locate it. The Assistant Director of Nursing confirmed the absence of a place for CNAs to document the provision of showers and acknowledged ongoing issues with documentation since a company change.
Failure to Implement DNR Status for a Resident
Penalty
Summary
The facility failed to ensure staff awareness and implementation of a Do Not Resuscitate (DNR) status for a resident, leading to a deficiency in honoring the resident's advance directive. The facility's policy requires that a resident's code status be clearly documented in designated sections of the medical record, including physician orders, care plans, and documents. However, there was a discrepancy in the documentation for the resident in question. The electronic medical record and physician's orders indicated a Full Code status, while a DNR document was present under the document tab, signed by the physician at a later date. During an interview, a Licensed Practical Nurse (LPN) was unaware of the DNR status, as she relied on the physician's order and code status, which showed Full Code. The DNR document was not found in the facility's DNR book, indicating a lack of communication and update in the resident's code status. The resident's son and Power of Attorney (POA) had requested a DNR order, but there was a delay in its implementation, as the physician signed the form months after the initial request. This oversight highlights a failure in the facility's process to update and communicate the resident's advance directive effectively.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for residents, as observed during a survey. In the 100 and 200 units, several deficiencies were noted. In one resident's room, the bathroom had peeling paint under the soap dispenser, and the grout around the toilet was discolored. Another room had a sitting chair with a large stain and tears on the seat. Additionally, a linen cart in the hallway was broken. Multiple wheelchairs were found with torn armrests, affecting several residents. During a follow-up tour, the Maintenance Director and Regional Maintenance Director acknowledged these issues. The Maintenance Director mentioned relying on residents and rehabilitation staff to report wheelchair repairs and stated he would begin auditing all wheelchairs, noting he had only been in the position for a few months.
Deficiency in Restorative Services Documentation and Implementation
Penalty
Summary
The facility failed to ensure that restorative services were adequately provided to a resident, leading to a deficiency. The policy for Restorative Nursing Programs, implemented on 05/01/24, requires that a resident's Restorative Nursing Plan include the frequency and duration of activities, and that restorative aides implement the plan and document the activities. However, for the resident in question, the facility did not adhere to these guidelines. The resident, who was cognitively intact with a BIMS score of 14, was admitted on 05/23/23 and had a physician order for Active Range of Motion (AROM) and bed mobility services dated 06/13/23, but this order lacked specified frequency and duration. The facility's documentation revealed that the resident received AROM services only twice in July 2024, despite the standard program being three times a week. Interviews with restorative CNAs indicated that the resident sometimes refused services, but there was no documentation to support this claim or to show that services were provided three times weekly. The facility administrator confirmed that the frequency and duration should have been documented in the order, highlighting a lapse in following the established restorative care plan and documentation procedures.
Failure to Provide Timely Nail Care for Resident
Penalty
Summary
The facility failed to provide timely and ongoing nail care for a resident who required substantial to maximum assistance with activities of daily living (ADLs). The policy on nail care, implemented on 05/01/24, mandates routine cleaning and inspection of nails during ADL care, with trimming and filing scheduled regularly. However, the care plan for the resident, who was cognitively intact and needed significant assistance, did not include any information related to nail care. Despite daily documentation by CNAs indicating that nail care was performed, observations revealed that the resident's fingernails were long and dirty over several days. Interviews and observations indicated that the resident had requested nail care, but it was not provided in a timely manner. The resident expressed dissatisfaction with the lack of nail care, stating that he had asked for his nails to be trimmed the previous week. The Activity Assistant, responsible for nail care during a weekly beauty hour, confirmed that the resident was on her list but was not attended to until several days later. This delay in providing nail care was acknowledged by a Registered Nurse, who was informed of the issue and the discrepancy in CNA documentation.
Failure to Provide Timely Care for Skin Tear
Penalty
Summary
The facility failed to provide timely care and treatment for a skin tear for a resident reviewed for skin conditions. The facility's policy requires that when a skin tear is discovered, an incident report should be completed, and the attending physician should be notified. However, in this case, there was no documentation in the Electronic Health Record (EHR) regarding the skin tear, no incident report was filed, and no care plan was developed for the skin tear. The resident, who was alert and oriented with a BIMS score of 15, was observed with a bandage on her right forearm, which she believed was due to scraping her arm on the bed rail. The Infection Control Preventionist applied a dressing to the arm after noticing a hematoma and later a skin tear, but did not notify the physician or obtain an order for the dressing. The Registered Nurse caring for the resident was unaware of the bandage, indicating a lack of communication and documentation regarding the resident's care.
Deficient Urinary Catheter Care and Maintenance
Penalty
Summary
The facility failed to provide appropriate indwelling urinary catheter care and maintenance for two residents, leading to deficiencies in care. For one resident, the Certified Nursing Assistant (CNA) did not follow the facility's catheter care policy, which required cleaning from the insertion site outward. Instead, the CNA cleaned the catheter tubing with a back-and-forth motion, which is not in line with the policy. This resident had a history of urinary tract infections (UTIs) with multidrug-resistant organisms (MDROs), indicating poor catheter care. The Assistant Director of Nursing (ADON) was informed of these concerns. For the second resident, the facility failed to secure the urinary catheter tubing with an anchoring device as per the physician's orders. Observations revealed that the resident did not have a leg strap or anchor to secure the catheter tubing, which could lead to urethral traction. This resident also had a history of UTIs with E. Coli. The ADON was made aware of the lack of an anchoring device, but the resident was transferred to the hospital before the issue could be addressed.
Deficiencies in Pain Management and Medication Administration
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident #294, who was admitted with diagnoses including syncope, musculoskeletal symptoms, and a cardiac pacemaker. Despite the resident's complaints of right chest wall pain following a fall, which was not alleviated by Tylenol, the nursing staff did not escalate the issue to pain management until prompted by the resident's persistent requests. A delay occurred in documenting and processing a verbal order for Tramadol, resulting in the resident not receiving the prescribed medication until the following day. Additionally, the facility did not administer medications as per physician orders for two other residents. Resident #4, who was at risk for pain, did not receive a Lidocaine patch for several days as it was marked as not available, and there was no documentation of pain monitoring during this period. Similarly, Resident #28, diagnosed with chronic pain syndrome, experienced multiple instances where a Lidoderm patch and Lotrisone cream were marked as unavailable, with no pain monitoring documented on those days. The Director of Nursing and the Pharmacist Consultant were unable to provide explanations for the unavailability of medications or the lack of pain monitoring documentation. The pharmacy confirmed that the medications were delivered to the facility, indicating a failure in the facility's medication management and documentation processes.
Documentation Deficiencies in Pain, Glucose, Nutrition, and ADL Care
Penalty
Summary
The facility failed to document pain levels for two residents who were at risk for pain and receiving pain management. Resident #4, admitted with a diagnosis of pain, had physician orders to monitor and record pain levels every shift, but no documentation was found in the electronic Medication Administration Record (eMAR) or Progress Notes. Similarly, Resident #28, diagnosed with Chronic Pain Syndrome, also had orders for pain monitoring, yet there was no documentation of pain levels recorded in the resident's records. The Director of Nursing confirmed the absence of documentation for both residents. The facility also failed to document blood glucose levels for Resident #81, who was diagnosed with Diabetes Mellitus Type 2 and required blood glucose monitoring before meals. Although nursing staff initialed that monitoring was done, the actual blood glucose numbers were not recorded in the eMAR, Vitals section, or Progress Notes, except for one instance. The Director of Nursing acknowledged the lack of documentation for blood glucose levels, except for the single recorded instance. Additionally, the facility did not document the percentage of meals consumed by Resident #70, who had a physician's order to report the percentage of snacks consumed. The Medication Administration Record showed initials and check marks but lacked specific percentages. The dietician confirmed the absence of documentation for snacks. Furthermore, Resident #22's care plan lacked information on nail care, and despite daily checkmarks indicating nail care was performed, the resident's nails were observed to be long and dirty. Lastly, Resident #292's care plan incorrectly included peritoneal dialysis, which was not applicable, and was later canceled by the MDS Coordinator.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to effectively implement its infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with certain medical conditions and devices. Observations revealed that several residents, including those with wounds, indwelling medical devices, and infections, did not have appropriate signage or Personal Protective Equipment (PPE) readily available in their rooms. For instance, Resident #1, with a sacral wound, had no EBP sign or PPE cart near the room, and Resident #292, with a dialysis catheter, also lacked EBP signage and PPE availability. Staff members demonstrated a lack of understanding and adherence to EBP protocols. For example, a registered nurse was observed administering medication via a PEG tube without wearing a gown, and a certified nursing assistant provided personal care to a resident with an indwelling urinary catheter without donning a gown. Interviews with staff revealed confusion about when PPE was required, indicating insufficient training or reinforcement of the facility's EBP policy. The Infection Control Preventionist acknowledged discrepancies in the implementation of EBP, such as the need for contact precautions for the entire duration of antibiotic treatment for a resident with an active MDRO. Despite in-service training provided in May, the facility's staff did not consistently follow EBP protocols, as evidenced by the lack of signage, PPE availability, and proper use during resident care. This inconsistency in following established infection control measures contributed to the deficiency identified by the surveyors.
Non-compliance with Arbitration Agreement Regulations
Penalty
Summary
The facility failed to comply with federal regulations regarding arbitration agreements in their Admission Agreement. Specifically, the Admission Agreement included a paragraph that required residents and their representatives to waive their right to a jury trial as a condition of admission and to receive care at the facility. This paragraph did not inform residents or their representatives that agreeing to arbitration was not a requirement for admission or continued care, nor did it provide them the right to rescind the agreement within 30 days of signing. This affected all 88 residents who had signed the admission agreement at the time of the survey. During the survey, the Admissions Director was informed of the issue with the wording in the Admission Agreement, which was not aligned with federal regulations. The director acknowledged the problem and stated she would inform the new owners about the need to amend the agreement. The facility owner was also made aware of the concern and acknowledged understanding of the issue. The deficiency was identified through a review of the facility's 'Arbitration Agreement Program Guide' and 'Arbitration Agreement,' which contained the required regulatory language, but the Admission Agreement did not reflect this compliance.
Failure to Provide Required Beneficiary Notification Forms
Penalty
Summary
The facility failed to provide the appropriate Beneficiary Notification Form (CMS Form 10055/SNF ABN) to two residents, identified as Resident #22 and Resident #70, upon their discharge from Medicare Part A services. Both residents had skilled benefit days remaining and chose to remain in the facility after their discharge from Part A services. However, the facility did not provide them with the required CMS Form 10055 (SNF ABN), which is necessary to inform residents of their potential liability for services not covered by Medicare. The Social Services Director (SSD), responsible for providing these notices, was unaware of the requirement for the SNF ABN form and did not have copies available to distribute. This lack of knowledge and preparation led to the failure in providing the necessary documentation to the residents, resulting in a deficiency noted by the surveyors. The SSD was informed of the requirement and provided with the necessary forms and instructions after the deficiency was identified.
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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