Titusville Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Titusville, Florida.
- Location
- 1705 Jess Parrish Ct, Titusville, Florida 32796
- CMS Provider Number
- 105448
- Inspections on file
- 23
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Titusville Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a homelike environment on two units, with multiple areas showing chipped paint, broken sheetrock, missing baseboards, holes in walls, and missing tiles. The Maintenance Director reported daily rounds and a reporting system for repairs, but some issues had been awaiting repair for an undetermined period. The Administrator acknowledged the need for repairs to meet resident environment standards.
Two residents did not receive care in accordance with physician orders and professional standards. One resident with hypertension did not have blood pressure monitored or documented as required before administration of antihypertensive medications, and the care plan for cardiovascular issues was delayed. Another resident with symptoms of a UTI experienced a delay in urine specimen collection for ordered diagnostic testing, with no documentation explaining the delay and inconsistent staff communication.
A resident with complex medical needs was documented as receiving Midodrine outside of physician-ordered blood pressure parameters on multiple occasions, with several nurses recording the medication as given despite orders to hold it. The MAR showed repeated documentation errors, and staff interviews confirmed that the medication was not always administered as recorded, nor were proper documentation codes used.
A resident with a Full Code status experienced a delay in CPR initiation due to confusion over contradictory DNR and Full Code orders. The resident was found unresponsive, and the LPN initially followed a hospice chart indicating DNR, leading to a delay in CPR until the code status was confirmed. Discrepancies in the timeline of events were noted, highlighting the facility's failure to promptly verify and act on the resident's code status.
A resident on hospice care was found unresponsive, and due to confusion over their code status, there was a delay in initiating CPR. The LPN initially believed the resident was a DNR based on incorrect hospice information, leading to a delay in CPR and calling 911. The facility's investigation was incomplete, failing to obtain timely staff statements and not reporting the incident to the State Survey Agency.
The facility did not provide a private setting for Resident Council meetings, holding them in an open area near the nurse's station, which led to residents fearing retaliation if they voiced complaints. During a meeting, 20 residents indicated they were afraid to complain about their care, and a review of council minutes showed few concerns were raised, suggesting underreporting due to fear.
The facility did not adequately address Resident Council concerns from June 2023 to June 2024, despite assurances from a new Administrator. The Activity Director, working alone and unaware of unresolved issues, communicated concerns to relevant departments but only received verbal resolutions. The lack of volunteers and the Director's hospitalization also led to a lack of activities, contributing to the Council's grievances.
Facility staff failed to inform residents of their rights, as revealed during a Resident Group meeting and review of Resident Council minutes. Residents and family members reported not receiving information about their rights upon admission or during their stay, and the Resident Council President confirmed that rights were not reviewed in meetings. The Activity Director, responsible for facilitating these meetings, could not provide documentation that resident rights had been reviewed or distributed.
The facility failed to provide a comprehensive activity program for its residents, resulting in a lack of engagement for three residents. One resident was left in bed without activities, another with severe cognitive impairment was not engaged, and a third expressed dissatisfaction with the lack of activities. The Activity Director struggled to manage alone, with no documentation of activities or one-to-one visits.
The facility failed to provide sufficient nursing staff, resulting in delayed medication administration for residents. Nurses were overwhelmed with high resident assignments and shared medication carts, causing significant delays in administering scheduled medications. Despite raising concerns, management did not provide feedback or solutions to address the staffing issues.
The facility failed to administer scheduled medications within the prescribed time for 31 residents due to staffing issues, leading to significant delays. Nurses were on split assignments, sharing medication carts, which caused delays in administering medications for conditions such as high blood pressure, pain, and depression. The facility's policy required medications to be given within one hour of the scheduled time, a guideline that was not followed. The DON acknowledged the issue, and the Medical Director discouraged splitting nurse assignments.
The facility was cited for a repeat deficiency in reporting due to insufficient auditing and oversight by the QAA/QAPI committee. The QAPI Plan required PIP subcommittees to identify improvement areas and report to the QAA Committee, but the facility failed to sustain prior improvements. The Administrator, new to the facility, could not confirm ongoing audits for past citations, acknowledging the system's failure.
The facility failed to update PASARR evaluations for two residents with newly diagnosed mental disorders. One resident, initially admitted with various conditions, was later diagnosed with schizophrenia, anxiety, and depressive disorders, but did not receive an updated PASARR. Another resident, admitted with bipolar disorder, received a new diagnosis of major depressive disorder, yet the PASARR was not updated. The DON and Interim DON acknowledged these oversights.
A resident was admitted with a diagnosis of schizophrenia, but the Level 1 PASARR evaluation completed by the hospital omitted this diagnosis. The interim Administrator and Social Service Director had differing views on responsibility for PASARR accuracy, while the Interim DON acknowledged the oversight and confirmed it was her responsibility to ensure accurate evaluations.
The facility failed to document education, consent, or contraindication for influenza and pneumococcal vaccines for four residents. Despite receiving vaccines, necessary records were missing, contrary to the facility's policy requiring documentation of consent, education, and prior vaccine administration.
A facility failed to maintain accurate medical records and medication administration. A resident's change in condition was not properly documented, with discrepancies in the timing of events and actions taken. Another resident did not receive prescribed eye drops as scheduled, and an LPN prematurely documented the administration. The DON acknowledged these practices were against policy, leading to deficiencies in care.
Failure to Maintain Homelike Environment Due to Unaddressed Maintenance Issues
Penalty
Summary
Surveyors observed multiple maintenance deficiencies on two of three units within the facility, including bubbled and chipped wall paint, broken sheetrock, missing baseboards, holes in walls, unpainted repairs, missing ceramic tiles, and bubbled surfaces on sink bases. These issues were noted in various locations such as the entrance to the 100-unit, outside and inside several resident rooms, and around fixtures like sinks, toilets, and windows. The physical environment in these areas did not meet standards for a safe, clean, comfortable, and homelike setting as required for residents. During interviews, the Maintenance Director stated that daily room rounds were conducted to identify maintenance issues and that staff could report problems verbally or through an electronic system. However, some of the identified deficiencies were already on the project list, but the Maintenance Director could not confirm how long they had been awaiting repair. The Administrator acknowledged the need for repairs to maintain a homelike environment. The facility's policy required timely repair or replacement of damaged structural surfaces, but the observed conditions indicated this was not consistently achieved.
Failure to Monitor Blood Pressure and Timely Collect Urine Specimen
Penalty
Summary
The facility failed to provide appropriate care and treatment according to physician orders and professional standards for two residents. For one male resident with a history of Alzheimer's Disease, stroke, and hypertension, the facility did not consistently monitor and document blood pressure readings as required. Despite being prescribed multiple antihypertensive medications, including one to be administered as needed for elevated systolic blood pressure, nursing staff did not check or record blood pressure at least once daily on 25 occasions over a two-month period. The resident's care plan did not include a cardiovascular/hypertension focus until the day the survey began, and the as-needed medication was never administered, with no documentation to support whether it was needed or not. Interviews with nursing staff, including LPNs, RNs, the Unit Manager, and the DON, revealed a consistent expectation that blood pressure should be checked and documented prior to administering antihypertensive medications. However, the medical record review showed this was not done, and the DON acknowledged the missing entries and the delayed addition of the care plan. Facility guidelines required nurses to obtain and record vital signs prior to medication administration, but this standard was not met for the resident in question. For another resident with diagnoses including muscle wasting, pneumonia, diabetes, and kidney failure, the facility failed to implement a physician's order for a urinalysis with culture and sensitivity in a timely manner. The resident and her son reported symptoms of a urinary tract infection and communicated these to staff, but the urine sample was not collected for over 24 hours after the order was placed. There was no documentation in the medical record explaining the delay, and communication among staff was inconsistent, with some CNAs unaware of the need for specimen collection. The DON confirmed there was no facility policy specifying a 48-hour window for specimen collection and stated that standard practice was to collect samples as soon as possible.
Failure to Accurately Document Medication Administration per Physician Orders
Penalty
Summary
The facility failed to maintain accurate documentation for medication administration for one resident with multiple diagnoses, including quadriplegia and neuromuscular dysfunction of the bladder. The resident had a physician's order for Midodrine 10 mg to be administered three times daily, with instructions to hold the medication if the systolic blood pressure exceeded 120. Review of the Medication Administration Record (MAR) showed that the medication was documented as given on multiple occasions when the resident's systolic blood pressure was above the ordered threshold. Specifically, in November, the medication was recorded as administered 14 times outside the parameters, and in October, 28 times, with several nurses involved in the documentation. Interviews with the assigned RN and the Director of Nursing (DON) confirmed that the MAR contained documentation errors, with the RN acknowledging that she may have checked off the medication as given in error and did not use the appropriate codes for held or not given medications. The DON was unable to provide a reason for the failure to follow the physician's order and acknowledged the expectation for accurate documentation. The facility's policy required corrections to be made in the electronic record, but the errors persisted over multiple months and involved several staff members.
Delay in CPR Due to Code Status Confusion
Penalty
Summary
The facility failed to follow its policy and procedure related to a resident's Full Code status, resulting in a delay in initiating Cardiopulmonary Resuscitation (CPR). The resident, a male with a history of anemia, type II diabetes, and occlusion and stenosis of the carotid artery, was admitted to hospice services with a diagnosis of moderate protein-calorie malnutrition. Despite having a physician's order for full resuscitation, there was confusion regarding the resident's code status, with contradictory orders for Full Resuscitation and Do Not Resuscitate (DNR) entered by an LPN. On the day of the incident, the resident was found unresponsive by a CNA, who reported this to the LPN. The LPN checked the hospice chart, which indicated a DNR order, and called hospice services, which initially confirmed the DNR status. However, hospice later called back to confirm the resident was a Full Code. This confusion led to a delay in initiating CPR, as the LPN waited for confirmation of the resident's code status before starting resuscitation efforts. The facility's documentation and investigation revealed discrepancies in the timeline of events, with conflicting reports from staff, EMS, and hospital records. The Code Blue Worksheet and staff statements indicated different times for when the resident was found unresponsive and when CPR was initiated. The facility's failure to promptly verify and act on the resident's Full Code status placed all residents at risk and resulted in Immediate Jeopardy.
Removal Plan
- CPR was initiated for resident #100 and resident was transferred from the facility with a rhythm via EMS and passed away at the hospital.
- Assistant DON initiated staff education on Code Status Orders and Response Policy and Procedure to include procedure for initiating CPR and documentation of the event. 31 out of 31 licensed nurses were educated. Re-education was initiated for licensed nursing clinical staff to be completed.
- Facility audit of 100 out of 100 residents advance directives was completed, to confirm accuracy of code status present in the front of the medical records and that it matched the physician's orders in the EMR.
- Additional audit of 21 out of 21 residents receiving hospice services conducted to confirm code status of record with hospice matches the facility's record. The hospice chart stored at the facility was combined with the facility's hard chart, removing individual hospice binders.
- The Regional President provided education to the Administrator and Interim DON on their essential core functions and the code of conduct.
- The Risk Management Consultant provided education to the Administrator and DON on the Abuse Prevention Program and conducting thorough investigations.
- A total of 9 Code Blue Drills has been completed covering all shifts in order to ensure staff are knowledgeable and prepared to accurately verify resident code status in an emergency and ensure staff provide CPR in a timely manner.
- Ad Hoc Quality Assurance and Compliance committee reviewed removal plan.
Failure to Timely Report and Investigate Delay in CPR
Penalty
Summary
The facility failed to report potential abuse and/or neglect violations concerning a delay in cardio-pulmonary resuscitation (CPR) for a resident who was a Full Code. The resident, who was on hospice care with a terminal diagnosis, was found unresponsive by a CNA during the night shift. The CNA informed an LPN, who then checked the resident's code status and initially believed the resident was a Do Not Resuscitate (DNR) based on incorrect information from the hospice. This led to a delay in initiating CPR. The LPN called the hospice to verify the resident's code status and was initially told the resident was a DNR. However, the hospice later confirmed that the resident was a Full Code. During this time, the LPN also contacted the physician and the facility's Director of Nursing before starting CPR and calling 911. The EMS report indicated a delay in CPR initiation due to confusion over the resident's code status, with CPR eventually being performed and the resident transported to a hospital. The facility's investigation into the incident was incomplete and inaccurate, as it failed to obtain timely statements from all involved staff and did not submit the required Immediate or 5-Day Report to the State Survey Agency. The Risk Manager acknowledged the discrepancies in the investigation and the need for further information to determine the exact timeline of events. The facility reopened the investigation during the survey due to these inconsistencies and planned to file an immediate report as new information emerged.
Lack of Privacy in Resident Council Meetings Leads to Fear of Retaliation
Penalty
Summary
The facility failed to promote an environment where residents could voice grievances about care and treatment without fear of discrimination or reprisal. During an interview with the Resident Council President, it was revealed that Resident Council meetings were held in a non-private area, specifically the atrium on the back of the 200 hall, which was not conducive to private discussions due to staff presence. The Activity Director confirmed the lack of a private area for these meetings. During a Resident Council Group Meeting held in this open area, 20 residents expressed fear of retaliation if they complained about their care, indicating a significant issue with the facility's handling of resident grievances. A review of Resident Council minutes from March to June 2024 showed few voiced concerns, suggesting a possible underreporting of issues due to fear of retaliation.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to properly and promptly respond to Resident Council concerns and grievances, as evidenced by the Resident Council minutes from June 2023 to June 2024. The minutes revealed that the Council felt their concerns were not addressed or resolved on multiple occasions, including June 2023, August 2023, December 2023, April 2024, May 2024, and June 2024. A new Administrator was introduced in April 2024 and assured the Council that concerns were being addressed, but the Council continued to feel their issues were unresolved in subsequent months. The Activity Director, who worked alone in the department, confirmed that concerns from the April 2024 meeting were not addressed or resolved. The Director explained that Resident Council concerns were communicated to the relevant department, with a two-week follow-up, but resolutions were only received verbally and communicated at the next meeting. The Activity Director was unaware of any unresolved issues, despite the Council's ongoing dissatisfaction. Additionally, the absence of volunteers and the Director's hospitalization led to a lack of activities during that period, further contributing to the Council's grievances.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility staff failed to review and inform residents of their rights, as evidenced by findings from a Resident Group meeting and review of Resident Council minutes. During a meeting held in an open area near the nurse's station, seven residents and family representatives reported they were unaware of their rights, had not received a copy of their rights upon admission or during their stay, and that these rights were not reviewed during Resident Council meetings. The Resident Council President confirmed that resident rights had not been reviewed in these meetings. A review of the Resident Council minutes from June 2023 to June 2024 showed that while the agenda indicated resident rights were reviewed monthly, there was no documentation or pamphlet provided to confirm this. The Activity Director, responsible for facilitating these meetings since February 2024, could not confirm or provide documentation that resident rights had been reviewed or distributed during the meetings.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and well-being of its residents, as evidenced by the lack of engagement for three sampled residents. Resident #10 was observed spending all his time in bed without participation in any group or individual activities. The Activity Director acknowledged that Resident #10 was often left alone, with minimal interaction, and there was no documentation of any activities provided to him. Similarly, Resident #39, who had severe cognitive impairment, was not engaged in any suitable activities. The Activity Director interacted with Resident #39's roommate but not with him, and there was no record of activities provided to Resident #39. Resident #80 expressed dissatisfaction with the lack of activities, noting that there was nothing to do except watch TV. The Activity Director confirmed that during his leave, no activities were conducted, and he struggled to manage the workload alone. He admitted to not having a list of residents requiring one-to-one visits or documentation of such visits. The facility lacked volunteers, and the Activity Director was the sole staff member responsible for activities, which included attending meetings and writing progress notes. The Activity Director was unable to provide Resident Assessment forms or documentation of group participation and one-to-one visits for Residents #10 and #39.
Insufficient Nursing Staff Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, particularly in administering medications on time. Observations and interviews revealed that scheduled 9 AM medications were significantly delayed, with some being administered as late as 11:46 AM and 11:54 AM. This delay was attributed to the insufficient number of nurses available, as one nurse was often assigned to cover multiple wings, leading to a split assignment. The shared use of medication carts further exacerbated the delay, as nurses had to wait for their turn to access the cart. Nurses reported being overwhelmed by the number of residents they were responsible for, with some having up to 47 residents on their assignment. The staffing coordinator and Director of Nursing (DON) acknowledged the staffing issues, noting that the facility was staffed based on census and adjusted for acuity. However, the current staffing levels were insufficient to meet the residents' needs, particularly with the opening of a new wing, which increased the workload without a corresponding increase in staff. The report highlighted that the facility's staffing challenges led to delays in medication administration, with 31 residents receiving their medications outside the prescribed time parameters. Despite concerns being raised by the nursing staff about the unmanageable workload and its impact on resident care, there was no indication of feedback or action from management to address these issues. The DON acknowledged the need for more nurses to provide individualized attention and enhance care, but the current staffing model did not support this need.
Medication Administration Delays Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that scheduled medications were administered within the prescribed time parameters for 31 residents on the 100 Wing during the 7 AM to 3 PM shift. This deficiency was observed through a combination of interviews, observations, and record reviews. Registered Nurse (RN) K and Licensed Practical Nurse (LPN) H were noted to be administering 9 AM medications well past the scheduled time, with some medications being given as late as 1:52 PM. The delay in medication administration was attributed to staffing issues, where nurses were assigned to split assignments between different wings, leading to shared medication carts and further delays. Several residents were directly affected by these delays. For instance, a resident received their 9 AM medications at 11:52 AM, which included medications for high blood pressure, pain, and congestive heart failure. Another resident's medications for anxiety, depression, and high blood pressure were administered at 12:11 PM. The report highlights that the facility's policy required medications to be administered within one hour before or after the scheduled time, a guideline that was not adhered to in these instances. The Director of Nursing (DON) acknowledged the issue, explaining that the split assignment of nurses was due to the facility's census. The DON also noted that there was no documentation indicating that residents, their physicians, or responsible parties were notified of the late medication administration. The Medical Director emphasized the importance of administering medications at specific times and discouraged the practice of splitting nurse assignments between wings.
Repeat Deficiency in Reporting Due to Insufficient Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior improvement measures. The facility's QAPI Plan outlined that each Performance Improvement Project (PIP) subcommittee should identify areas for improvement, collect and analyze data, and provide the QAA Committee with a summary report, analysis, and recommendations. However, the facility was cited for a deficiency at F 609 for failing to report during a previous recertification survey and was found to be in noncompliance again for the same issue during the current survey. This repeat deficiency was attributed to insufficient auditing and oversight, as the QAA Committee's action plans/PIPs were typically set for three months and considered complete if the issue was resolved, without ensuring continued audits for previous citations. The Administrator, who had been at the facility for about a month, was unable to confirm whether audits were still being conducted for past citations and acknowledged the system's failure, leading to the repeat violation.
Failure to Update PASARR for Residents with New Mental Disorders
Penalty
Summary
The facility failed to update and refer residents with newly diagnosed mental disorders for Level II Preadmission Screening and Resident Review (PASARR) evaluations. Resident #1, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease and cognitive communication deficit, was later diagnosed with schizophrenia, anxiety, and depressive disorders. Despite these new diagnoses, the facility did not update the resident's Level I PASARR or refer for a Level II PASARR evaluation, as confirmed by the Director of Nursing (DON). Similarly, Resident #72, admitted with bipolar disorder and other conditions, received a new diagnosis of major depressive disorder. However, the facility did not perform a new Level I PASARR or request a Level II evaluation. The Interim DON acknowledged the oversight and confirmed that the resident's PASARR was not updated to reflect the new diagnosis, contrary to the facility's policy requiring PASARR updates following significant changes in a resident's mental condition.
Inaccurate PASARR Evaluation for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the accuracy of a Level 1 Preadmission Screening and Resident Review (PASARR) evaluation for a resident admitted with a diagnosis of schizophrenia. The resident was admitted from the hospital with this diagnosis, but the Level 1 PASARR completed by the hospital social worker did not include schizophrenia. The interim Administrator indicated that Social Services was responsible for completing PASARRs, while the Social Service Director stated that the Director of Nursing (DON) was responsible for reviewing and ensuring their accuracy. The Interim DON expressed surprise that the resident was admitted with schizophrenia, which necessitated a Level 1 PASARR, and confirmed that it was her responsibility to ensure the accuracy of these evaluations. She acknowledged that the omission of the schizophrenia diagnosis was significant and that another Level 1 PASARR should have been conducted to determine if a Level II PASARR was necessary.
Lack of Documentation for Vaccinations
Penalty
Summary
The facility failed to provide necessary documentation for influenza and pneumococcal vaccinations for four residents out of a sample of five reviewed for immunizations. Specifically, there was no documentation of education, consent, refusal, or medical contraindication for these vaccines. Resident #5, who was admitted with chronic obstructive pulmonary disease, obstructive sleep apnea, dementia, type II diabetes, and heart failure, lacked documentation for the pneumococcal vaccine. Resident #10, with diagnoses including metabolic encephalopathy and dementia, received the influenza vaccine but without documented education or consent. Resident #44, admitted with muscle wasting, metabolic encephalopathy, type II diabetes, and pneumonia, had no documentation for either vaccine. Similarly, Resident #55, with hypertensive emergency and stage 4 chronic kidney disease, received the influenza vaccine without the necessary documentation. The Director of Nursing confirmed the absence of records for education, consent, refusal, or contraindication for the vaccines in question. The facility's policy mandates that all residents be offered the pneumococcal vaccine unless there is documented evidence of prior administration, medical contraindication, refusal, or no order. The influenza vaccine should be offered during the optimal immunization period, typically from October to March. The policy also requires staff to screen new admissions for previous pneumococcal vaccine administration, obtain consent or declination for immunizations, secure a physician's order, review vaccine information with the resident or their representative, and document these actions in the medical record. However, these procedures were not followed for the residents mentioned, leading to the deficiency noted in the report.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate medical records for a resident who experienced a change in condition. A male resident, admitted with diagnoses including anemia, diabetes, and malnutrition, was under hospice care. On a specific date, a Licensed Practical Nurse (LPN) documented that the resident had expired, but there was no prior documentation in the resident's clinical records indicating when the change in condition was identified. Interviews with staff revealed that the resident was found unresponsive earlier than documented, and actions taken were recorded on a CPR log rather than in the clinical record. The Director of Nursing (DON) and other staff acknowledged the lack of documentation in the resident's records. Another deficiency was identified in the administration of medication for a resident with glaucoma. The resident was supposed to receive eye drops twice a day, but on one occasion, the resident and her daughter reported that the medication was not administered as scheduled. The Medication Administration Record (MAR) inaccurately showed that the eye drops were given. An LPN admitted to documenting the administration of the medication before actually administering it, which was against the facility's policy. The DON confirmed that this practice was incorrect and could lead to inaccuracies in medication administration records. These deficiencies highlight issues with documentation and medication administration within the facility. The lack of proper documentation for the resident who expired and the premature recording of medication administration for another resident indicate a failure to adhere to professional standards and facility policies. These actions and inactions contributed to the deficiencies identified during the survey.
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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