University Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Miami, Florida.
- Location
- 724 Nw 19th St, Miami, Florida 33136
- CMS Provider Number
- 106100
- Inspections on file
- 19
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at University Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found four bouquets of flowers stored on shelves with fruits and vegetables in the walk-in refrigerator, contrary to the facility's food storage policy. Both the Dietary Supervisor and Corporate CDM confirmed that the flowers, intended for Nurses' week, should not have been in the refrigerator. This issue had the potential to affect most residents who were eating orally.
Confidential paperwork with residents' names, photos, and room numbers was left unattended and visible on a medication cart by an RN, making private information accessible to unauthorized individuals. The DON confirmed that all resident information should remain confidential, in line with facility policy.
A resident with severe cognitive impairment and a history of heart failure continued to have a BiPAP machine and related interventions listed in their care plan after physician orders discontinued its use. The BiPAP machine remained in the room, and staff were unclear about its status, leading to outdated care plan documentation that did not reflect current orders or the resident's needs.
A plastic bag containing loose pills and medications in containers was found left unattended on top of a medication cart on the fourth floor. An RN had removed the medications from a resident's room but left them unsecured on the cart after being called away for an emergency. Facility policy and the DON require all medications to be kept in a locked cart, but this was not followed.
The facility experienced repeated deficiencies in food storage practices, including unsanitary conditions in the ice cream freezer and improper storage of flower bouquets with produce in the walk-in refrigerator, affecting most residents who eat orally. The QAPI committee, despite regular meetings with department heads, failed to monitor and resolve these recurring issues, leading to continued noncompliance.
A resident with dementia hit her head on a wheelchair armrest during an assisted transfer, but the incident was not immediately reported by the CNA. The injury was only identified after a family member noticed bruising. The facility's protocol for reporting incidents was not followed, leading to a delay in notifying the resident's physician and representative.
A resident with dementia and impaired mobility was injured during a transfer when a CNA failed to properly position a wheelchair and let go of the resident, causing her to hit her head. The incident was not reported immediately, and injuries were discovered later by a family member. The facility's protocol for accident reporting was not followed, highlighting a lapse in supervision and communication.
A resident sustained injuries during a transfer when a CNA failed to position the wheelchair correctly and let go of the resident, causing her to hit her arm on the wheelchair's armrest. The incident was not reported immediately, and the injuries were discovered by a family member. The resident required substantial assistance for transfers, and the facility's policies emphasize safety and supervision, which were not followed in this case.
A resident in an LTC facility was injured during a transfer when she hit her arm on a wheelchair. The CNA did not properly position the wheelchair and failed to report the incident to the nurse, leading to a delay in informing the resident's family and physician. The facility's protocol for reporting and documenting incidents was not followed.
Improper Storage of Non-Food Items in Walk-In Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to store food under sanitary conditions in the walk-in refrigerator, where four bouquets of flowers were found lying on the shelves among fruits and vegetables. This was identified during an initial kitchen tour with the Dietary Supervisor and Corporate CDM, who both confirmed that the flowers should not have been stored in the refrigerator. The facility's Food Storage Policy requires that food storage areas be maintained in a clean, safe, and sanitary manner, and that perishable foods are stored immediately after delivery. The presence of non-food items, specifically flower bouquets intended for Nurses' week, among food items was documented with photographic evidence. This deficiency had the potential to affect 128 out of 133 residents who were eating orally at the time of the survey.
Failure to Secure Resident Confidential Information
Penalty
Summary
Confidential paperwork containing residents' names, photographs, and room numbers was observed left unattended and visible on top of the fourth floor's south medication cart. This incident occurred while the cart was unattended, making the information accessible to unauthorized individuals. A registered nurse acknowledged leaving the paperwork on the cart and recognized that all resident information should be kept private. The Director of Nursing confirmed that all resident information is expected to remain confidential. Facility policy reviewed indicated that protected health information (PHI), including electronic PHI, must be safeguarded to prevent unauthorized access.
Failure to Update Respiratory Care Plan After Discontinuation of BiPAP
Penalty
Summary
The facility failed to update the respiratory care plan for a resident after physician orders discontinued the use of a BiPAP machine. Despite the discontinuation order dated 10/15/24, the resident's care plan continued to include interventions for BiPAP use, and the machine remained present in the resident's room. Multiple observations over several days confirmed the BiPAP machine and its tubing were still at the bedside, with the mask stored in a drawer. Staff interviews revealed that the night supervisor believed the BiPAP was still being applied at night, although there were no active physician orders for its use. The MDS coordinator acknowledged that the care plan interventions for the BiPAP were only resolved months after the discontinuation order, and the DON confirmed the machine was left in the room due to family circumstances, but staff were not to administer it without an order. The resident involved had diagnoses including heart failure and insomnia, was severely cognitively impaired, and did not exhibit shortness of breath or require respiratory therapy according to recent assessments. The facility's policy required ongoing assessment and timely revision of care plans as resident conditions changed, but this was not followed in this case, resulting in outdated care plan interventions for respiratory therapy that no longer reflected the resident's current physician orders or needs.
Unsecured Medications Left Unattended on Medication Cart
Penalty
Summary
A plastic bag containing medications was observed left unattended on top of the south medication cart on the fourth floor, where 24 residents resided. The bag included loose pills and pills in containers. The medication cart was unattended at the time of observation. A Registered Nurse (RN) at the nursing station confirmed that the bag contained medications, which she had found in a resident's room. The RN stated she removed the medications from the room with the intention of notifying the supervisor but was called away to assist with an emergency, leaving the medications unsecured on the cart. Further interview with the RN revealed that any medications found in residents' rooms should be given to the supervisor and not left on the cart. The Director of Nursing (DON) confirmed that medications are to be kept in a locked cart and, if found in a resident's room, should be secured and labeled until picked up by family. Facility policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, with nursing staff responsible for maintaining medication storage areas. The observed practice did not comply with these requirements.
Repeated Deficiencies in Food Storage and QAPI Oversight
Penalty
Summary
The facility failed to implement effective action plans to correct previously identified quality deficiencies, specifically in the areas of food storage and the operation of its Quality Assurance and Performance Improvement (QAPI) committee. During a prior recertification survey, the facility was cited for not storing food under sanitary conditions, as evidenced by a buildup of ice in the ice cream freezer, which had the potential to affect nearly all residents who consumed food orally. In the most recent survey, a similar deficiency was observed, with flower bouquets being stored on shelves among fruits and vegetables in the walk-in refrigerator, again potentially impacting the majority of residents who eat orally. Additionally, the QAPI committee was cited for failing to adequately monitor and address these recurring problem areas. Despite holding monthly meetings with participation from key department heads, the committee did not ensure that previously identified issues were effectively resolved or that ongoing performance improvement projects were sufficiently evaluated. This lack of sustained oversight contributed to the recurrence of the same deficiencies.
Failure to Report Resident Injury During Transfer
Penalty
Summary
The facility failed to immediately inform a resident's representative and physician about an accident that resulted in an injury requiring medical attention. The incident involved a resident who, during an assisted transfer, hit her head on the armrest of a wheelchair. This incident went unreported initially, and the bruising was only identified after a family member noticed it and reported it to the staff. The resident, who has a diagnosis of dementia and is moderately impaired cognitively, required substantial assistance for transfers and was at low risk for falls according to a recent assessment. On the day of the incident, the resident was being transferred by a CNA who did not properly position the wheelchair before the transfer. The CNA held the resident with one hand and the wheelchair with the other, leading to the resident losing control and hitting her head. The CNA did not report the incident immediately as she did not observe any immediate bruising or injury. It was only after the family member's observation that the incident was reported, and an assessment was conducted. The Director of Nursing confirmed that the protocol for reporting such incidents was not followed, as the CNA failed to notify the facility about the incident on the day it occurred. The incident was only documented after the family member's report, and subsequent assessments, including an x-ray, were conducted. The facility's policy requires all accidents or incidents to be reported and investigated, but this protocol was not adhered to in this case.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. IMMEDIATE CORRECTIVE ACTION: Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers and reporting of incidents on Resident #1 did not have any negative outcomes related to the alleged deficient practice. Staff B received 1:1 education from the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. Nursing staff was in-serviced by the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Any resident in the facility have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents with change in condition without proper notification of physician and resident's representative. No issues were identified. SYSTEMATIC CHANGES: The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. The Director of Nursing/Designee will review all new incidents/changes in condition during the morning meeting to ensure proper notification of resident's representative and physician according to facility policy. MONITORING: The Director of Nursing/Designee will conduct daily rounds and chart review x 5 days, then weekly x 4 weeks, then random biweekly review, to ensure that physician and resident's representative are promptly notified of significant changes in condition. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.
Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident during a transfer, resulting in injuries that were not immediately reported by staff. The resident, who was moderately impaired cognitively and required substantial assistance for transfers, sustained a head injury when a CNA attempted to transfer her from the bed to a wheelchair. The CNA did not position the wheelchair correctly and let go of the resident, causing her to hit her head on the wheelchair's armrest. The incident was not reported immediately, and the injuries were discovered later by a family member. The resident had a history of dementia and was at risk for falls due to muscle weakness and impaired mobility. Despite being on fall precautions, the CNA did not follow proper transfer procedures and failed to report the incident to the nursing staff. The resident's care plan included interventions to encourage her to ask for assistance during transfers, but these were not effectively implemented. The CNA admitted to not reporting the incident because she did not notice any immediate bruising or injuries. The incident was eventually reported to the Director of Nursing and the physician, who ordered x-rays that showed no fractures. However, the delay in reporting and assessing the resident's injuries highlights a lapse in the facility's protocol for accident and incident reporting. The facility's policy requires all accidents or incidents to be investigated and reported promptly, but this was not adhered to in this case.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. **IMMEDIATE CORRECTIVE ACTION:** Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers on Resident #1 did not have any negative outcomes related to the alleged deficient practice. Nursing staff was in-serviced by the Director of , with competency completed on safe resident transfers on and. **IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED:** Any resident requiring assistance with transfers have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents needing assistance with transfer to ensure that staff are aware and that facility policy is being followed. **SYSTEMATIC CHANGES:** The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. Nursing staff was in-serviced by the Director of , with competency completed on safe resident transfers on and. **MONITORING:** The Director of Nursing/Designee will conduct weekly random observation and competency checks with nursing staff x four weeks, then monthly random observation and competency checks x 3 months to ensure nursing staff are transferring residents safely according to facility policy and procedures. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.
Resident Injury During Unsafe Transfer
Penalty
Summary
The facility staff failed to operate equipment safely, resulting in a resident sustaining injuries during a transfer. The incident involved a Certified Nursing Assistant (CNA) who was transferring the resident from the bed to a wheelchair. During the transfer, the CNA did not position the wheelchair correctly and let go of the resident momentarily, causing the resident to hit her arm on the wheelchair's armrest. This incident was not immediately reported by the CNA, and the injuries were later discovered by a family member. The resident involved in the incident required substantial to maximal assistance for chair or bed-to-chair transfers, as indicated in their care plan. The care plan also highlighted the resident's risk related to mobility and included interventions such as encouraging the resident to ask for assistance when attempting to transfer. Despite these precautions, the CNA did not follow the correct procedure for transferring the resident, which contributed to the accident. The facility's policies on safety and supervision of residents emphasize the importance of making the environment as free from accident hazards as possible. However, the CNA failed to report the incident to the nurse, which was against the facility's policy on accidents and incidents. The Director of Nursing confirmed that the CNA was reprimanded for not reporting the incident, and the incident was later documented in the facility's incident log.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. **IMMEDIATE CORRECTIVE ACTION:** Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers on Resident #1 did not have any negative outcomes related to the alleged deficient practice. Nursing staff was in-serviced by the Director of with competency completed on safe resident transfers on and. **IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED:** Any resident requiring assistance with transfers have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents needing assistance with transfer to ensure that staff are aware and that facility policy is being followed. **SYSTEMATIC CHANGES:** The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. Nursing staff was in-serviced by the Director of with competency completed on safe resident transfers on and. **MONITORING:** The Director of Nursing/Designee will conduct weekly random observation and competency checks with nursing staff x four weeks, then monthly random observation and competency checks x 3 months to ensure nursing staff are transferring residents safely according to facility policy and procedures. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.
Failure to Report Resident Injury
Penalty
Summary
The facility failed to immediately inform the resident's representative and physician about an accident that resulted in an injury requiring medical attention for one resident. During an assisted transfer, the resident hit her arm on the wheelchair, and the incident went unreported until a family member identified and reported it to the staff. The resident was observed with a small discoloration under the right eye and scratches on both arms. The resident required substantial assistance for chair/bed-to-chair transfers and had a care plan indicating a risk for falls related to mobility. Despite this, the Certified Nursing Assistant (CNA) did not properly position the wheelchair before transferring the resident, leading to the incident. The CNA failed to report the incident to the nurse, which was a breach of protocol. The Director of Nursing (DON) confirmed that the protocol required staff to report such incidents to the doctor and family, complete an incident report, and document the occurrence. However, there was no documentation related to the incident in the progress notes, and the CNA was reprimanded for not reporting the incident. The facility's policy required all accidents or incidents to be investigated and reported, but this was not adhered to in this case.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. **IMMEDIATE CORRECTIVE ACTION:** Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers and reporting of incidents on. Resident #1 did not have any negative outcomes related to the alleged deficient practice. Staff B received 1:1 education from the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. Nursing staff was in-serviced by the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. **IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED:** Any resident in the facility have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents with change in condition without proper notification of physician and resident's representative. No issues were identified. **SYSTEMATIC CHANGES:** The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. The Director of Nursing/Designee will review all new incidents/changes in condition during the morning meeting to ensure proper notification of resident's representative and physician according to facility policy. **MONITORING:** The Director of Nursing/Designee will conduct daily rounds and chart review x 5 days, then weekly x 4 weeks, then random biweekly review, to ensure that physician and resident's representative are promptly notified of significant changes in condition. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.
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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