Villa Maria Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Miami, Florida.
- Location
- 1050 Ne 125th Street, North Miami, Florida 33161
- CMS Provider Number
- 105232
- Inspections on file
- 21
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 12 (2 serious)
Citation history
Health deficiencies cited at Villa Maria Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and an unsteady gait, identified as high risk for elopement, exited the facility undetected after a group activity. Staff did not immediately notice the absence, and the resident was later found by law enforcement wandering in a busy neighborhood, despite existing care plan interventions and facility policies intended to prevent such incidents.
A resident with dementia and an unsteady gait, identified as high risk for elopement, was able to leave the facility undetected after a group activity. Despite existing policies and a care plan for elopement risk, staff failed to provide adequate supervision and monitoring, and security procedures at the facility gate were insufficient. The resident was later found by law enforcement in a nearby neighborhood and transported to a hospital for evaluation.
A resident with dementia and a known risk for wandering was able to leave the facility undetected after an activity, due to inadequate supervision and lapses in security procedures. The resident exited through an electronic gate while staff were distracted, and was later found in a nearby neighborhood and transported to a hospital. The facility failed to follow established protocols for monitoring and supervising high-risk residents, resulting in the resident's elopement.
The QAA Committee did not effectively identify or address ongoing supervision deficiencies, leading to repeated incidents, including the elopement of a resident with exit-seeking behaviors who left the facility undetected through an electronic gate. This pattern of inadequate oversight and failure to implement corrective actions has the potential to impact all residents.
A resident who eats independently was not served a meal during a scheduled dining period, while their tablemate received and began eating their meal. Staff interviews revealed the omission was due to a kitchen error and confusion regarding the resident's assigned dining location, resulting in the resident not receiving a meal tray as required by facility policy.
Surveyors found several resident areas in unsanitary and disrepair conditions, including water damage, detached air conditioning units, stained furniture, and exposed wall surfaces. Interviews with environmental services and maintenance staff confirmed ongoing issues with room cleanliness and timely repairs, resulting in a failure to provide a safe, clean, and homelike environment.
Two residents with significant cognitive and physical impairments were exposed to accident hazards when a required floor mat was not properly positioned for one resident at risk for falls, and an open container of hazardous disinfectant wipes was left on another resident's bedside table. Staff interviews and facility policy confirmed that these actions did not meet established safety protocols.
A resident with acute respiratory failure did not receive oxygen therapy as prescribed, as the nasal cannula was observed out of the nostrils or in the mouth on multiple occasions while oxygen was running. Staff did not identify the improper placement until alerted by a surveyor, despite regular checks and physician orders for continuous oxygen via nasal cannula.
A resident was not provided with a meal tray in a timely manner while seated at a table for two, resulting in her table mate being served and eating before her. This incident, along with a previous issue involving an uncovered urinary catheter drainage bag, demonstrates the facility's failure to implement effective QAPI actions to address dignity-related deficiencies.
Two residents receiving enteral tube feedings were observed with improper infection control practices, including an uncapped and leaking feeding tube and uncovered feeding tube caps left on a bedside chair. Staff interviews confirmed that these practices did not align with facility protocols, and the DON acknowledged the infection control concerns.
A Life Safety Code survey identified that a facility's fire alarm system and fire panel were not properly maintained, resulting in non-operational magnetic door locks and flashing lights on exit doors. The Maintenance Supervisor acknowledged repeated malfunctions and unsuccessful repair attempts, leading to Immediate Jeopardy. The Nursing Home Administrator noted that the facility was seeking estimates for a replacement fire panel. Despite routine inspections, there was a lack of communication with residents and their families about the system failures, highlighting significant safety risks in the event of a fire emergency.
The facility failed to maintain a functional fire alarm system, impacting the safety and well-being of residents, staff, and visitors. Despite routine inspections and repair attempts, the outdated motherboard could not be fixed or integrated with a new panel. The facility is in the process of obtaining estimates and bids for a new wireless fire alarm system.
A facility failed to ensure dignity for a resident with an indwelling catheter by not fully covering the urinary drainage collection bag with a dignity bag, despite the resident's preference for privacy and the facility's protocol requiring it.
The facility failed to transmit the Discharge-Return Anticipated MDS to CMS within the required 14-day period for a resident discharged to a short-term general hospital. The delay was due to an oversight by the MDS Coordinator, as confirmed by the Regional MDS Coordinator.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in their care plans. One resident's use of dentures was not documented, another resident's tobacco use was inaccurately recorded, and a third resident's oxygen therapy was not coded in the MDS.
The facility failed to follow physician orders for bilateral floor mats for four residents at risk for falls. Observations showed mats were often not in place, and staff interviews revealed inconsistencies in ensuring mats were replaced after being removed for care or cleaning.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia and an unsteady gait exited the facility undetected by staff. The resident had a documented history of elopement risk, as indicated in the care plan and elopement risk assessment, which included interventions such as placing a photograph on a wander list, using a pink armband, and redirecting attention away from exit areas. On the day of the incident, the resident participated in a bingo activity and was left waiting to be transported back to their room. Staff later discovered the resident's wheelchair empty and initiated a search, but the resident was not found within the facility. The facility's timeline and staff interviews revealed that there was a delay in recognizing the resident's absence and activating the Code Pink alert. Staff checked the resident's room and surrounding areas before initiating a facility-wide search. The security officer on duty did not observe the resident leaving, as attention was divided between managing gate access for a transport van and a visitor. The resident was able to exit the facility and travel approximately 0.7 miles away, eventually being found by law enforcement wandering in a high-traffic neighborhood. Record reviews and staff interviews confirmed that the resident was at high risk for elopement and that staff were aware of this risk. Despite existing policies and care plan interventions, the resident was able to leave the facility without detection, indicating a failure to provide adequate supervision and a secure environment. The incident resulted in the resident being exposed to significant environmental hazards before being located and returned to the facility.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses of dementia and an unsteady gait, identified as high risk for elopement, was able to leave the facility undetected by staff. The resident had a documented care plan indicating elopement risk, including interventions such as placement on a wander list, use of a pink armband, and staff monitoring. On the day of the incident, the resident participated in a bingo activity and was left waiting in a wheelchair after the activity concluded. Staff discovered the wheelchair empty and, after searching the immediate area and the resident's room, activated a Code Pink to report the missing resident. Despite the facility's policies and procedures for elopement prevention and accident hazard reduction, the monitoring and supervision provided were insufficient. Staff interviews revealed that although multiple staff members were present during the activity and responsible for transporting residents back to their rooms, the resident was able to leave the area without being noticed. Security procedures at the facility gate were also inadequate, as the security officer was distracted by managing both incoming and outgoing traffic, allowing the resident to exit the premises without detection. The resident was found by law enforcement approximately 0.7 miles from the facility, wandering in a high-traffic neighborhood, and was subsequently transported to a hospital for evaluation. The incident demonstrated a failure to provide a secure environment and adequate supervision for a resident at known risk for elopement, as required by facility policy and regulatory standards. The lack of effective monitoring and communication among staff contributed to the resident's unauthorized departure and delayed response in locating the individual.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to implement and ensure effective and efficient preventative measures to prevent the neglect and elopement of a resident who was identified as high risk for elopement due to a diagnosis of dementia and a history of wandering. The resident's care plan included interventions such as placing a photograph on a wander list, redirecting attention away from exit areas, assisting with meaningful activities, and alerting staff to monitor the resident's location. Despite these interventions, the resident was left unsupervised after an activity, and staff did not maintain the assigned level of supervision. On the day of the incident, the resident participated in a Bingo activity that concluded at 4:00 PM. The resident was waiting to be transported back to their room, but when staff arrived, only the resident's empty wheelchair was found. Staff searched the surrounding areas and the resident's room before activating a Code Pink at 4:45 PM. The facility is located in a high-traffic area, increasing the risk associated with elopement. The resident was able to exit the facility undetected through an electronic gate at the front of the building. The security officer on duty was distracted by managing both an outgoing transport van and an incoming visitor, resulting in both gates being open simultaneously and a lapse in monitoring the exit. The resident was later found in a nearby residential neighborhood and transported to a local hospital for evaluation. Interviews with staff revealed gaps in supervision and communication, as well as a lack of adherence to established protocols for monitoring high-risk residents. The facility's failure to ensure that residents were not able to leave the premises and to implement the assigned level of supervision directly contributed to the resident's elopement and placed the resident at risk for harm.
Failure to Identify and Address Supervision Deficiencies Resulting in Resident Elopement
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) Committee failed to identify and address quality concerns related to adequate supervision of residents, resulting in repeated deficient practices. Despite having a QAPI program and holding regular QAA Committee meetings with interdisciplinary attendance, the committee did not effectively track, measure, or prioritize quality deficiencies, nor did it systematically analyze underlying causes. This lack of effective oversight led to ongoing issues with supervision and accident prevention, as evidenced by a history of citations for related deficiencies. On August 4, 2025, the facility failed to provide adequate supervision and effective services to prevent the elopement of a resident with known exit-seeking behaviors. The resident was able to leave the facility undetected through an electronic gate in the front of the building. This incident, along with previous citations for similar issues, demonstrates a pattern of insufficient supervision and failure to implement effective corrective actions, potentially affecting all 191 residents in the facility.
Resident Not Served Meal During Scheduled Dining Period
Penalty
Summary
During a lunch meal observation, a resident who eats independently did not receive a meal tray while seated in the dining room. The resident's tablemate was served and began eating, but the resident was left without a meal. Staff interviews revealed that the resident's tray was not included in the meal cart due to a kitchen error. The seating arrangement confirmed the resident was assigned to the table according to the facility's dining plan, but the meal was not delivered as expected. Further interviews with staff, including a CNA and the Food Service Director, indicated that meal trays were distributed based on a list provided by the charge nurse. The kitchen staff followed this list to serve meals, but an oversight led to the omission of the resident's tray. The Director of Nursing noted that the resident was present in the dining room during meal service, although this was not their assigned dining location, which contributed to the error. The facility's policy requires that residents be treated with dignity and respect, but this was not upheld in this instance.
Failure to Maintain Sanitary and Homelike Resident Environment
Penalty
Summary
Surveyors observed multiple resident areas on the facility's third floor North and East Units that were unsanitary and in disrepair. Specific findings included water damage to walls, water on the floor under air conditioning units, detached baseboards, and air conditioning units that were either falling off or detached from the wall. Additional observations included a heavily stained bedside chair and a hand sanitizer dispenser that had been ripped off the wall, exposing the concrete underlayer. Photographic evidence was collected for these deficiencies. Interviews with the Director of Environmental Services and the Director of Maintenance revealed that housekeeping staff are scheduled daily to clean and sanitize resident rooms, bathrooms, and common areas, including cleaning all furniture. The Director of Maintenance described a process for reporting and addressing maintenance issues, noting that some air conditioning units in resident rooms required repair. Despite these processes, the observed deficiencies indicated that the facility failed to maintain a safe, clean, and homelike environment for residents as required by policy.
Failure to Maintain Safe Environment and Prevent Accident Hazards
Penalty
Summary
The facility failed to provide a safe environment in accordance with its own policies regarding accident hazards for two vulnerable residents. For one resident with a history of falls and significant cognitive impairment, observation revealed that while the resident was in bed, a required floor mat was not properly positioned; instead, it was placed against the wall rather than beside the bed as ordered. Staff interviews confirmed that floor mats are to be placed on both sides of the bed when the resident is in bed, and stored away only when the resident is out of bed. The resident’s care plan and physician’s orders specifically required bilateral floor mats due to the resident’s high risk for falls and decreased safety awareness. For another resident with severe cognitive impairment and total dependence for activities of daily living following a cerebral infarction, an open container of disinfectant wipes was found on the bedside table. The wipes contained hazardous chemicals, including high concentrations of ethyl alcohol and quaternary ammonium compounds, with manufacturer warnings indicating the need for secure storage. Staff interviews confirmed that such disinfectant wipes are not permitted in resident rooms due to the risk of inappropriate use, especially for residents who are not alert and oriented. Facility policy also prohibits hazardous items from being kept in resident rooms and requires staff to routinely check for such hazards. Both incidents were identified through direct observation, record review, and staff interviews, demonstrating a failure to adhere to facility policies and procedures designed to minimize accident hazards and ensure resident safety. The deficiencies involved lapses in environmental safety checks and improper storage of hazardous materials, directly affecting residents with significant cognitive and physical impairments.
Failure to Ensure Proper Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that oxygen therapy was delivered as prescribed for a resident with a primary diagnosis of acute respiratory failure. Observations on two separate occasions revealed that the resident's nasal cannula was not properly positioned in the nostrils while oxygen was running at 2 liters per minute, as ordered by the physician. On one occasion, the nasal cannula was not in the resident's nostrils, and on another, it was observed in the resident's mouth. In both instances, staff were alerted by the surveyor to correct the placement of the oxygen tubing. Medical record review confirmed that the resident was admitted with acute respiratory failure and had physician orders for continuous oxygen via nasal cannula. The resident's care plan included interventions to administer oxygen as ordered and monitor for signs of respiratory distress. Staff interviews indicated that routine checks and vital sign monitoring were performed, but the improper placement of the nasal cannula was not identified by staff prior to surveyor intervention. The facility's policy required provision of respiratory therapy services as ordered by a physician.
Repeated Failure to Ensure Resident Dignity During Meal Service
Penalty
Summary
The facility failed to implement effective actions through its Quality Assurance and Performance Improvement (QAPI) program to address previously identified quality deficiencies related to resident dignity. During a prior recertification survey, the facility was cited for not ensuring dignity when a resident's indwelling urinary catheter drainage collection bag was not fully covered with a privacy bag. In the most recent survey, a similar deficiency was identified under F550 (Resident Rights), where a resident was not provided with a meal tray in a timely manner during dining. The resident was seated at a table for two in the dining room, and while her table mate was served and had started eating, she was left without a meal tray. Observations, interviews, and record reviews confirmed that the QAA committee, which includes interdisciplinary members and meets monthly, had not ensured that effective corrective actions were implemented to prevent recurrence of dignity-related deficiencies. Despite the facility's policy outlining systematic processes for evaluating care and addressing root causes, the repeated citation indicates that the measures in place were insufficient to ensure all residents received dignified care, particularly during meal service.
Failure to Maintain Infection Control for Enteral Feeding Tubes
Penalty
Summary
The facility failed to follow infection control standards and procedures for two residents receiving enteral tube feedings. For one resident with multiple sclerosis and a gastrostomy, observation revealed the feeding tube was left uncapped and leaking on the feeding pump, with dry residue noted on the pump surface. The resident's care plan identified risks related to the gastrostomy tube, including the need for daily cleansing and monitoring for infection, but these precautions were not observed during the survey. Physician orders specified continuous enteral feeding, and the resident was dependent on activities of daily living and received more than half of nutritional intake via tube feeding. For another resident with a gastrostomy, multiple observations showed enteral feeding tubing caps stored uncovered on the bedside chair, both when the feeding was inactive and running. Staff interviews indicated that the standard practice was to clean and cap the feeding equipment and store unused caps in a sanitary manner, but this was not followed as evidenced by the uncovered caps. The Director of Nursing confirmed that feeding tubes should always be capped or placed in a protective bag if a cap is unavailable, acknowledging the infection control concerns presented by the photographic evidence.
Fire Alarm System Malfunction Poses Safety Risks
Penalty
Summary
The facility failed to ensure a safe environment for all occupants by neglecting to maintain the Fire Alarm system and the faulty fire panel, placing residents, staff, and visitors at risk in the event of a fire. The deficiency was identified during a Life Safety Coded survey on March 12, 2024, where it was discovered that the magnetic door locks on exit doors and flashing lights were not operational, hindering individuals from exiting the facility safely during emergencies. The facility's Maintenance Supervisor acknowledged that the fire alarm had experienced repeated malfunctions, with attempts made to repair the system but without successful completion, leading to the determination of Immediate Jeopardy starting on January 5th, 2024. The Nursing Home Administrator disclosed that the facility was in the process of seeking estimates and bids for the replacement of the fire panel, which was deemed outdated and unable to function properly. Despite routine maintenance inspections, the facility failed to notify residents, their families, or representatives of the system failures, indicating a lack of communication regarding critical safety issues within the facility. The deficiency highlighted a significant risk to the safety and well-being of all occupants due to the non-functioning fire alarm system and panel, posing serious threats in the event of a fire emergency.
Failure to Maintain Functional Fire Alarm System
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the highest practicable physical, mental, and psychological well-being of its residents. During an interview, the Maintenance Supervisor revealed that the fire alarm system was undergoing routine inspections but was not functioning properly. Despite following normal procedures and submitting documents for repairs, the work was not completed. The issue recurred, and the company responsible for repairs attempted to fix the motherboard, which was too old to be repaired or integrated with a new panel. Consequently, the fire alarm system failed to send signals to the doors to work properly, and the facility administration was in the process of obtaining estimates and bids for a new wireless fire alarm system. The Nursing Home Administrator confirmed that the building was old and had undergone an addition. Maintenance inspections were conducted weekly, monthly, and quarterly. The alarm company tried to fix the outdated motherboard but failed, and attempts to integrate a new panel were unsuccessful. The facility's Policies and Procedures for Utilities Management and Safety Management Plans emphasized the importance of providing a safe and comfortable environment for patients, staff, and visitors. However, the failure to maintain a functional fire alarm system compromised the safety and well-being of the facility's residents, staff, and visitors.
Failure to Ensure Dignity for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure dignity for a resident with an indwelling catheter, as evidenced by the resident's urinary drainage collection bag not being fully covered by a dignity bag. On multiple occasions, the resident was observed with an uncovered drainage bag, both in his room and outside his room while being transported to therapy. The resident expressed a preference for a leg bag for more freedom and privacy, but the facility's protocol requires the use of a dignity bag to cover the drainage bag when the resident is out of bed. Staff members acknowledged the requirement but failed to consistently implement it, resulting in the resident's dignity being compromised. The resident, who was admitted with a diagnosis of Benign Prostatic Hyperplasia (BPH) and had no cognitive impairment, required various levels of assistance for daily activities. Despite the care plan and physician orders specifying the need for the drainage bag to be covered, staff members did not adhere to this protocol. The facility's policy on resident privacy and dignity, which mandates that all care procedures be performed with maximum privacy, was not followed in this instance, leading to the observed deficiency.
Failure to Transmit MDS Data Within Required Timeframe
Penalty
Summary
The facility failed to electronically transmit the Discharge-Return Anticipated Minimum Data Set (MDS) to the Centers for Medicare and Medicaid Services (CMS) within the required 14-day period for one resident who was discharged to a short-term general hospital. Specifically, the clinical records for the resident revealed that the Discharge Return Anticipated MDS, dated 12/04/2023, was not transmitted within the mandated timeframe. Instead, the MDS was transmitted on 03/14/2024, well beyond the 14-day requirement. An interview with the Regional MDS Coordinator on 03/15/2024 confirmed that the assessment was completed but not transmitted on time due to an oversight by the facility's MDS Coordinator. The facility's policy and procedures for the Resident Assessment Instrument (RAI) and the Interdisciplinary Care Planning Process, which were reviewed on 02/22/2024, mandate that completed RAI data must be transmitted to the state within regulatory timeframes. This failure to adhere to the policy resulted in the deficiency noted in the report.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in their care plans. Resident #86 was admitted with a care plan indicating a risk for nutrition and hydration issues due to missing or broken teeth. However, the MDS did not reflect the resident's use of dentures, which were received on 01/25/2024. The resident later reported issues with the dentures, but this was not documented in the MDS, and the MDS Coordinator admitted to not marking dentures because the resident did not inform her about wearing them. Resident #29, who had a diagnosis including pneumonia due to Coronavirus, bipolar disorder, and schizophrenia, was noted in the care plan to be able to smoke independently. However, the MDS inaccurately indicated that the resident did not use tobacco. The resident's smoking habits and preferences were documented in other records, but this information was not accurately reflected in the MDS. The MDS Coordinator acknowledged the error and stated that her assistant was responsible for the incorrect coding. Resident #166, diagnosed with emphysema, was observed using oxygen therapy, which was ordered at a rate of three liters per minute. Despite this, the MDS did not code the use of oxygen therapy in Section O for Special Treatments. The MDS Coordinator confirmed that the oxygen therapy was documented in the Medication Administration Records (MAR) and visually assessed but was not included in the MDS. The coordinator did not know why this was missed and stated that she would make the correction.
Failure to Follow Fall Precaution Orders
Penalty
Summary
The facility failed to provide a safe environment by not following physician orders to place bilateral floor mats for four residents who were at risk for falls. Observations revealed that the floor mats were either not in place or improperly positioned, despite physician orders and care plans indicating their necessity. For instance, Resident #36 was observed on multiple occasions with one or both floor mats folded and leaning against the wall, contrary to the physician's order for bilateral floor mats when in bed. Interviews with staff confirmed that the mats were removed for various reasons, such as serving meals, but were not promptly replaced as required. Resident #71, who had a recent fall resulting in a shoulder fracture, was also observed without the required bilateral floor mats on several occasions. Staff interviews revealed a lack of awareness and inconsistency in ensuring the mats were in place, with some staff members unaware of the current location of the mats. The treatment administration record indicated that the order for bilateral floor mats was signed off every shift, yet the mats were not observed in place during multiple checks. Similarly, Resident #23 and Resident #171 were found without the necessary floor mats in place. Resident #23's floor mat was observed folded and leaning against the wall, and staff admitted to removing it for care activities but failing to replace it. Resident #171 was observed with only one floor mat in place, and the other mat was either folded or missing. Staff interviews highlighted a pattern of removing mats for care or cleaning and not promptly replacing them, despite clear orders and care plans requiring their use to prevent falls and injuries.
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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