W Frank Wells Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Macclenny, Florida.
- Location
- 210 N 2nd St, Macclenny, Florida 32063
- CMS Provider Number
- 105210
- Inspections on file
- 14
- Latest survey
- December 10, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at W Frank Wells Nursing Home during CMS and state inspections, most recent first.
The facility failed to maintain proper sanitation and food handling practices, with black biological growth observed on kitchen equipment, undated food items in storage, and improper hand hygiene by staff during meal service. Despite training, staff did not adhere to procedures, leading to potential foodborne illness risks.
The facility's QAPI committee lacked the required participation of the Medical Director, who did not attend meetings from July to November 2024, except for one in June by phone. The Medical Director did not receive program data or provide feedback on quality deficiencies, and no delegate was sent in his place. The facility's QAPI Plan included the Medical Director as a member, but his contract did not specify QAPI responsibilities.
The facility failed to address missing wall trim in three rooms on the east hall, leaving sharp and splintered wood exposed. Observations revealed that several beds were missing wall trim, resulting in jagged edges and unfinished wood. The Maintenance Operations Director acknowledged the issue, but no current work orders were in place. Staff interviews indicated a breakdown in communication and follow-up regarding maintenance requests, with no specific maintenance personnel assigned to the facility.
A resident with a history of encephalopathy and dependence on supplemental oxygen was observed receiving oxygen at 1 liter per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by a nurse, and staff interviews revealed a lack of clarity in ensuring the correct oxygen flow rate. The facility's policy required adherence to physician orders for oxygen administration.
A resident with dietary restrictions due to GERD and other medical conditions was served food items they disliked and could not consume, despite having informed the facility of their preferences. The certified dietary manager acknowledged an error in updating the resident's meal ticket, leading to a deficiency in meeting the resident's nutritional needs.
A resident with severe cognitive impairment managed to leave the facility unsupervised twice due to inadequate oversight and resources. The facility failed to ensure proper functioning of wander monitoring devices and door alarms, and lacked systematic staff training on elopement prevention. The administration did not investigate why a fire exit door alarm was disarmed, contributing to the resident's ability to exit the facility.
A resident with severe cognitive impairment and a history of elopement risk managed to exit a facility through a disarmed fire exit door, highlighting deficiencies in the facility's QAPI process. The facility failed to conduct a thorough investigation, lacked comprehensive staff training on elopement procedures, and had insufficient wander monitoring systems. Only a small portion of the staff received training on the use of fire door alarms, and no elopement drills were conducted in the year prior to the incident.
A resident with severe cognitive impairment and a history of wandering managed to exit the facility undetected on two occasions. The facility lacked a systematic process to protect residents at risk of elopement, with no investigation into disarmed fire exit alarms and inadequate staff training on elopement prevention. The resident's care plan was not revised after the initial incident, and safety checks were inconsistently documented, contributing to the resident's ability to elope again.
A resident with severe cognitive impairment and a history of wandering exited a facility through a disarmed fire exit door without staff knowledge. The facility lacked a systematic process for staff education on elopement risks, did not revise care plans after previous elopement attempts, and had insufficient staff training and elopement drills. The absence of a comprehensive policy for wander monitoring devices and inadequate documentation of door checks contributed to the deficiency.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, which could potentially lead to foodborne illness affecting all residents. During an initial tour of the kitchen, surveyors observed black biological growth on the gaskets and doors of the reach-in freezer and walk-in cooler. Additionally, several food items in the cooler were found without date marks, including liquid egg products, cottage cheese, potato salad, and cooked chicken. The walk-in freezer had food on the floor, and the stand mixer and food slicer were found with dried food debris. Dust and debris were also noted on ceiling tiles, and dead roach carcasses were found in the dish room and near the ware washing sink. Further observations revealed improper hand hygiene and glove use by dietary staff during meal service. Employees were seen changing gloves without washing their hands multiple times, and one employee washed her hands inappropriately. The Certified Dietary Manager (CDM) and other staff members confirmed that they were responsible for date marking and cleaning but failed to ensure these tasks were completed. The CDM was unaware of the black biological growth and dust on the ceiling tiles and acknowledged the need for cleaning the floors and equipment. Interviews with staff revealed a lack of training and awareness regarding proper hand hygiene and glove use. Employee C admitted to not being trained to wash hands between glove changes and improperly disposing of used gloves. Despite attending training sessions on hand hygiene and food safety, staff did not consistently follow procedures. The facility's policies and procedures outlined the importance of proper sanitation and food handling, but these were not effectively implemented, leading to the observed deficiencies.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee with the required members, as the Medical Director did not attend QAPI meetings on a monthly or quarterly basis from July 2024 through November 2024. The QAPI meeting minutes revealed that the Medical Director only attended the June meeting by phone, and there was no evidence of communication of program data to the Medical Director for his review. Consequently, the Medical Director did not provide meaningful feedback on potential quality deficiencies and trends that might have required more frequent monitoring. Interviews with the Administrator, Chief Nursing Officer, and Director of Nursing confirmed that the Medical Director is a committee member, but his contract and job description did not specifically include responsibilities related to the QAPI Committee. The Chief Nursing Officer discussed Performance Improvement Plans (PIPs) with the Medical Director but did not send him any data, and he did not provide feedback to the committee. The Medical Director also did not send a delegate to attend the meetings. The facility's QAPI Plan listed the Medical Director as a committee member, emphasizing the importance of data-driven decisions and the involvement of healthcare practitioners in the QAPI process.
Failure to Address Missing Wall Trim in Resident Rooms
Penalty
Summary
The facility failed to address missing wall trim in three rooms on the east hall, leaving sharp and splintered wood exposed. This deficiency was observed during room inspections, where it was noted that several beds were missing wall trim, resulting in jagged edges and unfinished wood being exposed. Photographic evidence was obtained to document these conditions. The Maintenance Operations Director acknowledged the issue, stating that work orders were typically managed through an electronic program called Service Desk, but no current work orders were in place to address the missing wall trim in the affected rooms. Interviews with staff revealed a breakdown in communication and follow-up regarding maintenance requests. A Certified Nursing Assistant reported that environmental concerns, including the missing wall trim, had been communicated multiple times to the clerk responsible for submitting work orders. However, the Maintenance Director admitted to missing these rooms during follow-up rounds. Additionally, it was noted that there was no specific maintenance personnel assigned to the facility, as they worked at a nearby hospital and only attended to the facility when called. The Administrator confirmed that there was no facility policy for maintenance repairs or requests.
Failure to Administer Prescribed Oxygen Flow Rate
Penalty
Summary
The facility failed to provide oxygen at the prescribed flow rate for a resident who was dependent on supplemental oxygen. Observations on two separate occasions revealed that the resident was receiving oxygen at 1 liter per minute via nasal cannula, despite the physician's order specifying a flow rate of 2 liters per minute. This discrepancy was confirmed by a registered nurse during an interview. The resident's medical record indicated a history of encephalopathy, dependence on supplemental oxygen, and generalized anxiety disorder, with moderately impaired cognition as assessed by the BIMS score. The resident's care plan highlighted an altered respiratory status and a risk for ineffective breathing patterns due to cardiovascular compromise and a history of upper respiratory infection. Despite these documented needs, the facility's staff did not adhere to the prescribed oxygen therapy. Interviews with staff revealed a lack of clarity in ensuring the correct oxygen flow rate, as a certified nursing assistant stated she relied on the nurse to verify the prescribed rate. The facility's policy required a physician's order for oxygen administration, which was not followed in this instance.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, leading to a deficiency in providing a nourishing, palatable, well-balanced diet that meets the resident's daily nutritional and special dietary needs. The resident, who has a diagnosis of type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, GERD, and hyperlipidemia, expressed that despite informing the facility of their food dislikes and dietary restrictions due to GERD, they continued to receive meals containing those items. Specifically, the resident was served bacon and sausage gravy, which were documented as dislikes on their meal ticket. Interviews with facility staff revealed that the certified dietary manager (CDM) was responsible for assessing residents' food preferences and updating meal tickets, but an error occurred in this case. The CDM acknowledged the mistake upon being informed of the uneaten food on the resident's tray. The facility's policy emphasizes the residents' right to dignity, respect, and participation in decisions about their care, which was not upheld in this instance. The registered dietician, who had been with the facility for a month, indicated that she had not yet provided dietary teaching, and the CDM was responsible for updating meal preferences, highlighting a gap in the process that led to the deficiency.
Failure to Prevent Resident Elopement Due to Inadequate Oversight and Training
Penalty
Summary
The facility administration failed to provide adequate oversight and resources to prevent elopement, resulting in a resident with severe cognitive impairment leaving the premises unsupervised. The resident, who was assessed as at risk for elopement, had a wander monitoring device placed on her ankle. Despite this, she managed to exit the facility through a fire exit door on two occasions. The first incident occurred when the resident pushed open the fire exit door, triggering the alarm, but no care plan interventions were reviewed or revised afterward. The second incident involved the resident being found outside the facility, with the fire exit door alarm disarmed, and no investigation was conducted to determine why the alarm was disarmed. The facility lacked a systematic process to educate staff, identify environmental risks, and implement relevant interventions to protect residents from elopement. There were no documented elopement drills in the year preceding the incident, and staff orientation and annual training did not include information on elopement or wandering. After the incident, only a portion of the staff received training on elopement prevention and response, and the facility's elopement policy and procedures were not included in the new hire orientation. The facility's failure to ensure proper functioning of the wander monitoring devices and door alarms, along with inadequate staff training and oversight, contributed to the resident's ability to leave the facility unsupervised. The administration's lack of investigation into the disarmed door alarm and insufficient staff training on elopement prevention and response were significant factors in the deficiency.
Removal Plan
- Frequent visual checks to monitor for increased wandering behaviors.
- Education for door monitoring and wander monitoring device use and function.
- Education for elopement will be provided.
- All residents re-evaluated for wandering risk.
- Facility reviews of the elopement policy and procedure.
- Quotes obtained, and a project initiated for providing upgraded wander guard systems to the east wing, west wing, restorative dining room (doors), and south hall exit doors.
- Verification of wander guard placement and use for all residents.
- Review of monitoring tools for door checks, wander guard device checks.
- Staff education on the arming of the door system with the key.
- Continue with wander guard device checks and placement as ordered for those residents at wandering risk.
- Staff education of the Elopement policy and procedures.
- Performance Improvement Plan to assess and monitor progress of the initiatives put into place to avoid further occurrence. Review of PIP with QA&A committee.
- Review of Interdisciplinary Team assessment upon resident admission for residents deemed to be at risk for wandering behaviors, and continuation of wandering resident assessments with updates to elopement book as required.
- All residents re-evaluated for wandering resident risk assessment.
Deficiency in Elopement Prevention and Staff Training
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) process to monitor and audit practices related to resident elopements. This deficiency was highlighted by the incident involving a resident identified as an elopement risk, who managed to exit the facility through a disarmed fire exit door. The QAPI committee did not adequately address the incomplete investigation following the resident's elopement, nor did it ensure comprehensive staff training on elopement procedures and the proper use of fire exit door alarms. The resident in question had a history of severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 00 out of 15, and was assessed as at risk for elopement upon admission. Despite these assessments, the facility's interventions were insufficient, as evidenced by the resident's ability to exit the facility undetected. The fire exit door alarm was found to be disarmed, and there was no investigation into why this occurred. Additionally, the facility lacked a policy and procedure for wander monitoring devices, and only two of the seven facility exits were equipped with wander monitoring device sensor alarms. Staff training and participation in elopement drills were also inadequate. Only a small fraction of the staff received training on elopement procedures and the use of the key to arm and disarm fire door alarms. Furthermore, no elopement drills were conducted in the year leading up to the incident, and the only drill conducted afterward involved a limited number of staff. This lack of preparedness and training contributed to the facility's inability to prevent the resident's elopement and ensure the safety of other residents at risk for wandering.
Removal Plan
- Frequent visual checks to monitor for increased wandering behaviors.
- Education for door monitoring and wander monitoring device use and function.
- Education for elopement will be provided.
- All residents re-evaluated for wandering risk.
- Facility reviews of the elopement policy and procedure.
- Quotes obtained, and a project initiated for providing upgraded wander guard systems to the east wing, west wing, restorative dining room (doors), and south hall exit doors.
- Verification of wander guard placement and use for all residents.
- Review of monitoring tools for door checks, wander guard device checks.
- Staff education on the arming of the door system with the key.
- Continue with wander guard device checks and placement as ordered for those residents at wandering risk.
- Staff education of the Elopement policy and procedures.
- Performance Improvement Plan to assess and monitor progress of the initiatives put into place to avoid further occurrence. Review of PIP with QA&A committee.
- Review of Interdisciplinary Team assessment upon resident admission for residents deemed to be at risk for wandering behaviors, and continuation of wandering resident assessments with updates to elopement book as required.
- All residents re-evaluated for wandering resident risk assessment.
Failure to Protect Resident from Elopement
Penalty
Summary
The facility failed to protect a resident, identified as at risk for elopement, from leaving the premises undetected. The resident, who had severe cognitive impairment and a history of wandering, was admitted with a wander monitoring device placed on her ankle. Despite this, she managed to exit the facility through a fire exit door on two occasions. The first incident occurred when the resident pushed open the fire exit door, triggering the alarm, but no care plan interventions were reviewed or revised afterward. The second incident involved the resident being found outside the facility, with the fire exit door alarm disarmed, allowing her to leave undetected. The facility did not have a systematic process in place to protect residents at risk of elopement. There was no investigation into why the fire exit door's alarm was disarmed, and the facility lacked a policy and procedure for wander monitoring devices. Additionally, the facility's staff orientation and annual training did not include information on elopement or wandering, and there were no documented elopement drills in the year preceding the incident. The facility's failure to implement necessary interventions and revise the care plan after the initial incident contributed to the resident's ability to elope a second time. The facility's environment posed additional risks, with only two of seven exits fitted with wander monitoring device sensor alarms, both near the front entrance. The resident's care plan and physician's orders were not adequately followed, as evidenced by missing documentation of 15-minute safety checks ordered after the second elopement incident. The facility's lack of consistent staff training and failure to conduct regular elopement drills further exacerbated the risk to residents, particularly those identified as at risk for elopement.
Removal Plan
- Frequent visual checks to monitor for increased wandering behaviors.
- Education for door monitoring and wander monitoring device use and function.
- Education for elopement will be provided.
- All residents re-evaluated for wandering risk.
- Facility reviews of the elopement policy and procedure.
- Quotes obtained, and a project initiated for providing upgraded wander guard systems to the east wing, west wing, restorative dining room (doors), and south hall exit doors.
- Verification of wander guard placement and use for all residents.
- Review of monitoring tools for door checks, wander guard device checks.
- Staff education on the arming of the door system with the key.
- Continue with wander guard device checks and placement as ordered for those residents at wandering risk.
- Staff education of the Elopement policy and procedures.
- Performance Improvement Plan to assess and monitor progress of the initiatives put into place to avoid further occurrence. Review of PIP with QA&A committee.
- Review of Interdisciplinary Team assessment upon resident admission for residents deemed to be at risk for wandering behaviors, and continuation of wandering resident assessments with updates to elopement book as required.
- All residents re-evaluated for wandering resident risk assessment.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to provide adequate supervision and implement sufficient interventions to prevent elopement for a resident identified as at risk. The resident, who had severe cognitive impairment and a history of wandering, was able to exit the facility through a fire exit door that was disarmed. This door was not equipped with a wander monitoring device sensor, and the alarm system was not properly engaged, allowing the resident to leave the premises without staff knowledge. The facility did not have a systematic process in place to educate staff on elopement risks, identify environmental hazards, or revise care plans to protect residents at risk of elopement. Despite the resident's known risk and previous attempts to leave the facility, there were no revisions to the care plan or additional interventions implemented after the resident's initial attempt to exit through the same door. The facility's lack of a comprehensive policy and procedure for wander monitoring devices contributed to the deficiency. Staff training and elopement drills were insufficient, with many staff members not receiving training on elopement prevention and response. The facility's failure to conduct regular elopement drills and ensure all staff were trained in the use of door alarms and wander monitoring devices further exacerbated the risk to residents. The lack of documentation and oversight regarding door checks and alarm functionality also played a significant role in the deficiency.
Removal Plan
- Frequent visual checks to monitor for increased wandering behaviors.
- Education for door monitoring and wander monitoring device use and function.
- Education for elopement will be provided.
- All residents re-evaluated for wandering risk.
- Facility reviews of the elopement policy and procedure.
- Quotes obtained, and a project initiated for providing upgraded wander guard systems to the east wing, west wing, restorative dining room (doors), and south hall exit doors.
- Verification of wander guard placement and use for all residents.
- Review of monitoring tools for door checks, wander guard device checks.
- Staff education on the arming of the door system with the key.
- Continue with wander guard device checks and placement as ordered for those residents at wandering risk.
- Staff education of the Elopement policy and procedures.
- Performance Improvement Plan to assess and monitor progress of the initiatives put into place to avoid further occurrence. Review of PIP with QA&A committee.
- Review of Interdisciplinary Team assessment upon resident admission for residents deemed to be at risk for wandering behaviors, and continuation of wandering resident assessments with updates to elopement book as required.
- All residents re-evaluated for wandering resident risk assessment.
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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