Ybor City Center For Rehabilitation And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Tampa, Florida.
- Location
- 1709 Taliaferro Ave, Tampa, Florida 33602
- CMS Provider Number
- 105891
- Inspections on file
- 20
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Ybor City Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of dementia repeatedly complained of left wrist and arm pain and developed swelling and an abnormal arm position over several weeks. An LPN initially notified an ARNP, who ordered a hand/wrist X‑ray and PRN Tylenol; the X‑ray was negative, and the resident’s representative was told the results were clear. A PTA later reported ongoing wrist pain to nursing, and Pain Management documented significant pain with movement and ordered routine Tylenol and topical gel, but no further nursing assessments were documented. During a routine visit, the ARNP did not document a focused assessment of the left upper extremity. The resident’s representative observed worsening swelling and severe pain with minimal touch, made multiple unsuccessful attempts to reach the DON by phone, and ultimately insisted in person that the resident be sent to the hospital. After the Medical Director noted over four weeks of arm swelling and pain and inability to perform range of motion, the resident was transferred to the emergency room, where a longstanding left shoulder dislocation was diagnosed.
A resident with severe frailty, contractures, and multiple comorbidities was admitted for respite care and assessed as high risk for pressure wounds. Despite physician recommendations for frequent repositioning, use of positioning supports, and pressure-relieving devices, these interventions were not included in the care plan or consistently provided. The resident developed multiple new pressure wounds, leading to severe infection and subsequent amputation, with staff confirming that key preventive measures were not implemented.
The facility did not maintain an effective pest control program, as live roaches and flies were observed in two rooms across different halls. Staff reported frequent pest sightings but failed to consistently document them in pest sighting logbooks, and unapproved pesticide sprays were used inside the building. Personal items were exposed to chemicals, and food trays were left in resident rooms, contributing to the pest problem. The facility's pest control policy was not consistently followed, and grievances about pests remained unresolved.
A resident with severe cognitive impairment and expressive aphasia was repeatedly administered medication against her will by an LPN, who held the resident's nose and mouth closed after she refused and spit out the medication multiple times. The incident was witnessed by two CNAs, and the resident verbally expressed refusal throughout the event. Facility policy and leadership confirmed that residents have the right to refuse medications, which was not honored in this case.
A resident with severe cognitive impairment and dementia was subjected to physical force by an LPN during medication administration after repeatedly refusing to take her medication. The LPN held the resident's nose and mouth closed while using a syringe to administer the medication, despite the resident's verbal refusals and care plan instructions to respect refusals and use redirection. The incident was witnessed by two CNAs and later reported to the DON, with the LPN admitting to the action.
Medications, including prescription and OTC drugs, were found unsecured in unlocked cabinets, a medication refrigerator, and a treatment cart on two units. These storage areas were accessible to residents, visitors, or unlicensed staff, and staff interviews confirmed that medications should have been locked at all times according to facility policy.
The facility failed to provide adequate ADL care, including showering and incontinence care, for several residents. One resident with multiple health issues received insufficient showers and incontinence care documentation. Another resident, admitted for knee replacement rehab, lacked documentation for toilet use assistance. A third resident with cognitive impairments missed scheduled baths, with inadequate documentation of care. Staff interviews confirmed these deficiencies, indicating systemic issues in care plan execution and documentation.
The facility failed to ensure that four residents had access to the call light system. Observations showed that call lights were placed out of reach for these residents, with confirmation from an LPN and the DON. The residents had varying levels of cognitive and physical impairments, and the facility's CNA job description required prompt response to call lights, which was not met.
A resident admitted with multiple health issues did not receive timely physical and occupational therapy services due to the absence of the Director of Rehabilitation, who failed to arrange adequate coverage. The delay in therapy initiation was not communicated to the Director of Nursing or the Nursing Home Administrator, leading to a significant oversight in care.
A facility failed to maintain accurate medical records for a resident, leading to a deficiency. The resident's admission records contained incorrect language documentation, and there was incomplete documentation for ADLs and nursing progress notes. The discharge Against Medical Advice (AMA) lacked sufficient details. Interviews revealed staff were unaware of specific medications given and reasons for the AMA discharge, and the facility lacked a skilled nursing policy.
Failure to Timely Assess and Escalate Care for Persistent Upper Extremity Pain and Swelling
Penalty
Summary
The deficiency involves the facility’s failure to timely and adequately address a resident’s ongoing left upper extremity pain and swelling despite multiple reports and observable changes in condition. The resident was admitted with dementia, severe cognitive impairment (BIMS score of 6), muscle weakness, and chronic kidney disease. On 1/7/2026, nursing documented that the resident was yelling that her hand hurt, and an ARNP was notified, who ordered an X‑ray of the hand/wrist and PRN Tylenol. The X‑ray on 1/7/2026 showed no fracture, anatomic alignment, and no soft tissue swelling. The resident’s RR was informed that the X‑ray was clear. A change in condition report was completed that same day for hand pain, but no further documented nursing assessment of the left upper extremity followed after this initial workup. On 1/9/2026, a PTA performing a quarterly therapy screen noted that the resident complained of left wrist pain and resisted giving her hand when positioned on her side. The PTA reported these concerns to the unit nurse and documented them on a communication form, but the medical record contained no subsequent nursing assessment by an LPN in response to this report. Pain Management evaluated the resident starting 1/17/2026 for left wrist pain and swelling and ordered routine Tylenol and a topical gel. The Pain Management provider later stated he did not perform range of motion because the resident was in too much pain when her wrist was moved and that he relied on nursing to report further pain, which they did not. The ARNP saw the resident again on 2/3/2026 for a routine visit and acknowledged being aware of prior pain and discomfort in the left hand and wrist, but her progress note contained no documented range of motion or focused assessment of the left hand, wrist, or shoulder; she later stated she did not know why she failed to document her assessment. During this period, the resident’s RR observed progressive changes. After being told the initial X‑ray was clear, he visited about a week later and noticed swelling of the arm and an abnormal hanging position of the hand. When he lightly touched the arm above the wrist, the resident screamed in pain. He reported this to nursing and made multiple phone calls requesting to speak with the DON about the plan of care but did not receive a return call. Eventually, he went to the facility, located the DON, and showed her the resident’s arm; when the DON and physician touched the arm, the resident again screamed in pain. The RR insisted on hospital transfer, while the DON initially suggested trying other in‑house measures. A nursing note dated 2/10/2026 documented that the RR requested emergency room evaluation for left hand/wrist edema and pain and a provider change. The Medical Director examined the resident that day, noting left arm swelling and pain present for over four weeks, the resident’s refusal to allow range of motion, and the inability to fully examine the axilla. He agreed with the RR to send the resident to the emergency room for immediate imaging. At the hospital, the resident was found to have a left shoulder dislocation that could not be reduced, and the hospital physician documented that the shoulder appeared to have been dislocated for a long time. The facility’s change‑in‑condition policy required prompt notification and documentation of changes in condition, but the facility was unable to provide an assessment change‑in‑condition policy beyond the general notification policy, and the record lacked timely, thorough nursing assessments in response to repeated reports of pain and swelling. Additional staff interviews corroborated that the resident repeatedly voiced pain without corresponding documented follow‑up assessments. A CNA recalled hearing the resident yelling in pain while passing meal trays and reported this to the nurse, after which she only heard that an X‑ray had been done. An LPN stated that about a month before the hospital transfer, a CNA reported the resident’s hand pain; she observed some swelling, notified the ARNP, and obtained the initial X‑ray and PRN Tylenol, but she did not describe any further systematic reassessment after the negative X‑ray. The DON stated that her expectation was that when another discipline reported a change in condition, the nurse should notify the physician and family and complete a change‑in‑condition note, with follow‑up documentation that the physician and family were made aware. She also stated that 2/10/2026 was the first time she personally assessed the resident and observed that the resident was in pain and unable to move her arm. The combination of repeated complaints of pain, observed swelling and abnormal arm positioning, lack of documented follow‑up assessments after therapy and Pain Management reports, and delayed escalation to hospital evaluation led to the discovery of a longstanding left shoulder dislocation. The facility’s own documentation and staff statements show that, despite multiple indicators of a persistent and worsening problem with the resident’s left upper extremity, there was no timely, comprehensive reassessment or escalation of diagnostic evaluation beyond the initial negative hand/wrist X‑ray and symptomatic treatment with Tylenol and topical gel. The ARNP’s lack of documented assessment of the left upper extremity during the 2/3/2026 visit, the absence of nursing assessments following therapy’s 1/9/2026 report of continued wrist pain, and the failure of the DON to respond to multiple calls from the RR about the resident’s condition all contributed to the delay in identifying the true source of the resident’s pain. Ultimately, the resident’s RR’s insistence on hospital transfer prompted the emergency room evaluation that revealed the left shoulder dislocation, which the hospital physician believed had been present for at least a month.
Failure to Implement Pressure Injury Prevention Measures for High-Risk Resident
Penalty
Summary
A resident with a history of Alzheimer's disease, dementia, prior CVA with right-sided contractures, right lower extremity osteomyelitis, and multiple comorbidities was admitted for respite care. Upon admission, the resident was assessed as being at high risk for pressure wounds due to severe frailty, immobility, and peripheral vascular disease. Physician recommendations included frequent turning and repositioning, use of positioning supports such as wedges and heel protectors, pressure redistributing mattress, and daily wound care. However, these recommendations were not transcribed into the resident's care plan or implemented in daily care routines. During the resident's stay, the baseline plan of care only included general interventions such as daily skin inspection, moisturizing, and encouraging nutrition, but omitted specific physician-ordered interventions for pressure injury prevention. Staff interviews and record reviews revealed that the resident was not provided with an air mattress, heel boots, or adequate offloading supports, despite these items being available in facility supply. Documentation in the Treatment Administration Record showed completion of some skin care interventions, but there was no evidence of regular turning, repositioning, or use of pressure-relieving devices as ordered. The wound care nurse and DON were unaware of the resident's deteriorating skin condition until notified by the resident's representative. The deficiency was identified when the resident's representative discovered multiple new pressure wounds on the resident's right foot, heel, and knee, which were not present prior to admission. The wounds were severe enough to require emergency transfer to the hospital, where the resident was diagnosed with severe sepsis and ultimately underwent a right foot amputation. Facility staff confirmed that the required interventions for pressure injury prevention were not consistently implemented, and the care plan did not reflect the physician's recommendations for high-risk skin care management.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of live roaches in two resident rooms located in separate halls. Observations revealed several roaches behind a nightstand and under an armoire/closet in one room, as well as flies and a food tray left on a resident's bed in another. Staff interviews confirmed ongoing sightings of roaches in these areas, with staff reporting that pests persist despite regular exterminator visits. Staff also indicated that they often notify maintenance verbally but do not document pest sightings in the designated logbooks, contrary to facility policy. Additionally, staff were observed using unapproved pesticide sprays inside the facility, and personal resident items were exposed to these chemicals during attempts to control pests. A review of pest sighting logbooks showed inconsistent and incomplete documentation, with exterminator invoices noting a lack of reported activity and requesting improved use of the logbooks. The facility's policy requires staff to report and document pest sightings, use only approved pest control measures, and remove residents from affected areas until control measures are implemented. However, interviews with staff and the NHA revealed that these procedures were not consistently followed, and grievances regarding pest issues remained unresolved at the time of the survey.
Failure to Honor Resident's Right to Refuse Medication
Penalty
Summary
A resident with severe cognitive impairment, vascular dementia, psychosis, and major depressive disorder was observed to have her right to refuse medication violated. The resident's care plan acknowledged her history of refusing medications and outlined interventions such as explaining procedures, allowing time for adjustment, and leaving and returning later if care was resisted. Despite these interventions, staff did not honor the resident's repeated verbal refusals of medication. On the day of the incident, the resident was being assisted by two CNAs when an LPN attempted to administer her medication. The resident spit out the medication twice when offered on a spoon. The LPN then left the room, returned with a syringe, and administered the medication by holding the resident's nose and mouth closed until she swallowed, despite the resident verbally expressing refusal. Both CNAs present witnessed the event and reported that the resident was saying, "I don't want it, I don't want it," during the process. The LPN admitted to using this method to ensure the resident took her medication, stating it was not done maliciously and referencing the resident's history of being combative when not medicated. The facility's policy and the Director of Nursing confirmed that residents have the right to refuse medications and that such rights must be honored, especially for those with cognitive impairments. The incident was also documented in a psychiatric note, which confirmed the nurse's actions and the resident's difficulty with communication due to expressive aphasia.
Resident's Rights Violated During Medication Administration
Penalty
Summary
A resident with severe cognitive impairment, vascular dementia, psychosis, and major depressive disorder was observed to have her rights violated when a nurse used physical force to administer medication. The resident, who had a history of being resistive to care and difficulty communicating due to expressive aphasia, repeatedly refused her medication by spitting it out. Despite this, the nurse attempted to administer the medication multiple times, ultimately resorting to holding the resident's nose and mouth closed while using a syringe to force the medication into her mouth. Multiple staff members witnessed the incident and reported that the resident verbally expressed her refusal by saying, "I don't want it, I don't want it." The nurse admitted to the action, stating that she did not act maliciously and referenced using a similar method with her own children. The incident was documented in a psychiatric note, which confirmed the nurse's admission and the resident's ongoing difficulty with communication and resistance to care. The facility's policy prohibits all forms of abuse, including physical abuse, and requires immediate reporting of any alleged violations. The actions taken by the nurse were inconsistent with the resident's care plan, which emphasized respecting refusals, using redirection, and allowing time for the resident to adjust. The incident was not immediately reported by the witnessing CNAs, but was later brought to the attention of the Director of Nursing, who confirmed that the resident's right to refuse medication should have been honored.
Failure to Secure Medication Storage Areas
Penalty
Summary
Medications, including prescription and over-the-counter (OTC) drugs, were observed to be improperly stored and unsecured on two units within the facility. On the 400-unit, the nurses' station door was left open with no staff present, and both the medication refrigerator and cabinets containing OTC medications were unlocked and accessible. These conditions persisted during multiple observations throughout the day, with photographic evidence obtained. On the 300-unit, a treatment cart containing prescription medications and wound care supplies was left unlocked and unattended in a resident common area. Staff interviews confirmed that the medication storage areas should have been locked at all times and accessible only to authorized personnel. An LPN acknowledged that the refrigerator and cabinet should have been secured but had not yet been locked. The DON stated that it was her expectation that all medication storage areas, including treatment and medication carts, remain locked when not in use. Facility policy also requires all medications, except for emergency drug kits, to be stored in locked areas accessible only to authorized staff.
Deficiencies in ADL Care and Documentation
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADLs) care, specifically in showering and incontinence care, for several residents. Resident #2, who had multiple health issues including acute respiratory failure, COPD, and muscle weakness, required assistance with toileting and showering. Despite care plans indicating the need for regular showers and incontinence checks, documentation showed that Resident #2 received only two showers in October 2024 and had significant gaps in incontinence care documentation. Interviews with staff confirmed the lack of documentation and adherence to the care plan. Resident #3, admitted for rehabilitation after a knee replacement, also experienced deficiencies in care. The resident required assistance with transfers and toilet use, but documentation for bladder and bowel elimination was missing for several shifts. Interviews revealed that staff failed to document the resident's needs and care provided, despite the resident's requirement for assistance due to mobility issues. Resident #4, who had cognitive impairments and required total assistance with ADLs, was not bathed according to the facility's schedule. Documentation showed missed shower opportunities and inadequate recording of bathing activities. Staff interviews confirmed the lack of adherence to the bathing schedule and the absence of documentation for refusals or alternative care provided. These deficiencies highlight a systemic issue in the facility's documentation and execution of care plans for residents requiring assistance with daily living activities.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that four residents had access to the call light system, as observed during a survey. Resident #5 was found lying in bed with the call light pull string placed on a bedside dresser, out of reach, and obscured by boxes. Resident #6's call light was positioned behind and above the resident, making it inaccessible. Staff B, an LPN, confirmed that both residents could not reach their call lights. Resident #5 had a BIMS score indicating intact cognition, while Resident #6 had severe cognitive impairment. Further observations revealed that Resident #9's call light was on the floor, wrapped around the bed control cord, and Resident #10's call light was on a bedside dresser, out of reach. The Director of Nursing confirmed the inaccessibility of the call lights for these residents. Resident #9 had intact cognition, while Resident #10 was blind with intact cognition. The facility's job description for CNAs included the responsibility to ensure call lights are promptly answered, highlighting a failure in meeting this standard.
Failure to Provide Timely Therapy Services
Penalty
Summary
The facility failed to provide timely therapy services for a resident, identified as Resident #2, who was admitted with multiple diagnoses including acute respiratory failure with hypoxia, COPD, and muscle weakness. The resident required both physical and occupational therapy five times a week as per physician orders. However, there was a delay in initiating these therapy services, with physical therapy starting on 10/12/2024 and occupational therapy on 10/14/2024, despite the resident being admitted on 10/7/2024. The delay in therapy services was attributed to the absence of the Director of Rehabilitation (DOR), who was out ill and did not arrange for adequate coverage. The DOR admitted that the resident might have been missed and acknowledged that under Medicare guidelines, evaluations should occur within 48 hours. The DOR also mentioned that a therapist was available on 10/12/2024, but the resident was not on the schedule. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were also unaware of the lapse in therapy services. Interviews with facility staff revealed a lack of communication and planning to ensure continuity of care during the DOR's absence. The facility's policy required physician orders to be validated by therapists before initiating therapy services, but this process was not effectively managed. The failure to provide timely therapy services was a significant oversight, as the resident was at risk for various complications without the necessary therapeutic interventions.
Deficiency in Medical Record Maintenance and Communication
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, leading to a deficiency in safeguarding resident-identifiable information. The resident was admitted following a hospital stay with several diagnoses, including an artificial knee joint and anxiety disorder. However, discrepancies were found in the resident's admission records, such as incorrect language documentation, which stated the resident spoke Spanish instead of English. Additionally, the continence evaluation was incomplete, and there was a lack of documentation for the resident's Activities of Daily Living (ADLs) during specific shifts. Furthermore, there were no nursing progress notes for a particular day, and the documentation regarding the resident's discharge Against Medical Advice (AMA) was insufficient, lacking details about communication with the physician or facility administration. Interviews with facility staff revealed further issues. The Director of Nursing (DON) admitted to working a shift without recalling specific medications given to the resident and was unaware of the reasons behind the resident's AMA discharge. The Nursing Home Administrator (NHA) and Social Services Director (SSD) confirmed the absence of necessary documentation and noted the transition of the Risk Manager position during the period in question. The facility lacked a skilled nursing policy, which contributed to the incomplete documentation and communication failures regarding the resident's care and discharge.
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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