Alwyn C Cashe State Veterans Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Orlando, Florida.
- Location
- 5255 Raymond St, Orlando, Florida 32803
- CMS Provider Number
- 106151
- Inspections on file
- 10
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Alwyn C Cashe State Veterans Nursing Home during CMS and state inspections, most recent first.
A resident’s room was changed from a private room after it was determined that a private room was no longer medically necessary, but the facility only notified the family representative verbally and did not provide the required written notice. The SW documented a telephone notification and recalled discussing the change in person, noting the representative’s dissatisfaction. Despite having a policy that residents or their representatives must receive written notice with the reason for any room change before it occurs, the facility did not issue such written notice, and the NHA reported being unaware that written notification was required in addition to verbal communication.
A resident with dementia, CHF, chronic atrial fibrillation, edema, and a documented pacemaker had active orders for Eliquis, Lasix, Toprol, compression stockings when out of bed, and cardiology follow‑up, and was fully dependent for ADLs per the MDS. Despite this, review of the comprehensive care plan showed it did not address the resident’s edema with compression stockings or the presence and monitoring of the pacemaker. The DON and MDS Coordinator confirmed that these problems and related interventions were missing from the care plan and had not been incorporated in a timely, individualized, and comprehensive manner as required by facility policy.
A resident with dementia, CHF, edema, and chronic venous hypertension had physician orders for Lasix, a cardiology consult, and compression stockings to be applied when out of bed, but the care plan did not address edema with compression stockings. On observation, the resident was seated in a wheelchair without TED hose, with visibly red and swollen lower legs. A CNA reported that TED stockings were normally applied by night-shift CNAs and acknowledged they had not been put on that morning, despite knowing they were required when the resident was out of bed. An LPN documented in the medical record that the compression stockings were on, stating she assumed the task had been completed after being told the resident’s feet were swollen, and facility leadership later confirmed that this documentation was inaccurate.
A resident with dementia, chronic atrial fibrillation, CHF, atherosclerotic heart disease, edema, and a pacemaker had an active physician order for a cardiology consult that was not carried out for more than three months. The resident, dependent for all ADLs and on anticoagulant, diuretic, and antiplatelet therapy, was observed with red, swollen lower extremities. The DON was unaware of the consult status and could not locate any cardiology notes, while the Nurse Scheduler, responsible for arranging outside specialist visits, admitted the cardiology order was overlooked and assumed a prior vascular appointment made the consult unnecessary, despite confirmation that the last cardiology visit had occurred over a year earlier.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised after staff failed to provide adequate supervision and did not ensure that door alarms and electronic wander alert systems were functioning. Staff on duty were unaware of the resident's elopement risk, did not hear any alarms, and did not complete required hourly rounding. Maintenance records confirmed the alarm system was out of order prior to the incident, and no interim monitoring was implemented until after the resident's elopement.
A resident with severe cognitive impairment and a known risk for elopement exited the facility unsupervised after staff failed to provide adequate supervision and did not respond to door or wander alert alarms. The resident was not noticed missing until found outside by a staff member arriving for work, having traversed multiple hazardous areas. Staff interviews confirmed lapses in supervision and alarm response, and the facility's QAPI Committee identified staff supervision and alarm function as contributing factors.
The facility failed to respect residents' rights by not asking for their preferences regarding the use of clothing protectors during meals. Staff were observed placing protectors on residents in the memory care and Patriot Units without consent. The DON confirmed that staff should ask residents before applying protectors, as per facility policy.
A facility's infection prevention program was compromised when a laundry aide improperly folded linen by placing it against their body, risking cross-contamination. Despite the presence of management, no corrective action was taken at the time. The facility's policy requires attention to hygiene, but the aide could not recall their infection control training date, and spot checks by the Infection Preventionist were not documented.
The facility failed to create comprehensive care plans for two residents, one with dementia and diabetes who required specific assistance with eating, and another with cognitive impairment and hearing loss needing communication support. The MDS Coordinator acknowledged the inadequacies in the care plans, which did not address the residents' specific needs.
A facility failed to maintain a clean CPAP machine for a resident with obstructive sleep apnea. The resident's spouse noted that the distilled water in the machine's canister was not emptied daily, and the canister was not left to dry. An RN confirmed the canister was not clean. The care plan lacked interventions for maintaining the CPAP machine, and physician orders did not include cleaning instructions.
The facility failed to prevent medication errors exceeding 5% for residents, with errors involving a Lidocaine patch not removed from a resident's back and medications administered over two hours late. The interim DON acknowledged the high error rate and issues with late documentation.
A facility failed to implement its abuse and neglect policies, resulting in a resident's critically high BNP lab result not being promptly reported to a physician. The RN involved did not ensure the information was communicated to a supervisor or the oncoming shift, and the facility did not remove the staff from resident care during the investigation. Additionally, the facility failed to re-educate all staff on the abuse and neglect prohibition policy after the neglect allegation was substantiated.
A facility failed to monitor a resident's Depakote levels as ordered, missing scheduled lab tests for nearly a year. The resident, with a history of brain injury and mood disorders, was on Divalproex. Despite recommendations for dose reduction, the Consultant Pharmacist's reviews did not address the missing lab tests. The Psychiatric APRN and Consultant Pharmacist were unaware of the oversight, and the facility's policy requiring lab test reviews was not followed.
A facility failed to effectively use its QAPI program to monitor a PIP aimed at preventing recurrence of deficient practices. A resident's critically high lab result, indicative of heart failure, was not promptly reported, leading to hospitalization. The facility's monitoring process was not effectively implemented, and audits were not accessible. Another incident involved an abnormal chest x-ray result not reported for two days, highlighting the failure in the review process.
A resident with a history of heart failure had a critically high BNP level that was not promptly reported to the physician. The responsible RN left messages but did not ensure the physician was informed before her shift ended, and the result was not communicated to a physician until nearly 24 hours later by an LPN. The facility's policy on communication was not followed, leading to a delay in addressing the critical lab result.
A resident with CHF had an abnormal chest x-ray result that was not promptly reported to the physician, leading to a delay in intervention. The x-ray, ordered due to coughing, showed patchy bibasilar infiltrates but was not communicated until two days later, despite being available the day after the order. The resident's condition worsened, requiring hospital transfer. Facility policy requires immediate notification of abnormal results, which was not followed.
A resident with Alzheimer's and severe dementia was improperly restrained in a wheelchair using his shirt, inhibiting his movement and causing psychosocial harm. Staff members, including RNs and CNAs, were aware of the restraint, which was applied without proper assessments or physician orders, violating facility policy.
A resident with severe dementia in a Memory Care Unit was improperly restrained by staff using his shirt to secure him to a wheelchair, without proper assessments or a physician's order. The facility was aware of the resident's behavioral issues prior to admission but failed to implement adequate behavioral monitoring or supervision. Staff interviews revealed a lack of understanding and training regarding restraint use and behavioral management, and the unit was often inadequately staffed, contributing to the deficiency.
A facility failed to effectively use its QAPI program to address an incident where a cognitively impaired resident was found restrained in a wheelchair without proper assessments or a physician's order. The DON acknowledged the restraint was unacceptable, and the facility did not develop a PIP or conduct audits. The Staff Developer's education efforts were insufficient, with discrepancies in attendance records. The QAPI committee did not address the incident in their meeting, and no detailed root cause analysis was conducted.
A resident with Alzheimer's and severe dementia was repeatedly restrained in a wheelchair using his shirt, which was not reported by staff as required by the facility's abuse policy. Multiple staff members observed the restraint but did not report it, and the facility's investigation was incomplete, lacking thorough documentation and failing to report involved licensed staff to appropriate agencies.
Failure to Provide Required Written Notice Before Room Change
Penalty
Summary
The facility failed to provide written notice to a resident’s family representative before making a room change, as required by its own Resident Rights and Resident Notification policy. A male resident, admitted from another nursing home and later readmitted from an acute care hospital, had his room changed on 11/26/25 because a private room was no longer deemed medically necessary. The Social Worker reported that the facility’s practice was to notify residents or their representatives verbally, either in person or by telephone, and maintained a handwritten log of such notifications. The log indicated that the resident’s family representative was called on 11/25/25 and informed of the impending room change, and the Social Worker recalled discussing the change with the representative the following day, noting the representative was unhappy about it. However, there was no written notice provided, despite the facility’s written standards stating that residents or their representatives have the right to receive written notice, including the reason for the room change, before the change is made. The Nursing Home Administrator stated she was not aware that written notification was required in addition to verbal notification.
Failure to Include Pacemaker and Compression Stockings in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop an individualized, comprehensive care plan that addressed a resident’s pacemaker and use of compression stockings. A male resident with dementia, cognitive communication deficit, type 2 diabetes mellitus, chronic venous hypertension with bilateral lower extremity inflammation, atherosclerotic heart disease, chronic atrial fibrillation, CHF, and edema was admitted from another nursing home and later readmitted from an acute care hospital. The hospital transfer form (3008) documented that the resident had a pacemaker, and active physician orders included Eliquis for atrial fibrillation, Lasix for edema and CHF, Toprol for hypertension, compression stockings to be applied when out of bed, and a cardiology consultation. The most recent Quarterly MDS showed moderate cognitive impairment and dependence on staff for all ADLs, and that the resident was receiving high‑risk anticoagulant, diuretic, and antiplatelet medications. On review of the current comprehensive care plan, surveyors found that it did not include the resident’s edema with compression stockings or the presence and monitoring of the pacemaker. The Interim DON confirmed the resident had a pacemaker and could not locate any physician orders to monitor the pacemaker, nor care plan entries for the device or for compression stockings related to edema. The MDS Coordinator stated that comprehensive care plans were developed and revised using the medical record, new orders, face‑to‑face assessments, and IDT discussions, and acknowledged that the care plan for this resident had not been updated to include the pacemaker and compression stockings until the previous evening, despite these needs being present since the beginning. The facility’s written policy required that comprehensive care plans include measurable objectives, interventions, goals, and timetables and be developed within specified time frames, but these elements were not applied to the resident’s pacemaker and compression stocking needs.
Failure to Follow Physician Orders for Compression Stockings and Inadequate Care Planning for Edema
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide ordered compression stockings for a male resident with dementia, type 2 diabetes mellitus, chronic venous hypertension with bilateral lower extremity inflammation, atherosclerotic heart disease, CHF, and edema. The resident was dependent for all ADLs and had active orders for Lasix for edema and CHF, a cardiology consult, and compression stockings to be applied when out of bed. The comprehensive care plan did not include a focus or interventions for edema with compression stockings. During observation, the resident was seen sitting in a reclining wheelchair outside without compression stockings, with bare lower legs visible from the end of his trousers to the top of his socks, and both legs appeared red/dark red and visibly swollen. The assigned CNA stated the resident normally wore TED hose daily and that night shift CNAs usually applied them when residents were gotten out of bed; she acknowledged the resident should have had the stockings on when out of bed and that the previously assigned CNA had not applied them that morning. The assigned LPN stated the resident was supposed to wear TED stockings daily and acknowledged being told earlier that the resident’s feet were swollen; she said she had documented in the medical record that the stockings were on, explaining she assumed the task had been completed. The Unit Manager confirmed that the LPN had documented the stockings as applied and stated nurses were expected to document only after confirming orders were implemented; in a joint observation, the Unit Manager noted the resident’s legs were red and swollen and that the stockings should have been applied. The Interim DON also confirmed that the LPN had signed off that the compression stockings were applied, despite being informed they were not, and the facility assessment indicated the facility provided nursing services for monitoring and management of residents with chronic cardiac conditions.
Failure to Obtain Ordered Cardiology Consultation for Pacemaker Patient
Penalty
Summary
The facility failed to ensure that ordered cardiology services were provided for a male resident with multiple cardiac conditions, including atherosclerotic heart disease, chronic atrial fibrillation, congestive heart failure, and the presence of a pacemaker. The resident was admitted from another nursing home and later readmitted from an acute care hospital, with active physician orders that included Eliquis for atrial fibrillation, Lasix for edema and CHF, Toprol for hypertension, compression stockings, and a cardiology consultation. The resident’s MDS showed moderate cognitive impairment and dependence on staff for all ADLs, and he was receiving high‑risk anticoagulant, diuretic, and antiplatelet medications. During observation, the resident was seen in a reclining wheelchair with both lower legs visibly discolored red/dark red and swollen. Record review and staff interviews revealed that a physician’s order for a cardiology consultation had been in place since 9/18/25, but no cardiology provider notes or evidence of a completed consult were found in the medical record. The Interim DON stated she was unaware of the status of the consult and confirmed the resident, who had a pacemaker, should have had a cardiology consult shortly after the order was written. The Nurse Scheduler, who was responsible for arranging outside specialist appointments, acknowledged that the cardiology consult order had not been completed and stated it had “fell by the wayside.” She reported that she had assumed a prior vascular appointment meant a cardiology consult was not needed and later learned from the cardiology provider that the resident’s last cardiology visit had been more than a year earlier. The facility’s own assessment tool indicated it provided nursing services to manage residents with chronic cardiac conditions, yet the ordered cardiology consultation for this resident was not obtained for over three months.
Failure to Prevent Elopement Due to Inadequate Supervision and Malfunctioning Alarms
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not ensuring staff maintained a secure environment and implemented measures to prevent elopement. A male resident with severe cognitive impairment, Alzheimer's disease, dementia, and a history of wandering was identified as an elopement risk and had interventions in place, including an electronic wander alert bracelet and hourly rounding. Despite these interventions, the resident was able to exit the facility unsupervised during the early morning hours, and his absence went unnoticed by staff for over two hours until he was found by staff arriving for the day shift. Interviews with staff revealed that there were lapses in supervision and communication. The CNAs and the LPN on duty were not fully aware of the resident's elopement risk or the need for specific supervision. The nurse assigned to the unit was an agency nurse unfamiliar with the residents and was not informed about the resident's exit-seeking behavior. Staff did not hear any alarms during the incident, and it was later discovered that the electronic wander alert system and door alarms were malfunctioning. Maintenance records confirmed that the alarm system at the relevant exit door had been out of order prior to the incident, and a vendor had been called for repairs, but no interim measures were put in place to monitor the door until after the elopement occurred. Documentation also showed that staff failed to complete required hourly rounding as indicated in the resident's care plan, with no evidence that rounds were conducted as instructed. The facility's own investigation and root cause analysis confirmed that inadequate supervision and failure to secure the fire exit door after the resident attempted to exit earlier in the shift contributed to the elopement. The lack of functioning alarms and insufficient staff awareness and supervision directly led to the resident's unsupervised exit from the facility.
Removal Plan
- Resident #1 was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. Resident #1 was placed on one-to-one supervision.
- Patient Health Questionnaire (PHQ) evaluations were completed by the Licensed Clinical Social Worker for resident #1 for three consecutive days. Resident #1 did not exhibit any signs or symptoms of mental anguish or distress.
- Employees were assigned to sit near the exit door on every shift until all the alarm settings and door functions were completed. The person designated to monitor the door had full view of the other two doors located on the secured unit.
- Hourly unit monitoring was initiated and facility management increased their presence on the floor.
- The facility conducted an elopement drill and continued daily drills on every shift. Elopement Drills were completed weekly on each shift.
- The maintenance team was educated by the Administrator to ensure doors functioned appropriately and if identified as dysfunctional to immediately initiate door monitoring process, notify the Nursing Home Administrator (NHA), DON and Operations Review Specialist and begin repairs as appropriate.
- Staff education began which included abuse, neglect, responding to alarms, resident monitoring/supervision and accountability. Education was provided to staff on a rolling basis until 95% of staff were educated. Remaining staff will be educated upon return from leave and are scheduled to work.
- All audits for corrective measures were reviewed in the Ad HOC QAPI meetings.
- All audits for corrective measures were reviewed in monthly QAPI meeting and will be reviewed monthly for a minimum of three months or more until substantial compliance is achieved.
- Staff interviews were conducted with 14 staff members representing all shifts to ensure knowledge of elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement, abuse and neglect.
- The resident sample was expanded during the survey to include four additional residents who were at risk for elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations, care plans and physician orders for residents #8 through #11.
Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Issues
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with severe cognitive impairment from eloping. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and a cognitive communication deficit, was identified as an elopement risk and had a care plan in place that included an electronic wander alert bracelet and hourly rounding. Despite these interventions, the resident was able to exit the facility unsupervised during the early morning hours. Staff assigned to monitor the resident did not notice his absence until he was found outside the facility by another staff member arriving for work. Interviews with staff revealed that there were two CNAs and one nurse on duty at the time of the incident. The CNAs reported that they had asked the nurse to watch the residents while they assisted other residents, but the nurse left to administer medications, leaving the residents unsupervised. None of the staff on duty heard any door or wander alert alarms during the shift, and the resident's absence went unnoticed for an extended period. The resident was eventually found in the front vestibule of the facility by a staff member arriving for work, and staff on the unit were unaware he was missing until he was returned. A review of the resident's likely elopement route showed that he exited through a fire exit door, traversed various outdoor areas including a parking lot, a two-lane road, and landscaped beds, before entering the front vestibule. Along the way, he passed potential hazards such as an electric generator, commercial dumpsters, and a retention pond with an unlocked gate. The facility's elopement policy stated that alarms are meant to assist but do not replace necessary supervision, and the root cause analysis by the facility's QAPI Committee determined that staff failed to provide appropriate supervision, with alarm and door function issues also contributing to the incident.
Removal Plan
- Resident #1 returned to the secured unit with facility staff. He was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. Resident #1 was placed on one-to-one supervision.
- Patient Health Questionnaire (PHQ) evaluations were completed by the Licensed Clinical Social Worker for resident #1 for three consecutive days. Resident #1 did not exhibit any signs or symptoms of mental anguish or distress.
- Resident #1 was re-evaluated for elopement risk and the elopement risk care plan was updated.
- Employees were assigned to sit near the exit door on every shift until all the alarm settings and door functions were completed.
- A vendor was called and came in to assess the door and submit work order.
- The red screamer alarm annunciator was changed to alarm continuously until silenced by use of a key.
- All resident wander alert bracelets were checked for all residents identified as at risk for elopement and verified as functional.
- All residents were reassessed for elopement risk and re-evaluated.
- All elopement binders in place were reviewed by Registered Nurse (RN) Supervisor and found to be accurate with 23 residents identified as at risk for elopement. Elopement binders were updated with every new admission, new elopement assessment, discharge and as needed.
- All locations of the wander alert system were evaluated and found to be in working order.
- Maintenance Department staff audited wander alert system for functionality at all locations and conducted daily audits for one month and then weekly thereafter.
- Maintenance checked all doors to ensure they locked and latched; and audited the doors for functionality daily for week then weekly for three months then monthly thereafter.
- Care plans were reviewed for all residents identified to be at risk for elopement.
- Wander alert bracelets are checked daily for functioning and noted on the Treatment Administration Record.
- The facility conducted an elopement drill and continued daily drills on every shift. Elopement Drills were completed weekly on each shift.
- The maintenance team was educated by the Administrator to ensure doors functioned appropriately and if identified as dysfunctional to immediately initiate door monitoring process, notify the Administrator, DON and Operations Review Specialist and begin repairs as appropriate.
- Staff education began which included abuse, neglect, elopement policy and responding to alarms, and door alarm function. Remaining staff will be educated upon return from leave and are scheduled to work.
- The magnetic lock on the fire exit door was repaired.
- The elopement/wander alert device was upgraded on the identified fire exit door.
- All audits for corrective measures were reviewed in the Ad HOC QAPI meetings.
- All audits for corrective measures were reviewed in monthly QAPI and will be reviewed monthly for a minimum of three months or more until substantial compliance is achieved.
- Interviews were conducted with staff members representing all shifts. Staff interviews revealed they were knowledgeable of the elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement, abuse and neglect.
Failure to Respect Residents' Preferences for Clothing Protectors
Penalty
Summary
The facility failed to honor the residents' rights to self-determination and dignity by not recognizing their individual preferences regarding the use of clothing protectors during meals. On multiple occasions, staff members were observed placing clothing protectors on residents in the memory care unit and the Patriot Unit without first asking for their consent or preference. Specifically, on February 24th, staff were seen putting clothing protectors on 19 residents in the Freedom memory care unit dining room without inquiring if they wanted them. Similarly, on February 25th, a CNA was observed doing the same for residents in the Patriot Unit. On February 27th, another CNA admitted to placing clothing protectors on residents without asking for their preference, explaining that she assumed they were accustomed to wearing them. The Director of Nursing and the Regional DON were unaware of this practice and confirmed that staff should ask residents for their preference before putting on clothing protectors. The facility's policy, dated June 5, 2020, states that staff should offer clothing protectors to residents, indicating a failure to adhere to established guidelines and respect residents' rights.
Improper Linen Folding Techniques Lead to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper linen folding techniques observed in the laundry area. During an observation, a laundry aide was seen folding a bed sheet by placing it against their body, which is against proper hygiene protocols. Despite the presence of the administrator, housekeeping manager, and laundry supervisor, none of the managers corrected the aide's actions, leading to potential cross-contamination when the bed sheet was tossed onto previously folded items. The housekeeping manager acknowledged the issue by stating the bed sheet would be re-washed, but the administrator could not explain why the staff was not corrected at the time. The facility's policy on laundry workers emphasizes the importance of attention to detail and hygiene in folding clothes, yet the laundry aide could not recall the date of their infection control training. The Infection Preventionist mentioned that the laundry supervisor is responsible for training staff on infection control and conducts random spot checks, although these checks are not documented. The Infection Preventionist also highlighted the need for managers to intervene when they observe breaches in infection control, suggesting that staff need reminders to avoid falling into bad habits.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #49, who was admitted with diagnoses including dementia and type 2 diabetes, had a care plan that noted a feeding self-care deficit but did not specify the level of assistance required for eating and drinking. This lack of detail in the care plan was highlighted by the resident's wife, who expressed concern about his weight loss and insufficient assistance with meals. The MDS Coordinator acknowledged the care plan's inadequacy in specifying the necessary assistance level. Resident #10, admitted with conditions such as Parkinson's disease and vascular dementia, had a severe cognitive impairment and moderate hearing difficulty. Despite these challenges, the facility did not develop a comprehensive care plan to address his communication deficit related to hearing loss. The MDS Coordinator confirmed that a care plan should have been created to address this triggered area, as indicated by the Care Area Assessment. The failure to develop these care plans reflects a significant oversight in meeting the residents' needs.
Failure to Maintain Clean CPAP Machine for Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident's CPAP machine, which is essential for managing obstructive sleep apnea (OSA). Resident #49, who was admitted with multiple diagnoses including dementia, metabolic encephalopathy, dysphagia, OSA, and Diabetes Mellitus Type II, was dependent on staff for all activities of daily living. On February 26, 2025, the resident's spouse reported that the distilled water in the CPAP machine's canister was not being emptied daily as required, and the canister was not being left to dry. An observation by RN C confirmed that water remained in the canister and it was not clean. Although RN C stated that it was everyone's responsibility to clean the machine, the night shift staff was specifically responsible for handling the CPAP machine. The physician orders did not include instructions for cleaning the machine, and the care plan lacked interventions to ensure the CPAP machine was maintained in a clean condition.
Medication Administration Errors Exceed 5% in Facility
Penalty
Summary
The facility failed to prevent medication errors greater than 5% for three of four residents sampled for medication administration. Specifically, Resident #29, who was admitted with diagnoses including unspecified dementia and chronic leg ulcer, experienced a medication error when a Lidocaine patch was not removed from the previous day before a new one was applied. Additionally, the Lac-Hydrin lotion was administered two hours late. The Medication Administration Record indicated that the patch should have been removed the night before, but it was not, leading to the error. Resident #18, admitted with conditions such as Alzheimer's disease and atrial fibrillation, also experienced medication errors. The resident's medications, including Eliquis and Sertraline, were administered over two hours late. The nurse responsible for administering these medications cited difficulties in knowing the residents and their locations as reasons for the delay. The interim Director of Nursing acknowledged the medication error rate and the issue with late medication administration, noting that the facility had a liberal medication pass policy and issues with late documentation.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its policy and procedures for the prohibition of abuse and neglect, specifically in providing staff education, conducting a thorough incident investigation, and protecting residents in response to an allegation of neglect. This deficiency was identified in the case of a resident who had a critically high BNP laboratory result that was not promptly reported to a physician. The resident, who had a history of dementia, hypertension, atrial fibrillation, and a cardiac pacemaker, was later diagnosed with acute on chronic congestive heart failure after being transferred to the hospital. The Registered Nurse (RN) responsible for the resident's care received notification of the abnormal lab result but only left a voicemail for the physician and did not ensure the information was communicated to a supervisor or the oncoming shift. The facility's Risk Manager confirmed that the RN did not follow up appropriately, and the neglect allegation was substantiated. The Interim Director of Nursing stated that the expectation was for nurses to speak directly with a provider about abnormal results, and if unsuccessful, to escalate the issue to a supervisor. Additionally, the facility did not remove the involved staff from resident care during the investigation, as required by their policy. The Risk Manager and Administrator acknowledged that the facility did not follow its procedures for protecting residents during the investigation period. Furthermore, the facility failed to re-educate all staff on the abuse and neglect prohibition policy and procedures after the neglect allegation was substantiated, as the Staff Developer was not informed of the need for re-education upon returning from leave.
Failure to Monitor High-Risk Drug Levels
Penalty
Summary
The facility failed to conduct a thorough medication regimen review and ensure adequate monitoring of a high-risk drug for a resident. The resident, a male with a history of traumatic brain injury, dementia, and mood disorders, was prescribed Divalproex for mood disorder. The physician ordered laboratory tests to monitor the resident's Depakote levels every three months, but these tests were not conducted as scheduled in June, September, and December 2024. The Consultant Pharmacist's monthly reports recommended a gradual dose reduction for the resident's Divalproex in July and December 2024, which the physician declined. However, the reports did not address the absence of the required laboratory tests. The Interim DON confirmed that the tests were not conducted at the required intervals and acknowledged that the missing lab tests should have been identified during the monthly reviews by the consultant pharmacist. Interviews with the Psychiatric APRN and the Consultant Pharmacist revealed a lack of awareness and oversight regarding the monitoring of the resident's Depakote levels. The Psychiatric APRN admitted to an oversight in not noticing the missing lab tests, while the Consultant Pharmacist stated that laboratory tests were the responsibility of the nursing department and were not part of her monthly review tasks. The facility's policy indicated that the medication regimen review should include laboratory test results, but this was not adhered to, leading to the deficiency.
Failure to Monitor Critical Lab Results
Penalty
Summary
The facility failed to effectively utilize its Quality Assurance and Performance Improvement (QAPI) program to monitor a Performance Improvement Project (PIP) aimed at preventing the recurrence of deficient practices. Specifically, the facility did not ensure timely and appropriate follow-up on critical laboratory results for one of the residents reviewed. The issue was identified when the Risk Manager (RM) discovered that a critically high laboratory result, indicative of heart failure, was not promptly reported to the physician, leading to the resident's hospitalization with a new diagnosis of congestive heart failure. The facility initiated a PIP to address the issue of critical lab results not being followed up and addressed in a timely manner. However, the monitoring process, which involved daily use and review of the 24-hour report, was not effectively implemented. The RM indicated that nurses failed to document the critical test result on the 24-hour report, and there was no communication at the change of shift to ensure continuity of care. Additionally, the audits intended to ensure all critical and abnormal laboratory test results were noted and reported were not accessible, as the previous Director of Nursing (DON) might have shredded or discarded them. Further investigation revealed another incident where an abnormal chest x-ray result was not reported to the provider for two days, despite the facility's interventions to prevent such occurrences. The RM acknowledged that if the 24-hour report had been reviewed according to the auditing process, the DON or the Unit Manager should have followed up. The lack of documentation of audits and review of findings by the QAPI committee made it impossible to evaluate the effectiveness or success of the existing PIP.
Failure to Promptly Report Critical Lab Result
Penalty
Summary
The facility failed to promptly report a critical laboratory result to the ordering physician for one resident. The resident, a male with a history of dementia, hypertension, atrial fibrillation, and a cardiac pacemaker, was readmitted to the facility with acute on chronic congestive heart failure. A critically high Brain Natriuretic Peptide (BNP) level was reported to the facility, but the responsible nurse, RN A, did not ensure the physician was notified before the end of her shift. RN A received the critical BNP result and attempted to contact the physician by leaving messages but did not take further steps to ensure the physician was informed. There was no evidence that RN A communicated the critical result to a supervisor or the oncoming shift nurse. Consequently, the critical result was not reported to a physician until almost 24 hours later by LPN C, who discovered the oversight upon reviewing the resident's medical record. The Interim Director of Nursing stated that the expectation was for nurses to immediately notify medical providers of abnormal test results and to escalate the issue if necessary. The facility's policy emphasized the importance of communication between clinical team members, including the need for a complete oral report during shift changes. However, this protocol was not followed, leading to a delay in notifying the physician of the critical laboratory result.
Failure to Promptly Report Abnormal X-ray Results
Penalty
Summary
The facility failed to promptly report an abnormal chest x-ray result to the ordering physician for a resident diagnosed with acute on chronic congestive heart failure (CHF). The resident, a male with a history of dementia, hypertension, atrial fibrillation, and a cardiac pacemaker, was readmitted to the facility with CHF and later transferred to the hospital. On 1/14/25, a chest x-ray was ordered due to the resident's coughing, but the result, which showed patchy bibasilar infiltrates, was not communicated to the physician until 1/17/25, despite being available on 1/15/25. The delay in reporting the abnormal x-ray findings resulted in a lack of timely intervention, as the resident's condition worsened, leading to shortness of breath and low oxygen saturation levels. The Interim Director of Nursing stated that nurses are expected to immediately notify medical providers of abnormal test results, but there was no documentation of such notification until two days after the x-ray was completed. The facility's policy emphasizes the importance of communication between clinical team members, particularly regarding abnormal x-rays, but this protocol was not followed in this instance.
Improper Use of Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which resulted in psychosocial harm. The resident, a male with Alzheimer's disease and severe dementia, was admitted to the facility with a history of agitation, falls, and cognitive impairments. Despite the resident's care plan indicating no use of restraints, staff members used the resident's clothing to restrain him in his wheelchair, inhibiting his movement and potentially causing harm. Multiple staff members, including the Director of Nursing, Registered Nurses, and Certified Nursing Assistants, were aware of the use of the resident's shirt as a restraint. The restraint was applied by pulling the shirt over the back of the wheelchair, effectively securing the resident and preventing him from standing or moving freely. This action was taken without proper assessments, physician orders, or informed consent, violating the facility's policy on restraint use. The report includes several accounts from staff members who observed the resident restrained in his wheelchair. Some staff members expressed concern about the safety and appropriateness of the restraint, while others justified its use due to the resident's agitated behavior. The facility's policy clearly states that any device restricting a resident's movement is considered a restraint, and the use of such restraints requires a thorough evaluation and physician order, which was not obtained in this case.
Inadequate Staffing and Training in Memory Care Unit Leads to Improper Restraint
Penalty
Summary
The facility failed to ensure that the Memory Care Unit had sufficient staff with the appropriate competencies and skills to meet the behavioral health needs of its residents, particularly for one resident with severe dementia and agitation. This resident, who had a history of Alzheimer's disease, sundowning, and exit-seeking behaviors, was physically restrained by nursing staff using his shirt to secure him to a wheelchair. This action was taken without proper assessments or a physician's order, which is against the facility's policy. The Director of Nursing (DON) acknowledged that the use of any type of restraint was unacceptable without the proper assessments and a physician order. The report highlights that the facility was aware of the resident's behavioral issues prior to admission, as indicated in the Application for Admission and the Hospital Discharge Summary. Despite this, the facility did not implement adequate behavioral monitoring or supervision. The resident's medication schedule was altered without apparent justification, and pain management was delayed, potentially exacerbating his agitation. The facility's staff, including the DON, failed to initiate behavior monitoring as a scheduled task, and there was no evidence of increased supervision or specific behavioral management approaches during periods of extreme agitation. Interviews with staff revealed a lack of understanding and training regarding the use of restraints and behavioral management for residents with dementia. Several staff members, including CNAs and RNs, admitted to not recognizing the use of the shirt as a restraint and were uncertain about the facility's policies on abuse, neglect, and restraint use. The facility's staffing levels were also inadequate, with only one CNA often assigned to the Memory Care Unit during night shifts, which was insufficient to meet the care and safety needs of the residents. This lack of adequate staffing and training contributed to the inappropriate use of restraints and the failure to provide necessary care and supervision for the resident involved.
Failure to Address Unauthorized Restraint Incident
Penalty
Summary
The facility failed to utilize its Quality Assurance and Performance Improvement (QAPI) program effectively to identify the root cause of an incident involving the unauthorized restraint of a cognitively impaired resident. The incident occurred when a speech therapist found the resident restrained in a wheelchair with a sweater hooked over the handles. The resident was known to be agitated, sometimes aggressive, and at risk for falls, but the restraint was applied without proper assessments or a physician's order. The Director of Nursing (DON) acknowledged that the restraint was unacceptable and confirmed that the facility did not develop a performance improvement plan (PIP) or conduct audits following the incident. The Staff Developer was responsible for educating staff on abuse, neglect, and restraint protocols after the incident. However, the education was verbal, and no post-test was given to validate comprehension. The attendance sheets showed discrepancies, with only about 50% of the facility staff having signed, contrary to the 80% reported by the Staff Developer. Additionally, there were duplicate signatures, and some signatures were from non-employees, indicating a lack of thoroughness in the educational process. The QAPI committee, which included the Administrator, Medical Director, DON, Risk Manager, and department heads, did not address the incident in their meeting held the day after the mandatory reports were submitted. The committee discussed issues from the previous month, and the restraint incident was not on the agenda. The DON confirmed that the facility did not conduct a detailed root cause analysis and did not explore other possible causative factors such as staffing ratios or the need for specialized education for staff in the Memory Care Unit.
Failure to Report and Document Unauthorized Restraint Use
Penalty
Summary
The facility failed to implement its abuse prohibition policy and procedures by not ensuring that frontline staff recognized and reported the use of an unauthorized physical restraint on a resident. The resident, a male with Alzheimer's disease and severe dementia, was found restrained in his wheelchair with his shirt pulled over the handles, which restricted his movement. This incident was observed by multiple staff members, including RN Supervisors and CNAs, but was not reported to the Director of Nursing (DON) or the Administrator as required by the facility's policy. The investigation revealed that the restraint was not an isolated incident, as the resident was restrained on multiple occasions. Staff members, including RN Supervisors and CNAs, witnessed the resident being restrained but did not report it, either because they were unaware it was considered a restraint or because they deferred to the judgment of others. The facility's investigation confirmed that the use of the resident's shirt as a restraint was verified as physical abuse, yet the findings were not thoroughly documented, and the involved licensed staff were not reported to the appropriate agencies. The facility's investigation was incomplete and lacked thorough documentation of the incidents. The DON and Risk Manager acknowledged that the investigation report did not clearly indicate that the use of the restraint was not a one-time occurrence. Additionally, video footage that could have provided further evidence was not preserved, and the facility's final report failed to include all relevant findings. The facility's failure to report the incidents appropriately and to document the investigation findings accurately contributed to the deficiency.
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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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