Birchwood Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sarasota, Florida.
- Location
- 3250 12th St, Sarasota, Florida 34237
- CMS Provider Number
- 105389
- Inspections on file
- 25
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Birchwood Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that multiple residents had unsecured medications left at bedside, including melatonin gummies, eye vitamins, nasal decongestant spray, antacid tablets, arthritis powder, and vaporizing rub stored on nightstands and overbed tables. Nursing staff, the ADON, and the DON all stated that medications should not be kept unlocked in resident rooms and should instead be locked in a med cart or, for residents with self-administration orders, in a locked box. The facility’s written policy requires all drugs and biologicals to be stored in locked compartments and specifies that compartments containing medications must be locked when not in use.
Surveyors found that the facility's designated resident smoking area in the courtyard lacked a required self-closing metal butt can for cigarette disposal, as mandated by NFPA 101. The Maintenance Director confirmed the absence of this fire safety equipment during the inspection.
A resident with right-sided hemiplegia and aphasia, dependent on staff for ADLs, did not receive ordered passive range of motion (PROM) exercises or brace application as documented in the care plan and physician's orders. Staff interviews revealed a lack of awareness and implementation of these interventions, and review of the Treatment Administration Record showed no documentation of the required care, resulting in a deficiency for failure to maintain or improve range of motion.
Surveyors identified expired medications in two medication carts during a review, including an expired bottle and a gel for a resident that was past its use date. The facility's policy requires checking expiration dates before administration, but the DON confirmed expired medications should not be present and noted that cart checks occur weekly but need better follow-through.
A medication error rate of 8% was identified when an LPN crushed and administered two extended-release medications to a resident, despite both being contraindicated for crushing. The facility's policies and physician orders required staff to avoid altering medications when contraindicated, and both the consultant pharmacist and DON confirmed the error. This deficiency was observed during a survey and was based on direct observation, record review, and staff interviews.
The facility did not ensure RN coverage for at least 8 consecutive hours on two reviewed days, as required by federal regulations. Staffing records and time sheets showed that on these days, RN hours fell short, and staff interviews confirmed no other RN was present to meet the requirement.
A resident with significant physical and cognitive impairments did not receive prescribed passive range of motion exercises or brace application as ordered in their care plan and physician's orders. Staff were unaware or did not implement the required interventions, and documentation confirming these treatments was absent.
A resident with a right hand contracture and history of stroke did not receive ordered passive range of motion (PROM) exercises or splint/brace application as documented in the care plan and physician's orders. Staff interviews revealed a lack of awareness and implementation of these interventions, and review of records confirmed no documentation of PROM or splint use during the review period.
The facility did not provide RN services for the required 8 consecutive hours on two days, as staffing records and time sheets confirmed that RN coverage fell short. Staff interviews verified that no other RN was present and no call-offs occurred, resulting in a deficiency in meeting minimum RN staffing requirements.
Surveyors found expired Acetaminophen and Lorazepam topical gel on two medication carts, despite facility policy requiring expiration date checks before administration. The DON confirmed expired medications should not be present and noted that weekly cart checks were not consistently followed.
A medication error rate of 8% was identified when an LPN crushed and administered two extended-release medications—Metoprolol Succinate ER and Klor-Con M20—by mixing them in pudding for a resident, despite facility policy and drug guidelines contraindicating this practice. Both the consultant pharmacist and DON confirmed that these medications should not have been crushed, and alternative forms should have been used.
A resident with a history of falls and medical conditions fell and sustained a major injury due to inadequate supervision and assistance. Despite having a care plan with interventions, the resident attempted to go to the bathroom unassisted, resulting in a fall. The facility failed to document specific interventions or monitoring frequency, and the resident's call light was not within reach. Staff monitoring was inconsistent, and no new interventions were added to the care plan to prevent further incidents.
A resident with a history of falls and sensory impairments fell while attempting to use the bathroom unassisted, resulting in a major injury. Despite having a care plan that included assistance with toileting and the use of a call bell, the resident was found on the floor with the call light not engaged. Staff interviews revealed inconsistent monitoring, and the care plan had not been updated with new interventions to prevent further falls.
The facility failed to provide a clean and comfortable environment, with issues such as stained floors, peeling wallpaper, and malfunctioning equipment. A resident reported difficulties with a non-functioning bed control, which had been unresolved despite informing staff. The Administrator acknowledged the environmental concerns and a failure in the work order process.
Unsecured Medications Left in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s safe storage of medications when multiple residents were observed with unsecured medications at bedside. On two consecutive days, one resident’s room was observed to contain an unlocked bottle of Melatonin 10 mg gummies and a bottle of brand-name eye vitamin soft gels on the nightstand. Another resident’s room was observed on two days with an unsecured bottle of Allergy Nasal Mist (Oxymetazoline HCl 0.05% nasal decongestant) on the overbed table. A third resident’s room was observed on two days with an unlocked bottle of Antacid Extra Strength tablets, a box of Aspirin Pain Reliever/Caffeine/Pain Reliever Aid arthritis powder, and a bottle of vaporizing rub on the overbed table. Photographic evidence was obtained for each of these observations. In interviews, LPN staff members acknowledged that these medications should not have been stored in residents’ rooms and stated that medications should be locked in the medication cart at all times. The Assistant Director of Nursing stated that medications should not be in any resident’s room unless the resident has an order to self-administer, in which case they must be locked in a box in the room; otherwise, medications are to be locked in the medication cart. The Director of Nursing stated that medications should never be left in a resident’s room unlocked and should be locked at all times. Review of the facility’s “Medication Storage and Labeling” policy, issued 3/21 and revised 1/24, documented that all drugs and biologicals are to be stored in locked compartments, with compartments containing drugs and biologicals locked when not in use and unlocked medication carts never left unattended.
Noncompliance with Smoking Area Fire Safety Requirements
Penalty
Summary
During a fire life safety survey, it was observed that the facility failed to comply with National Fire Protection Association (NFPA) 101 smoking regulations. Specifically, the established smoking area in the courtyard, which was the only designated area for residents to smoke, did not have a self-closing metal butt can as required by the standard. This deficiency was identified during a facility tour conducted between 1:00 p.m. and 5:00 p.m. with the Maintenance Director present. The surveyor noted that the absence of a self-closing metal container for cigarette disposal in the smoking area was a direct violation of NFPA 101 (2012 and 2021 Editions) section 19.7.4(6). The regulation mandates that metal containers with self-closing cover devices, into which ashtrays can be emptied, must be readily available in all areas where smoking is permitted. The report also clarified that smoking tower disposal receptacles do not meet the requirement for ashtrays or self-closing metal containers. The Maintenance Director acknowledged the findings during the interview that was conducted concurrently with the observations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report. The deficiency was based solely on the lack of required fire safety equipment in the designated smoking area.
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 in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , an order was placed for two new red cigarette butt cans by the Director of Maintenance. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , the Maintenance Director, and Administrator will conduct an audit on facility's red cigarette butt cans to identify potential issues with the cans and to ensure they are opening and closing fully. Any issues identified were corrected. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. 4) 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 conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. The cans and to ensure they are opening and closing fully. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (4) 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 conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (4) 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 conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met.
Failure to Provide and Document Range of Motion Interventions
Penalty
Summary
A deficiency was identified when the facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with limited mobility. The resident, who had a history of right-sided hemiplegia and aphasia following a cerebrovascular event, was dependent on staff for activities of daily living and had documented functional limitations in the upper and lower extremities on one side. The care plan and physician's orders specified that the resident should receive passive range of motion (PROM) exercises and application of a brace to the right side, with specific instructions for timing and monitoring. Despite these documented interventions, observations and record reviews revealed that the resident did not receive the ordered PROM or brace application. The Minimum Data Set (MDS) assessment indicated that the resident had not received passive or active range of motion or brace assistance for at least 15 minutes in the previous seven days. Interviews with staff members, including CNAs and LPNs, showed a lack of awareness or implementation of the prescribed interventions, with one CNA stating that the resident did not have anything in place for the right side at the time of observation, and an LPN not being aware of any device for the resident's right side. Further review of the Treatment Administration Record (TAR) confirmed the absence of documentation that PROM or brace application had been performed as ordered. The Director of Nursing verified the lack of documentation and confirmed that the resident had an active order for these interventions. The failure to provide and document the required care and services led to the deficiency under the federal regulation for maintaining or improving range of motion and mobility.
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 it is required. F688 Increase/Prevent Decrease in ROM/Mobility (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident # 31 was assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On the order was clarified with MD to indicate donning and doffing of , as well as performing PROM. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken, On Audit was completed by Director of Nursing/designee on residents who had orders for /braces to ensure order indicated donning and doffing equipment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By Current Nurses and staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and Prevention of decrease in ROM/Mobility by the DON/Designee. Newly hired licensed nurses/ . Staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and prevention of decrease in ROM/Mobility by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) 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: Director of Nursing/Designee to conduct audits of 5 residents with physician orders for a /brace 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the physician order includes documentation of donning and doffing /brace. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Expired Medications Found in Medication Carts
Penalty
Summary
Surveyors found that the facility failed to remove expired medications from two of four medication carts reviewed, specifically the "Colonial 1" and "Heritage" carts. During observations, one bottle with an expired date was found on the Colonial 1 cart, and a bottle of gel 0.5 mg/mL for a resident was found on the Heritage cart with packaging that specified it should not be used after a certain date. Photographic evidence was obtained for both findings. The facility's policy requires that the expiration or beyond-use date on medication labels be checked prior to administration. In an interview, the DON acknowledged that expired medications should not be present in the medication carts and stated that medication carts are checked on Sundays, but indicated there was a need to improve follow-through with these checks.
Plan Of Correction
F755-Pharmacy Services/Procedures/Pharmacist/Records (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On the expired and gel were removed from the medication carts. Audit was conducted of remaining medication carts with no other concerns were noted related to the alleged deficient practice. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; An audit was completed by the Director of Nursing/designee on all medication carts and medication rooms to ensure there were no outdated or expired medications. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By current licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee. Newly hired licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee at orientation as a part of the systematic changes. (4) 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 Director of Nursing/Designee will conduct audits of medication carts and medication weekly for 4 weeks, then once a week for 4 weeks, and then monthly for 1 month to ensure that there are no expired or outdated medications present and medications are stored properly. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by federal regulations, resulting in an observed error rate of 8% out of 25 opportunities. During medication administration, an LPN was observed crushing and administering two extended-release medications to a resident, despite both medications being contraindicated for crushing. The physician's order allowed for medications to be crushed or diluted unless contraindicated, but the extended-release formulations specifically should not have been altered in this way, as confirmed by reference sources and the facility's consultant pharmacist. The facility's policies require medications to be administered according to prescriber orders and for staff to consult with a physician or pharmacist if there are concerns about medication appropriateness or potential adverse consequences. Both the consultant pharmacist and the Director of Nursing confirmed that the extended-release medications should not have been crushed and that alternative formulations or orders should have been sought. The incident was identified during an unannounced recertification survey, and the deficiency was based on direct observation, record review, and staff interviews.
Plan Of Correction
F759-Free of Medication Error Rate of 5% or More (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Staff A was educated regarding medication administration and the "Do not Crush" list on medication cart. On Resident #22 was assessed by a licensed nurse with no negative findings. MD was notified of medication error with orders received to change the form of the 2 identified medications. Started treatment on . (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On Audit was completed by Director of Nursing/designee on current residents to identify if medications needed to be crushed. Any identified meds were changed to the appropriate form. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , Current Licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee. Newly hired licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee at orientation as a part of the systematic changes. (4) 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: Director of Nursing/Designee to conduct observations of medication administration 3x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that licensed Nurses are administering medications properly. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) provided services for at least 8 consecutive hours per day, 7 days a week, as required by federal regulations. Record review of staffing forms and RN time sheets revealed that on two separate days, the number of RN hours worked fell below the required 8 consecutive hours. Specifically, on one day, only 7.87 hours were worked, and on another, only 5.42 hours were worked. Further examination of RN time sheets confirmed that on these days, the RN clocked in and out in a manner that resulted in less than the required consecutive hours of coverage. Interviews with the Labor Coordinator and the Nursing Home Administrator confirmed that no other RN worked on those days to supplement the hours, and there were no call-offs reported. The Labor Coordinator acknowledged the discrepancy as a mistake, and the Administrator verified the shortfall in RN coverage. The deficiency was identified through review of facility records and staff interviews, with no mention of resident-specific incidents or medical histories related to the deficiency.
Plan Of Correction
F727-RN 8 Hrs/7 days/wk What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Administrator completed a comprehensive review of RN hours for the previous 2 weeks and found that there were 8 consecutive hours of RN coverage. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , Audit was completed by Administrator/designee of Staffing hours for past 2 weeks to ensure that Staffing requirements are met, Including 8 consecutive RN hours every day of the week day. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By /205, the Staffing coordinator, Administrator and Human Resources and Director of Nursing will be educated on the components of F727 with an emphasis on 8 consecutive hours seven days a week of RN hours per day and schedule requirements by the Regional Vice President of Operations/Designee. (4) 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: Administrator/Designee to conduct audits of staffing report 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that Staffing requirements are met and that there are 8 consecutive RN hours every day of the week. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Ordered Range of Motion and Brace Application
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with significant physical and cognitive impairments. The resident, who had a history of hemiplegia, hemiparesis, and aphasia, was dependent on staff for activities of daily living and had documented functional limitations in the upper and lower extremities on one side. The care plan and physician's orders specified that the resident should receive passive range of motion (PROM) exercises and application of a brace to the affected limb, with specific instructions for timing and monitoring. However, observations revealed that the resident did not have the prescribed device in place, and staff interviews indicated a lack of awareness or implementation of the required interventions. Review of documentation, including the Treatment Administration Record (TAR) and CNA Kardex, showed no evidence that PROM or brace application had been performed as ordered. Staff interviews confirmed that the interventions were not being carried out, and the Director of Nursing verified the absence of documentation for these treatments. As a result, the facility did not meet the licensure requirement to provide adequate and appropriate health care and services consistent with the resident's care plan and physician's orders.
Plan Of Correction
F688 Increase/Prevent Decrease in ROM/Mobility (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident # 31 was assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On , the order was clarified with MD to indicate donning and doffing of , as well as performing PROM. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On Audit was completed by Director of Nursing/designee on residents who had orders for /braces to ensure order indicated donning and doffing equipment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By , Current Nurses and staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and Prevention of decrease in ROM/Mobility by the DON/Designee. Newly hired licensed nurses/ , Staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and prevention of decrease in ROM/Mobility by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) 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: Director of Nursing/Designee to conduct audits of 5 residents with physician orders for a /brace 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the physician order includes documentation of donning and doffing /brace. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Ordered Range of Motion and Splinting Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with a right hand/wrist contracture and a history of hemiplegia and hemiparesis following a stroke. The resident was dependent on staff for activities of daily living and had severely impaired cognitive skills, making them rarely or never understood. The care plan and physician's orders specified that passive range of motion (PROM) and splint/brace application should be performed, with detailed instructions for timing and monitoring. However, observations revealed that the resident did not have a splint in place, and staff interviews indicated a lack of awareness or implementation of the splinting intervention. The resident was noted to experience significant pain with hand movement, and there was no evidence that PROM or splint/brace application had been provided as ordered. Review of documentation, including the Treatment Administration Record (TAR), showed no record of PROM or splint application for the resident during the specified period. Staff interviews confirmed that the interventions were not being carried out, and the Director of Nursing verified the absence of documentation for these required treatments. The facility's failure to follow the care plan and physician's orders resulted in a lack of appropriate care to maintain or improve the resident's range of motion.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours on two separate days during a 14-day staffing review period. Review of staffing records and RN time sheets showed that on the specified dates, the RN coverage was 7.87 hours and 5.42 hours, respectively, both falling short of the required 8 consecutive hours. Interviews with the Labor Coordinator confirmed that no other RN worked on those days and there were no call-offs, indicating a scheduling error. The Nursing Home Administrator verified the deficiency in RN coverage for those days.
Expired Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from two of four medication carts reviewed. Specifically, one bottle of Acetaminophen with an expiration date of 5/2025 was found on the Colonial 1 medication cart, and one bottle of Lorazepam topical gel labeled 'Do not use after 7/10/25' was found on the Heritage medication cart for a resident. The facility's Medication Administration policy requires staff to check expiration or beyond use dates prior to administering medications. During an interview, the Director of Nursing acknowledged that expired medications should not be present in the carts and stated that medication carts are checked weekly, but follow-through on these checks needs improvement.
Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% out of 25 opportunities. During medication administration, an LPN was observed crushing and administering two extended-release medications—Metoprolol Succinate ER 25 mg and Klor-Con M20 (Potassium Chloride Extended Release)—to a resident by mixing them in pudding. The physician's order allowed medications to be crushed or diluted as needed unless contraindicated. However, both medications are extended-release formulations, and crushing them is contraindicated according to standard drug references. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed that extended-release tablets should not be crushed, and alternative formulations should have been sought if the resident was unable to swallow the tablets whole. The facility's policies require medications to be administered as prescribed and for any deviations or concerns to be documented and communicated to the prescriber. These procedures were not followed in this instance, resulting in a medication error that contributed to the facility's elevated error rate.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for a resident with a history of falls and other medical conditions. The resident, who was legally blind and hard of hearing, had a care plan that included interventions such as assistance with toileting and reminders to use the call bell for help. However, the resident attempted to go to the bathroom unassisted, resulting in a fall and a major injury that required hospital admission and surgical repair. The incident occurred when a registered nurse found the resident on the floor in front of the bathroom door, with the call light not engaged. The resident had attempted to go to the bathroom unassisted, despite being known to require assistance. The Director of Nursing (DON) acknowledged that the resident had toileting times in place and was known to be at risk, but there was no documentation of specific interventions or monitoring frequency. The resident's room was moved closer to the nursing station after the incident, but the call light was still not within reach, and the privacy curtain and room door made observation difficult. Interviews with staff revealed that monitoring and supervision were inconsistent, with no set times for checking on the resident. The facility's Quality Assurance Performance Improvement Plan showed no reduction in incidents, and education was provided to staff, but there was no documentation of new care plan interventions to prevent further accidents. The facility's failure to implement and document adequate supervision and interventions contributed to the resident's fall and injury.
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 it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Resident #850 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On Resident #8500's care plan was reviewed with the Interdisciplinary Team and revised to reflect appropriate interventions to minimize risk of. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On a quality review was completed by Director of Nursing/designee on Residents identified to be at increased risk for to ensure that appropriate interventions have been put into place and reflected on the care plan. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By, Licensed Nurses and Certified Nursing Assistants were educated on the components of F689 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk for by the Director of Nursing/Designee. Newly hired licensed nurses and Certified Nursing Assistants will be educated on the components of F689 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk for by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) 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: Director of Nursing/Designee to conduct audits of 5 residents care plans 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that appropriate interventions were put into place to minimize risk of. The findings of these quality monitoring...s to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, identified as Resident #850, who had a history of falls and was legally blind and hard of hearing. The resident's care plan included interventions such as assistance with toileting, encouraging the use of a call bell, and wearing appropriate footwear. Despite these interventions, the resident attempted to go to the bathroom unassisted, resulting in a fall and a major injury requiring hospital admission and surgical repair. The incident occurred when a Registered Nurse found the resident on the floor in front of the bathroom door, with the call light not engaged. The resident had attempted to go to the bathroom unassisted, despite being known to require assistance. The Director of Nursing acknowledged that the resident had no prior falls since admission and that interventions were in place, but there was no documentation of specific supervision or monitoring times. The resident's room was moved closer to the nursing station after the incident, but the call light was still not within reach, and the privacy curtain and door were often closed, making observation difficult. Interviews with staff revealed that monitoring and supervision were inconsistent, with no set times for checking on the resident. The Director of Rehab noted that the resident required assistance with all activities and could roll over in bed with minimal help. Despite the facility's efforts to educate staff on fall prevention, the care plan for Resident #850 had not been updated with new interventions to prevent further falls, and there was no documentation of increased supervision or monitoring.
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 it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #850 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. Resident #850's care plan was reviewed with the Interdisciplinary Team and revised to reflect appropriate interventions to minimize risk of. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A quality review was completed by Director of Nursing/designee on Residents identified to be at increased risk to ensure that appropriate interventions have been put into place and reflected on the care plan. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Licensed Nurses and Certified Nursing Assistants were educated on the components of N201 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk by the Director of Nursing/Designee. Newly hired licensed nurses and Certified Nursing Assistants will be educated on the components of N201 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) 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: Director of Nursing/Designee to conduct audits of 5 residents' care plans 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that appropriate interventions were put into place to minimize risk of. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Environmental and Maintenance Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean, sanitary, and comfortable environment for its residents, as evidenced by multiple environmental issues observed during a tour. These issues included stained and cracked floors in the activity room, missing and peeling cove base in several rooms, a dried black substance on a handrail, peeling wallpaper with orange discoloration in common hallways, and dirty, scuffed walls in various rooms. Additionally, corners and crevices where floors meet walls were found to have caked-in dirt. Photographic evidence was obtained to document these deficiencies. A resident reported that his bed had not been functioning properly since his arrival at the facility a few months prior. The control to adjust the bed's head position was not working, requiring the resident to physically get out of bed to make adjustments, which was difficult for him. Despite informing multiple staff members, including the Administrator, the issue remained unresolved. Interviews with staff revealed a lack of awareness and communication regarding the bed's malfunction, with the Maintenance Director only becoming aware of the issue during the survey. The Administrator acknowledged the environmental concerns and noted a failure in the work order process, which contributed to the unresolved maintenance issues.
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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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