Community Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Plant City, Florida.
- Location
- 2202 W Oak Ave, Plant City, Florida 33563
- CMS Provider Number
- 105029
- Inspections on file
- 20
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Community Convalescent Center during CMS and state inspections, most recent first.
The facility did not ensure adequate kitchen staffing on several days, resulting in only one cook and one dietary aide present for meal shifts and requiring CNAs to be pulled from their regular assignments to assist in the kitchen. This led to delays in meal service, use of disposable serving ware, and missed resident care tasks such as showers, as CNAs' floor assignments were not always covered.
Surveyors identified extensive deficiencies in food storage, labeling, and sanitation, with numerous undated and unlabeled food items, spoiled produce, and improper storage of raw meats. Dietary staff failed to follow hand hygiene and glove use protocols, moving between tasks without washing hands or changing gloves. Cleaning and temperature logs were incomplete or missing, and the kitchen environment was unsanitary, with evidence of bio growth and insect activity. These findings reflect a failure to maintain a clean, safe, and sanitary environment in accordance with professional standards.
The facility did not update its facility-wide assessment to include emergency plans, required staff competencies for residents with different acuity levels, or specific staffing needs for each shift. Staff interviews revealed a lack of awareness and understanding of the assessment process, and the assessment itself was missing critical sections as identified during record review.
Surveyors identified multiple infection control deficiencies, including unattended open meal carts, failure to provide hand hygiene to residents before meals, unclean laundry areas with soiled linens and dust-covered equipment, an overfilled sharps container with syringes protruding above the fill line, and a dialysis patient with a red-stained towel and dirty fingernails. Staff interviews confirmed inconsistent cleaning and infection control practices.
The facility did not complete required antibiotic use monitoring for four months, with missing or incomplete surveillance forms and infection mapping. The DON, acting as Infection Preventionist, was unable to locate necessary documentation and had not educated nursing staff on proper form completion or infection control. Required audits and Quality Assurance reviews of antibiotic use were not documented as per policy.
Surveyors found multiple rooms with holes in walls, peeling ceilings, unpainted surfaces, missing baseboards, and bio growth in two wings. The Maintenance Director acknowledged responsibility but had not completed a comprehensive review, and only one room was listed in the work order system despite numerous deficiencies observed. Facility policies and job descriptions required proper maintenance, but these standards were not met in the affected areas.
The facility did not provide scheduled activities for residents on several observed days due to the absence of the Activity Director and lack of coverage, despite having an activity calendar and a policy requiring activities to meet residents' needs. Interviews with the DON and NHA confirmed that no one was available to conduct activities as planned.
Several residents were not offered the Influenza or Pneumococcal vaccines as required, and for those who were, there was no documentation of vaccine administration. The DON, acting as Infection Preventionist, had not checked immunization status or provided required education, and facility policy steps for consent, orders, and documentation were not consistently followed.
The facility did not ensure that three residents were properly offered and documented for the COVID-19 vaccine, with one not being offered the vaccine and two lacking documentation of administration after being offered. The DON, acting as Infection Preventionist, had not checked immunization status or provided required education, contrary to facility policy.
A resident with chronic health conditions reported missing and damaged clothing, and multiple residents expressed concerns about slow grievance resolution, especially regarding laundry. The facility did not provide evidence that grievances were resolved or that required follow-up actions were completed, and documentation was incomplete, contrary to facility policy.
The facility failed to complete a required Level II PASRR for a resident with multiple mental health diagnoses and did not ensure the accuracy of a Level I PASRR for another resident by omitting updated diagnoses. These deficiencies occurred despite facility policy requiring comprehensive preadmission screening and regular review of PASRR documentation.
Two residents were found with long, discolored fingernails and reported that staff had not offered or provided regular nail care, despite care plans instructing nail checks and trimming on bath days. Documentation showed inconsistent provision of nail care, incomplete shower logs, and lack of proper documentation for refusals. Staff interviews confirmed that nail care was not always performed, especially when CNAs were assigned to other duties, and the facility did not have a specific ADL policy.
A dependent resident with multiple medical conditions was not assisted out of bed by staff, despite her care plan requiring staff assistance for transfers. The resident reported not receiving help to use the toilet or attend activities, and was observed lying in bed on several occasions. Staff interviews confirmed that assistance was only provided upon resident request, which was inconsistent with facility policy and the resident's care plan.
A resident with multiple chronic conditions and intact cognition was observed to have severely overgrown and malformed toenails. Although the resident expressed a need for podiatry care, staff had not ensured timely assessment or referral to podiatry services. Documentation did not specify whether toenail care was provided, and facility leadership was unclear about the referral process and podiatry visit frequency.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents, resulting in an unsafe environment.
Two residents with complex medical needs experienced significant, unaddressed weight loss due to inadequate monitoring, lack of updated care plan interventions, and insufficient interdisciplinary communication. Both residents reported dissatisfaction with their diets and did not receive appropriate dietary modifications or supplements in a timely manner, despite clear evidence of nutritional decline.
A resident with a PICC line had a soiled dressing that was not changed according to physician orders and facility policy, despite visible signs of soiling and documentation discrepancies. The DON confirmed the dressing was not changed as required, and the facility's infection prevention policy was not followed.
The facility did not consistently post the Daily Nursing Staffing form as required, with outdated information displayed at the entrance and no posting on the 2nd floor. Staff interviews confirmed the form was not updated daily and was only posted at the front, and there was no facility policy addressing this requirement.
A medication error rate of 6.67% was identified when an LPN administered medications to a resident after updating orders for a probiotic and stool softener, but before the new orders were scheduled to begin. The LPN did not follow facility policy to confirm the timing of medication orders on the MAR prior to administration, resulting in two errors during thirty observed opportunities.
A resident with a history of stroke, dementia, and dysphagia, who required staff assistance and supervision during meals, was left unsupervised with a meal tray and consumed food without help. Staff failed to check the care plan or provide the necessary support, and the resident received an incorrect food item. The resident was later found unresponsive, required emergency interventions, and died after being transported to the hospital. The deficiency was due to staff not following the care plan and not ensuring proper supervision and dietary management.
A resident with dementia, dysphagia, and a history of stroke, who required staff assistance and supervision during meals, was left unsupervised with a meal tray. Staff failed to follow the care plan and did not check the resident's needs before providing the meal. The resident was later found unresponsive after eating alone, required emergency interventions, and subsequently died. The deficiency was due to staff not implementing required care plan interventions for safe feeding.
A resident with dementia, dysphagia, and a history of stroke was left unsupervised and without assistance during a meal, despite care plan and speech therapy recommendations requiring staff support. The resident consumed her meal alone, was later found unresponsive, and emergency interventions were initiated for suspected choking. Documentation and interviews confirmed that staff did not follow the care plan or provide the necessary supervision, leading to the resident's death.
Insufficient Kitchen Staffing and Inappropriate Use of CNAs
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service on four out of eight days reviewed. Observations and punch detail reports showed that on multiple occasions, only one cook and one dietary aide were present for meal shifts, and certified nursing assistants (CNAs) were pulled from their regular assignments to assist in the kitchen. Staff interviews confirmed that it was common for the kitchen to be understaffed, resulting in delays in meal service, use of disposable serving ware due to lack of dishwashing support, and CNAs being reassigned without coverage for their original duties. The interim Food Services Manager was unsure about the adequacy of kitchen staffing, and the Staffing Coordinator acknowledged that CNAs had to fill in for kitchen staff, though she claimed it was not frequent. Further interviews revealed that when CNAs were moved to the kitchen, their floor assignments were not always covered, leading to missed resident care tasks such as showers. The Nursing Home Administrator stated that the Dietary Manager was responsible for kitchen staffing and that CNAs were not given additional training when assisting in the kitchen, as their duties were limited to tray service. Facility policy required ongoing monitoring and evaluation of staffing adequacy, but the documented practices and staff statements indicated that these procedures were not consistently followed, resulting in insufficient kitchen staffing and disruption of both dietary and resident care services.
Widespread Food Storage, Sanitation, and Hand Hygiene Failures in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and nourishment rooms regarding food storage, labeling, sanitation, and staff hygiene practices. Numerous food items in the walk-in refrigerator, freezer, and dry storage were found to be undated, unlabeled, and in some cases, visibly spoiled or contaminated with bio growth. Open containers of milk, fruit bowls, and various other food items lacked proper labeling and dating, while some produce and meats were observed with mold or other signs of spoilage. Additionally, food items were not always stored in accordance with professional standards, with raw meats improperly stored and prepared foods left uncovered or inadequately covered. Staff were repeatedly observed failing to follow proper hand hygiene and glove use protocols. Several dietary staff members were seen moving between tasks such as plating food, handling dirty dishes, and performing temperature checks without washing hands or changing gloves as required. Staff were also observed scratching their heads, picking items up from the floor, and then resuming food preparation duties without performing hand hygiene. These lapses occurred despite facility policies mandating hand washing before and after glove use, between tasks, and after contact with unsanitary surfaces. Sanitation and cleaning logs were incomplete or missing, with dishwashing and refrigeration temperature logs showing multiple unrecorded dates. The kitchen environment was found to be unsanitary, with dirty pots and pans left in sinks, food particles and bio growth present in various areas, and evidence of insect activity near dishwashing equipment. The facility's own policies require daily, weekly, and monthly cleaning schedules, as well as proper documentation of cleaning and temperature checks, but these were not consistently followed or documented. Staff interviews confirmed a lack of adherence to established procedures for food storage, labeling, and sanitation.
Facility Assessment Lacks Emergency and Staffing Details
Penalty
Summary
The facility failed to update its facility-wide assessment to include necessary components such as emergency plans, staff competencies required for caring for residents with varying acuity levels, and specific staffing needs for each shift. Review of the existing facility assessment revealed it lacked sections addressing these critical areas. During interviews, the Staffing Coordinator indicated she was unaware of the facility assessment and based daily staffing solely on the current census, without reference to a comprehensive assessment. The Nursing Home Administrator reported updating the assessment upon arrival to the facility, focusing on a general overview of the building, residents, services, and employee information, but did not include the required details regarding emergency preparedness, staff competencies, or shift-specific staffing needs. No policy related to the facility assessment was provided.
Infection Control Lapses in Meal Service, Laundry, and Sharps Management
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control program. Meal carts on two separate floors were left open and unattended, exposing unused food trays in foam containers to the environment. Staff were seen delivering meal trays to residents without offering hand hygiene prior to meals in one hallway and two dining rooms. Additionally, eating utensils were left open to the environment and unattended while staff passed meal trays. The facility's hand hygiene policy did not address providing residents with hand hygiene before meals. In the laundry room, several infection control lapses were noted. A personal cell phone was found on the table used for folding linens, and the wall air conditioning unit and a floor fan, both in use, were covered in dust. One dryer was not working and was being used to store clean clothes, while the vents under other dryers contained lint. The area around the washers was dirty, with water stains, a soiled blanket on the floor, and uncleanable porous foam tubes with crusty substances on one washer. Staff interviews confirmed that some of these issues had been ongoing and that cleaning practices were not consistently effective. A resident receiving dialysis was observed with a red-stained towel under the left upper arm, reportedly from a bleeding dialysis site, and had long, dirty fingernails. The resident stated that staff did not offer hand hygiene before meals. Additionally, a sharps container attached to a treatment cart was found to be overfilled, with syringes sticking out above the fill line, contrary to the container's labeling. These findings were supported by photographic evidence and were not in accordance with the facility's infection prevention and control policy.
Failure to Implement and Monitor Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement and monitor its antibiotic stewardship protocol as required. Record reviews and interviews revealed that antibiotic use monitoring was not completed for four consecutive months. Specifically, the Antibiotic Stewardship Book lacked surveillance documentation for August, and the forms for May, June, and July were incomplete and missing required information. The infection mapping for these months was also absent. The DON, who serves as the Infection Preventionist, was unable to locate necessary forms and had not provided education to nurses on how to properly complete the surveillance forms. Additionally, she acknowledged that she had not educated staff on infection control practices. The facility's policy requires comprehensive documentation for antibiotic prescriptions, including dose, route, duration, start and end dates, planned days of therapy, and indication. Audits of antibiotic prescriptions and monitoring of community-acquired infection prevalence data are also mandated, with findings to be presented at monthly Quality Assurance meetings. However, the DON could not provide evidence of such discussions or documentation for several months, nor could she locate point prevalence rates for the same period. The DON stated that she does not allow prophylactic antibiotic orders by physicians, but the lack of surveillance and documentation indicates the protocol was not followed as outlined in facility policy.
Failure to Maintain Safe and Homelike Environment Due to Building Disrepair
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in two of its four wings, specifically 100 East and 200 East. During facility tours, multiple rooms were found with holes in the walls, peeling ceilings, unpainted walls, missing baseboards, and bio growth on window sills. These deficiencies were directly observed on two separate dates, with photographic evidence obtained. The Maintenance Director acknowledged responsibility for building upkeep but admitted that a comprehensive room-to-room review had not been completed. The process for reporting and addressing maintenance issues involved staff entering work orders into an electronic system, which the Maintenance Director then prioritized. However, only one room with wall damage was listed as open or in progress in the work order documentation, despite the multiple deficiencies observed. During interviews, the Maintenance Director was unable to provide explanations for the unresolved issues in several rooms and stated there was no current resolution for fixing certain problems, such as ceiling damage or relocating residents from affected areas. Review of the facility's policies and the Maintenance Director's job description confirmed the expectation for maintaining the building in good repair and ensuring a safe environment for residents. Despite these requirements, the observed conditions indicated a failure to uphold these standards in the affected wings.
Failure to Provide Scheduled Resident Activities
Penalty
Summary
The facility failed to provide scheduled activities for residents on three out of four days observed. Observations on multiple occasions throughout the days revealed that no activities were conducted as listed on the activity calendar, including events such as Pokeno, Blackjack, Church, Room Visits, Movement and Music, Sing a Long, Bingo, and Movie Monday. The activity calendar indicated that these activities were planned, but they did not occur as scheduled. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the absence of the Activity Director, who had been out since the previous Friday, and the subsequent call-out of the assigned replacement, resulted in no one being available to conduct activities. The NHA acknowledged that there should have been coverage for activities when the Activity Director was unavailable. Review of the facility's policy indicated that activities should be provided at a frequency to meet the individual needs of residents, including their medical, emotional, spiritual, therapeutic, and recreational needs.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were consistently offered and administered the Influenza and Pneumococcal vaccines as required. Record reviews for four out of five sampled residents revealed that several were not offered the Influenza vaccine, and for those who were, there was no documentation indicating receipt of the vaccine. Similarly, some residents were not offered the Pneumococcal vaccine, and for others, there was no documentation of administration despite being offered. The facility's policy requires annual offering and documentation of these vaccines, including obtaining consent and physician orders, but these steps were not consistently followed. During an interview, the DON, who also serves as the Infection Preventionist, stated she had not checked residents' immunization status and was waiting on a new code from Florida Shots. She also acknowledged that she had not provided education to residents regarding the vaccines, although the facility policy requires staff to complete a form when education is provided. The lack of adherence to policy and incomplete documentation contributed to the deficiency in ensuring residents were properly offered and administered the required vaccinations.
Failure to Offer and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that residents were properly offered and documented for the COVID-19 vaccine, as evidenced by record reviews and interviews. Specifically, three out of five sampled residents were not managed according to facility policy: one resident was not offered the COVID-19 vaccine at all, while two others were offered the vaccine but had no documentation indicating whether they received it. The facility's policy requires that all residents be offered the COVID-19 vaccine and any eligible boosters, with proper documentation of administration, consent, or declination in the medical record. During an interview, the DON, who also serves as the Infection Preventionist, stated she had not checked any residents' immunization status and was waiting on a new code from Florida Shots. She also acknowledged that she had not provided education to any residents regarding the COVID-19 vaccine, despite the existence of a form for documenting such education. The facility's policy outlines specific procedures for offering, obtaining consent, and documenting immunizations, which were not followed in these cases.
Failure to Follow Grievance Process for Laundry-Related Complaints
Penalty
Summary
The facility failed to follow its grievance process for a resident who reported multiple issues with missing and damaged clothing, as well as concerns about laundry practices. The resident, who had diagnoses including type 2 diabetes and chronic kidney disease, reported missing three pairs of cargo pants and damage to other clothing items after laundering. Despite the resident filing grievances and being told the items would be replaced, the facility did not provide evidence that the items were replaced or that the grievances were resolved. Documentation in the grievance log and reports was incomplete, with missing resolution dates and lack of confirmation that the issues were addressed. The Nursing Home Administrator was unable to specify what actions had been taken regarding the grievances and acknowledged that grievances were marked as completed without the required follow-up or proof of resolution. Additionally, during a resident council meeting, multiple residents expressed concerns about the facility's slow response to grievances, particularly regarding laundry issues. Residents reported missing and damaged clothing and a lack of communication about the outcomes of their grievances. The facility's grievance policy requires prompt efforts to resolve concerns and documentation of resident satisfaction upon completion, but these procedures were not followed as evidenced by incomplete records and unresolved issues.
Deficient PASRR Screening and Documentation for Mental Illness and Intellectual Disability
Penalty
Summary
The facility failed to complete a required Level II Pre-admission Screening and Resident Review (PASRR) for one resident and did not ensure the accuracy of a Level I PASRR for another. One resident was admitted with diagnoses including unspecified bipolar disorder, insomnia, and depression, and their PASRR indicated diagnoses of bipolar disorder, depressive disorder, and PTSD. Despite these diagnoses and the resident exhibiting symptoms of depression following the loss of a spouse, the PASRR did not identify any disorder resulting in functional limitations or issues with interpersonal functioning, and it was determined that a Level II PASRR was not required. The resident's care plan, however, included trauma-informed care for PTSD and the use of psychotropic medications for bipolar disorder and insomnia. The Director of Clinical Reimbursement confirmed that a Level II PASRR should have been completed for residents with such diagnoses who remain in the facility for more than 30 days. For another resident, the facility did not update the Level I PASRR to reflect new diagnoses of anxiety and insomnia that were added after the initial admission. The PASRR only listed depressive disorder, omitting the later diagnoses. The Director of Clinical Reimbursement stated that updating PASRRs is typically the responsibility of Social Services, but there was uncertainty about the regular review process for PASRRs and whether all relevant diagnoses were being consistently documented. The facility's policy requires preadmission screening and review of PASRRs for suspicion of serious mental illness or intellectual disability, but these procedures were not followed as required in these cases.
Failure to Provide Adequate Nail Care for Two Residents
Penalty
Summary
Surveyors identified that the facility failed to provide adequate nail care for two residents who were sampled for activities of daily living (ADLs). One resident was observed multiple times with fingernails extending 1/3 to 1/2 inch past the fingertips, discolored, and with a dark substance present. The resident reported not wanting long fingernails and stated that staff had not offered to cut them, with documentation showing nail care was only provided eight out of twenty-seven days. The resident's care plan indicated a self-care performance deficit related to weakness and activity intolerance, as well as impaired cognitive function due to dementia, but did not address any behaviors related to refusing care. Staff interviews confirmed that nail care should be provided by CNAs or nurses, with special consideration for diabetic residents. Another resident was observed with long fingernails and a dark brown substance caked underneath. This resident expressed a preference for regular nail care and reported that staff did not mention or offer to cut fingernails, and that toenail care was only provided once every two months. The resident indicated willingness to perform self-care if supplies were available. Documentation revealed several days where nail care was not provided, and shower logs were incomplete for the requested period. Staff interviews indicated that refusals for ADL care were not consistently documented with reasons, and that ADL care may not be provided when CNAs are assigned to other duties. The facility's care plan for one resident instructed staff to check and trim nails on bath days and as necessary, but records showed this was not consistently done. The facility lacked a specific ADL policy, and the process for documenting refusals was not always followed according to the facility's own declination form. Photographic evidence was obtained to support the findings.
Failure to Assist Dependent Resident with Transfers and Activities of Daily Living
Penalty
Summary
A deficiency occurred when a dependent resident was not provided assistance to get out of bed, despite being unable to perform this activity independently. Observations on multiple occasions showed the resident lying in bed with her call light within reach, reporting that staff would not assist her to the toilet or help her attend activities. The resident, who had diagnoses including muscle wasting, atrophy, a femur fracture, and diabetes, was cognitively intact according to her BIMS score. Her care plan specified that she required assistance from one staff member for transfers, with the goal of preventing decline in her ability to perform activities of daily living (ADLs). Interviews revealed that a CNA assigned to the resident had not assisted her out of bed and only did so when residents specifically requested it. The DON confirmed that all residents should be offered the opportunity to get out of bed, regardless of whether they ask. The CNA job description also outlined responsibilities for assisting residents with transfers and mobility. The failure to provide necessary assistance resulted in the resident remaining in bed and missing activities, contrary to her care plan and facility policy.
Failure to Provide Timely Podiatry Services for Resident with Foot Care Needs
Penalty
Summary
The facility failed to assess and obtain podiatry services for a resident with significant foot care needs. Observations revealed that the resident's toenails were malformed, thickened, discolored, and extended past the tips of the toes. The resident expressed a need for a podiatrist to cut their toenails. Staff interviews indicated that the resident's name was placed in a folder for the Social Worker to add to the podiatry list, but the issue had not been previously brought to the attention of nursing staff by aides. Documentation showed that nail care was provided as needed, but did not specify whether this included toenails, and there was no evidence that the resident had refused podiatry or nail care services. The resident had multiple medical diagnoses, including chronic respiratory failure, end stage renal disease, and dependence on dialysis, and was cognitively intact. Physician orders allowed for podiatry services as needed, and the care plan required assistance with personal hygiene. Interviews with facility leadership revealed uncertainty about the frequency of podiatry visits and a lack of clarity regarding the process for referring residents to podiatry services. The deficiency was identified through observations, record reviews, and staff interviews, which demonstrated a breakdown in communication and follow-through regarding the resident's foot care needs.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Nutritional Status and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status, specifically body weight, for two residents who experienced significant weight loss. One resident, with multiple diagnoses including muscle wasting, anemia, dysphagia, diabetes, and depression, lost 15.15% of body weight since admission. Despite triggering for significant weight loss, the care plan and interventions were not updated after the loss was identified. The resident reported not eating the provided food due to dislike and not being offered alternatives or snacks, and staff interviews confirmed a lack of new dietary interventions following the weight loss. Another resident, also with complex medical conditions such as muscle wasting, dysphagia, and GERD, lost 8.31% of body weight in just over a month. The resident was on a pureed diet and reported not liking the food, having difficulty eating due to dental issues, and not receiving adequate dietary variety. The nutrition evaluation noted the resident was not meeting estimated nutritional needs, and although a supplement was recommended, the care plan did not reflect updated interventions after the significant weight loss was discovered. The order for weekly weights, as recommended by the dietitian, was not present in the physician orders. Interviews with staff, including the DON and SLP, revealed a lack of awareness and communication regarding the residents' weight loss. The SLP was not informed of the weight loss, and the DON was unaware of the extent of the issue or the absence of weekly weight orders. The facility's policy required more frequent monitoring and interdisciplinary communication for significant weight loss, but these steps were not documented or implemented for the affected residents.
Failure to Change Soiled PICC Line Dressing per Policy
Penalty
Summary
The facility failed to ensure the intravenous catheter dressing for a resident with a peripherally inserted central catheter (PICC) was changed according to professional standards and facility policy. Observations revealed that the resident's PICC line dressing was soiled, with a dark dry-looking substance and a red wet-looking substance visible under the clear dressing. The dressing was dated several days prior and had not been changed as required. Review of the resident's physician orders indicated that the IV dressing was to be changed every 7 days and as needed (PRN) for soiling or dislodgement. However, the Medication Administration Record (MAR) showed that while the dressing was documented as changed on certain dates, it was not actually changed when soiled, as required by the orders. Interviews with the Director of Nursing (DON) confirmed that the dressing had not been changed as documented and that the dressing should have been changed when soiled. The facility's infection prevention policy required transparent, semi-permeable membrane dressings to be changed at least every 7 days and PRN if the dressing became wet, loose, soiled, or if skin integrity was compromised. The failure to change the dressing as needed for soiling was confirmed through observation, record review, and staff interviews.
Failure to Appropriately Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to appropriately post the Daily Nursing Staffing form as required. Observations revealed that the posted form near the reception area was outdated, displaying a date from three days prior. Additionally, the Daily Nursing Staffing form was not posted on the 2nd floor during multiple observations over several days. Interviews with the Staffing Coordinator and the Nursing Home Administrator confirmed that the form was only posted at the entrance and not updated daily as required. It was also noted that the facility did not have a policy related to the posting of the nursing staffing form.
Medication Error Rate Exceeds 5% Due to Improper Timing of Order Changes
Penalty
Summary
The facility failed to maintain a medication error rate below 5.00%, as evidenced by two medication errors identified during the observation of thirty medication administration opportunities. Specifically, an LPN administered nine medications to a resident, including changes to the resident's probiotic and stool softener, after receiving new orders from the provider. The LPN updated the electronic medication profile and administered the medications, but the new orders for docusate (from capsule to tablet) and for the probiotic (from lactobacillus to saccharomyces) were scheduled to begin at later times, not at the time of administration. The LPN documented the administration in the electronic record, but the timing did not align with the scheduled start of the new orders. Review of the resident's Medication Administration Record (MAR) confirmed that the previous orders for docusate and lactobacillus were discontinued just prior to the administration, and the new orders were set to begin later in the day. The DON confirmed that both medications should have been administered after the new orders became active. Facility policy requires staff to review and confirm medication orders on the MAR prior to administration, but this procedure was not followed, resulting in a medication error rate of 6.67%.
Failure to Provide Required Supervision and Assistance During Meals Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident from neglect by not ensuring supervision and assistance during mealtimes, despite the resident's documented need for such support due to a history of cerebral infarction, dementia, and dysphagia. The resident was dependent on staff for feeding, as indicated in her care plan and medical records, which specified a mechanically altered diet and substantial/maximal assistance with eating. On the day of the incident, staff provided the resident with a covered food tray in her room and left her unsupervised, allowing her to consume her meal without the required assistance or monitoring. The resident was later found unresponsive by her roommate, who alerted a nurse. Facility staff initiated emergency interventions, including the Heimlich maneuver and CPR, and Emergency Medical Services were called. The resident was transported to the hospital, where she expired. Interviews and documentation revealed that staff did not check the resident's care plan prior to providing the meal, and there was a lack of communication and understanding among staff regarding the resident's need for supervision and assistance during meals. Additionally, the resident received the wrong food item on her tray, which was not consistent with her prescribed diet. Further investigation showed that the resident's family and speech language pathologist had previously communicated the need for supervision during meals due to the resident's tendency to eat too quickly and her inability to sense food on one side of her mouth. Despite these recommendations, staff routinely left the resident to feed herself and did not provide the necessary supervision or assistance. The facility's failure to follow the care plan and ensure proper supervision and dietary management directly contributed to the resident's choking incident and subsequent death.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- The facility incorporated an additional notification on resident meal tickets through the meal tracker system to ensure facility staff are aware of the care and services needed by residents to include supervision and/or assistance during mealtimes in order to prevent further instances of neglect. The addition of this tray ticket notification indicator was complete.
- The DON and NHA received directed education by the Regional Nurse Consultant regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals.
- Facility staff were provided education by the DON or designee regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals. Contracted staff members were provided education regarding abuse, neglect, and misappropriation. Nursing and therapy staff were provided education by the DON or designee on ensuring proper resident supervision and/or assistance during meals. Education regarding the added notification on resident meal tickets was provided including the meaning of the indicator and what to do when they see it. This education was completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities. This meeting was held.
Failure to Implement Care Plan Interventions for Assisted Dining
Penalty
Summary
A deficiency occurred when facility staff failed to implement care plan interventions for a resident with a history of cerebral infarction, dementia, and dysphagia, who was dependent on staff for feeding and required supervision during meals. Despite clear documentation in the care plan and recommendations from the speech language pathologist for close supervision and assistance with eating, the resident was left unsupervised with a meal tray in her room. Staff did not check the care plan prior to providing the meal, and the resident consumed food without the required assistance or supervision. The resident, who had moderate cognitive impairment and was on a mechanically altered diet, was found unresponsive after eating unsupervised. Interviews and medical record reviews confirmed that the resident had a history of difficulty swallowing, required a mechanically soft diet, and was dependent on staff for eating. The care plan specifically indicated the need for one staff member to assist with eating and for supervision due to the resident's cognitive deficits and swallowing risks. However, staff members, including CNAs and LPNs, did not follow these interventions, and some were unaware of the resident's needs, relying instead on verbal shift reports or assumptions about the resident's abilities. As a result of these failures, the resident was discovered unresponsive with food present, required emergency interventions including the Heimlich maneuver and CPR, and was subsequently transported to the hospital, where she expired. The investigation revealed that staff did not consistently review or implement care plan interventions, and the resident was not provided the necessary supervision and assistance during meals as required by her care plan and physician orders.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- An audit was completed of care plans for current residents related to necessary dietary interventions to ensure that residents requiring assistance receive appropriate care during mealtimes as per the resident care plan and CNA documentation system. The audits for meal tray accuracy and appropriate level of assistance were initiated and is currently ongoing. There are currently 50 audits at this time. The tray line audit reviewing adequate consistency and items matching meal tickets was initiated and is ongoing, there are currently 118 audits at this time.
- The DON and NHA received directed education by the Regional Nurse Consultant on ensuring that resident care plans are implemented during meal times and ensuring that staff have knowledge of the resident care plan/CNA documentation system interventions.
- A total of 90 out of 90 Licensed nursing staff and Certified Nursing Assistants were provided education by the DON or designee on ensuring that resident care plans are implemented during meal times and ensuring that staff have knowledge of the resident care plan/CNA documentation system interventions. This education was 100% completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities.
Failure to Provide Required Supervision and Assistance During Meals Resulting in Resident Death
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dementia, and dysphagia was not provided the required supervision and assistance during mealtime, as outlined in her care plan and supported by speech therapy recommendations. The resident was dependent on staff for feeding and required a mechanically altered diet, yet staff failed to check her care plan before delivering her meal tray and left her unsupervised in her room. The resident consumed her meal without assistance, despite documented needs for close supervision due to her cognitive impairment and swallowing difficulties. On the day of the incident, the resident was found unresponsive by a nurse after her roommate alerted staff. The nurse and other staff initiated emergency procedures, including CPR and the Heimlich maneuver, due to suspected choking. EMS arrived and continued resuscitation efforts, noting the presence of emesis and food in the resident's airway. The resident was transported to the hospital, where she later expired. Documentation and interviews confirmed that the resident had not been consistently assisted or supervised during meals, and her care plan interventions were not followed by the staff responsible for her care. Interviews with facility staff, the resident's family, and the speech language pathologist revealed that the resident's need for supervision and assistance during meals was known but not consistently communicated or implemented. Staff members involved in meal delivery and care did not review the care plan or receive adequate handoff information regarding the resident's needs. The failure to provide supervision and assistance during meals, as required by the resident's care plan and clinical recommendations, directly led to the resident's choking incident and subsequent death.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- The facility incorporated an additional notification on resident meal tickets through the meal tracker system to ensure facility staff are aware of the care and services needed by residents to include supervision and/or assistance during mealtimes in order to prevent further instances of neglect. The addition of this tray ticket notification indicator was complete.
- The DON and NHA received directed education by the Regional Nurse Consultant regarding ensuring proper resident supervision and/or assistance during meals is occurring.
- A total of 104 out of 104 nursing and therapy staff were provided education by the DON or designee on ensuring proper resident supervision and/or assistance during meals. Education regarding the added notification on resident meal tickets was provided including the meaning of the indicator and what to do when they see it. This education was 100% completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities.
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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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