Fairway Oaks Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tampa, Florida.
- Location
- 13806 N 46th St, Tampa, Florida 33613
- CMS Provider Number
- 105305
- Inspections on file
- 21
- Latest survey
- February 21, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Fairway Oaks Center during CMS and state inspections, most recent first.
The facility failed to ensure dependent residents consistently received and had documented assistance with scheduled showers and bathing. A resident reported not having a shower since admission and had no shower documentation for nearly two weeks despite needing help with ADLs. Another cognitively intact resident with morbid obesity, diabetes, and kidney failure, who depended on staff for bathing, reported ongoing difficulty obtaining showers and had filed a grievance about shower care, while task logs showed questionable documentation practices. A third resident, dependent on staff for mobility and toileting, received only one shower during a period with multiple scheduled opportunities, with no recorded refusals, despite care plans and facility policy requiring assistance with hygiene and regular bathing.
A resident with multiple complex conditions, including CKD stage 4 and a nephrostomy, was admitted for skilled care, but the facility failed to complete the Admission/readmission Nursing Evaluation and did not perform required daily skilled documentation. Key sections of the admission assessment were left unsigned and missing critical information such as transfer method, weight-bearing status, presence of a nephrostomy tube, evaluation for mechanical lift use, and medication review/verification. Nursing documentation consisted mainly of eMAR entries for pain medications and a few brief notes on skin issues and a late entry describing a family-requested transfer to the hospital, with no admission note and no daily skilled notes despite the resident receiving PT/OT and skilled nursing. Leadership interviews confirmed that daily skilled notes should have been completed and that the admission evaluation was not finished, contrary to the facility’s own documentation policy.
A resident with multiple serious conditions, including HTN, COPD, stage 4 CKD, anemia, and terminal kidney atrophy, had a physician order for vital signs to be obtained every shift for five days. Review of the MAR showed missing BP entries and multiple instances where identical vital signs were documented across different shifts, despite the care plan directing staff to monitor vitals as ordered and PRN and to notify the MD of significant changes. During interviews, the ADON and NHA confirmed missing BPs and stated it was rare for a resident to have the same vitals on different shifts, while the interim DON acknowledged it was unlikely but not impossible, indicating that documentation was not complete or accurate as required by facility policy.
Two residents did not receive necessary outside professional services when staff failed to coordinate and follow through on podiatry and dermatology consults. One resident, who could not trim her own long, uncomfortable toenails, had a nursing note indicating need for a podiatry referral, but her name was never added to the podiatry visit list and no further action was documented. Another resident with morbid obesity, diabetes, and kidney failure had ongoing severe dry, itchy, scaly skin, with physician orders for dermatology consultation, follow-up, and ammonium lactate lotion, yet the MAR/TAR showed no treatment provided during the review period and there was no documentation of dermatology visits. The SSD reported relying on nursing to notify her of needed referrals, while nursing and leadership interviews revealed lack of awareness and verification of consult orders, resulting in missed or unconfirmed specialty services.
The facility failed to maintain cleanliness and safety in two community shower rooms, with surveyors observing brown substances on floors and shower chairs, hair in drains, and an unlocked cabinet with cleaning solutions. Staff interviews revealed unclear cleaning responsibilities between CNAs and housekeeping, contributing to the deficiencies.
A facility failed to provide required abuse and neglect training to a CNA, leading to a deficiency. The CNA was involved in an incident with a resident who was found in a concerning state by their representative. The CNA admitted to certain actions, but had not received retraining before returning to work, despite the facility's policy requiring such training.
A facility failed to report an alleged abuse incident involving a resident with Alzheimer's and dementia, who was found by her family with her hands tied behind her back. The family reported the incident to the DON, but the facility did not include the restraint allegation in their federal report. The CNA involved was suspended, and the Adult Protective Agency and police were contacted, but the complaint was not substantiated.
A resident with limited mobility and dementia was not provided with a wheelchair, despite being dependent on staff for transfers. Observations over several days showed the resident remained in bed, and staff interviews confirmed the absence of a wheelchair. The facility's policy on ADL care, which includes mobility support, was not followed.
Two residents were observed exposed in a high-traffic area without staff intervention. One resident was found with her gown pulled up, exposing her lower body, while another removed her top, exposing her upper body. Despite their cognitive impairments, staff did not promptly provide privacy or assistance, highlighting a deficiency in maintaining resident dignity and privacy.
A facility failed to ensure timely and accurate PASRR for a resident with schizoaffective disorder, major depressive disorder, and dementia. The Level I PASRR was incomplete, missing qualifying diagnoses. The RN MDS Director acknowledged the error and explained the facility's process for identifying residents with mental disorders, which involved the Admissions Department and nursing leadership. The facility lacked a PASRR policy.
The facility failed to develop and implement comprehensive care plans for residents with specific needs, leading to deficiencies in care. A resident with skin conditions did not have a care plan until prompted by surveyors. Two residents with cognitive impairments were observed with poor hygiene and inadequate assistance with activities of daily living, including bathing and feeding. Documentation inconsistencies and lack of staff adherence to care plans were noted.
Two residents in the facility did not receive adequate ADL care, including fingernail trimming and regular showers. One resident with severe cognitive impairment and multiple medical conditions was observed with long, unkempt fingernails and had not received a shower for nearly a month. Another resident with a history of cerebrovascular accident had long fingernails affecting her ability to eat and had only one shower in 30 days. The DON acknowledged the issues and noted discrepancies in care documentation.
A resident with severe cognitive impairment and skin conditions did not receive prescribed medication due to it being out of stock, and treatment records were inaccurately signed off by a nurse. The resident's representative reported inadequate follow-up on medical appointments, and facility staff acknowledged lapses in medication management and treatment responsibility.
The facility failed to provide proper catheter care for two residents, leading to deficiencies in infection prevention. One resident was observed with catheter tubing dragging on the floor while self-propelling in a wheelchair, and another had a catheter bag on the floor. Despite staff interactions, these issues were not addressed, posing contamination risks. The facility's catheter care policy was not consistently followed, resulting in care deficiencies.
A resident with PTSD did not receive trauma-informed care as their care plan lacked specific PTSD triggers, and staff were not trained annually as required. The resident expressed concerns about a person entering their room, which was not acknowledged by the attending LPN. Interviews revealed staff were unaware of the resident's care plan and psychiatric issues, and the facility's policy on trauma-informed care was not effectively implemented.
The facility failed to update the Daily Staffing Projection sheet for three days, leaving outdated information in the entrance lobby. The sheet, which should reflect current staffing numbers and resident census, was last updated on a weekday by the Staffing Coordinator, with the weekend supervisor responsible for updates on weekends. However, due to a lack of clarity and absence of a specific policy, the sheet remained unchanged, leading to inaccurate information being displayed.
A long-term care facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate. Errors included medications not administered as ordered or incorrectly documented for three residents with complex medical histories. The facility's policy on medication administration was not followed, leading to discrepancies in medication management.
The facility failed to maintain accurate medical records and ensure proper medication administration for several residents. Medications were documented as given but not observed being administered, and personal care records for a resident were inconsistent, leading to deficiencies in care standards.
Failure to Provide and Document Scheduled Showers and Bathing Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide and document assistance with bathing and showers for dependent residents in accordance with their care plans and facility policy. One resident reported not having had a shower since admission and only receiving one bed bath around the time of admission. Review of this resident’s admission record showed diagnoses including hypertensive heart disease without heart failure, unsteadiness of the feet, gait abnormalities, need for assistance with personal care, and blindness of the left eye. An MDS dated 2/8/2026 documented a BIMS score of 14, indicating the resident was cognitively intact. Review of the CNA task log for showers showed no documentation of showers or baths for 13 days, and the ADON and DON confirmed there were no shower sheets or task log entries, despite the care plan indicating the resident needed assistance with bathing and personal hygiene. Another resident was observed scratching and itching her arms and upper body, with scaly, dry, rough skin and large fishlike flakes. This resident stated she was supposed to see a dermatologist, that her family had discussed this with the facility, and that she was using regular store lotion without relief. She reported struggling to receive assistance with showers, stating that staff sometimes did not want to help and that she had filed a grievance about showers that she felt remained unresolved, although facility documentation showed the grievance as resolved after one shower was provided. Her admission record included morbid obesity due to excess calories, Type 2 diabetes, and unspecified kidney failure, and an MDS showed a BIMS score of 14. Her care plan documented an ADL self-care deficit and dependence on staff for bathing, including transfers into and out of the shower. The CNA task log for February 2026 showed a scheduled shower/bathing routine three evenings per week, but all entries had the same time stamp, which a CNA explained reflected documentation time rather than when care was actually provided. A third resident’s showering schedule indicated assistance with bathing was to be provided twice weekly on the evening shift. Review of documentation showed this resident received only one shower during the review period, despite three scheduled opportunities, and there was no documentation that the resident had refused bathing. The admission/readmission evaluation documented that this resident required extensive assistance with bed mobility and was dependent on staff for toileting and transferring. The care plan identified a potential ADL self-care deficit related to fatigue and chronic medical conditions, with interventions specifying the need for limited to extensive assistance of one to two staff for bathing. The ADON stated that residents are scheduled for showers twice a week and per preference, but at least twice weekly, and the facility’s ADL care and services policy required that residents unable to carry out ADLs independently receive appropriate support and assistance with hygiene, including bathing and showers.
Incomplete Admission Assessment and Lack of Daily Skilled Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records for a resident admitted with multiple complex medical conditions, including other artificial openings of urinary tract status, retroperitoneal fibrosis, stage 4 chronic kidney disease, unsteadiness on feet, generalized muscle weakness, need for assistance with personal care, and oropharyngeal dysphagia. The Admission/readmission Nursing Evaluation dated 1/30/26 at 5:41 p.m. was not completed and locked, with sections a, l, and n left unsigned. Section a lacked documentation of how the resident was transferred to the facility, whether there were weight-bearing restrictions, and did not document the presence of a nephrostomy tube. Section l did not include an evaluation for mechanical lift use or the resident’s ability to stand, pivot, or transfer with assistance, and section n did not show that medications were reviewed and verified. Record review showed that the Daily Skilled Note assessment had not been accessed or completed for this resident, despite the resident being on a skilled level of care and receiving specialized services and skilled nursing. The progress notes did not contain an admission note. Nursing documentation consisted primarily of eMAR entries related to administration of oral and topical pain medications and associated effectiveness checks, along with a single general note on 1/30/26 indicating a skin concern on the coccyx and notification of the emergency contact, and a skin/wound note on 2/2/26 documenting scar tissue to the sacrum, a surgical site to the right flank with minimal serous drainage and treatment in place, and scar tissue to the abdomen. There were no nursing eMAR or progress notes documenting the resident’s overall wellbeing on 2/4/26. A late entry note dated 2/7/26 for 2/6/26 at 9:30 a.m. documented that nursing was called to the resident’s room by administrative staff, that the resident did not appear to be in respiratory distress, and that a family friend and family member expressed concern and requested transfer to the hospital; EMS arrived before staff could obtain vital signs. Interviews with the Director of Rehab indicated the resident was receiving physical and occupational therapy in the room, had refused to go to the gym, and was status post nephrostomy placement. The ADON and Interim DON stated that, as a skilled resident, there should have been daily skilled charting notes, but these were not present. The NHA confirmed the Admission/readmission Evaluation was not completed and that there were no daily skilled notes other than a late entry for the resident’s departure. Staff C, an LPN, could not recall specific information about the resident from the chart. The facility’s documentation policy required objective, complete, and accurate documentation of services, assessments, treatments, and changes in condition, but there was no policy provided specific to completing an admission assessment or daily skilled notes.
Failure to Accurately Document and Monitor Ordered Vital Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, professional nursing standards, and the resident’s person-centered care plan for one resident. A physician order dated 1/30/26 directed staff to obtain the resident’s vital signs every shift for five days, but the order was not fully carried out. The Medication Administration Record (MAR) showed that vital signs were recorded on multiple shifts between 2/1/26 and 2/4/26; however, there were missing blood pressure entries, and several sets of vital signs were documented as being exactly the same across different shifts. Specifically, the record showed identical vital signs on two consecutive shifts on 2/1, identical vital signs between the night shift on 2/1 and the afternoon shift on 2/2, and identical vital signs on two consecutive shifts on 2/3. The resident’s care plan identified altered cardiovascular status related to hypertension and directed staff to monitor vital signs and weights as ordered and as needed, and to notify the physician of significant abnormalities or changes. The resident’s admission record listed multiple serious diagnoses, including retroperitoneal fibrosis, unspecified COPD, stage 4 CKD, unspecified anemia, atrophy of kidney (terminal), and primary hyperparathyroidism. During interviews, the ADON and Nursing Home Administrator confirmed that blood pressures were missing and acknowledged that it was rare for a resident to have the same vital signs on different shifts, while the Interim DON stated she would not say it was impossible for vital signs to be identical over different shifts. The facility’s documentation policy required that services provided be documented in a manner that is objective, complete, and accurate, and that medical records facilitate communication about the resident’s condition and response to care, which was not met in this case.
Failure to Coordinate Podiatry and Dermatology Consults for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure outside professional resources were obtained and coordinated for required services, specifically podiatry for one resident and dermatology for another. One resident reported to nursing staff that her toenails were very long, that she could not cut them herself, and that they were uncomfortable. A nursing progress note documented on 2/16/2026 that this resident’s nails were very long and that she needed a referral to a podiatrist. However, there was no further follow-up in the medical record regarding a podiatry referral, and the resident’s name did not appear on the podiatry visit list for the provider’s 2/18/2026 visit. Another resident, who was cognitively intact and had diagnoses including morbid obesity, Type 2 diabetes, and unspecified kidney failure, was observed in bed scratching and itching her arms and upper body, with scaly, dry, rough skin and small fishlike flakes. The resident stated she was supposed to see a dermatologist, that her family had discussed this with the facility the previous Friday, and that she was only using regular store lotion, which was not helping, while her itching was getting worse. Physician orders included a dermatology consultation for body itching, a follow-up with dermatology, and an order for ammonium lactate lotion to be applied twice daily for dry skin. Review of the MAR and TAR showed the resident was not receiving any treatment for the ongoing itching condition during the reviewed period. The facility’s own consult policy stated that Social Services would coordinate most resident referrals (such as podiatry and vision), that referrals should be based on physician evaluation and orders, and that Social Services would document referrals and maintain a listing of referral agencies. In practice, the Social Services Director reported that nursing staff were expected to notify her of residents needing podiatry so they could be added to the list, but there was no evidence this occurred for the resident with long nails. For the resident with dermatologic issues, the Social Services Director stated dermatology appointments were scheduled by nursing and that she had not been informed of any concerns, family complaints, or need for dermatology, and no grievance had been initiated. Nursing staff and the ADON were not aware of or did not verify dermatology orders or visits, and record review showed no documented dermatology visits or physician notes beyond a single prior encounter, indicating a lack of coordination and follow-through with outside dermatology services despite existing orders and ongoing symptoms.
Deficiency in Shower Room Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain cleanliness and safety in two community shower rooms, as observed by surveyors. On two separate occasions, surveyors noted the presence of a brown substance on the floors, shower chairs, and underneath mats in the shower rooms. Additionally, hair and gauze were found in the shower drains, and a comb with hair was left on a shower chair. A dirty linen bin was found with its lid on the floor, and a cabinet containing cleaning solutions was unlocked, with no key in sight. These observations were made in the shower rooms located between the 100-200 rooms hallway and the 400 rooms hallway. Interviews with staff revealed a lack of clarity and execution in cleaning responsibilities. The housekeeper stated that CNAs were responsible for cleaning the shower area after resident use, while housekeeping was tasked with routine cleaning and disinfection. The housekeeping supervisor and environmental services director confirmed that CNAs were expected to disinfect the shower room and equipment after each use, with housekeeping performing deeper cleaning weekly. However, the environmental services director was unaware of the unlocked cabinet issue. The facility's policy outlined specific cleaning procedures, including debris removal, surface cleaning, and inspection, which were not adhered to, leading to the observed deficiencies.
Failure to Provide Abuse and Neglect Training to Staff
Penalty
Summary
The facility failed to provide abuse and neglect training to one of its staff members, Staff X, a Certified Nursing Assistant (CNA). This deficiency was identified during a review of records and interviews, where it was found that Staff X had not received the necessary training on abuse and neglect prevention and response. The facility's policy requires all staff, including new and existing employees, to undergo training on abuse, neglect, exploitation, misappropriation, mistreatment, and injury of unknown origin (ANEMMI). However, Staff X was not included in the sign-in sheet for the in-service education conducted on March 14, 2024, which covered these topics. The incident leading to the deficiency involved Resident #100, who had a lower BIMS score and was known to wander frequently. On March 13, 2024, the resident's representative (RR) visited and reported finding the resident in a concerning state, with two briefs, a hospital gown tucked around her, and her hands bound behind her. The RR also noted that the call light was out of reach and the TV was not working. Staff X, who was responsible for the resident's care, admitted to moving the call bell and using a liner in the resident's brief to prevent her from digging her hands into her pants. The RR accused Staff X of double briefing and inappropriate conduct, leading to an investigation. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were informed of the allegations, and the case was reported to the abuse hotline and the police. The facility conducted evaluations on the resident, who was found to be in no pain and had no skin impairments. Despite the serious nature of the allegations, Staff X returned to work without completing any retraining or education on abuse and neglect, highlighting the facility's failure to ensure all staff received the necessary training as per their policy.
Failure to Report Alleged Abuse and Restraint
Penalty
Summary
The facility failed to report an alleged violation of abuse involving a resident to the State Survey Agency. The incident involved a resident with multiple medical diagnoses, including Alzheimer's disease and dementia, who was found by her family with her hands tied behind her back using a towel. The family also reported that the resident was double briefed and wet, with her call bell clipped to the curtain and the TV turned off. The family reported the incident to the Director of Nursing (DON), but the facility did not include the allegation of restraint in their federal reportable submission. During interviews, the Certified Nursing Assistant (CNA) involved stated that the resident was known to be active and that she had placed a liner in the resident's brief to prevent her from digging her hands into her pants. The CNA also mentioned that the resident's family was upset about the condition of the room and the resident's state. The CNA was suspended following the family's report, and the Adult Protective Agency and police were contacted, but the facility did not substantiate the complaint. The Nursing Home Administrator (NHA) acknowledged the report of the incident but stated that the allegation of restraint was not included in the federal report because there was no skin breakdown. The facility's policy requires immediate reporting of all allegations of abuse, neglect, or mistreatment, but the report did not reflect the full scope of the family's allegations. The facility's failure to report the alleged restraint and the conditions in which the resident was found constitutes a deficiency in adhering to reporting requirements.
Failure to Provide Wheelchair Mobility for Resident
Penalty
Summary
The facility failed to provide wheelchair mobility for a resident, identified as Resident #7, who was observed lying in bed during multiple observations over several days. The resident was admitted with diagnoses including dysphagia following cerebral infarction and unspecified dementia. The Minimum Data Set (MDS) indicated that the resident used a wheelchair for mobility, yet the care plan initiated on 09/10/2024 noted the resident's dependency on staff for transfers. Interviews with staff members, including CNAs and an RN, revealed that Resident #7 did not have a wheelchair and was not included on the list of residents to be assisted out of bed. Further interviews with the LPN/Unit Manager and the Rehab Director confirmed that Resident #7 was dependent, had limited mobility, and required a reclining wheelchair, which was not available. The Rehab Director mentioned that the resident was picked up for therapy services on 09/11/2024, but could not explain why the resident had not been provided with a wheelchair earlier. The facility's policy on ADL care and services emphasized the provision of appropriate support for mobility, which was not adhered to in this case.
Failure to Provide Resident Privacy
Penalty
Summary
The facility failed to provide privacy for two residents during a survey observation. Resident #76 was observed in her room with the door and privacy curtain fully open, lying in bed with her hospital gown pulled up, exposing her nude lower body. This occurred in a high-traffic hallway where staff, residents, and visitors frequently passed by, yet no staff intervened to provide privacy or assist the resident in covering up. The resident, who has cognitive impairments and various medical conditions, was unable to communicate her need for privacy. Despite being exposed for over ten minutes, staff did not take action until much later. Similarly, Resident #82 was observed seated in her wheelchair at the nurses' station, initially well-dressed and groomed. However, she later removed her top, exposing her upper body to staff and visitors passing by. A Personal Care Attendant (PCA) noticed the resident's actions but did not immediately assist her in redressing or moving her to a private area. Instead, the PCA eventually helped the resident put her shirt back on while she remained in the doorway, visible to others. The resident's medical records indicated a history of dementia and other conditions, but no prior incidents of disrobing were documented. Interviews with staff revealed that neither resident had a known history of disrobing, and staff were expected to provide privacy by closing doors or curtains and assisting residents in dressing. The facility lacked a specific privacy policy, relying instead on a general Resident Rights policy that emphasized treating residents with dignity and respect. Despite this, the staff failed to uphold these standards, resulting in the observed deficiencies.
Failure to Ensure Accurate PASRR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure timely and accurate Pre-Admission Screening and Resident Review (PASRR) for a resident with multiple mental health diagnoses. The resident was initially admitted with diagnoses including schizoaffective disorder bipolar type, major depressive disorder, dementia, and mood disorder due to a known physiological condition with depressive features. However, the Level I PASRR completed for this resident was found to be incomplete, as it did not indicate the qualifying diagnoses of depression, mood disorder, and dementia. During an interview, the RN MDS Director explained the facility's process for identifying residents with possible mental disorders or intellectual disabilities prior to admission. The process involved the Admissions Department and either the Director of Nursing or Assistant Director of Nursing reviewing clinical information to decide on admissions. The RN MDS Director was responsible for updating the PASRR when new diagnoses were identified or if the initial PASRR was incorrect. Upon reviewing the PASRR for the resident in question, the RN MDS Director acknowledged that it was incorrect and missing qualifying diagnoses. The facility did not have a PASRR policy in place.
Deficiencies in Care Plan Implementation for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with specific needs, leading to deficiencies in care. Resident #45, who was admitted with conditions including hemiplegia, psoriasis, and lymphedema, was observed with untreated skin conditions. Despite being admitted with these diagnoses, a care plan addressing his skin condition was only created after the surveyor's inquiry, indicating a delay in addressing his needs. The resident was also noted to have cognitive deficits, further complicating his ability to communicate his needs. Resident #44, diagnosed with dementia and other chronic conditions, was observed with poor personal hygiene, including long, untrimmed fingernails and disheveled hair. The resident expressed a desire for a shower, which had not been provided according to her preferences. The care plan for her activities of daily living (ADL) was not adequately implemented, as evidenced by the lack of assistance during meals and the absence of regular showers. The documentation showed inconsistencies in the recording of showers and nail care, with several instances of refusal not being properly documented or addressed by nursing staff. Resident #51, with a history of cerebrovascular accident and severe cognitive impairment, was also found to have inadequate ADL care. Observations revealed long fingernails with substances underneath, and the resident struggled with self-feeding due to her condition. The care plan did not reflect her current needs, and there was a lack of consistent documentation regarding her bathing routine. The DON acknowledged the discrepancies in care and documentation, highlighting the need for improved oversight and adherence to care plans.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADLs) care for two residents, specifically in the areas of fingernail care and showering. Resident #44, who has severe cognitive impairment and multiple medical conditions including dementia and brain cancer, was observed with long, unkempt fingernails and disheveled hair. Despite her need for assistance, she had not received a shower from 08/13/2024 to 09/10/2024, and her fingernails were not trimmed, leading to discomfort and potential hygiene issues. The Director of Nursing (DON) acknowledged the oversight and noted that the aides were responsible for reporting such needs to the nurse, but this process was not followed. Resident #51, also with severe cognitive impairment and a history of cerebrovascular accident, was observed with long fingernails and wearing the same clothing for several days. She had only received one shower in a 30-day period, and her fingernails were not trimmed, which affected her ability to eat properly. The DON recognized the infection control issue posed by the long nails and the need for more assistance during meals. The documentation in the medical records did not match the actual care provided, indicating a lack of consistency in care delivery and record-keeping. The facility's policy on ADL care and services was not adhered to, as residents who were unable to perform ADLs independently did not receive the necessary support to maintain good hygiene and nutrition. The DON admitted that the aides required more education and that the care plans needed to be updated to reflect the residents' current needs. The failure to provide adequate ADL care and the discrepancies in documentation highlight significant deficiencies in the facility's care practices.
Deficiency in Medication and Skin Care Treatment
Penalty
Summary
The facility failed to provide quality care and services according to standards of practice related to medication administration and skin care treatment for a resident with severe cognitive impairment and multiple medical conditions, including psoriasis and stasis dermatitis. Observations revealed that the resident was left in a hospital gown for extended periods and had scabs on his legs leaking yellow fluid. The resident's representative expressed concerns about the lack of follow-up on medical appointments and the resident's deteriorating skin condition. The facility's records showed that the resident was prescribed Otezla for psoriasis, but the medication was not administered on several occasions due to it being out of stock. A registered nurse admitted to signing off on medication and treatment records without verifying their completion, assuming they were done. The wound care nurse confirmed that the resident was no longer under wound care supervision, and daily treatments were supposed to be administered by the assigned nurse. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nurses, highlighted a lack of communication and responsibility regarding the resident's medication and treatment administration. The Director of Nurses acknowledged the medication was missing and should have been reordered, but could not explain why it was unavailable. The facility's policy emphasized that medication and treatment orders should be consistent with safe and effective practices, which was not adhered to in this case.
Deficiencies in Catheter Care and Infection Prevention
Penalty
Summary
The facility failed to provide proper care for residents with indwelling urinary catheters, leading to deficiencies in catheter management and infection prevention. Resident #82 was observed multiple times with her catheter tubing dragging on the floor while she was self-propelling in her wheelchair. Despite staff passing by and interacting with her, the issue was not addressed, posing a risk of contamination and infection. The resident, who had cognitive impairments, was unable to advocate for herself, and her responsible party was unaware of the issue until informed during an interview. Resident #13 was also found with her catheter bag on the floor, which is against the facility's guidelines for catheter care. The resident expressed a desire to resume therapy to improve her mobility but was planning to transfer to another facility. Staff interviews revealed that the catheter bag should be placed below the bladder and not on the floor, yet this standard was not maintained for Resident #13. The facility's catheter care policy emphasizes infection control and proper positioning of catheter bags and tubing. However, observations and interviews indicated that these guidelines were not consistently followed, leading to potential risks for the residents involved. The staff's failure to adhere to these protocols resulted in deficiencies in the care provided to residents with indwelling urinary catheters.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's care plan did not include specific PTSD triggers, and staff were not trained annually on trauma-informed care as required by the facility's policy. The resident, who had a history of major depressive disorder, schizoaffective disorder, unspecified psychosis, PTSD, other specified persistent mood disorders, anxiety disorder, and dementia, was observed expressing concerns about a particular person entering his room, which was not acknowledged by the attending Licensed Practical Nurse (LPN). Interviews with staff revealed a lack of awareness and understanding of the resident's care plan and psychiatric issues. One LPN admitted to not reviewing care plans and was unaware of any psychiatric issues the resident might have. Another LPN incorrectly identified a different resident as having a PTSD diagnosis. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that nurses should be familiar with care plans and that changes in resident conditions should be communicated through care plan meetings and assessments. However, the DON admitted that there was no ongoing education for staff on trauma-informed care beyond initial orientation. The facility's policy on trauma-informed care, revised in January 2024, outlined procedures for assessing residents for PTSD, developing comprehensive care plans, and providing culturally competent care. Despite this, the policy was not effectively implemented, as evidenced by the lack of specific PTSD triggers in the resident's care plan and the absence of annual staff training. The MDS Coordinator noted that the care plan's focus on trauma was based on psychiatric evaluations, which did not specify the resident's PTSD triggers.
Failure to Update Daily Staffing Information
Penalty
Summary
The facility failed to provide up-to-date and accurate daily staffing information for residents and visitors, as required. During an observation on 9/8/2024, it was noted that the Daily Staffing Projection sheet displayed in the facility's entrance lobby was outdated, showing information from 9/5/2024. This sheet, which should have been updated daily to reflect the current staffing numbers for each shift and the resident census, had not been updated for three days. Interviews with the front desk receptionist and the weekend supervisor revealed a lack of clarity regarding who was responsible for updating the form, with the weekend supervisor unaware of the current resident census. The Nursing Home Administrator confirmed that the Staffing Coordinator was responsible for updating the sheet on weekdays, while the weekend supervisor was tasked with this duty on weekends. However, the sheet had not been updated since 9/5/2024, and the Staffing Coordinator was unaware of the lapse, as she was off on 9/6/2024. The facility did not have a specific policy regarding the daily nursing assignment posting, although it was their standard practice to keep the information current. This oversight resulted in the failure to provide accurate staffing information to residents and visitors for three consecutive days.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate for three of four sampled residents. This was observed during medication administration by nursing staff, where several medications were either not administered as ordered or incorrectly documented as given. For Resident #498, medications such as Azithromycin and Flonase were documented as administered but were not observed being given. This resident had a history of cerebrovascular accident, heart failure, and chronic respiratory issues, necessitating precise medication management. Resident #93 also experienced medication errors, with medications like MiraLax and Ranolazine documented as given but not observed during administration. The resident's medical history included conditions such as COVID-19, diabetes, and atherosclerotic heart disease, which required careful adherence to prescribed medication regimens. The facility's Director of Nursing (DON) acknowledged that medications were not administered as per orders and that the documentation was inaccurate. For Resident #14, a discrepancy was noted in the dosage of Calcium administered, which was 500 mg instead of the ordered 600 mg. This resident had a history of rheumatoid arthritis, severe malnutrition, and hypertension, highlighting the importance of accurate medication administration. The facility's policy on medication administration emphasized the need for medications to be given as prescribed and documented accurately, which was not adhered to in these cases.
Deficiencies in Medication Administration and Personal Care Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records for several residents, leading to deficiencies in medication administration and personal care. For Resident #498, medications such as Azithromycin, Flonase, and Fluticasone-Salmeterol were documented as administered but were not observed being given. This discrepancy was confirmed by the Director of Nursing (DON) and the Advanced Practice Registered Nurse (APRN), who stated that medications should be administered as ordered and documented accurately. Similarly, for Resident #93, medications including MiraLax, Ranolazine, and Sennosides were documented as given but were not observed being administered. The DON confirmed these discrepancies upon reviewing the Medication Administration Review (MAR) and acknowledged them as medication errors. The APRN emphasized the importance of notifying the provider if medications are not given or are administered late. Additionally, Resident #51's personal care was inadequately documented, with inconsistencies in the records regarding bathing and nail care. The resident was observed with long, unclean fingernails and reported not having her nails cleaned or clipped. The DON verified that the shower sheets did not consistently indicate whether the resident received a shower or bed bath, and the documentation did not match the medical record. This lack of accurate documentation and care was noted as a deficiency in maintaining professional standards for resident care.
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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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