Groves Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Wales, Florida.
- Location
- 512 S 11th St, Lake Wales, Florida 33853
- CMS Provider Number
- 105269
- Inspections on file
- 27
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Groves Center during CMS and state inspections, most recent first.
Two residents with indwelling catheters did not receive necessary care to prevent or manage UTIs, including failure to follow physician orders for catheter changes, missed laboratory testing, and incomplete antibiotic administration. One resident developed a severe infection that progressed to Fournier's gangrene and sepsis, while another did not receive the full prescribed course of antibiotics, with no documentation or provider notification regarding the missed doses. Staff interviews revealed inconsistent training and documentation practices related to catheter care and change of condition.
The facility failed to follow physician orders for catheter care and lab monitoring, resulting in a resident developing a severe UTI that progressed to Fournier's gangrene and sepsis. Another resident did not receive the full course of prescribed antibiotics for a UTI, with no documentation of provider notification. Two residents with abnormal lab results did not have timely provider notification or documentation, and another resident experienced unmanaged pain for two days despite documented high pain levels and available orders for pain medication.
A resident with multiple medical conditions reported missing personal items, including a blanket and clothing. Despite repeated complaints to various staff members and a search of the laundry room, not all items were recovered and no formal grievance was filed or investigated, contrary to facility policy.
A resident with complex medical needs experienced a significant change in condition, including lethargy and pain, and received late medication administration. The resident's representative reported concerns to staff and the NHA, explicitly alleging neglect, but the incident was not reported or investigated as required by facility policy. Staff interviews confirmed the assigned LPN was absent from the unit for extended periods, and there was no documentation of provider notification or change of condition assessment.
The facility did not conduct a thorough investigation into an allegation of neglect involving a resident with a foley catheter. The NHA failed to contact the family, did not interview all relevant staff, and did not obtain necessary medical records or consult the resident's urologist. Key clinical details, such as the resident's pain complaints and the presence of wounds, were missed or unknown to the investigation team.
The facility did not ensure proper catheter care for several residents, including failure to change catheter bags as ordered, lack of securement devices for catheters, and inconsistent response to signs of infection such as cloudy lines and sediment. Staff interviews confirmed that securement devices were not used despite facility policy and best practice guidelines, and one resident developed a pressure injury at the catheter site due to lack of stabilization.
A resident with a colostomy and abdominal wounds experienced unmanaged pain for several days after admission, despite having orders for acetaminophen and Percocet. Nursing staff documented significant pain but did not administer the prescribed medications or notify a physician, and there was no documentation explaining the delay. Facility policy required prompt pain management, but these procedures were not followed, resulting in the resident's pain going untreated.
Two residents with complex medical conditions had abnormal lab results that were not communicated to their providers as required. In both cases, there was no documentation that the LPN or nursing staff notified the provider of the abnormal findings, despite facility policy and expectations for prompt notification and documentation. The DON and Regional Nurse Consultant confirmed the lack of documentation and acknowledged discrepancies in physician notifications.
Surveyors found that multiple residents did not receive timely incontinence care, with staff failing to respond promptly to call lights and leaving residents in soiled briefs for extended periods, particularly during night shifts. Residents with significant medical and functional needs were affected, and care plans requiring regular checks were not consistently followed, as confirmed by both resident interviews and care documentation.
Surveyors found that the facility did not ensure PPE was available or used for residents on Contact Precautions or Enhanced Barrier Precautions. Multiple rooms with posted precaution signs lacked accessible PPE, and staff entered rooms without donning required protective equipment. Staff interviews revealed confusion about isolation requirements and inconsistent application of infection control protocols for residents with MDROs, wounds, and IV access.
Surveyors observed live insects in multiple facility areas, including the dining and activity halls, and a resident reported persistent roaches in their room despite cleaning and spraying. Facility records showed ongoing pest control treatments for various pests, but interviews with the DOM and NHA revealed a lack of awareness and inconsistent responses to pest complaints, indicating the pest control program was not effective.
A grievance filed by a resident's family about missing dentures was not promptly or thoroughly addressed, with gaps in documentation, communication, and follow-up. The facility did not assign responsibility for the grievance, failed to document a resolution or satisfaction of the complainant, and did not maintain adequate records of communication, contrary to its own grievance policy.
A resident with chronic pain conditions did not receive a scheduled dose of Oxycodone because the medication supply ran out and was not reordered in time. Staff interviews revealed confusion about the process for obtaining narcotics from the automated dispensing machine and inconsistent communication with the pharmacy, resulting in a delay in medication delivery and a missed dose.
Several residents experienced significant delays and omissions in incontinence care, with reports of long wait times for assistance, incomplete documentation, and staff shortages leading to residents remaining in soiled briefs for extended periods. Staff interviews confirmed heavy workloads and insufficient staffing contributed to the failure to provide timely care as required by care plans and facility policy.
A facility failed to protect resident privacy and confidentiality when an RN disposed of used feeding bottles with identifiable information in an unsecured trash can and left a medication cart unattended with resident information exposed. The DON confirmed that staff should have marked off identifiable information before disposal.
Two residents with tracheostomies in a facility experienced deficiencies in care due to unconfirmed physician orders and lack of documentation for essential care activities. One resident, with severe cognitive impairment, had missing documentation for tracheostomy suctioning, medication administration, and vital sign monitoring. Another resident, cognitively intact, also faced similar issues with tracheostomy management and enteral feeding. The Director of Nursing confirmed the documentation gaps, which were against the facility's policies.
A resident with a tracheostomy did not receive care consistent with professional standards at an LTC facility. An RN failed to follow enhanced barrier precautions, including wearing a gown and performing proper hand hygiene, while providing care. The resident had a complex medical history and required specific care protocols, which were not followed, leading to a deficiency in care.
A facility failed to follow standard and enhanced barrier precautions during the care of two residents, leading to a deficiency in infection prevention and control. A registered nurse (RN) did not wear a gown or perform proper hand hygiene while providing care to a resident with a tracheostomy and gastrostomy tube, despite the requirement for enhanced barrier precautions. The facility's policies and the resident's care plan required the use of gloves and gowns during high-contact care activities, which the RN did not comply with.
Failure to Prevent and Manage UTIs in Residents with Indwelling Catheters
Penalty
Summary
The facility failed to provide necessary care and services to prevent urinary tract infections (UTIs) from developing or worsening in two residents with indwelling catheters. For one resident, the facility did not follow physician orders for a silver coated Foley catheter, failed to order and perform required laboratory tests, and did not change the catheter according to the prescribed schedule. The resident's medical records showed missed documentation of a urology appointment, lack of evidence that the ordered silver coated catheter was ever provided, and a significant gap between catheter changes. The resident experienced escalating pain, with pain levels documented as high as 10 out of 10, and there was a lack of timely assessment and documentation of vital signs and laboratory testing during a period of worsening symptoms. The resident ultimately developed a severe UTI that progressed to Fournier's gangrene and sepsis, as confirmed by hospital records, which also noted the resident had been requesting to be sent to the emergency room for several weeks prior to transfer. In the second case, another resident with a history of chronic health conditions and an indwelling catheter was prescribed a five-day course of Ertapenem for a UTI. The medication administration records showed that only three out of five doses were given, with no documentation explaining the missed doses or indicating that the provider was notified about the incomplete antibiotic course. There was also no evidence in the progress notes to account for the missed doses or any follow-up actions taken in response to the incomplete treatment. Interviews with staff revealed inconsistencies in knowledge and practice regarding catheter care, change of condition, and documentation. Some staff reported receiving only occasional in-service training, and there was a lack of demonstration-based education. Facility policies required staff to notify providers of abnormal findings and to document all relevant communications and follow-up actions, but these procedures were not consistently followed. The facility's own abuse prevention policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or distress, which was reflected in the findings for both residents.
Failure to Provide Necessary Care, Timely Provider Notification, and Pain Management
Penalty
Summary
The facility failed to provide necessary care and services as ordered and according to residents' preferences and goals, resulting in multiple deficiencies. For one resident with a history of neurogenic bladder and recurrent UTIs, the facility did not follow physician orders for a silver-coated Foley catheter, failed to change the catheter as scheduled, and did not order or document required laboratory tests to monitor for infection. The resident experienced escalating pain, which was documented but not adequately addressed, and there was a lack of timely provider notification regarding abnormal findings. Ultimately, the resident developed a severe UTI that progressed to Fournier's gangrene and sepsis, with hospital records indicating the resident had been requesting to go to the emergency room for weeks due to feeling unwell and experiencing foul-smelling drainage. Another resident with a UTI did not receive the full course of prescribed antibiotics, with only three out of five doses administered. There was no documentation explaining the missed doses or indicating that the provider was notified of the incomplete antibiotic therapy. This lapse in care placed the resident at risk for worsening infection or delayed recovery. Additionally, the facility failed to ensure that providers were notified of abnormal laboratory results for two other residents. In both cases, there was no documentation that the physician was informed of critical lab values, despite facility policy requiring prompt notification and documentation of such events. The facility also failed to manage pain appropriately for another resident who reported significant pain upon admission. Despite documented pain levels of 6 out of 10 and orders for pain medication, the resident did not receive any pain medication for two days, and there was no documentation of provider notification or explanation for the delay. Interviews with staff confirmed that pain of this severity should have prompted provider contact and administration of ordered medications. Facility policies reviewed emphasized the importance of timely pain management, provider notification, and documentation, all of which were not followed in these cases.
Failure to File and Investigate Grievance for Missing Resident Items
Penalty
Summary
The facility failed to ensure that a grievance was filed, investigated, and resolved for a resident who reported missing personal items. The resident, who was admitted with diagnoses including muscle wasting, atrophy, MRSA infection, and osteomyelitis, reported missing a blanket and several blouses. The resident and a family member searched the laundry room for the missing items, but not all items were recovered. Despite the resident's repeated complaints and the involvement of multiple staff members, including the Admissions Director and Housekeeping Director, no formal grievance was filed regarding the missing items. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. The Social Services Director was unaware of the missing items and confirmed that no grievance had been logged. The Admissions Director and Housekeeping Director both acknowledged the resident's complaints but did not initiate the grievance process, assuming the issue was being addressed informally. The facility's policy requires staff to assist residents in filing grievances and to document and investigate concerns, but this procedure was not followed in this case.
Failure to Report and Investigate Alleged Neglect Following Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely reporting and investigation of an allegation of neglect for one resident. The resident's representative reported concerns to staff regarding the resident's lethargy, pain, and delayed medication administration. The representative was unable to locate the assigned nurse for over an hour, and when the nurse was found, she was dismissive of the concerns. The representative explicitly told the Nursing Home Administrator (NHA) that he believed the resident was neglected, but did not receive any follow-up from the facility. Medical record review revealed that the resident, who had a complex medical history including end-stage renal disease, lupus, and chronic kidney disease, experienced a change in condition with increased lethargy and pain. Despite these changes and abnormal laboratory results, there was no documentation that a change of condition assessment was completed or that a provider was notified. Medications were administered late throughout the day, and staff interviews confirmed that the nurse assigned to the resident was repeatedly absent from the unit for extended periods without proper coverage. The facility's own policy required immediate reporting and investigation of alleged neglect, but the incident was not documented in the facility's reportable log, and there was no evidence that the required notifications or investigations were completed. Interviews with the DON and Regional Nurse Consultant confirmed that the expected procedures for assessment and provider notification were not followed. The NHA acknowledged that the nurse's actions could constitute neglect but did not ensure the incident was reported as required.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident with a foley catheter. The Nursing Home Administrator (NHA) became aware of the allegation when a Department of Children and Families (DCF) agent arrived and reported that the resident's family alleged the facility did not replace the resident's foley catheter or provide catheter care, which they believed led to an infection. The NHA did not contact the family for further information and was unsure about the details of the catheter order. The investigation did not include contacting the resident's urologist, and the NHA was unaware of the resident's complaints of severe pain that began several days before the resident was sent to the emergency room. The NHA stated that interviews were conducted with some staff, but could not provide records of these interviews, and did not interview all relevant staff involved in the resident's care. Additionally, the facility did not obtain hospital records related to the resident's care, citing difficulty in obtaining them, and was unaware of the presence of a perineal wound and an unstageable pressure injury where the foley catheter would lay. The Senior Regional Nurse Consultant (SRNC) was the only attendee aware of the hospital report indicating gangrene. The facility's own policy required a complete and thorough investigation, including interviews with all relevant parties and review of documentation, but these steps were not fully completed in this case.
Failure to Provide Proper Catheter Care and Securement
Penalty
Summary
The facility failed to provide proper catheter care for four residents, as evidenced by observations, interviews, and record reviews. Catheter drainage bags were not changed according to physician orders, with some bags dated well beyond recommended intervals. Multiple residents were observed with catheters lacking adhesive or stabilization devices, despite facility policy requiring securement to prevent movement and urethral traction. Cloudy catheter lines and sediment were noted, and staff responses to these findings were inconsistent, with some staff indicating irrigation or culture requests, but not adhering to established protocols. One resident had a pressure injury corresponding to the location of an unsecured catheter, and the Director of Nursing confirmed that securement devices were not in use, contrary to both facility policy and best practice guidelines. Staff interviews revealed that while in-service training on catheter care had occurred recently, there was no consistent application of securement practices, and demonstration training had not yet started. The facility's own policy and external best practice guidelines both emphasize the importance of securing catheters to prevent complications, but this was not implemented. Residents with a history of frequent UTIs and catheter-related wounds were not receiving care in accordance with these standards, as evidenced by the lack of securement and timely bag changes.
Failure to Provide Timely Pain Management for Resident with Colostomy
Penalty
Summary
A deficiency occurred when a resident with a history of Crohn's disease, abdominal wounds, and a colostomy experienced unmanaged pain upon admission. The resident reported that it took several days to receive pain medication, during which time her pain increased, especially when her colostomy bag broke and her skin became raw. The resident described the pain as severe, particularly during colostomy care and cleaning, and expressed distress over the delay in receiving pain relief. Review of the resident's records showed that pain was documented at a level of 6 out of 10, but neither acetaminophen nor Percocet, both of which were ordered, were administered on the days the pain was recorded. There was no documentation explaining why pain medication was not provided, nor any evidence that a physician was notified about the resident's pain levels during this period. Interviews with nursing staff and the DON confirmed that pain medication should have been administered and that a pain level of 6 warranted contacting the provider, but this did not occur. Facility policy required prompt assessment and management of pain, including obtaining physician orders and administering medication as needed. Despite these guidelines, the resident's pain was not addressed in a timely manner, and the care plan interventions to observe and manage pain were not followed. The lack of documentation and failure to provide ordered pain medication led to unmanaged pain for the resident.
Failure to Notify Providers of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure that providers were notified of abnormal laboratory results for two out of three residents reviewed. In the first case, a resident with a complex medical history including end-stage renal disease, systemic lupus erythematosus, and chronic kidney disease experienced seizures and was noted by her representative to be lethargic, in pain, and not her usual self. Despite laboratory tests being ordered and drawn, the assigned LPN informed the resident's representative that results would be reviewed when the doctor returned and did not notify the provider of the abnormal findings, which included low iron, glucose, and chloride, as well as elevated BUN, creatinine, and potassium. There was no documentation in the progress notes that the physician was informed of these abnormal results, and the primary care provider confirmed he was not contacted regarding the resident's pain, change in condition, or lab values on that day. In the second case, another resident with end-stage renal disease, epilepsy, thrombocytopenia, and a history of transient ischemic attack had STAT labs ordered due to tremors and feeling cold. The labs, which revealed multiple abnormal values such as low RBC, hemoglobin, hematocrit, platelet count, and high neutrophils, were completed and available the same day. However, there was no documentation that the provider was notified of these abnormal STAT lab results. The provider's assistant stated that notification and documentation of such results would be expected, but neither she nor the provider recalled being notified, and the facility's records did not show evidence of such communication. Interviews with the DON and Regional Nurse Consultant confirmed that the facility's policy requires prompt notification and documentation of abnormal lab results, especially for STAT and critical values. They acknowledged discrepancies in physician notifications and verified that there was no documentation of provider notification for either resident prior to discharge. The facility's policy also specifies that such communications should be documented in the progress notes or on the lab results sheet, but this was not done in these cases.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Surveyors identified that the facility failed to provide timely and appropriate incontinence care for four residents who were sampled. Multiple residents reported that staff did not respond promptly to call lights, especially during night shifts, resulting in residents remaining in soiled briefs for extended periods, sometimes until the next shift. In some cases, staff turned off call lights without providing care, and residents had to wait for significant periods, sometimes up to an hour and a half, before receiving assistance. These incidents were corroborated by resident interviews and review of care documentation, which showed missed incontinence care tasks across various shifts. The residents involved had significant medical histories and functional limitations. One resident had diagnoses including overactive bladder, muscle weakness, and required substantial assistance with toileting hygiene, being always incontinent for bowel and bladder. Another resident, with a history of femur fracture and diabetes, also required assistance and was always incontinent, but reported that staff response was slow, leading to prolonged periods in soiled briefs. A third resident, with severe cognitive impairment and hemiplegia, was dependent on staff for all toileting needs and was not a candidate for a toileting program, yet did not receive incontinence care as scheduled. A fourth resident, with a history of fracture and muscle atrophy, was occasionally incontinent and dependent on staff, but also experienced significant delays in care. Care plans for these residents specified the need for regular incontinence checks and care, including checking and changing upon arising, before and after meals, at bedtime, and as needed. Staff interviews revealed that CNAs relied on residents to use call lights to request care and checked on residents when time permitted, rather than following scheduled checks. The Director of Nursing acknowledged previous issues with night shift care and stated that residents should be checked every two hours, with documentation required for each shift. However, documentation and resident reports indicated that these protocols were not consistently followed, resulting in unmet care needs.
Failure to Provide PPE and Implement Isolation Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
Surveyors observed that the facility failed to ensure appropriate implementation of infection prevention and control measures for residents requiring isolation precautions. Multiple observations revealed that personal protective equipment (PPE) was not available outside or near the rooms of residents on Contact Precautions or Enhanced Barrier Precautions (EBP). Staff were seen entering rooms with posted precaution signs without donning PPE, and PPE storage was inconsistent, with mesh bags inside rooms often found empty. Signs indicating the need for EBP or Contact Precautions were posted, but the required PPE was not accessible as per facility policy and CDC guidelines. Residents involved had significant medical histories, including bacteremia, MRSA, ESBL infections, wounds, and intravenous access, all of which necessitate strict adherence to isolation protocols. Orders and care plans for these residents specified the need for EBP and Contact Precautions, yet observations showed that these precautions were not consistently followed. Staff interviews revealed confusion regarding which residents required which type of precautions, and there was a lack of clarity about the correct placement and availability of PPE. Some staff were unaware of the specific organisms present or the correct isolation status of residents, leading to further lapses in infection control. The facility's own policy required gloves and gowns to be donned before entering rooms under Contact Precautions, and for PPE to be available for EBP during high-contact activities. However, surveyors found that in at least five rooms with posted precaution signs, PPE was not supplied as required. Interviews with the infection preventionist, DON, and other staff confirmed inconsistencies in the application of precautions and the stocking of PPE. The lack of PPE availability and staff adherence to protocols directly contributed to the deficiency in the facility's infection prevention and control program.
Ineffective Pest Control Program Resulting in Ongoing Insect Infestations
Penalty
Summary
Surveyors observed multiple live insects in various areas of the facility during two consecutive days of inspection. On the first day, a live insect was seen crawling near the conference room in the 400-hall, and small flying insects were observed landing on surfaces in the dining hall/activity area while residents were present. The following day, another live insect was seen crawling near the 100-hall, with staff present in the area. Additionally, a resident reported the presence of roaches in their room, stating that staff had been notified, drawers were cleaned, and spraying had occurred, but the issue persisted. Facility documentation, including pest control service inspection reports, confirmed ongoing treatments for flies, rats, ants, and roaches, with pest sightings documented. Interviews with the Director of Maintenance and the Nursing Home Administrator revealed that pest control services were contracted and provided weekly, with additional visits arranged for emergencies. However, the Director of Maintenance denied the presence of roaches, attributing sightings to a local Florida bug, and was unaware of any pest complaints. The facility's pest control policy requires maintaining contracts, service logs, and evaluating service effectiveness, but observations and resident reports indicated the pest control program was not effective in preventing or addressing infestations.
Failure to Promptly Address and Resolve Grievance Regarding Missing Dentures
Penalty
Summary
The facility failed to ensure that a grievance regarding a resident's missing bottom dentures was promptly addressed and resolved to the satisfaction of the complainant. The grievance was filed by the resident's family member, and the facility's Grievance/Concern Log indicated the concern was resolved within two days. However, documentation revealed that the facility did not designate a specific individual or department to handle the grievance, and there was no documented conclusion or summary of findings. The log also did not indicate whether the grievance was resolved to the satisfaction of the resident or their representative. Interviews with facility staff, including the Nursing Home Administrator (NHA), Risk Management Consultant (RMC), Business Office Manager (BOM), and Social Service Director (SSD), revealed inconsistencies and gaps in communication and documentation. The BOM reported only one documented contact with the family on the day the resident left the facility, and a follow-up attempt was made nearly two months later. The SSD was unaware of the grievance and confirmed there were no social service notes in the resident's record regarding the missing dentures or related conversations with the family. The facility's policy required prompt efforts to resolve grievances, assignment of concerns to appropriate departments, and documentation of resident or representative satisfaction, none of which were fully met in this case. The resident involved had multiple medical diagnoses, including a femur fracture, diabetes, alcohol abuse, and malnutrition, and was transferred to the emergency room and did not return to the facility. The admission inventory indicated the resident had both top and bottom dentures, but the form was undated. Progress notes did not document the representative's concern or any facility communication regarding the missing dentures. The lack of thorough investigation, documentation, and follow-up led to the failure to resolve the grievance in accordance with facility policy.
Failure to Provide Timely Pain Medication Due to Reordering and Communication Lapses
Penalty
Summary
The facility failed to provide pain medication as ordered for one resident, resulting in a missed dose of Oxycodone 10 mg for non-acute pain. The resident, who had a history of spinal stenosis, neuralgia, neuritis, monoarthritis, and unspecified pain, reported issues with receiving pain medication over the past month. Record review confirmed that the medication count for Oxycodone reached zero on 4/25/2025, and a dose was missed on 4/26/2025. The prescription for the medication was faxed to the pharmacy on the morning of 4/26/2025, but the medication was not delivered until after 7:30 p.m. that day. Interviews with nursing staff and pharmacy representatives revealed that the process for obtaining narcotics from the automated medication dispensing machine was not consistently followed, and there was confusion regarding when and how to access emergency supplies. Staff indicated that nurses are expected to reorder narcotics when the count reaches ten pills, and that a warning is present on the medication card to prompt reordering. However, the medication was not reordered in time, and the resident went without the prescribed pain medication. The facility's policy requires timely communication of orders to the pharmacy, but this process was not effectively implemented in this instance.
Failure to Provide Timely and Consistent Incontinence Care
Penalty
Summary
Multiple residents experienced significant delays and omissions in receiving incontinence care, as evidenced by both resident interviews and documentation reviews. One resident reported that after activating her call light at night, a staff member entered, turned off the light, and left without providing care, resulting in her remaining in a wet brief until the next shift. This resident stated that such incidents occurred three to four nights per week, and that staff did not check on her during the night as care plans required. Documentation for this resident showed missing entries for incontinence care across several shifts, indicating a lack of consistent care and documentation. Another resident, who was always incontinent for bladder and bowel, reported that staff response to her requests for incontinence care was slow, often resulting in her waiting over forty-five minutes after urinating before being assisted. This was described as a daily occurrence. Documentation for this resident also revealed missing entries for incontinence care on multiple shifts. Additional residents described similar issues, including long wait times for call lights to be answered, especially during night shifts, and having to remain in soiled briefs for extended periods. One resident reported waiting up to an hour and a half for care, with staff sometimes turning off call lights without providing assistance. Staff interviews corroborated these findings, with CNAs reporting being assigned to care for large numbers of residents alone, making it difficult to provide timely incontinence care. Staff also indicated that care was sometimes left undone between shifts due to heavy workloads and insufficient staffing. The DON acknowledged ongoing struggles with staffing and confirmed that documentation of incontinence care was often incomplete, despite facility policies requiring residents to be checked every two hours and care to be documented on each shift.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records for three of the seven sampled residents. On October 1, 2024, a Registered Nurse (RN), identified as Staff A, was observed placing used tube feeding bottles with resident-identifiable information into an unsecured, publicly accessible trash can. This occurred for two residents, as the RN detached the feeding tubes from their gastrostomy sites and disposed of the bottles without removing or marking off the resident information. Additionally, the RN left a medication cart unattended with a computer open displaying a resident's medical information and a resident roster exposed on top of the cart. This lapse in security occurred while the RN went to the supply room and again when she returned to provide care to another resident, leaving the information accessible to other residents, staff, and visitors. The Director of Nursing confirmed that staff should have marked off any resident-identifiable information before disposal, as per the facility's policy on resident rights.
Deficiencies in Tracheostomy and Enteral Feeding Care
Penalty
Summary
The facility failed to provide care consistent with the comprehensive person-centered care plan for two residents with tracheostomies. For one resident, the facility did not confirm physician orders related to tracheostomy care, enteral feeding, and medication administration. There were multiple instances where documentation was lacking for essential care activities, such as tracheostomy suctioning, medication administration, and monitoring of vital signs. The resident's care plans indicated the need for enhanced barrier precautions, enteral nutrition, and pain management, but these interventions were not consistently documented as performed. Another resident, who was cognitively intact, also experienced deficiencies in care related to tracheostomy management and enteral feeding. Documentation was missing for the administration of medications, oxygen therapy, and the maintenance of enhanced barrier precautions. The resident's care plans included interventions for nutritional support, pain management, and respiratory care, but these were not consistently documented, indicating a failure to adhere to the prescribed care plan. The Director of Nursing acknowledged the lack of documentation and confirmed that staff were expected to document care activities. The facility's policies required accurate transcription and confirmation of physician orders, as well as documentation of procedures and observations. However, these policies were not followed, leading to gaps in care and documentation for both residents.
Inadequate Tracheostomy and Suctioning Care
Penalty
Summary
The facility failed to provide tracheostomy and suctioning care consistent with professional standards of practice and the resident's comprehensive person-centered care plan for a resident. During an observation, a registered nurse (RN) entered the resident's room without wearing a gown, which was required under enhanced barrier precautions due to the resident's tracheostomy and other medical devices. The RN performed various tasks, including detaching feeding tubes and suctioning the resident, without adhering to proper hand hygiene protocols. The RN did not perform hand hygiene between glove changes and handled equipment and resident care items without appropriate infection control measures. The resident involved had a complex medical history, including anoxic brain damage, respiratory disorders, and acute and chronic respiratory failure, among other conditions. The resident was dependent on staff for care and had a tracheostomy, requiring specific care and precautions. The facility's care plan for the resident included enhanced barrier precautions, which mandated the use of gloves and gowns during high-contact care activities. However, the RN did not follow these precautions, and there was a lack of documentation for tracheostomy care, including the recording of secretions and vital signs post-suctioning. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that the staff did not follow the expected infection control protocols. The DON confirmed that the RN should have worn a gown and performed hand hygiene between tasks. The ADON, who also served as the Infection Control Preventionist, reiterated the importance of hand hygiene and the proper use of personal protective equipment (PPE). The facility's policies on hand hygiene and barrier precautions were not adhered to, contributing to the deficiency in care provided to the resident.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to standard and enhanced barrier precautions during the care of two residents, leading to a deficiency in infection prevention and control. On multiple occasions, a registered nurse (RN) entered the room of a resident with a tracheostomy and gastrostomy tube without donning a gown, despite the requirement for enhanced barrier precautions. The RN was observed performing various care tasks, such as detaching feeding tubes and suctioning the tracheostomy, without proper hand hygiene between glove changes and without wearing the necessary personal protective equipment (PPE). The RN admitted to not following the enhanced barrier precautions, which were indicated by an orange sign on the resident's door. The resident had multiple medical conditions, including anoxic brain damage and respiratory failure, and required enhanced barrier precautions due to the presence of a tracheostomy, gastrostomy tube, and suprapubic catheter. Despite the facility's policy and the resident's care plan requiring the use of gloves and gowns during high-contact care activities, the RN did not comply with these protocols. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the expectations for staff to wear appropriate PPE and perform hand hygiene as per the facility's policies. The DON and ADON acknowledged that the RN's actions did not align with the facility's infection control protocols, which emphasize the importance of hand hygiene and the use of gowns and gloves during high-contact care activities to prevent the transmission of infections.
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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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