Kissimmee Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kissimmee, Florida.
- Location
- 2511 John Young Parkway North, Kissimmee, Florida 34741
- CMS Provider Number
- 106011
- Inspections on file
- 30
- Latest survey
- February 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kissimmee Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairments experienced falls due to inadequate care plans and supervision. One resident, dependent on staff for daily activities, had multiple falls without necessary interventions like frequent checks. Another resident's care plan included a dycem to prevent sliding from a wheelchair, but it was not consistently used, leading to falls. The facility failed to update care plans and ensure staff were informed of necessary interventions.
The facility failed to implement comprehensive care plans for two residents. One resident's care plan required padded bed rails for safety, but they were unpadded during the day. Another resident, who primarily spoke Spanish, had no communication plan addressing her need for an interpreter, leading to a medication error and distress. The facility's policy emphasizes person-centered care plans, but these were not adequately developed for the residents' needs.
A resident with type 2 diabetes experienced severe pain and did not receive timely medication. When the RN administered the medication, it was not documented in the MAR, and the resident's pain level was not assessed. Facility policies require accurate documentation, which was not followed, resulting in a deficiency.
A CNA in a facility referred to a resident requiring assistance with eating as a "feeder," which was acknowledged by the DON as a dignity issue. This terminology was used despite the facility's policy on promoting resident dignity and the CNA's competency in maintaining patient self-worth. The resident had a severe condition, as indicated by a low assessment score.
The facility failed to maintain communication with an external center for a resident's care, lacking documentation and follow-up on the resident's condition. Additionally, the facility did not provide appropriate activities for another resident with visual limitations, offering materials that did not meet their needs.
A resident at an LTC facility experienced neglect when a nurse attempted to administer a discontinued medication and placed a dropped pill back in the cup. The resident, who primarily spoke Spanish, reported the incident to the MDS Coordinator, but the facility failed to report the allegations to the State Agency and protect the resident during the investigation. The Director of Nursing and the nurse involved allegedly yelled at the resident, and the nurse was reassigned to the resident despite her request for a different caregiver.
A facility failed to promote dignity in dining for a resident who required assistance with eating. A CNA referred to the resident as a "feeder," a term acknowledged by the DON as a dignity issue. Despite passing required competencies, the CNA's language did not align with the facility's policy on resident dignity.
A facility failed to notify a resident's emergency contact and POA of a medication change. The resident, unable to make healthcare decisions, was discharged with specific medication orders, which were altered by the facility's physician without informing the resident's son, the healthcare surrogate. This affected the resident's alertness and participation in activities. The Unit Manager admitted the oversight, and there was no documentation of notification, violating the resident's right to be informed.
A resident with intact cognition was left unsupervised with a medication cup containing various pills, without a documented plan for self-administration. RN D admitted to leaving the medications with the resident, contrary to facility policy, which requires supervision during medication administration. The facility's policy mandates an interdisciplinary team evaluation for safe self-administration, which was not conducted.
A resident reported a medication error and mistreatment by staff, including a nurse attempting to administer a discontinued medication and placing a dropped pill back in a cup. The resident, who primarily spoke Spanish, faced communication barriers and alleged that the DON and nurse yelled at her. Despite reporting the incident to the MDS Coordinator and DCF, the facility failed to report the allegations to the State Agency and did not protect the resident during the investigation.
A facility failed to accurately document a major injury in a resident's MDS assessment. The resident, who had been readmitted from a hospital, reported breaking a bone after a fall. The MDS Transitional Nurse acknowledged the error, despite reviewing hospital documentation. The facility's policy requires accurate assessments, which was not followed.
The facility failed to implement comprehensive care plans for two residents. One resident's care plan specified padded bed rails for safety, but they were not in place, and staff were unaware of the requirement. Another resident, whose primary language was Spanish, did not have a communication care plan addressing her need for an interpreter, leading to a distressing medication incident. The facility's policy on person-centered care plans was not followed, resulting in deficiencies.
Two residents with severe cognitive impairments experienced falls due to the facility's failure to revise and implement appropriate care plan interventions. One resident suffered a hematoma after multiple falls, while another fell from a wheelchair due to the absence of a dycem. The care plans lacked necessary supervision measures, and staff were not adequately informed of changes, leading to repeated incidents.
A resident with visual impairment was not provided with suitable activities, receiving regular print materials instead of large print, leading to frustration and lack of engagement. The facility's assessment indicated the need for activities compatible with the resident's capabilities, which was not met.
A facility failed to maintain communication with an external treatment center for a resident receiving specific services. The resident's medical record lacked documentation of communication between the facility and the center. Staff interviews revealed that a communication binder previously used had not been utilized for over six months, and the center's staff faced challenges in contacting the resident's nurse. The ADON confirmed the absence of necessary documentation, highlighting a lapse in communication practices.
A resident with type 2 diabetes experienced severe pain and was given medication by an RN, but the administration was not documented in the MAR. The facility's policies require accurate documentation of all services provided, which was not followed in this case, as emphasized by the Unit Manager and DON.
The facility failed to maintain effective communication with hospice services, resulting in inadequate care for two residents. One resident experienced multiple falls and changes in condition without timely notification to hospice, while another resident's fall and subsequent pain were not communicated, leading to a delayed hospital transfer. The facility's policies and agreements with hospice providers were not followed, impacting the coordination of care.
An RN in an LTC facility failed to sanitize a portable monitoring device between its use on two residents during medication administration. The RN admitted to forgetting the procedure due to stress. The facility's IP confirmed that staff had been trained to use purple top wipes for sanitizing equipment, but the RN had not signed the recent in-service training. The DON emphasized the importance of cleaning equipment between uses to prevent cross-contamination.
The facility failed to monitor antibiotic use as required by their stewardship program. Several residents were prescribed antibiotics without proper follow-up testing or inclusion in the Control Report. The ADON/IP admitted to not analyzing prescribing trends or ensuring all residents on antibiotics were tracked, violating the facility's surveillance policy and stewardship commitment.
The facility failed to maintain its fire alarm system according to NFPA 101 standards, as evidenced by the lack of documentation for the annual air flow testing of duct detectors. During a record review and interview, the Maintenance Director acknowledged the absence of this critical testing, indicating non-compliance with NFPA 101 and NFPA 72 codes.
A resident admitted for respite care with brain cancer, cachexia, and quadriplegia did not receive proper care as per physician orders. The facility failed to administer and document Midodrine HCl for hypotension and did not monitor vital signs or check PEG tube residuals as required. The DON confirmed these omissions without providing an explanation.
The facility failed to provide adequate pressure ulcer care for three residents, resulting in incorrect or missing treatments. A resident with a stage 3 ulcer did not receive prescribed treatments due to lack of documentation. Another resident with a stage 4 ulcer was given incorrect ointment and lacked necessary supplements. A third resident received the wrong type of dressing, missing antimicrobial properties. These deficiencies highlight a failure in following wound care orders.
Failure to Implement Adequate Care Plans and Supervision
Penalty
Summary
The facility failed to revise and implement appropriate interventions for two residents, leading to deficiencies in their care. Resident #3, who had severe cognitive impairment, hearing loss, and vision issues, experienced multiple falls. Despite being dependent on staff for various activities, the care plan did not include necessary interventions such as frequent checks or appropriate supervision. The resident's care plan was not updated to reflect her need for constant supervision, and interventions like offering toileting after meals were not implemented. The resident's daughter expressed concerns about the lack of supervision and the resident's tendency to attempt activities independently, which were not adequately addressed by the facility. Resident #51, who also had severe cognitive impairment and required substantial assistance for daily activities, experienced falls in the facility's TV room. The care plan included the use of a dycem to prevent sliding from the wheelchair, but it was not consistently used or documented in the resident's care plan. Staff were unaware of the dycem's absence, and the resident's care plan did not reflect the need for increased supervision during times of behavioral changes. The facility's failure to ensure the dycem was used and to provide adequate supervision contributed to the resident's falls. The facility's policies on accidents and supervision, as well as comprehensive care plans, were not effectively implemented. The guidelines required communication and documentation of interventions across all disciplines, but this was not done. The care plans for both residents lacked necessary interventions, and staff were not adequately informed of their responsibilities. The facility's failure to update care plans and ensure staff were aware of and implemented necessary interventions led to the deficiencies observed.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: New risk evaluations were completed for Resident #51 to reflect accurate information, and their care plans and Kardex's were updated to reflect accurate risk assessments, with appropriate and individualized prevention interventions implemented. Resident #3 is no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. The MDS Coordinator and Unit Managers conducted a facility-wide audit of risk assessments and care plans for residents with a score of 12 or less to identify any discrepancies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) staff will receive mandatory training regarding review and use of Care Plan/Kardex prior to providing care to Residents. This education will also be completed upon hire and at least annually. All Direct Care staff will be in-service by. Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. Starting on all Licensed nurses (RNs and LPNs) and MDS staff on the proper completion of risk assessments, individualized care planning, and the importance of ensuring interventions are documented in the Kardex. All Licensed nurses (RNs and LPNs) and MDS staff will be in-service by. Any Licensed nurses (RNs and LPNs) and MDS staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed nurses (RNs and LPNs) and MDS staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or Designee will review a sample of five residents risk evaluations, care plans and Kardexs weekly for four weeks, then monthly for three months to ensure continued compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) Date of compliance
Deficiencies in Care Plan Implementation and Communication
Penalty
Summary
The facility failed to implement an individualized comprehensive care plan for a resident reviewed for safety precautions. The resident was admitted with diagnoses including fluid disturbances and speech issues. The Minimum Data Set (MDS) assessment indicated the resident was rarely or never understood. Despite the care plan specifying the use of padding on bed rails for safety, observations revealed the rails were unpadded during the day. A Certified Nursing Assistant (CNA) confirmed the absence of padding and was unaware of the reason. The Restorative Unit Manager stated the padding was only applied at night when the resident became agitated, contrary to the care plan's requirements. Another deficiency was identified for a resident reviewed for communication needs. This resident, who had intact cognition and primarily spoke Spanish, expressed a desire for an interpreter when communicating with healthcare staff. The MDS assessment noted her social isolation and dependence on staff for personal care. However, her care plan did not address her communication needs or preference for an interpreter. An interview with the resident revealed a recent incident where a nurse administered a discontinued medication and mishandled another medication, leading to distress. The resident preferred Spanish-speaking staff and had communicated this preference, but it was not reflected in her care plan. The facility's policy on comprehensive care plans emphasizes the development of person-centered plans that incorporate residents' personal and cultural preferences. Despite this, the care plans for both residents failed to address their specific needs as identified in their assessments. The MDS Coordinator acknowledged the oversight in the communication care plan and confirmed that the resident's preference for an interpreter was known but not documented in the care plan.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: For Resident #92, the pads were placed per the Resident's care plan. Resident #92 was reassessed to ensure all precautions were properly implemented. CNA Q was re-educated on the importance of following care plan interventions, especially for residents with. For Resident #56, the care plan was updated to reflect the resident's primary language of Spanish with the intervention of utilizing an interpreter as indicated. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents with a diagnosis of and Residents who do not speak English proficiently have the potential to be affected. A facility-wide audit of all residents with was conducted to ensure appropriate interventions were care planned and in place. MDS Coordinator conducted an audit of all residents with limited English proficiency to ensure their communication needs were appropriately care planned. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Nurse leadership team, including Director of Nursing, Assistant Director of Nursing, Unit Managers, and MDS Nurses received in-service training on by Regional Nurse on the requirement for comprehensive Resident Centered care plans with focus on Residents with and/or limited English proficiency. Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) will receive mandatory training on the importance of following individualized care plan interventions, ensuring safety interventions are in place for precautions per plan of care, and on communicating with Residents with limited English proficiency per plan of care to include use of Propio 1 Interpreter Line. All Direct Care staff will be in-service by. Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of 5 Residents with or Limited English Proficiency for four weeks, then 10 monthly for at least three months, to ensure care plans are accurately implemented and followed. Any discrepancies found will result in immediate correction and staff re-education. Audit results will be reviewed in the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings. (e) The compliance date is.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident. The resident, who was readmitted to the facility with diagnoses including type 2 diabetes, complained of severe pain rated at 10 out of 10. Despite informing the nurse, the resident did not receive medication promptly. When the Registered Nurse (RN) eventually administered the medication, she failed to document it in the MAR and did not assess the resident's pain level or location before administration. The facility's policies on charting and documentation, as well as medication administration, require that all services provided, including medications administered, be accurately documented in the resident's medical record. However, the RN did not document the administration of the medication or the resident's response to it. The Unit Manager and Director of Nursing both emphasized the importance of accurate documentation, which was not adhered to in this instance, leading to a deficiency in the facility's compliance with regulatory standards.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 18 assessed for, No. Notified physician and advised to discontinue order. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving medication have the potential to be affected. An audit was conducted for all current Residents receiving meds to ensure the assessment was completed and the medication administration was documented. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs, LPNs) will receive mandatory Education for all nurses on accurately documenting of prn medications on the MAR. All Nursing staff will be in-service by. Any Nursing staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not reoccur: DON, Unit managers or designee will observe 2 nurses medication administration of 2 residents 3 times a week for 2 weeks then 2 nurse's medication administration for 2 residents once a week for (3) months to ensure compliance. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. (e) The date of compliance is
Inappropriate Terminology Used by CNA Compromises Resident Dignity
Penalty
Summary
The facility failed to promote dignity in dining for a resident, as evidenced by the use of inappropriate terminology by a Certified Nursing Assistant (CNA). During an observation, the CNA referred to a resident who required assistance with eating as a "feeder," a term that was acknowledged by the Director of Nursing as a dignity issue. This terminology was used despite the facility's policy on promoting and maintaining resident dignity, which emphasizes treating each resident with respect and dignity. The resident in question had a severe condition, as indicated by a Minimum Data Set quarterly assessment score of 3 out of 15. The CNA had previously passed the required competencies for her job, which included maintaining and enhancing a patient's self-worth. However, the use of the term "feeder" was inconsistent with these competencies and the facility's policy, highlighting a failure to uphold the dignity and individuality of the resident.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: CNA H was counseled regarding the inappropriate [R], and provided immediate re-education on maintaining resident dignity and respectful communication. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who require assistance during meals have the potential to be affected. Residents with a score of 12 and over were interviewed by the Social Services Staff and Administrator to determine if they have experienced or witnessed any undignified language or treatment. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on [date], all staff will receive mandatory training on resident rights, dignity, and person-centered communication, with a focus on respectful language. All staff will be in-service by [date]. Any staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-serviced by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing (DON) or designee will conduct 5 meal service audits weekly for 1 month, then 10 monthly for at least two additional months, to ensure staff are promoting dignity. Findings from audits will be reviewed in the facility's Quality Assurance and Performance Improvement meetings, and corrective actions will be taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) Date of compliance: [date]
Deficiencies in Communication and Activity Program
Penalty
Summary
The facility failed to maintain ongoing communication and collaboration regarding the care and services for a resident receiving treatment at an external center. The resident's medical record indicated a moderate cognitive impairment, and the facility did not ensure consistent communication with the external center providing services. The Clinical Manager and Clinical Nurse from the center reported that a communication binder, previously used for documenting updates, had not been seen for over six months. Additionally, there was no consistent follow-up communication from the facility's nurses after each session to update the resident's condition. The Assistant Director of Nursing acknowledged the importance of such communication for coordinating care and confirmed the absence of documentation in the resident's medical record. The facility also failed to provide an ongoing program of activities that met the needs and interests of another resident. This resident, who had mild cognitive impairment and visual limitations, required activities compatible with their physical and mental capabilities, such as large print materials. However, the activity aide provided the resident with a regular print sudoku puzzle book and a coloring book, which did not accommodate the resident's visual needs. This oversight indicates a lack of attention to the resident's specific requirements as outlined in their comprehensive care plan.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Unit Manager contacted the provider to obtain Resident #12's updated treatment records, including recent lab results, treatment schedules, and any noted concerns. Resident #12's care plan was reviewed and updated to reflect current care needs, including accurate documentation and proper communication with providers, followed by monthly audits of 3 resident's records for an additional three months. Audit results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) The date of compliance is .
Failure to Report Allegations of Neglect and Protect Resident
Penalty
Summary
The facility failed to report allegations of neglect and protect a resident during an investigation. A resident, who had been at the facility for over two years, experienced an incident where a nurse attempted to administer a discontinued medication and another medication that the resident preferred to take every other night. The resident, who primarily spoke Spanish, tried to communicate with the English-speaking nurse about the medication error. During the interaction, a pill fell on the floor, and the nurse placed it back in the cup with the other medications. The resident refused to return the pills until she spoke with a supervisor, but the nurse left without calling one. The resident reported the incident to the MDS Coordinator the following morning, who then informed the management. The Director of Nursing (DON) and the nurse involved confronted the resident, allegedly yelling and calling her a liar. The resident felt disrespected and reported the incident to the Department of Children and Families (DCF), who visited the facility and took pictures of the pills. Despite the resident's request not to have the same nurse assigned to her again, the nurse was reassigned to her, causing the resident distress and fear of retaliation. The facility's reportable log did not show any neglect allegations reported by the resident. The Administrator acknowledged the DCF visits but did not consider the incidents as neglect, citing the time frame of care as a factor. The facility's policy on neglect and abuse was not followed, as the allegations were not reported to the State Agency, and the resident was not protected during the investigation.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Upon identification of the deficiency, the facility immediately self-reported the allegation to the State Agency. The accused nurse was removed from the schedule pending an investigation. Resident #56 was assessed by social services to ensure emotional and physical well-being. Supportive interventions, including psych services and reassurance, were provided. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. A review of grievances for the last 60 days was conducted by the Interdisciplinary Team, which included the Administrator, Social Services, DON, RVP, and Regional Nurse to determine if any other allegations of neglect had been unreported or inadequately investigated. Any identified concerns were immediately self-reported and addressed. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Coordinator and Director of Nursing were educated on by the RVP on reporting requirements utilizing FHCAs Decision Tree. Starting on all staff will receive mandatory training on identification, mandatory reporting, and investigation protocols. All staff will be in-service by. Any staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will conduct audits of five grievances per week for two months, followed by ten grievances per month for a minimum of three additional months, to ensure appropriate reporting and implementation of protective actions. Results of the audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions implemented as needed. (e) The date of compliance is.
Failure to Promote Resident Dignity in Dining
Penalty
Summary
The facility failed to promote dignity in dining for a resident, identified as #51, who was part of a sample of 59 residents reviewed for dignity. The deficiency was observed when a Certified Nursing Assistant (CNA) referred to the resident as a "feeder," a term used to describe residents who require assistance with eating. This term was used during a conversation with a surveyor and was also noted in the resident's care plan, known as the Kardex. The CNA questioned whether this terminology was appropriate, indicating a lack of awareness about its impact on resident dignity. The Director of Nursing acknowledged that referring to residents as "feeders" is a dignity issue and confirmed that CNAs should not use such terms. Despite having passed the required competencies for her job, which included maintaining and enhancing a patient's self-worth, the CNA used language that did not align with the facility's policy on promoting and maintaining resident dignity. The facility's policy, revised recently, emphasizes the intent to protect and promote resident rights and to treat each resident with respect and dignity.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: CNA H was counseled regarding the inappropriate and provided immediate re-education on maintaining resident dignity and respectful communication. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who require assistance during meals have the potential to be affected. Residents with a score of 12 and over were interviewed by the Social Services Staff and Administrator to determine if they have experienced or witnessed any undignified language or treatment. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all staff will receive mandatory training on resident rights, dignity, and person-centered communication, with a focus on respectful language. All staff will be in-service by Any staff not in serviced by this date will be in serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing (DON) or designee will conduct 5 meal service audits weekly for 1 month, then 10 monthly for at least two additional months, to ensure staff are promoting dignity. Findings from audits will be reviewed in the facility's Quality Assurance and Performance improvement meetings, and corrective actions will be taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) Date of compliance
Failure to Notify POA of Medication Change
Penalty
Summary
The facility failed to notify the emergency contact and Power of Attorney (POA) of a change in medication for a resident who was unable to make healthcare decisions independently. The resident, who had a history of disorientation and poor judgment, was discharged from the hospital with specific medication orders. However, the facility's physician altered the medication regimen without informing the resident's son, who was the designated healthcare surrogate and POA. This change in medication affected the resident's alertness and ability to participate in daily activities, as reported by the family. The facility's policy required that when a resident was incapable of making decisions, their representative should be informed of any changes. Despite this, the Unit Manager of the Specialized Subacute Unit acknowledged that the resident's son was not notified of the medication change, and there was no documentation of such notification in the resident's clinical record. This oversight led to a deficiency in the resident's right to be informed and participate in their treatment decisions, as outlined in the federal regulations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The responsible party for Resident #20 was notified of the dosage adjustment and current medication regime for. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. A review of all recent medication changes over the past 14 days was conducted to ensure responsible parties were notified as required. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Licensed staff (RNs and LPNs) will receive mandatory training on the requirement/policy to notify residents and/or responsible parties of medication changes and the facility's Notification of Changes Policy, ensuring clear expectations for timely documentation. All Licensed staff will be in-service by. Any Licensed staff not in serviced by this date will be in-service prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct audits of medication changes Monday thru Friday for 2 weeks, then 10 monthly for three months, to ensure responsible party notifications are completed and documented. Any instances of non-compliance will result in immediate re-education and corrective action. Audit results will be reviewed during the facility's monthly Quality Assurance and Performance Improvement meetings. (e) Date of Compliance
Failure to Evaluate Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was evaluated for safe self-administration of medications. Resident #5, who had intact cognition as per the Minimum Data Set (MDS) quarterly assessment, was observed with a medication cup containing various pills on her bedside table without staff supervision. Registered Nurse (RN) D later entered the room and asked the resident to take her medications, which she did. However, there was no physician order or plan of care documented for the resident to self-administer medications. RN D admitted to leaving the medications with the resident and stepping out of the room, which was against the facility's policy. The Unit Manager (UM) and Director of Nursing (DON) confirmed that medications should not be left at the bedside and must be administered under supervision. The facility's policy requires an interdisciplinary team to determine if a resident can safely self-administer medications, but this process was not followed for resident #5.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected: The nurse ensured that Resident #5 took medications provided. The physician was notified of the incident, and no negative outcomes were identified. The nurse involved was re-educated on proper medication administration practices, including the requirement to observe the resident taking medications and ensure proper documentation. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Licensed staff (RNs and LPNs) will receive mandatory training on medication administration policies, emphasizing the prohibition of leaving medications unattended. All Licensed staff will be in-service by. Any Licensed staff not in serviced by this date will be in-service prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The DON or designee will conduct weekly audits of medication administration with 2 nurses for at least 2 Residents 3 times a week for 2 weeks, then at least 8 Residents monthly for three months to ensure adherence to the policy. Any non-compliance identified will result in immediate re-education and corrective action. Audit findings will be reviewed during the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings. (e) Date of compliance:
Failure to Report Allegations of Neglect and Mistreatment
Penalty
Summary
The facility failed to report allegations of neglect and mistreatment involving a resident to the State Agency and did not protect the resident during the investigation. The resident, who had been in the facility for over two years, reported an incident where a nurse attempted to administer a discontinued medication and another medication that the resident preferred to take every other night. The resident, who primarily spoke Spanish, tried to communicate with the nurse, who only spoke English, about the medication error. During the interaction, a pill fell on the floor, and the nurse placed it back in the cup with other medications, which the resident refused to take. The resident requested to speak with a supervisor, but the nurse did not comply and left the room. The following morning, the resident reported the incident to the MDS Coordinator, who arranged for a Spanish-speaking staff member to assist with communication. The Director of Nursing (DON) and the night nurse confronted the resident, allegedly yelling and calling her a liar. The resident felt disrespected and reported the incident to the Department of Children and Families (DCF), who visited the facility and took pictures of the pills. The resident expressed fear of retaliation and reported previous issues with staff not providing timely personal care. Despite the resident's request not to have the same nurse assigned to her, the nurse was reassigned to her care, causing further distress. The facility's reportable log did not include the resident's allegations, and the Administrator (NHA) was unaware of the DCF's visit concerning the resident's complaints. The NHA and DON did not initially report the incident as neglect, and the facility's policy on reporting and investigating allegations was not followed. The DCF Investigator confirmed discussing the allegations with the facility, but the NHA claimed not to have been informed of the specific reasons for the DCF's visit. The facility's failure to report and investigate the allegations properly resulted in a deficiency in meeting regulatory requirements.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Upon identification of the deficiency, the facility immediately self-reported the allegation to the State Agency. The accused nurse was removed from the schedule pending an investigation. Resident #56 was assessed by social services to ensure emotional and physical well-being. Supportive interventions, including psych services and reassurance, were provided. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. A review of grievances for the last 60 days was conducted by the Interdisciplinary Team, which included the Administrator, Social Services, DON, RVP, and Regional Nurse to determine if any other allegations of neglect had been unreported or inadequately investigated. Any identified concerns were immediately self-reported and addressed. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Coordinator and Director of Nursing were educated on reporting requirements utilizing FHCAs Decision Tree. Starting on all staff will receive mandatory training on identification, mandatory reporting, and investigation protocols. All staff will be in-service by Any staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will conduct audits of five grievances per week for two months, followed by ten grievances per month for a minimum of three additional months, to ensure appropriate reporting and implementation of protective actions. Results of the audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions implemented as needed. (e) The date of compliance is . F 609
Inaccurate MDS Assessment for Major Injury
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, specifically regarding the documentation of a major injury. The resident, who had been readmitted from an acute care hospital, reported having broken his right bone after a fall while coming out of the bathroom. Despite this incident, the MDS Discharge Assessment and the 5-day assessment did not reflect the resident's status of having a major injury. This discrepancy was acknowledged by the MDS Transitional Nurse responsible for completing the assessments. The MDS Transitional Nurse admitted that the assessments did not indicate the major injury status of the resident, despite having reviewed hospital documentation before completing the MDS assessment and care plan. The Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual provides specific instructions for coding major injuries, which were not followed in this case. The facility's policy requires comprehensive and accurate assessments of each resident's functional capacity, which was not adhered to in this instance.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The MDS for Resident #109 has been reviewed and corrected to accurately reflect the with major injury. The Care Plan for Resident #109 has been reviewed and updated to include interventions related to prevention and management. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. A facility-wide audit of all current residents who experienced in the past 90 days has been conducted to ensure the MDS accurately reflects their history and any major injuries. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: On all staff responsible for MDS completion, including the MDS Coordinator and MDS Assistant, have been re-educated by Regional Nurse on the proper coding of with major injuries to include training on accurate MDS documentation, specifically regarding Section J1900 (with Injury). Also, education was provided to ensure that all hospital diagnoses, including, are promptly reviewed and incorporated into MDS assessments and care plans. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing (DON) or designee will conduct weekly audits of 3 completed MDS for accuracy in section J1900, with a focus on with major injuries, for 2 months, then monthly for at least three additional months. Audit results will be reviewed in the facility's Quality Assurance and Performance Improvement meetings, and corrective actions will be implemented as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) Date of compliance
Deficiencies in Care Plan Implementation and Communication
Penalty
Summary
The facility failed to implement an individualized comprehensive care plan for a resident reviewed for safety precautions. The resident, who had difficulty being understood, was observed with unpadded bed rails despite the care plan specifying padding for safety. A CNA confirmed the absence of padding and was unaware of why the pads were not in place. The Restorative Unit Manager stated that padding was only applied at night due to the resident's agitation during that time. The Director of Nursing expected staff to review and implement care plans, which was not adhered to in this instance. Another deficiency was noted for a resident reviewed for communication needs. This resident, whose primary language was Spanish, expressed a desire for an interpreter when communicating with healthcare staff. Despite this, the care plan did not address her communication needs or preference for Spanish-speaking staff. The resident experienced a communication issue with a nurse regarding medication, which led to distress and a lack of resolution as no supervisor visited her that night. The MDS Coordinator acknowledged the absence of a communication care plan and confirmed that the resident's preference for an interpreter was documented in the MDS assessment. The facility's policy on comprehensive care plans emphasizes the development of person-centered plans that incorporate residents' personal and cultural preferences. However, the facility failed to adhere to this policy in the cases of the two residents. The care plans did not adequately address the specific needs and preferences of the residents, leading to deficiencies in their care and communication, as observed during the survey.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: For Resident #92, the pads were placed as per the Resident's care plan. Resident #92 was reassessed to ensure all precautions were properly implemented. CNA Q was re-educated on the importance of following care plan interventions, especially for residents with. For Resident #56, the care plan was updated to reflect the resident's primary language of Spanish with the intervention of utilizing an interpreter as indicated. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents with a diagnosis of and Residents who do not speak English proficiently have the potential to be affected. A facility-wide audit of all residents with was conducted to ensure appropriate interventions were care planned and in place. MDS Coordinator conducted an audit of all residents with limited English proficiency to ensure their communication needs were appropriately care planned. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Nurse leadership team, including Director of Nursing, Assistant Director of Nursing, Unit Managers, and MDS Nurses received in-service training on by Regional Nurse on the requirement for comprehensive Resident Centered care plans with focus on Residents with and/or limited English proficiency. Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) will receive mandatory training on the importance of following individualized care plan interventions, ensuring safety interventions are in place for precautions per plan of care, and on communicating with Residents with limited English proficiency per plan of care to include use of Propio 1 Interpreter Line. All Direct Care staff will be in-service by. Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of 5 Residents with or Limited English Proficiency for four weeks, then 10 monthly for at least three months, to ensure care plans are accurately implemented and followed. Any discrepancies found will result in immediate correction and staff re-education. Audit results will be reviewed in the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings. (e) The compliance date is.
Failure to Revise and Implement Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to revise and implement appropriate interventions for two residents, leading to deficiencies in their care plans. Resident #3, who had severe cognitive impairment and hearing loss, experienced multiple falls, including one that resulted in a hematoma on her forehead. Despite her need for frequent supervision and assistance, the care plan did not include interventions for 15-minute checks or adequate supervision. The resident's daughter expressed concerns about the lack of supervision and the resident's tendency to attempt tasks independently, which contributed to her falls. Resident #51, also with severe cognitive impairment, experienced falls from her wheelchair in the TV room. The care plan included the use of a dycem to prevent sliding, but it was not consistently used or documented in the resident's Kardex. Staff members were unaware of the dycem's absence, and the resident's care plan did not reflect the necessary interventions for increased supervision, especially during the evening when the resident's behaviors worsened. The facility's policies on accidents and supervision, as well as comprehensive care plans, were not effectively implemented. The interdisciplinary team failed to update care plans with appropriate interventions after incidents, and communication among staff regarding care plan changes was inadequate. This lack of coordination and oversight contributed to the residents' repeated falls and the facility's failure to meet regulatory requirements for comprehensive care planning.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: New risk evaluations were completed for Resident #51 to reflect accurate information, and their care plans and Kardex's were updated to reflect accurate risk assessments, with appropriate and individualized prevention interventions implemented. Resident #3 is no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. The MDS Coordinator and Unit Managers conducted a facility-wide audit of risk assessments and care plans for residents with a score of 12 or less to identify any discrepancies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Direct Care staff (RNS, LPNs, and C.N.A.S) staff will receive mandatory training regarding review and use of Care Plan/Kardex prior to providing care to Residents. This education will also be completed upon hire and at least annually. All Direct Care staff will be in-service by . Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. Starting on all Licensed nurses (RNs and LPNs) and MDS staff on the proper completion of risk assessments, Individualized care planning, and the importance of ensuring interventions are documented in the Kardex. All Licensed nurses (RNs and LPNs) and MDS staff will be in-service by . Any Licensed nurses (RNs and LPNs) and MDS staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed nurses (RNs and LPNs) and MDS staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or Designee will review a sample of five residents' risk evaluations, care plans and Kardex's weekly for four weeks, then monthly for three months to ensure continued compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) Date of compliance
Failure to Provide Appropriate Activities for Visually Impaired Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs and interests of a resident, identified as Resident #58, who was part of a sample of 59 residents. The resident had been diagnosed with conditions including visual impairment and required large print materials for reading. Despite this, the facility provided the resident with a regular print sudoku puzzle book and a coloring book, which the resident could not use due to her visual limitations. This led to the resident expressing frustration and stating that she could not see the contents of the books. Observations revealed that the resident was often left without appropriate activities. On multiple occasions, the resident was seen either standing at her door or sitting on her bed without any suitable activities being provided. The Activity Director acknowledged that the materials given to the resident did not meet her needs, as they were not compatible with her physical and mental capabilities. The facility's assessment indicated that care should be based on evidence-based, data-driven methods considering the resident's conditions and needs, which was not adhered to in this case.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Resident #58 was assessed for activity preferences. Preferences were added to the care plan. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents with visual have the potential to be affected. 100% audit of all MDS assessments to identify residents with visually. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Administrator provided education to Activity Director and Activity Staff starting on regarding resident activity preferences and ensuring activities are compatible with the Residents physical and mental capabilities. Activity Director and Activity Staff will be in-service by The Activity Director and Activity Staff not in serviced by this date will be in serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Activity Director and Activity Staff will be in-service by the ADON during their orientation. The Activity Director will complete Activity Preference assessment on all visually residents. (d) How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Administrator or designee will interview at least 5 residents weekly for 4 weeks for activity preferences offered as desired, then interview 10 residents monthly for the 3 months. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. (e) The compliance date is.
Lack of Communication with External Treatment Center
Penalty
Summary
The facility failed to maintain ongoing communication and collaboration regarding the care and services for a resident who required specific treatments at an external center. The resident's medical record showed no documentation of communication between the facility's nursing staff and the external center from a specified period. The Unit Manager expected the facility's Communication Record to be completed and sent with the resident to the center, and for the nursing staff to review and include the returned form in the resident's medical record. However, there were no Communication Records or any other documentation of communication with the center in the resident's medical record. Interviews with staff from both the facility and the external center revealed that the facility used to send a binder for communication, but it had not been used for six months or more. The Clinical Manager and Clinical Nurse at the center confirmed that they had not received regular communication from the facility after each session, and sometimes faced difficulties in reaching the resident's nurse at the facility. The Assistant Director of Nursing acknowledged the importance of communication for coordinating care and verified the absence of documentation in the resident's electronic medical record, indicating a lapse in the facility's communication practices.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Unit Manager contacted the provider to obtain Resident #12's updated treatment records, including recent lab results, treatment schedules, and any noted concerns. Resident #12's care plan was reviewed and updated to reflect current care needs, including communication protocols between the facility and the provider. (b) Identification of other residents having the potential to be affected was accomplished by: All residents receiving have the potential to be affected. A facility-wide audit was conducted to identify all residents receiving and assess the adequacy of communication and documentation related to their care. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Licensed staff (RNs and LPNs), including unit managers, received education on care coordination, proper documentation, and the importance of interdisciplinary collaboration. All Licensed staff (RNs and LPNs), including unit managers will be in-service by Any Licensed staff (RNs and LPNs), including unit managers not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed staff (RNs and LPNs), including unit managers will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of all residents' records for one month, ensuring accurate documentation and proper communication with providers, followed by monthly audits of 3 residents' records for an additional three months. Audit results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) The date of compliance is
Failure to Document Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident. The resident, who was readmitted with diagnoses including type 2 diabetes, complained of severe pain rated 10 out of 10. Although the resident reported the pain to a nurse and was subsequently given medication by a Registered Nurse (RN), the administration of the medication was not documented in the MAR. Additionally, there was no progress note entered by the RN regarding the administration of the medication or the resident's pain on that day. The facility's policies require that all services provided, including medication administration, be documented accurately in the medical record to facilitate communication among the interdisciplinary team. The General & Restorative Unit Manager and the Director of Nursing both emphasized the importance of accurate documentation, which was not adhered to in this instance. The failure to document the medication administration and the resident's condition was a deviation from the facility's established procedures and expectations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 18 assessed for, No. Notified physician and advised to discontinue order. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving medication have the potential to be affected. An audit was conducted for all current Residents receiving meds to ensure the assessment was completed and the medication administration was documented. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs, LPNs) will receive mandatory Education for all nurses on accurately documenting of PRN medications on the MAR. All Nursing staff will be in-service by. Any Nursing staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not reoccur: DON, Unit managers or designee will observe 2 nurses' medication administration of 2 residents 3 times a week for 2 weeks, then 2 nurses' medication administration for 2 residents once a week for 3 months to ensure compliance. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. (e) The date of compliance is.
Failure in Communication with Hospice Services
Penalty
Summary
The facility failed to maintain effective communication between nursing staff and hospice services, leading to inadequate treatment, monitoring, and continuity of care for two residents receiving hospice care. Resident #3, who had severe cognitive impairment and was receiving hospice care, experienced multiple falls and changes in condition. Despite the facility's policy requiring immediate notification to hospice staff, the hospice was not informed of these incidents, including a significant fall that resulted in a hospital visit. Interviews with facility staff and hospice personnel revealed a lack of documentation and communication regarding these changes in condition. Resident #469, who had severe cognitive impairment and was under hospice care, experienced a fall and subsequent pain, which was not communicated to the hospice in a timely manner. The resident's granddaughter was informed of the incident by the hospice nurse, not the facility, and requested a hospital transfer. The hospice nurse and social worker confirmed they were not notified of the resident's fall and subsequent condition changes, despite the facility's policy and agreement with the hospice provider requiring such communication. The facility's Director of Nursing and other staff acknowledged the expectation for nurses to communicate any changes in condition to hospice staff and document these communications. However, the lack of adherence to these protocols resulted in a failure to provide coordinated care for residents receiving hospice services, as evidenced by the incidents involving residents #3 and #469.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Hospice provider was made aware on of the regarding resident #3 during an in-person visit. The hospice provider was made aware on of the for resident #469 via phone call with case manager. In person communication re: between hospice provider and facility occurred on. Residents #3 and #469 are no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving Hospice services have the potential to be affected. A facility-wide audit was conducted to identify all residents receiving hospice services and assess the adequacy of communication of with hospice providers occurred timely. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs and LPNs), including unit managers, received education on hospice care communication, proper documentation, and the importance of interdisciplinary collaboration. Nursing staff (RNs and LPNs), including unit managers, will be in-service by Any Nursing staff (RNs and LPNs), including unit managers not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff (RNs and LPNs), including unit managers, will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of all hospice residents' records for 4 weeks, ensuring accurate documentation and proper communication with hospice providers, followed by monthly audits of 3 hospice residents' records for an additional three months. Audit results will be reviewed in the facility's Quality Assurance and Performance improvement (QAPI) meetings, with corrective actions taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) The date of compliance is
Failure to Sanitize Monitoring Device Between Residents
Penalty
Summary
During a medication administration task, a Registered Nurse (RN) failed to clean a portable monitoring device between its use on two residents. The RN used the device to take the vital signs of one resident and then proceeded to use it on another resident without sanitizing it in between. The RN admitted to being stressed and forgetting to clean the device, which is a required procedure to prevent cross-contamination between residents. The facility's Infection Preventionist (IP) confirmed that the staff had been trained to use purple top wipes to sanitize equipment, following the manufacturer's guidelines for drying and contact times. However, the RN involved had not signed the recent in-service training on this procedure. The Director of Nursing (DON) reiterated the expectation that all equipment should be cleaned between uses to prevent cross-contamination, as outlined in the facility's policy and CDC recommendations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The monitor was Residents #98 and #1 received a skin check and there was no evidence of Inservice for RN D on proper monitor by IP nurse. (b) Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. All monitors were. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) were educated in Prevention and Control Policy, proper of the monitor, and their roles in preventing the spread of communicable and licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) will be in-service by. Any licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not: The IP nurse or designee will observe 2 staff 3 times a week for proper monitor for of 2 weeks then 2 staff twice weekly for 2 weeks then 2 staff monthly for up to 3 months. Any deficient practice found during the audits will be corrected immediately by the IP nurse or designee and/or corrective action done as appropriate. This plan of correction will be monitored at the QAPI meeting until such time consistent substantial compliance has been met. The IP Nurse will report the audit findings in the QAPI meeting. (e) The date of compliance is.
Failure in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to develop a comprehensive system to monitor antibiotic use, as required by the stewardship program under CFR 483.80(a)(3). The review of records revealed that several residents were prescribed antibiotics without proper monitoring or follow-up testing. Specifically, resident #99 was prescribed an antibiotic without a subsequent culture and sensitivity test to confirm the appropriateness of the treatment. Additionally, residents #53, #87, and #20 were also receiving antibiotics, but their cases were not included in the facility's Control Report, which is supposed to track all antibiotic use. The Assistant Director of Nursing (ADON) and Infection Preventionist (IP) admitted to not analyzing trends in antibiotic prescribing or ensuring that all residents on antibiotics were included in the monthly Control Report. The facility's surveillance policy required tracking of all residents and their antibiotic use, but this was not adhered to. The ADON/IP also confirmed that the oversight led to residents not being part of the Control Report, which is reviewed during the facility's Quality Assurance meetings. This lack of a comprehensive monitoring system indicates a failure to adhere to the facility's stewardship commitment statement, which was signed by key personnel, including the Administrator and Medical Director.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Preventionist conducted an audit of all residents currently receiving to ensure appropriate indications, duration, and monitoring. The facility notified prescribing providers to ensure compliance with stewardship guidelines and discontinued or adjusted any orders that did not meet clinical necessity. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving have the potential to be affected. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs and LPNs) will receive education by the Preventionist on stewardship, including appropriate specimen collection, early signs of, and the risks of overuse. All Nursing staff (RNs and LPNs) will be in-service by Any Nursing staff (RNs and LPNs) not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff (RNs and LPNs) will be in-service by the ADON during their orientation. The Preventionist was educated by the Regional Nurse on regarding Stewardship and Control Policy. (c) How the corrective action(s) will be monitored to ensure the practice will not recur: The Preventionist will conduct audits of all new orders for compliance with stewardship protocols 5 days per week for 2 weeks then at least 5 weekly for two months, and monthly thereafter. Findings will be reported during the monthly QAPI meetings, and corrective actions will be implemented as needed. Compliance with the Stewardship Program will be reviewed during the facility's annual control risk assessment.
Failure to Conduct Annual Air Flow Testing for Duct Detectors
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with the National Fire Protection Association (NFPA) 101 standards. During a record review with the Maintenance Director, it was found that there was no evidence of the annual air flow testing for the duct detectors being conducted. This deficiency was identified during an interview and record review on February 24, 2025, at 8:45 AM. The Maintenance Director acknowledged and concurred with the findings, indicating a lapse in the required testing and maintenance procedures. The report highlights that the facility did not comply with the NFPA 101 and NFPA 72 codes, which require regular testing and maintenance of fire alarm systems. The absence of documentation for the duct detectors' annual air flow testing suggests a failure to adhere to these safety standards, which are critical for ensuring the proper functioning of the fire alarm system. This oversight was confirmed through both the record review and the interview with the Maintenance Director.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Duct Detectors annual air flow testing was scheduled and completed on 3/25/25. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. The Maintenance Director reviewed all the other required Fire Alarm System testing and found no other testing deficiencies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Administrator provided re-education to the Maintenance Director and Maintenance staff on the Fire Alarm System on 3/14/25 to include: Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72). (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or Designee will review All Fire Alarm System testing weekly for 4 weeks and then monthly for 2 months to ensure compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) The compliance date is 3/28/25. 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. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Duct Detectors annual air flow testing was scheduled and completed on 3/25/25. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. The Maintenance Director reviewed all the other required Fire Alarm System testing and found no other testing deficiencies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Administrator provided re-education to the Maintenance Director and Maintenance staff on the Fire Alarm System on 3/14/25 to include: Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72). (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or Designee will review All Fire Alarm System testing weekly for 4 weeks and then monthly for 2 months to ensure compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) The compliance date is 3/28/25.
Failure to Follow Physician Orders for Medication and Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was admitted for respite care with diagnoses including brain cancer, cachexia, and quadriplegia. The resident had a PEG tube for feeding assistance. A physician's order dated May 11, 2024, required the administration of Midodrine HCl 10 mg twice daily for hypotension. However, the Medication Administration Report (MAR) for May 2024 showed that on May 14, 2024, at 9:00 PM, the administration record for this medication was left blank, indicating a failure to document or possibly administer the medication. Additionally, the facility did not comply with a physician's order dated May 10, 2024, to monitor the resident's vital signs every 12 hours, including blood pressure, pulse, respirations, and temperature. The MAR for May 2024 also showed that on May 14, 2024, at 9:00 PM, there was no documentation of vital signs being obtained. Furthermore, another order required checking the PEG tube residual every shift and notifying the MD, but the MAR indicated that this was not done on the same date and time. The Director of Nursing confirmed these omissions but did not provide an explanation for the failure to follow or document the orders.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent worsening of existing pressure ulcers for three residents. Resident #3, who was admitted with a stage 3 pressure ulcer, did not receive the prescribed wound care treatments as there were no orders documented in the Treatment Administration Record (TAR) or clinical record after 4/21/24. Despite multiple evaluations by the Wound Specialist physician recommending specific treatments, these were not recorded or administered, and the resident's wound was observed without the appropriate dressing. Resident #17, admitted with a stage 4 pressure ulcer, also did not receive the correct treatment as per the Wound Specialist physician's recommendations. The clinical record lacked orders for Zinc Sulfate and the updated Vitamin C dosage, and the resident was incorrectly administered Venelex ointment instead of the recommended treatments. The facility staff documented the administration of Venelex in the electronic Medication Administration Record (eMAR) instead of the TAR, leading to a failure in following the correct treatment plan. Resident #9, with a stage 4 pressure ulcer, received incorrect treatment from 4/18/24 to 6/12/24. The resident was supposed to receive Calcium Alginate with silver, but instead received Calcium Alginate without silver, which lacks the antimicrobial properties necessary for effective wound care. The facility's failure to update and follow the wound care orders as prescribed by the Wound Specialist physician contributed to the deficiencies observed in the care of these residents.
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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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