Lexington Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 6300 46th Ave N, Saint Petersburg, Florida 33709
- CMS Provider Number
- 105072
- Inspections on file
- 33
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Lexington Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to prevent accidents and provide adequate supervision for a resident with severe cognitive impairment who sustained a fall with injury, and did not ensure a safe environment for two residents who smoked and required wheelchairs, requiring them to navigate unassisted through hazardous areas without staff supervision or proper smoking receptacles.
Surveyors identified multiple sanitation and maintenance issues in the kitchen, including dirty equipment, rusted surfaces, stained ceiling filters, water leaks, insect presence during food prep, and trash accumulation both inside and outside the kitchen. The Certified Dietary Manager was aware of several issues but cited challenges with cleaning procedures and shared responsibilities for maintaining cleanliness.
Several dependent residents did not receive consistent assistance with ADLs, including grooming, nail care, shaving, toileting, and showers, as required by their care plans. Residents reported long waits for help, missed care, and unmet hygiene needs, while staff interviews and documentation confirmed lapses in providing and recording necessary support.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and directly affected residents requiring assistance with bowel and bladder management.
Multiple staff were observed failing to follow infection prevention protocols, including improper incontinence and catheter care without glove changes or hand hygiene, lack of PPE use in a contact isolation room, and non-compliance with policies on artificial fingernails and hair containment. Documentation of staff competency and infection control training was incomplete, and staff interviews revealed gaps in education and monitoring.
A resident with a gastrostomy tube was observed independently administering enteral nutrition without an assessment, physician order, or care plan focus authorizing self-administration. Despite having intact cognition and relevant diagnoses, the facility did not follow its policy requiring interdisciplinary assessment and documentation for self-administration of medications.
A resident with dementia and significant confusion suffered an unwitnessed fall resulting in a skull fracture. Despite care plan interventions, the DON did not report the incident as an injury of unknown source, citing no care plan violation, even though staff and the PMHNP indicated the resident was unable to request assistance. Facility policy required reporting such incidents, but this was not done.
A resident with intact cognition was transferred to the hospital for evaluation and treatment without receiving written notification about bed-hold options or appeal rights prior to the transfer. The required transfer and discharge notice form was incomplete and dated after the resident's return, and staff interviews confirmed that the necessary documentation and notifications were not provided at the time of transfer.
A resident with a new diagnosis of major depressive disorder did not have a properly completed or submitted Level II PASRR evaluation request following a significant change in condition. Facility staff failed to provide evidence of notification to the state authority, and documentation was incomplete and unsigned, contrary to policy requirements.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of the resident's needs.
A resident with a recent history of falls did not have timely, written, signed, and dated physician progress notes following each required visit. Staff and DON confirmed that physician documentation was missing from the medical record for several months, contrary to facility policy, with the missing notes later found in the medical records department.
A resident with ESRD on dialysis did not receive multiple prescribed medications as ordered, with missed doses documented as refusals. The resident reported not refusing medications but missing them due to being at dialysis. Staff interviews confirmed that physician notification and documentation were required for missed doses, but these steps were not completed.
Surveyors found that the medication error rate in the facility was 5 percent or greater, indicating that medication administration was not consistently accurate and exceeded regulatory standards.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as observed during the survey.
The facility did not provide documentation of required quarterly visual inspections and semi-annual testing for fire service backflow tamper switches, which were found installed but not included in inspection or testing reports. The Facility Manager confirmed these devices had not been inspected or tested as required by NFPA standards.
Surveyors identified that the facility did not properly maintain its automatic fire sprinkler system, with multiple corroded and dust-loaded sprinkler heads found in areas such as the front porch, laundry washroom, and behind the dryers. These deficiencies were confirmed by the Facility Manager during the inspection.
An employee was observed smoking outside of a designated area on facility property where required noncombustible ashtrays and self-closing metal disposal containers were not provided, despite the facility's no-smoking policy. The deficiency was confirmed by the Facility Manager during the survey.
A corridor door with a self-closing mechanism leading to the clean utility room by the nurse's station failed to close or self-latch when tested, as confirmed by the Facility Manager. This failure to maintain the fire door in accordance with NFPA 101 and NFPA 80 standards resulted in a deficiency.
The facility failed to implement an effective infection prevention and control program, resulting in ongoing skin rashes among residents and staff. Multiple residents reported itching and lack of effective treatment or cleaning measures. Staff also experienced similar symptoms, and the facility's infection preventionist did not track the outbreak effectively. The DON and NHA were unaware of the full scope of the issue, leading to continued spread.
The facility failed to provide timely care plan meeting notifications, hindering resident and representative participation in care planning. A resident with severe cognitive impairment had insufficient attempts to contact their POA, while another resident with intact cognition received inadequate notification. Additionally, a resident with moderate cognitive impairment lacked documentation for care plan invitations and summaries. The MDS Coordinator acknowledged issues with documentation and notification processes.
Failure to Prevent Accidents and Ensure Safe Smoking Environment
Penalty
Summary
The facility failed to implement appropriate interventions and provide adequate supervision to prevent accidents and injuries for multiple residents. One resident with severe cognitive impairment, a history of falls, and a recent diagnosis of dementia and agitation was found on the floor with a skull fracture after attempting to get out of bed unassisted. The resident's care plan included reminders to request assistance and keeping the call light within reach, but interviews with staff and the psychiatric nurse practitioner revealed that the resident was unable to use the call light due to confusion and severe cognitive deficits. Despite these known limitations, no additional supervision or interventions were implemented prior to the fall, and the psychiatric nurse practitioner was not notified of the incident, which would have required a follow-up assessment. Additionally, the facility failed to ensure a safe environment for residents who smoke. Two residents who required the use of a wheelchair and had mobility impairments were required to sign out on a leave of absence and navigate unassisted through the parking lot, over speed bumps, and across potholes to reach an off-premises smoking area. Observations confirmed that no staff supervision or smoking receptacles were present in the area where these residents smoked. One resident was observed struggling to move her wheelchair over a speed bump, and both residents expressed concerns about the difficulty and safety of accessing the designated smoking area. Review of the facility's policies and staff interviews indicated that smoking assessments were completed without direct observation of residents smoking, and staff were unclear about the requirements for supervision and safe smoking practices. The facility's policy stated that resident supervision should be based on individual assessments and physician orders, but in practice, residents with mobility and cognitive impairments were left unsupervised in potentially hazardous environments, leading to avoidable risks and incidents.
Sanitation and Maintenance Deficiencies in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed multiple sanitation and maintenance deficiencies in the facility's main kitchen during an inspection. The juice machine filter was found with visible dirt and debris, and the Certified Dietary Manager (CDM) was unaware of how to clean it, stating that new filters would need to be ordered and installed by the vendor. The juice machine itself had brown stains and rust on its stainless-steel surfaces, which the CDM indicated could not be cleaned. Ceiling filters above food preparation and service areas were stained and covered in dust and dirt, and a light fixture near the food prep area had brown stains and bio-growth. Water was observed leaking near this light fixture, and the CDM confirmed that maintenance was aware of the issue. Kitchen mixer utensils stored above clean dishes were found with dust and sticky substances, and the CDM stated these were no longer in use and should have been removed. In the freezer, ice buildup was present on surfaces and on top of food boxes, which the CDM acknowledged and said maintenance would address. Additionally, an insect was observed flying over chicken being prepared for lunch, which the CDM attributed to staff leaving the back door open, allowing insects to enter the kitchen. The chicken was immediately discarded. Outside the kitchen, trash and standing water were found near the kitchen door, with the CDM noting that the water was leaking from an air conditioning unit and had been an ongoing problem, leading to mosquito breeding. The area around the dumpster was littered with trash, including used gloves, papers, and incontinence pads. The CDM stated that cleaning responsibilities were shared between nursing and maintenance, but enforcement was difficult. Facility policy requires all food preparation and service areas to be maintained in a clean and sanitary condition, but these observations indicated noncompliance.
Failure to Provide Consistent Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several dependent residents, as evidenced by direct observations, resident interviews, and record reviews. Multiple residents were found with untrimmed fingernails, facial hair, and reported not receiving help with grooming tasks such as nail trimming and shaving, despite care plans indicating the need for staff assistance. Residents expressed that staff either promised help that was not delivered or stated that staff were too busy to assist. Care plans for these residents documented self-care deficits and required staff interventions, including hands-on assistance and cueing, which were not consistently implemented. In addition to grooming deficiencies, residents reported and records confirmed delays and inconsistencies in receiving toileting care and showers. Some residents described waiting over an hour for staff to respond to call lights for toileting assistance, resulting in prolonged periods of incontinence. Documentation in the CNA Kardex revealed multiple dates where toileting care was not recorded, and residents reported not receiving showers as scheduled or preferred. Staff interviews confirmed that residents should be changed every two hours and that documentation should occur at the time of care, but this was not consistently practiced. The affected residents had significant medical histories, including dementia, hemiplegia, Parkinson’s disease, encephalopathy, spinal cord injury, morbid obesity, and chronic illnesses, all contributing to their dependence on staff for ADLs. Despite individualized care plans outlining the need for substantial or maximal assistance with hygiene, grooming, and toileting, the facility did not ensure these services were provided as required. Facility policy also mandated support for ADLs to maintain residents’ hygiene and dignity, but observations and interviews demonstrated that these standards were not met for multiple residents.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care provided to residents requiring assistance with bowel and bladder management.
Infection Control Lapses in Staff Practices and Policy Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in staff practices and policy implementation. Certified Nursing Assistants (CNAs) were observed providing incontinence and catheter care without adhering to proper infection control protocols. One CNA used the same cleansing wipe to clean both the peri area and catheter tubing of a resident with a urinary catheter, without changing gloves or performing hand hygiene, even after contact with stool. Another CNA provided catheter care using a single washcloth for both the penis and catheter tubing, again without changing gloves or performing hand hygiene. Review of competency checklists revealed incomplete documentation and a lack of observed return demonstrations for these staff members, with one CNA stating she had not received additional training at the current location and the Infection Preventionist confirming that visual skills check-offs were not routinely performed or documented. Additional deficiencies were observed regarding staff adherence to facility policies on personal appearance and use of personal protective equipment (PPE). One LPN was observed with artificial fingernails extending past the fingertips, in violation of CDC recommendations and facility expectations, though the employee handbook did not explicitly prohibit artificial nails. Another staff member was observed with long, untethered braids that came into contact with a resident and bed linens during care, despite the expectation for staff to be neat and well-groomed. The facility's policy on employee appearance was found to be vague and did not specifically address artificial nails or hair containment. Further, staff failed to implement contact isolation precautions as required. Two CNAs entered a contact isolation room without donning PPE or gloves and did not perform hand hygiene before entering. One CNA stated he was unaware of the resident's contact precautions, while the other admitted to not paying attention to the signage. Interviews with the Infection Preventionist and DON revealed that while infection control is discussed during orientation, there is no structured or documented observation of staff practices, and compliance rates are not tracked. These failures collectively demonstrate a lack of consistent implementation and monitoring of infection prevention and control measures.
Failure to Assess and Authorize Self-Administration of Enteral Nutrition
Penalty
Summary
The facility failed to ensure that an assessment for self-administration of enteral nutrition was completed for a resident who was observed independently administering his enteral nutrition via gastrostomy tube. During observation, the resident was seen self-administering his enteral nutrition with the head of his bed flat. The resident confirmed that although nurses typically provide his enteral nutrition during scheduled meal times, he also self-administers it. Review of the resident's medical record revealed diagnoses including malignant neoplasm of the thyroid gland, severe protein calorie malnutrition, gastroesophageal reflux disease, and gastrostomy status. The resident had a BIMS score indicating intact cognition and had active physician orders for enteral feeding, but there was no documentation of an assessment for self-administration of enteral nutrition. Further review showed there was no physician order authorizing the resident to self-administer his enteral nutrition, nor was there any indication in the care plan that self-administration was permitted or planned. Facility policy requires an interdisciplinary team assessment and physician order before a resident may self-administer medications, including enteral nutrition, and mandates that the care plan reflect this arrangement. Staff confirmed that no such assessment, order, or care plan focus was present for this resident.
Failure to Report Serious Injury of Unknown Source and Neglect
Penalty
Summary
The facility failed to report an allegation of serious injury of unknown source and neglect for a resident who experienced an unwitnessed fall resulting in a skull fracture. The resident, who had a history of cognitive impairment, dementia, and confusion, was found on the floor with facial injuries and was subsequently diagnosed with a skull fracture and scalp contusion at the hospital. Her care plan included interventions such as the use of a mechanical lift with two staff for transfers and keeping the call light within reach, but she attempted to get out of bed without assistance. Interviews revealed that the DON did not consider the incident an adverse event or injury of unknown source, stating there was no violation of the care plan since the resident did not call for help. The DON also indicated that the event did not need to be reported to the State Agency. However, the resident's PMHNP and an LPN both described the resident as very confused and unable to use the call light or request assistance, contradicting the DON's assessment of the resident's capabilities. The PMHNP was not informed of the fall, and the LPN stated the resident would not have known how to use the call light. A review of facility policy showed that all reports of abuse, neglect, or injuries of unknown origin are to be reported to local, state, and federal agencies as required by regulations. The policy also requires immediate reporting of suspected abuse, neglect, or injury of unknown source to the administrator and other officials according to state law. Despite these requirements, the facility did not report the incident as required.
Failure to Provide Timely Written Notification of Hospital Transfer and Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notification to a resident and the resident's representative prior to a hospital transfer. A resident with intact cognition, as indicated by a BIMS score of 15, reported not receiving any information about bed-hold options before being transferred to the hospital for evaluation and treatment of shortness of breath and chest pain. The resident expressed concern about returning to the facility in time to retain her bed, indicating a lack of communication regarding her rights and options during the transfer process. Record review showed that the Nursing Home Transfer and Discharge Notice form for the resident was incomplete, missing both the physician/designee and resident/representative signatures, and was dated after the resident's return from the hospital. Interviews with staff confirmed that the required notification and documentation were not provided at the time of transfer, and the facility's policy requires such notifications to be completed on the same day as the transfer. The deficiency was identified through review of records and staff interviews.
Failure to Notify State Authority After Significant Change in Mental Health Condition
Penalty
Summary
The facility failed to notify the appropriate state mental health or intellectual disability authority after a significant change in the mental condition of a resident with a new diagnosis of major depressive disorder. The resident was originally admitted with no indication of serious mental illness or intellectual disability, as documented in the initial PASRR screening. However, after a new diagnosis of major depressive disorder was made, there was no evidence that a Level II PASRR evaluation request was properly completed, signed, or submitted to the state agency. The documentation provided lacked signatures, patient identification, and proof of transmission, and no Level II evaluation or determination was available by the end of the survey. Interviews with facility staff, including the DON and ADON, revealed that the process for identifying and referring residents with new mental health diagnoses relies on provider communication and internal notification. Despite this, the required referral and documentation for the resident's significant change in condition were not completed according to policy and regulatory requirements. The facility's policy mandates that residents with new or suspected mental disorders or intellectual disabilities be referred for a Level II PASRR evaluation, but this process was not followed in this case.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not ensure that all aspects of the resident's needs were assessed and addressed in a comprehensive and measurable manner.
Failure to Maintain Timely Physician Progress Notes
Penalty
Summary
A deficiency was identified when the attending physician failed to provide written, signed, and dated progress notes following each required visit for one resident. The resident, who had a recent history of falls and required stitches, did not have timely physician progress notes documented in the electronic medical record. Review of the resident's records revealed gaps in physician documentation, with the most recent notes either missing or not uploaded for several months. Staff interviews confirmed that only psychiatric and ARNP notes were present, and the Director of Nursing acknowledged the absence of physician notes for an extended period, stating that this was not optimal. Further review of facility policy indicated that physician progress notes are required to be maintained for each resident and must reflect each visit, including the physician's signature and date. The deficiency was further substantiated when the DON confirmed that summaries in the record did not constitute physician notes and that the lack of documentation for several months was unacceptable. The missing notes were later found in the medical records department, which had a staffing vacancy, but this did not mitigate the initial failure to maintain timely and complete physician documentation as required by facility policy.
Failure to Administer Medications as Ordered and Notify Physician of Missed Doses
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and did not document physician notification for missed medications for a resident with end stage renal disease (ESRD) who was dependent on renal dialysis. Review of the resident's Medication Administration Record (MAR) for June and July 2025 revealed multiple missed doses, including 31 missed doses of Lactobacillus, five missed doses of house protein, and single missed doses of atorvastatin calcium, ferrous sulfate, and a multivitamin. The MAR indicated these medications were marked as refused, but the resident stated she sometimes did not receive her medications because she was at dialysis and denied refusing them. Interviews with nursing staff and the Director of Nursing confirmed that a refusal should be documented, the physician should be notified, and a progress note should be entered. However, there was no documentation of physician notification for the missed medications. Facility policy requires medications to be administered as prescribed, refusals to be followed by physician notification, and medication errors to be documented and reviewed. These procedures were not followed in this case, resulting in the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified through observations and review of food service practices, which revealed that residents were not always provided with meals that met their individual dietary needs and preferences.
Failure to Inspect and Test Fire Service Backflow Tamper Switches
Penalty
Summary
The facility failed to maintain the automatic fire alarm system (AFAS) in accordance with NFPA 101 and NFPA 72 requirements. During a record review with the Facility Manager, it was discovered that there was no documentation of the required quarterly visual inspections and semi-annual testing of the fire service backflow tamper switches. These devices were not listed on any inspection or testing reports, indicating that they had not been included in the facility's regular fire alarm system maintenance program. During a facility tour, the tamper switches were observed to be installed on the fire service backflow device. In an interview, the Facility Manager acknowledged that they were unaware the devices were not being inspected or tested. The deficiency was identified through both documentation review and direct observation, confirming that the required maintenance and testing procedures for these components of the fire alarm system were not being followed.
Plan Of Correction
The facility Administrator/Designee contacted vendor to service the backflow tamper switches. The fire service backflow tamper switches were inspected and tested by a vendor company. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining the fire service backflow tamper switches in accordance with NFPA 101, which includes servicing and maintaining documentation of the fire service backflow tamper switches inspections. The Nursing Home Administrator/Designee will audit appropriate documentation of inspections conducted and quarterly documentation as it relates in accordance with NFPA 101. These audits will be conducted monthly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The facility Administrator/Designee contacted vendor to service the backflow tamper switches. The fire service backflow tamper switches were inspected and tested by a vendor company. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining the fire service backflow tamper switches in accordance with NFPA 101, which includes servicing and maintaining documentation of the fire service backflow tamper switches inspections. The Nursing Home Administrator/Designee will audit appropriate documentation of inspections conducted and quarterly documentation as it relates in accordance with NFPA 101. These audits will be conducted monthly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Failure to Maintain Fire Sprinkler System per NFPA Standards
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system (AFSS) in accordance with NFPA 101 and NFPA 25 standards. During a facility tour with the Facility Manager, surveyors observed multiple deficiencies in the sprinkler system, including corroded and dust-loaded sprinkler heads. Specifically, all 14 pendant sprinkler heads in the front porch and exterior covered drive were found to be corroded, as well as 2 of 3 pendant sprinkler heads in the laundry washroom. Additionally, 1 of 2 upright sprinkler heads behind the dryers was corroded, and another upright sprinkler head in the same area was loaded with dust. These findings were confirmed through interviews with the Facility Manager conducted at the time of observation. The report documents that the facility did not meet the required standards for inspection, testing, and maintenance of the AFSS, as outlined in the referenced NFPA codes. No information about residents or their medical conditions is included in the report.
Plan Of Correction
The facility Administrator/Designee contacted a vendor to service the 14 pendant sprinkler heads located at the front porch and cover drive, the 2 pendant sprinkler heads located in the laundry washroom, the 1 upright sprinkler head located behind the dryers, and the 1 sprinkler head covered with dust behind the dryers, as it relates to meeting compliance with NFPA 101. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining sprinkler heads in accordance with NFPA 101, which includes maintaining them free of dust or corrosion. The Nursing Home Administrator/Designee will conduct weekly audits for 3 months on 5 sprinkler heads to ensure they are maintained in accordance with NFPA 101, including being free of dust and corrosion. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The facility Administrator/Designee contacted a vendor to service the 14 pendant sprinkler heads located at the front porch and cover drive, the 2 pendant sprinkler heads located in the laundry washroom, the 1 upright sprinkler head located behind the dryers, and the 1 sprinkler head covered with dust behind the dryers, as it relates to meeting compliance with NFPA 101. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining sprinkler heads in accordance with NFPA 101, which includes maintaining them free of dust or corrosion. The Nursing Home Administrator/Designee will conduct weekly audits for 3 months on 5 sprinkler heads to ensure they are maintained in accordance with NFPA 101, including being free of dust and corrosion. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Failure to Provide Required Smoking Safety Equipment
Penalty
Summary
During a facility tour, an employee was observed smoking on the property outside of a designated smoking area. The area where the employee was smoking did not have ashtrays made of noncombustible material and safe design, nor were there metal containers with self-closing cover devices available for ashtray disposal, as required by NFPA 101 and NFPA 1 standards. These observations were confirmed in real time with the Facility Manager. At the exit conference, the administrator stated that the facility has a smoking regulations policy that prohibits smoking anywhere on the property at any time. Despite this policy, the observed smoking incident occurred, and the required smoking safety equipment was not present in the area where the violation took place. No information about residents or their medical conditions was included in the report.
Plan Of Correction
The Staff member was identified and was immediately educated on the facility's non-smoking policy. The nursing home administrator conducted walking rounds of the outdoor areas surrounding the facility as it relates to any concerns with facility adherence to non-smoking policy. No concerns were identified. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator/Designee re-educated facility staff on the non-smoking policy. The Nursing Home Administrator/Designee will conduct a random audit weekly 3 times a week on the facility staff's adherence to the facility's non-smoking policy by visual inspection. These audits will be conducted weekly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The Staff member was identified and was immediately educated on the facility's non-smoking policy. The nursing home administrator conducted walking rounds of the outdoor areas surrounding the facility as it relates to any concerns with facility adherence to non-smoking policy. No concerns were identified. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator/Designee re-educated facility staff on the non-smoking policy. The Nursing Home Administrator/Designee will conduct a random audit weekly 3 times a week on the facility staff's adherence to the facility's non-smoking policy by visual inspection. These audits will be conducted weekly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station was called for servicing and repairs. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Failure to Maintain Self-Closing Fire Door Mechanism
Penalty
Summary
During a recertification survey, it was observed that the facility failed to maintain fire doors in accordance with NFPA 101 and NFPA 80 standards. Specifically, the corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station did not close or self-latch when tested. This observation was made during a facility tour with the Facility Manager, who confirmed the findings at the time of inspection. The deficiency was identified based on direct observation and interview, with no mention of any specific residents or patient involvement. The report notes that all fire door assemblies are required to be labeled, maintained in a legible condition, and equipped with functioning self-closing or automatic-closing devices. The failure to ensure the door's proper operation constituted noncompliance with the cited NFPA standards.
Plan Of Correction
The corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station was called for servicing and repairs. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Inadequate Infection Control Leads to Skin Rash Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the ongoing skin rashes among residents and staff. The report highlights that four residents were reviewed for ongoing skin rashes, and it was found that the facility did not ensure proper cleaning and isolation measures. A family member of one resident reported that the resident's room and personal items were not cleaned properly after treatment for a skin condition, leading to a recurrence of symptoms. Additionally, other residents reported similar issues, with complaints of itching and lack of effective treatment or cleaning measures. Interviews with staff revealed that multiple residents across different units were experiencing rashes and itching, yet there were no transmission-based precautions in place. Staff members also reported experiencing similar symptoms, which they treated themselves. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were not fully aware of the extent of the issue, and the facility's infection preventionist had not been tracking the outbreak effectively. The lack of communication and documentation contributed to the failure to address the spread of the condition. The facility's policies on surveillance and treatment of communicable conditions were not followed, as evidenced by the absence of skin scrapings to diagnose the rashes and the lack of deep cleaning in affected areas. The DON and Nursing Home Administrator (NHA) were unaware of the full scope of the issue, and the facility did not consider the situation an outbreak, which would have prompted more rigorous tracking and intervention measures. This oversight led to the continued spread of the condition among residents and staff.
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) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? Residents #5 and #6 diagnosed as possible by Director of Nursing/Preventionist obtained orders on for contact isolation for affected residents #5 and #6. Resident #7 returned from the hospital where she was treated for on Director of Nursing/Preventionist obtained orders upon returning from the hospital, for contact isolation for resident #7. Resident #8 skin clear and free of upon assessment on. Affected rooms were deep cleaned on or before using the deep clean protocol for their room, clothing, and personal items. Preventionist initiated line listings on and notification for residents who have/had rashes that could be indicative of. Preventionist initiated line listings on and notification for staff who have/had rashes that could be indicative of. Preventionist initiated line listings for visitors and notification who have/had rashes that could be indicative of on. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? House Wide Skin sweep completed on or before by nursing leadership to evaluate all residents for a indicative of. As applicable, orders obtained for treatment, transmission-based precautions were initiated, and the deep clean protocol for their room, clothing, and personal items. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? The Director of Nursing provided education to the Preventionist on transmission-based precautions and initiating a line listing for new and/or suspected rashes that could be indicative of. Staff educated, by Director of Nursing/Preventionist/Designee on or before regarding the facility policies and procedures for reporting potentially illness and rashes to Preventionist or Nursing administration for themselves. Director of Nursing/Preventionist/Designee will identify any residents, staff, or visitors ongoing that may have had exposure or at risk of potentially illness to identify if any would require initiating a line listing and/or isolation precaution. Director of Nursing/Preventionist/Designee will monitor documentation and new orders weekly for treatment to identify if any would require initiating a line listing and/or isolation precautions due to a suspicious will. Any residents found with a will undergo a deep cleaning of their room, clothing, and personal items bagged and cleaned as indicated. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be implemented? Director of Nursing or Designee to complete audit to ensure compliance with identification of rashes possibly requiring transmission-based precautions. Audits will be completed 3x weekly for x4 weeks, then twice weekly x4 weeks, then weekly. NHA to review audits monthly for compliance. The DON or will report their findings to the Quality Assurance committee Monthly until such time that substantial compliance has been met.
Failure to Facilitate Timely Care Plan Meeting Notifications
Penalty
Summary
The facility failed to facilitate timely care plan meeting notifications, preventing residents and their representatives from participating in the development and implementation of person-centered care plans. For Resident #6, the facility did not make sufficient attempts to contact the resident's Power of Attorney (POA) for care plan meetings. Despite the resident's severe cognitive impairment, only one attempt was made to contact the POA by mail, and no further attempts were documented. Additionally, there was a lack of documentation for care plan invitations and summaries for several comprehensive assessments, and the last care plan note was dated back to 2021. Resident #17, who had intact cognition, did not receive adequate notification for care plan meetings. The facility mailed an invitation to the POA only six days before a scheduled meeting, and there was no documentation of care plan invitations or summaries for several assessments. The MDS Coordinator stated that the resident did not normally participate in meetings, and the facility only reached out to family members if they expressed interest, which contributed to the lack of resident involvement. For Resident #23, who had moderate cognitive impairment, the facility failed to provide documentation of care plan invitations or summaries for certain quarterly assessments. Although the resident and a family member participated in some meetings, there was no documentation of care plan notes or IDT narrative notes in the clinical record. The MDS Coordinator acknowledged the absence of uploaded summaries and stated that summaries were done with every care plan meeting, but they were not consistently documented in the resident's electronic records.
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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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