Life Care Center Of New Port Richey
Inspection history, citations, penalties and survey trends for this long-term care facility in New Port Richey, Florida.
- Location
- 7400 Trouble Creek Road, New Port Richey, Florida 34653
- CMS Provider Number
- 106049
- Inspections on file
- 17
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of New Port Richey during CMS and state inspections, most recent first.
The facility failed to maintain emergency exit doors according to NFPA 101 standards. During a facility tour, it was observed that the exit door by Room 114 did not latch when closed. This was confirmed by the maintenance director, indicating a lapse in the facility's maintenance protocols for door inspections and testing.
The facility failed to address grievances raised by the resident council, including delayed call light responses, staff not wearing name tags, and insufficient staffing. Despite discussions in meetings, these issues were not logged or documented as resolved, contrary to facility policies. Interviews revealed a lack of understanding and execution of the grievance process by the Activities Director and Nursing Home Administrator.
The facility failed to complete or update PASRRs for several residents with mental illness and intellectual disabilities. This oversight affected six residents, whose PASRR documentation was either incomplete or outdated, failing to include necessary diagnoses and evaluations. The facility's policy mandates thorough screening and evaluation, but these procedures were not followed, leading to the identified deficiencies.
The facility failed to ensure competent nursing staff, resulting in multiple deficiencies. A resident with documented allergies was served inappropriate food items, and another had undated bandages. There was also a failure to follow up on a medication order with a black box warning. Additionally, residents were not provided adequate nutrition and hydration, with one resident missing lunch before a medical appointment and others not being offered hydration in the activities room.
A resident experienced a significant weight loss, which was not addressed in their care plan. Despite documented weight loss and meal refusals, the care plan was not updated with new interventions. Staff interviews revealed a lack of communication and coordination, as the resident consistently ate less than 25% of meals, yet this was not effectively communicated or reflected in the care plan.
A facility failed to follow up on a medication order with a black box warning for a resident, resulting in the resident not receiving the medication since admission. Additionally, another resident missed a meal due to an outing, and staff did not provide a meal or snack upon return. Furthermore, a resident was observed without hydration in the activities room, contrary to facility expectations.
A resident experienced a significant weight loss of 10.53%, but the facility failed to complete a timely assessment or update the care plan. Despite the resident's nutritional risk due to advanced age, there was no documented assessment or physician notification. Staff noted the resident's poor meal intake, and the RD confirmed the lack of an updated assessment and interdisciplinary team meeting.
The facility failed to accurately code the MDS assessments for two residents. One resident was incorrectly coded as discharged to home/community instead of the hospital, while another was coded as discharged to a hospital instead of home. The inaccuracies were confirmed by the MDS Coordinator and DON, and the facility lacked a specific policy to address this issue.
A resident experienced a significant weight loss of 10.53%, which was not addressed in their care plan. The facility staff, including a CNA and Diet Technician, were unaware of the weight loss, and the Registered Dietician confirmed that the care plan was not updated with new interventions. The interdisciplinary team did not meet to address the resident's weight loss, and the focus was on the resident's ability to eat independently rather than meal consumption.
The facility failed to maintain adequate hydration and meal provision for residents, as observed in several cases. A resident missed lunch due to a medical appointment and was not provided with food upon return, while two other residents were observed without hydration. Staff interviews revealed a lack of communication and adherence to facility policies on hydration and nutrition, contributing to these deficiencies.
A resident did not receive a prescribed medication with a black box warning due to a lack of follow-up by the facility. The medication was not sent by the pharmacy, and the issue persisted since the resident's admission. The DON contacted the PCP and ARNP, who advised discontinuing the medication. The facility's policy on medication shortages was not adhered to, as the nurses failed to collaborate with the pharmacy and physician for an alternative.
The facility exceeded the acceptable medication error rate, reaching 10.34% due to staff failing to administer the 81 mg Delayed Release medication as ordered to two residents. Despite the facility's policy requiring adherence to the 10 rights of medication administration, errors occurred during observations involving an LPN and an RN, which were later confirmed by the Unit Manager and reported to the DON.
The facility failed to securely store medications, leaving them accessible to unauthorized individuals. Medications, including a custom medication bottle, an inhaler, and creams, were found in residents' rooms without corresponding physician orders for administration or self-administration. The Director of Nursing confirmed that medications should be stored in locked compartments and administered by nursing staff unless a self-administration order is present, which was not the case for the involved residents.
A resident with documented intolerances to milk and wheat was repeatedly served these items, despite requests for alternatives like almond milk. The facility's dietary staff failed to ensure meal tickets reflected the resident's preferences, leading to inappropriate food being served.
Failure to Maintain Emergency Exit Doors
Penalty
Summary
The facility failed to maintain emergency exit doors in accordance with NFPA 101 standards. During a facility tour conducted on March 6, 2025, between 11:30 a.m. and 2:00 p.m., it was observed that the exit door by Room 114 did not latch when in the closed position. This observation was made in the presence of the maintenance director, who confirmed the findings during an interview conducted concurrently with the observations. The deficiency highlights a failure in the facility's maintenance, inspection, and testing of doors, as required by NFPA 101 and NFPA 80 standards. The report indicates that fire door assemblies are to be inspected and tested annually, and non-rated doors should be routinely inspected as part of the facility's maintenance program. However, the failure of the exit door to latch properly suggests a lapse in these maintenance protocols, as the individuals responsible for door inspections and testing are expected to possess the necessary knowledge, training, or experience to ensure compliance.
Plan Of Correction
4/5/25 On March 6, 2025, a security and fire protection company repaired the latch on the exit door by room 114. A facility-wide audit on exit doors was performed by a security and fire protection company on March 6, 2025, with no variances noted. Education was provided to the Maintenance Staff by the Executive Director on March 27, 2025, about NFPA 101 Inspection & Testing Doors per (2012 and 2021 Editions). Monthly audits will be completed by the Maintenance Director or Designee to ensure the exit doors are maintained. These audits will be reviewed in the Quality Assurance Performance Improvement meeting for three months until substantial compliance is met.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the resident council were fully and promptly addressed. During a resident council meeting, ten participants confirmed ongoing complaints about delayed responses to call lights, particularly during the third shift, and the lack of staff wearing name tags. Residents also expressed concerns about insufficient staffing, which affected the availability of restorative care, and issues with the facility's cable TV service. Despite these grievances being discussed in meetings, they were not logged in the grievance log or documented as addressed. The resident council meeting minutes revealed several unresolved issues, including the need for staff to wear name tags, education on diets, and the installation of a second rod in closets for wheelchair users. Additionally, residents requested Spanish language lessons due to language barriers with staff. Other concerns included the need for department heads to be identified, visitors not signing in and out, and the absence of garbage bags in restrooms. These grievances were not documented or followed up on, as required by the facility's policies. Interviews with the Activities Director (AD) and the Nursing Home Administrator (NHA) highlighted a lack of understanding and execution of the grievance process. The AD was unaware of the need to initiate grievances from council meetings, while the NHA believed that grievances were addressed promptly and documented. However, the facility's policies on resident council and grievance programs were not adhered to, as grievances were not logged, and resolutions were not communicated effectively to the residents.
Plan Of Correction
On , the Executive Director reviewed the last 3 months of resident council meeting minutes with the Resident Council President and wrote a grievance for the identified concerns. All residents have the potential to be affected. Appropriate notice and invitations were provided for a Resident Council meeting. The Resident Council meeting was held on with, Long Term Care Certified Ombudsman present and residents report satisfaction with facility response to the previously cited grievances. On , the facility Executive Director/Nursing Home Administrator educated the Activities Director on the Resident Council policy and procedures as well as the facility Grievance policy and procedures. A Resident Council concern/grievance follow up form was created and incorporated to ensure that the Executive Director and Resident Council President confirm each month that follow up to grievances brought forth in the Resident Council meeting is appropriate. Results of the Resident Council concern/grievance follow up forms will be tracked and trended and reported monthly to the Quality Assurance Performance Improvement Committee until sustained compliance achieved.
Failure to Complete PASRRs for Residents with Mental and Intellectual Disabilities
Penalty
Summary
The facility failed to complete or update the Pre-admission Screening and Resident Reviews (PASRRs) for residents with mental illness and intellectual disabilities. This deficiency was identified for six residents out of 23 reviewed. The PASRR process is crucial for determining whether individuals with mental or intellectual disabilities require the level of services provided by a nursing facility and if they need specialized services. The facility's oversight in this process led to incomplete or outdated PASRR documentation for these residents. For Resident #12, the Level I PASRR was not revised to include diagnoses of major mental health conditions. Similarly, Resident #57's PASRR was left blank, and qualifying diagnoses were not submitted for consideration. Resident #66's PASRR was incomplete, and a Level II evaluation was not conducted despite qualifying diagnoses. Resident #30's PASRR was also incomplete, with no Level II evaluation submitted. Resident #73's PASRR did not document a qualifying diagnosis, and Resident #84's PASRR was incomplete, lacking a Level II evaluation for consideration of their diagnoses. The facility's policy requires that potential admissions are screened for serious mental or intellectual conditions through a Level I PASRR before admission. A positive Level I screen necessitates a Level II evaluation by the state-designated authority. The facility is responsible for ensuring these screenings are completed and updated as necessary, and for notifying the appropriate state authority when a resident experiences a significant change in their condition. However, the facility failed to adhere to these procedures, resulting in the identified deficiencies.
Plan Of Correction
A new screening was completed on or before for Resident #12, #57, #66, #30, #73, and #84 to accurately capture applicable diagnoses. For any that resulted in Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor, requested documentation has been submitted and is pending third party vendor review. Current residents have the potential to be affected. Current resident Preadmission Screening and Resident Review Forms will be reviewed by to ensure accuracy. For any inaccurate Preadmission Screening and Resident Review Form identified, a new screening will be completed and Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor if applicable. The facility process will be to review new admission Preadmission Screening and Resident Review Forms in the facility clinical meeting and submit revisions or requests for Resident Review Evaluation if applicable. Director of Nursing / Nursing Home Administrator/or Designee will educate Social Services Department staff, Nursing Administration staff, and Admissions Department Staff on Preadmission Screening and Resident Review Form accuracy, specific to ensuring that the Preadmission Screening and Resident Review Form captures applicable diagnoses referenced on the Preadmission Screening and Resident Review Form screening form. Director of Nursing / Nursing Home Administrator/ or Designee will audit 8 Preadmission Screening and Resident Review Forms per week for accuracy. For any inaccurate Preadmission Screening and Resident Review Form identified, a new screening will be completed and Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor if applicable. Results of the audits will be tracked and trended and reported to the monthly QAPI meeting until sustained compliance achieved.
Deficiencies in Nursing Competency and Resident Care
Penalty
Summary
The facility failed to ensure competent staff were available to provide skilled nursing care and services, resulting in multiple deficiencies. One significant issue involved a resident who was served food items containing allergens, specifically wheat and milk, despite having documented allergies to these substances. The dietary staff, including the Certified Dietary Manager and Dietary Aides, acknowledged the error, stating that the resident's meal ticket was not properly reviewed, leading to the resident being served inappropriate food items. The facility was also out of almond milk, which was the resident's preferred alternative, and the family was expected to supply it. Another deficiency was observed with a resident who had undated bandages on their left side, contrary to the facility's policy requiring bandages to be dated and initialed by the nursing staff. This oversight was confirmed by the Director of Nursing and other nursing staff, who acknowledged the importance of dating bandages to track when they were last changed. Additionally, there was a failure to follow up on a physician's order for a medication with a black box warning for another resident. The medication was not administered since admission due to a lack of communication between the facility and the pharmacy, and the nursing staff did not notify the resident's physician to seek further instructions. The facility also failed to provide adequate nutrition and hydration services. One resident was not given lunch before a medical appointment and was not offered any food upon returning to the facility. Furthermore, several residents were observed in the activities room without being offered hydration, and staff were not aware of the residents' hydration needs. The Director of Nursing stated that residents should be offered hydration at least once an hour, and dietary staff should be notified to provide meals or snacks for residents who miss mealtime due to appointments.
Plan Of Correction
Resident # 163 was discharged from the facility. Resident # 66 was assessed with no negative outcome. Resident #73 was changed by our Nurse with no negative outcome. Resident # 91, 16, and 49 were assessed with no negative outcomes. Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with food have the potential to be affected. Residents with food will be reviewed to ensure no related consequences. Residents with have the potential to be affected by not being dated. Residents with will be reviewed to ensure are dated. Residents with medications with black box warnings have the potential to be affected. They will be reviewed to ensure no black box medication related negative effects. Current residents with since will be evaluated for negative consequences from not being provided a meal or snack with a scheduled outing. Residents' whose Activities of Daily Living are dependent on staff that spend time in the activity day rooms for hydration were reviewed to ensure the necessary assistance and fluids are being provided according to the resident needs and plan of care. The Director of Nursing / Staff Development Coordinator will complete training to the Licensed nurses and Certified Nursing Assistants on the process for ensuring food items that residents are to are not accessible, the facilities hydration policy and process with a focus on the residents that are dependent upon staff to meet their hydration needs. The training will also review the process for communicating resident to the kitchen and ensuring residents receive a snack or meal according to resident preferences. The Director of Nursing/ Staff Development Coordinator will educate licensed nurses on the need to ensure are dated and follow up on physician ordered black box warnings is completed timely. The Director of Nursing / Designee will complete 5 random weekly audits of day rooms to ensure residents do not have access to food to verify staff understanding of the education provided. The Director of Nursing/Designee will complete 5 random observations of to ensure they are labeled and 5 random audits of residents with black box warning to ensure physician orders are followed up on. In addition, the Director of Nursing/ Designee will interview 3 residents per week to determine if residents who have have been offered and/or provided a meal or snack and complete 5 random observations of dependent residents in the activity day rooms to ensure they are being provided and assisted with hydration. These audits, interviews and observations will validate staff competency and knowledge of the facility processes. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance improvement meeting until sustained compliance achieved.
Failure to Update Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident. The resident, identified as #162, experienced a 10.53% weight loss, which was not addressed in the care plan. The care plan, last updated prior to the weight loss, included interventions such as dietician evaluations and medication administration but did not reflect the recent significant weight change. Observations and interviews revealed that the resident had a history of variable intake and meal refusals, which were not adequately addressed. The resident's family noted a significant decrease in the resident's eating habits. Staff interviews indicated that the resident consistently ate less than 25% of meals, yet this was not communicated effectively to the nursing staff or reflected in the care plan. The facility's Registered Dietician confirmed that the resident's significant weight loss was documented but not followed up with appropriate care plan updates or interdisciplinary team meetings. The dietician had recommended supplements, but there was no evidence of a revised care plan or additional interventions to address the resident's nutritional decline. The lack of communication and coordination among staff contributed to the failure to update the resident's care plan appropriately.
Plan Of Correction
The facility residents with significant loss have the potential to be affected by not revising the care plan with changes and new interventions. Residents with a significant loss will be reviewed by the Registered Dietitian/Designee to determine if a significant change assessment and or care plan revision is needed. Revisions and updates will be completed as indicated. The Director of Nursing / Designee will educate the Registered Dietitian, Dietary Tech, Minimum Data Set Coordinators on the need to complete an assessment, and revise the care plan with new interventions for residents with a significant change in status in loss so that the care plan accurately reflects the resident. The Director of Nursing/Designee will complete 3 random weekly audits on loss to determine if the care plan accurately reflects the residents significant loss and/or if revisions are needed. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Medication and ADL Deficiencies in Resident Care
Penalty
Summary
The facility failed to follow up on a physician's order for a medication with a black box warning for one resident. The Director of Nurses (DON) discovered that the resident had not received the medication since admission due to the pharmacy withholding it because of the black box warning. The pharmacy was waiting for a response from the facility, which had not been provided. The DON contacted the Primary Care Provider (PCP), who was uncomfortable making a decision about the medication and advised consulting a specialist. Another deficiency involved the failure to ensure that a resident's activities of daily living (ADLs) were completed and maintained. A Certified Nurses Assistant (CNA) was unsure about the resident's meal schedule and did not provide a snack or meal when the resident missed lunch due to an outing. The resident returned to the facility without having eaten, and staff failed to offer a meal or snack upon her return. The Certified Dietary Manager was not informed of the resident's outing, which would have allowed for meal arrangements to be made. Additionally, a resident was observed in the activities room without hydration for an extended period. Staff interviews revealed that residents should have water available at all times, and hydration should be offered at least once an hour. However, this was not the case for the resident observed. The Director of Nursing expected staff to ensure hydration was available, especially during activities, but this expectation was not met, leading to the deficiency.
Plan Of Correction
Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with black box medication and assisted hydration. Residents whose Activities of Daily Living are dependent on staff for hydration that spend time in the activity rooms were reviewed to ensure the necessary assistance and fluids are being provided while in the activity day rooms. Residents who have scheduled outings have the potential to be affected by not having staff arrange, provide and complete alternative options for meals and/or snacks to accommodate the outing. Current residents with since were evaluated for negative consequences from not being provided a meal or snack with a scheduled outing. The Director of Nursing/Designee in-serviced the licensed and certified nursing staff on the hydration policy including offering and providing assist with fluids, meals and snacks based on the residents' needs and plan of care. This training includes the facility process for residents who have scheduled outings including communicating to the kitchen for timely tray delivery to accommodate the resident needs and preferences with meals, hydration and snacks with the residents on outings as needed. The Dietary Director will educate kitchen staff on the facility process for communicating and accommodating meal or snack delivery for residents with. The Director of Nursing / Designee will complete 5 weekly activity day room observations of residents dependent on staff for hydration to ensure appropriate assist and hydration is being offered to meet the resident's hydration needs.
Failure to Conduct Timely Assessment for Significant Weight Loss
Penalty
Summary
The facility failed to complete a significant change assessment within 14 days for a resident who experienced a notable weight loss. The resident, who was at risk for nutritional decline due to advanced age and other health conditions, showed a 10.53% weight loss. Despite this significant change, there were no documented assessments related to the change in status, and the care plan was not updated accordingly. Observations and interviews revealed that the resident was not eating much, with staff noting that the resident consumed less than 25% of meals. The resident was on a mechanically altered diet with supplements, but there was no evidence of a change in condition being submitted or the physician being notified of the significant weight loss. The Registered Dietician (RD) confirmed that the resident's assessment had not been updated and that the interdisciplinary team had not met to address the resident's significant weight loss. The facility's policy required immediate notification of significant changes in a resident's condition, but this was not followed. The Director of Nursing acknowledged that the physician should have been contacted, and the care plan updated. The failure to conduct a timely assessment and update the care plan represents a deficiency in the facility's compliance with regulatory requirements.
Plan Of Correction
Resident #162 was discharged from the facility. Facility residents with a significant loss are at risk of being affected by not having a significant change assessment. Residents with significant loss were reviewed by the interdisciplinary team to determine if a significant change was indicated. A significant change assessment will be completed if needed. The Director of Nursing/Designee will educate the Minimum Data Set Coordinators, Registered Dietitian, and Dietary Tech on the criteria for determining a significant change with loss and the need to complete a significant change assessment if the criteria is met. The Director of Nursing/Designee will complete 3 random weekly audits on residents with significant loss to determine if a significant change Minimum Data Set assessment was completed. Results of the audits will be tracked and trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Inaccurate MDS Coding for Resident Discharges
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were accurately coded for two residents. Resident #108 was admitted with diagnoses including Type 2 diabetes without complications and acute failure with major recurrent, moderate. The MDS for Resident #108 inaccurately indicated a discharge to home/community, while the resident was actually transferred to the hospital for further evaluation and treatment due to increased no output. This discrepancy was identified through a review of the resident's records. Similarly, Resident #110, who was admitted with acute failure and Type 2 diabetes without complications, was inaccurately coded in the MDS as being discharged to a short-term general hospital. However, the discharge summary revealed that Resident #110 was discharged home in stable condition with his daughter. Interviews with the MDS Coordinator and the Director of Nurses confirmed the inaccuracies in the MDS coding for both residents. The facility did not have a specific policy to address this issue, relying instead on the Resident Assessment Instrument (RAI) to ensure accurate MDS coding.
Plan Of Correction
Resident (#108) and Resident (#110) Minimum Data Sets were modified to reflect the accurate discharge status. Residents that were discharged from the facility have the potential to be affected. Residents discharged from the facility in the last 30 days were reviewed by the Minimum Data Set coordinator/ designee to ensure accurate coding of the discharge on the minimum data set. Those found to be inaccurate will be modified to accurately reflect the residents discharge location. The Director of Nursing/Designee provided education to the Minimum Data Set coordinators, Case Manager and Social Service Director on the process for identifying the discharge location and accurate coding of the Minimum Data Set. The Director of Nursing/Designee will complete 3 random weekly audits on discharged residents to ensure residents discharged status was coded accurately. Results of the audits will be tracked and trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident. The resident, identified as Resident #162, experienced a 10.53% weight loss, which was not addressed in the care plan. The care plan, last updated prior to the weight loss, included interventions such as dietician evaluations and medication administration but did not reflect the recent significant weight change. Observations and interviews revealed that the resident was not eating much, and family members confirmed the resident's decreased appetite. The facility's staff, including a Certified Nursing Assistant (CNA) and the Diet Technician (DT), were unaware of the resident's significant weight loss. The DT stated that she was responsible for nutritional assessments upon admission but did not know about the resident's weight loss. The Registered Dietician (RD) confirmed that she had documented the weight loss but had not seen the resident in person. The RD acknowledged that the care plan should have been updated with new interventions and that the interdisciplinary team had not met to address the resident's weight loss. Interviews with the Occupational Therapist (OT) revealed that the focus was on the resident's ability to eat independently rather than meal consumption. The OT stated that the dietician would typically communicate with the Director of Rehab (DOR) if there were concerns about weight loss. The facility's policy on comprehensive care plans emphasized the need for timely updates and revisions by an interdisciplinary team, but this was not followed in the case of Resident #162.
Plan Of Correction
Resident # 162 was discharged from the facility. Facility residents with significant loss have the potential to be affected by not revising the care plan with changes and new interventions. Residents with a significant loss will be reviewed by the Registered Dietitian/Designee to determine if a significant change assessment and or care plan revision is needed. Revisions and updates will be completed as indicated. The Director of Nursing/Designee will educate the Registered Dietitian, Dietary Tech, Minimum Data Set Coordinators on the need to complete an assessment, and revise the care plan with new interventions for residents with a significant change in status in loss so that the care plan accurately reflects the resident. The Director of Nursing/Designee will complete 3 random weekly audits on residents with a significant loss to determine if the care plan accurately reflects the residents significant loss and/or if revisions are needed. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Deficiencies in Resident Hydration and Meal Provision
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately maintained for several residents, particularly concerning meals, snacks, and hydration. Resident #91 was observed in various locations without access to hydration and reported not having eaten lunch before a medical appointment. The resident was not provided with food during the appointment or upon returning to the facility, despite staff being aware of the situation. Interviews with staff revealed a lack of communication and coordination regarding the resident's meal arrangements, with the Certified Dietary Manager and nursing staff unaware of the resident's missed meal. Additionally, Resident #16 was observed without hydration while sitting in the activities room. The resident's medical records indicated a need for substantial assistance with eating, and the CNA responsible for the resident was unsure about the frequency of providing hydration. Similarly, Resident #49 was also observed without hydration in the activities room, with medical records showing a need for maximal assistance with eating. Staff interviews highlighted a lack of consistent hydration monitoring, with expectations for hourly checks not being met. The facility's policy on hydration and nutrition requires that residents receive sufficient food and fluids, with hydration always available. However, observations and staff interviews indicated that these procedures were not consistently followed, leading to deficiencies in resident care. The Director of Nursing and Regional Director of Clinical Services acknowledged the lack of monitoring and communication regarding resident hydration and meal arrangements, contributing to the identified deficiencies.
Plan Of Correction
Resident #91 was discharged from the facility. Resident #16 and 49 were assessed with no negative outcomes. Residents that are dependent on staff for hydration that spend time in the activity day rooms are at risk of not being offered and assisted hydration. Residents whose Activities of Daily Living are dependent on staff for hydration that spend time in the activity rooms were reviewed to ensure the necessary assistance and fluids are being provided while in the activity day rooms. Residents who have scheduled outings have the potential to be affected by not having staff arrange, provide, and complete alternative options for meals and/or snacks to accommodate the outing. Current residents were evaluated for negative consequences from not being provided a meal or snack with a scheduled outing. The Director of Nursing/Designee in-serviced the licensed and certified nursing staff on the hydration policy, including offering and providing assistance with fluids, meals, and snacks based on the residents' needs and plan of care. This training includes the facility process for residents who have scheduled outings, including communicating to the kitchen for timely tray delivery to accommodate the residents' needs and preferences with meals, hydration, and snacks during outings as needed. The Dietary Director will educate kitchen staff on the facility process for communicating and accommodating meal or snack delivery for residents. The Director of Nursing/Designee will complete 5 weekly activity day room observations of residents dependent on staff for hydration to ensure appropriate assistance and hydration is being offered to meet the residents' hydration needs. The Director of Nursing/Designee will also complete 3 random weekly interviews and/or observations to ensure residents are being provided an earlier meal/snack or meal/snack upon return based on resident need or preference. Results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
Failure to Follow Up on Medication with Black Box Warning
Penalty
Summary
The facility failed to follow up on a physician's order for a medication with a black box warning for a resident. The resident was admitted with a prescription for a medication that was not sent by the pharmacy due to the black box warning. The Licensed Practical Nurse (LPN) noticed the medication was out and placed a STAT order, but the issue had been ongoing since the resident's admission. The Director of Nursing (DON) was informed and contacted the pharmacy, which revealed they were waiting for a response from the facility regarding the black box warning. The DON then reached out to the Primary Care Provider (PCP), who deferred the decision to discontinue the medication to the resident's Advanced Registered Nurse Practitioner (ARNP). The ARNP stated that if contacted earlier, she would have recommended discontinuing the medication upon admission. The facility's policy on medication shortages was not followed, as the nurses did not collaborate with the pharmacy and physician to determine a suitable therapeutic alternative. The pharmacist confirmed that the facility should have contacted them to understand why the medication order was not completed.
Plan Of Correction
Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with black box medication warnings have the potential to be affected by not following up on a physician order. Residents with black box sever interactions were reviewed for any missing, late, ordered or not available medications. Physicians will be notified if indicated. Director of Nursing/Designee will in-service the licensed staff on the facility process if a medication is unavailable from Pharmacy due to formulary coverage, contraindications, drug-drug interactions, drug interaction, black-box warnings or other clinical reason. The facility will collaborate with the Pharmacy and physician/prescriber to determine a suitable therapeutic alternative if needed. This in-service will also have a focus on reporting medications not available in Grand Rounds and in the morning clinical meeting. The Unit Managers/Designee will complete 5 random weekly audits on residents with black box sever interactions to ensure follow up with the physician has been completed and the medication is available if medication is approved for the resident. Results of the audits will be tracked trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 10.34% during the survey. This deficiency was identified through observations, record reviews, and interviews involving two residents. Specifically, during a medication administration observation, a Licensed Practical Nurse (LPN) administered several medications to a resident but failed to provide the 81 mg Delayed Release medication as ordered. Similarly, a Registered Nurse (RN) administered medications to another resident but also omitted the 81 mg Delayed Release medication as per the physician's order. The Director of Nursing (DON) was informed of these medication administration concerns by the Unit Manager, who verified the omissions. The facility's policy on medication administration emphasizes adherence to the 10 rights of medication administration, including ensuring the right drug is administered as per the physician's order. However, the staff failed to comply with this policy, leading to the identified medication errors.
Plan Of Correction
Residents #102 and #361 were evaluated for any negative consequences with none noted. The physicians and resident representatives were notified with no new orders received. Facility residents that receive medications have the potential to be affected. The Director of Nursing/Staff Development Coordinator will complete medication administration competencies on each licensed nurse to validate staff competency related to medication administration with focus on preventing medication errors. The Director of Nursing/Staff Development Coordinator will educate licensed nurses on the policy and procedure for medication administration including following physician orders and preventing medical errors. The Director of Nursing/Staff Development Coordinator will complete 5 random weekly medication administration observations to ensure medications are provided as ordered. Observations will be completed on each shift and weekends. Results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and were inaccessible to unauthorized staff, residents, and visitors. During observations, medications were found in the rooms of five residents, including a custom medication bottle, an inhaler, and various creams, none of which had corresponding physician orders for administration or self-administration. These medications were left on bedside tables or in accessible areas, contrary to the facility's policy that requires medications to be stored in locked compartments or administered by nursing staff unless a self-administration assessment is completed. The Director of Nursing confirmed that medications should be stored in treatment or medication carts and administered by nursing staff unless there is a self-administration order, which was not present for any of the residents involved. The facility's policy also mandates that medications should not be left at the bedside and should be securely stored to prevent unauthorized access. The failure to adhere to these protocols resulted in medications being accessible to residents and potentially unauthorized individuals, posing a risk to resident safety.
Plan Of Correction
Residents #265, #63, #12, #164 and #18 medications were removed and properly stored with the permission of the resident or resident representative. Facility residents have the potential to be affected by medications being accessible to unauthorized staff, residents, and visitors. The Director of Nursing and Unit Managers completed 100% observation of each resident's room to ensure medications are not accessible to unauthorized staff, residents, and visitors. Residents that had medications not stored appropriately were removed and stored in the medication carts or residents' locked drawer, if a physician order is in place for self-administration, with the resident or resident representative's permission. The Director of Nursing/Designee will complete 5 random weekly observations of resident rooms to ensure there are no medications that are accessible to unauthorized staff, residents, and visitors. The results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
Failure to Accommodate Resident's Food Intolerances
Penalty
Summary
The facility failed to provide food that accommodates a resident's intolerances and preferences, as evidenced by the case of a resident who was served wheat and milk despite having documented intolerances to these items. The resident, who was observed eating breakfast in her room, reported that she had been served wheat and milk on multiple occasions, despite her requests for alternatives such as almond milk. The resident's care plan and physician orders indicated that she should not be served milk or wheat, and that almond milk should be used instead. However, the facility did not have almond milk available at the time, and the resident's meal ticket incorrectly included items she was intolerant to. Interviews with the facility's dietary staff, including the cook, dietary aides, Certified Dietary Manager (CDM), and Diet Technician (DT), revealed a breakdown in communication and responsibility. The dietary aides admitted to errors in reviewing meal tickets, and the CDM acknowledged that the resident was served items she was intolerant to, despite having documented these preferences. The DT confirmed her role in updating meal tickets and expressed confusion over the oversight. The facility's policy on food preferences and intolerances was not effectively implemented, leading to the resident being served inappropriate food items.
Plan Of Correction
Resident #163 was discharged from the facility. Residents with food intolerances and preferences have the potential to be affected by not honoring intolerances and preferences. The Registered Dietician/diet tech will review residents with food intolerances to ensure the residents' tray ticket and care plan are accurate. The diet tech/food service director will interview residents to ensure their food preferences are accurate and are correct on residents' tray tickets. The facility added a food tray checker at the end of the tray line to verify the tray is accurate, honoring the resident's intolerances and food preferences. The Registered Dietitian/Designee will in-service the food and nutrition staff on the process for ensuring residents with intolerances are not served those food items and that food preferences are honored. This training will include the process for checking the tray prior to serving. The Director of Nursing/Designee will in-service licensed nurses, certified nursing assistants, and activity staff on the need to ensure that the items on the tray match the tray ticket and that food items that the residents are to avoid or have intolerances to are not served, and that food preferences are provided. The Registered Dietitian/Designee will complete 5 random weekly meal observations to ensure that residents are not served items they are to avoid or have intolerances to and are provided their food preferences. The results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
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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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