Menorah House
Inspection history, citations, penalties and survey trends for this long-term care facility in Boca Raton, Florida.
- Location
- 9945 Central Park Blvd N, Boca Raton, Florida 33428
- CMS Provider Number
- 105685
- Inspections on file
- 25
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Menorah House during CMS and state inspections, most recent first.
A resident with COPD, hypertension, GERD, epilepsy, and intact cognition was care planned to receive assistance with ADLs, including bathing and personal hygiene, and was scheduled for showers three times per week. Despite this, documentation for weekly showers and skin observations was left blank, and there were no nursing notes or behavior monitoring entries indicating refusals of showers or hair care. The resident and a relative reported that the resident had not received a full body bath or hair wash since admission, and observation showed oily hair, a dry scalp, and complaints of itchiness. Therapy staff described the resident as alert, oriented, and participatory in grooming with standby assistance, while CNAs and nursing staff acknowledged that showers and hair washes had not been provided, refusals were not consistently documented, and nursing was not notified of missed care.
Two residents with pressure ulcers received wound care that was not performed in a sanitary manner. For a resident with a sacral pressure ulcer and multiple comorbidities, an LPN, assisted by a CNA, conducted a dressing change without placing a clean barrier between the open sacral wound and a contaminated diaper and Hoyer lift net padding, allowing the uncovered wound to rest on and repeatedly contact these contaminated surfaces during the procedure. For another resident with a mid-upper back pressure ulcer and chronic conditions including COPD, hypertension, GERD, and epilepsy, the same LPN and CNA performed a dressing change without a clean barrier between the uncovered back wound and contaminated bedding, allowing the wound area to contact the bedding throughout the treatment. The LPN later acknowledged not using a clean barrier, and leadership confirmed that the dressing changes should have been done in a safe and sanitary manner.
The facility failed to maintain food safety standards, with a refrigerator exceeding temperature limits and improperly stored food items. Dented cans were not marked, and sanitation solution levels were too high. Personal items were found in the food production area.
The facility failed to provide pureed meals with the correct consistency for residents requiring such diets. Observations revealed grainy and lumpy textures in pureed foods, contrary to the smooth, pudding-like consistency required. Residents expressed dissatisfaction with the meals, leading to low intake. Interviews with staff confirmed the inconsistency with guidelines.
The facility failed to follow infection control guidelines, particularly Enhanced Barrier Precautions (EBP), for several residents. Staff did not wear protective gowns during high-contact activities for residents with specific medical needs, and there was a lack of signage and PPE carts. These lapses were observed in the care of multiple residents, indicating a systemic issue in the facility's infection control practices.
The facility failed to develop and document comprehensive care plans for two residents. One resident expressed loneliness and a desire for activities, but no activities care plan was documented. Another resident required specific medical care and precautions, but no care plan was created for their needs. Staff interviews confirmed the absence of these care plans, and the facility's leadership acknowledged the oversight.
The facility failed to maintain accurate records for controlled drugs for three residents. Medications were either removed from the cart without being documented as administered or documented as administered without being signed out. The DON and an LPN Unit Manager indicated that audits are conducted to reconcile these records, but discrepancies were still found.
The facility failed to provide a safe, clean, and homelike environment in nine resident rooms. Observations included stained flooring and walls, disrepair of baseboards, and stained privacy curtains. A dim bathroom light, inadequate privacy curtain coverage, and a broken dresser drawer were also noted. Strong odors and blackened baseboards were found during an environmental tour.
The facility failed to provide adequate dining assistance, maintain an activities program, and ensure timely medication and medical care for residents. Two residents did not receive necessary help during meals, leading to inadequate nutrition. Another resident lacked engagement in activities, feeling lonely and unsupported. Additionally, medication administration was delayed, and medical orders were not followed, compromising residents' health and well-being.
The facility failed to maintain resident dignity and privacy, as evidenced by undignified language, lack of eating assistance, and exposure during personal care. Two residents were left without proper meal assistance, and another was referred to as a "feeder." Privacy was compromised for several residents, with open doors and inadequate coverage during care. Additionally, a resident experienced a delay in receiving their meal, highlighting a failure to adhere to dignity policies.
The facility failed to provide dignified eating assistance and maintain privacy for residents. One resident was left unattended with a food tray for 25 minutes, while another was referred to as a "feeder". Privacy issues included a resident without a privacy pouch for a drainage bag, another with an open door during personal care, and a resident exposed in bed with the door open.
The facility failed to document the notification of two residents' representatives regarding changes in their conditions. One resident was transferred to the hospital due to unstable vitals without a documented Change in Condition Evaluation or notification of the representative. Another resident, observed to be sluggish with fluctuating oxygen levels, was transferred to the ER, but the notification section was left blank. The LPN acknowledged the presence of family members but did not document their awareness.
The facility failed to maintain a safe, clean, and homelike environment in 9 out of 64 rooms. Observations included stained flooring and walls, disrepair of baseboards, and stained privacy curtains. Some rooms had strong odors, and a resident's privacy curtain did not cover the window area. The Environmental Services Representative acknowledged these issues and mentioned plans to replace baseboards and flooring.
The facility failed to develop comprehensive care plans for two residents, one of whom expressed loneliness and lacked an activities care plan, while the other required specific medical care and Enhanced Barrier Precautions without corresponding care plans. Interviews and observations revealed a lack of documentation and coordination among staff, leading to these deficiencies.
The facility failed to assist two residents who required partial assistance during meals, resulting in inadequate consumption of their meals. Observations showed that staff were not present to help the residents, despite their assessed needs for support with eating.
A resident's preferences for activities were not met due to the lack of a written care plan and documentation of activities. The resident expressed feelings of loneliness and reported missing personal items, while the Activities Director admitted to not documenting one-on-one visits or activities. Despite claims of engagement, inconsistencies were noted between the resident's and the AD's accounts.
The facility failed to provide proper care for three residents, including late medication administration and missing equipment. A resident did not receive timely medications, and their Pleur-X tube was not drained as ordered, causing distress. Another resident experienced late medication administration on multiple occasions. A third resident lacked an abduction pillow as ordered, with staff unaware of its absence.
A facility failed to provide timely and adequate nutritional support for two residents. One resident was admitted without a feeding order for 20 hours, and observations showed improper management of the feeding tube. Another resident received significantly less formula than prescribed, with discrepancies in administration. Staff interviews confirmed delays and errors in following physician orders, leading to inadequate nutrition.
The facility failed to ensure accurate dispensing and administration of controlled drugs for three residents. A resident's medication was removed from the cart but not documented as administered, while another's was documented as administered but not removed. The DON and an LPN Unit Manager acknowledged the responsibility for auditing medication reconciliation, but discrepancies persisted.
The facility failed to provide meals that matched the dietary preferences of two residents, leading to a deficiency. One resident with moderate cognitive impairment did not receive mashed potatoes and had unwanted potato skins, while another resident did not receive the salads listed on their meal ticket. The dietary manager acknowledged the issue, despite having checkpoints to ensure meal accuracy.
The facility's nurse call systems in the Galilee and Masada wings were found deficient during a fire safety tour, with several corridor lights failing to illuminate as required by NFPA 99 standards. The Maintenance Director acknowledged these deficiencies.
The facility did not maintain its Essential Electrical System (EES) as per NFPA 99 standards, lacking a supply of generator replacement parts for high mortality items. This was observed during a fire safety tour with the Maintenance Director, who acknowledged the deficiency. The issue was discussed with the Administrator and Maintenance Director during the exit conference.
The facility was found non-compliant with NFPA 101 standards for egress doors. Observations revealed missing signage on main entrance doors with delayed egress locks, unauthorized multiple locks on the Dining Room Patio exit, and improper locking mechanisms on Rehabilitation emergency exit doors. The Maintenance Director acknowledged these deficiencies.
The facility failed to maintain their commercial cooking facility according to NFPA 101 standards. During a fire safety tour, it was observed that two gas-powered appliances, a steamer and an oven, were on castors without means to prevent strain on the gas connection. The Maintenance Director acknowledged the findings, which were reviewed with the Administrator.
The facility failed to maintain fire/smoke barriers as per NFPA 101 standards, with penetrations found in a 2-hour fire-rated wall and a smoke wall during a fire safety tour. The Maintenance Director acknowledged these findings, which were reviewed with the Administrator. The report highlights the need for thorough inspections to ensure all penetrations are sealed to maintain safety.
During a fire safety tour, a facility was found to have improper use of power strips and lack of GFCI protection. Power strips were plugged into other power strips at the Reception desk and Telecommunication Room, and a vending machine lacked GFCI protection. Additionally, televisions in several resident rooms were plugged into power strips within six feet of the patient care area, violating safety regulations. The Maintenance Director acknowledged these findings.
The facility did not maintain documentation for the 5-year hydrostatic test of the fire department connection and the 5-year internal inspection of the fire-line backflow preventer, as required by NFPA 101. This was identified during a record review with the Maintenance Assistant, who acknowledged the findings, and discussed with the Administrator and Maintenance Director.
The facility failed to maintain portable fire extinguishers according to NFPA 101 standards, with three out of twelve extinguishers either obstructed or improperly installed. The Telecommunication Equipment Room had an obstructed class ABC extinguisher and lacked a clean agent extinguisher, while extinguishers near Rooms 203 and 209 were blocked by carts. These issues were confirmed by the Maintenance Director and discussed with the Administrator.
A facility failed to monitor and document a resident's pain level as ordered and did not record the administration of pain medication. The resident had a care plan for pain management, but the MAR lacked documentation of pain levels and medication administration, despite records showing Tramadol was removed for the resident. These issues were confirmed by the DON.
A facility failed to verify and administer an IV antibiotic, Vancomycin, for a resident upon admission. The hospital's order for Vancomycin IV during dialysis was intended for Home Health Care and was not included in the discharge orders reconciled by the nurses. The order was not reviewed or clarified in a morning meeting with the DON, ADON, Administrator, and Social Services. A Dialysis Center RN reported that the resident's spouse mentioned the need for Vancomycin IV, but the on-duty nurse incorrectly stated that the resident was receiving oral Vancomycin. There was no evidence that the order was clarified with the physician.
Failure to Provide Scheduled Showers and Hair Care for a Cognitively Intact Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate ADL care, specifically bathing and hair care, to a cognitively intact resident despite an existing ADL policy and individualized care plan. The facility’s policy required a consistent and effective approach to ADL care, including bathing, hygiene, hair care, and regular monitoring and documentation of ADL needs and outcomes. The resident’s ADL care plan, initiated shortly after admission, identified a need for assistance with ADLs due to weakness and decreased mobility following a recent hospitalization, and directed staff to encourage and assist with all ADL tasks, including bathing and personal hygiene, while observing for changes in capabilities. Record review showed that the resident was admitted with COPD, hypertension, GERD, and epilepsy, and had a BIM score of 14, indicating intact cognition. The resident was scheduled on the unit’s shower list to receive showers three times per week, but the computerized CNA task section for weekly showers/skin observation and the paper shower schedule form were left blank and not completed. CNA documentation reflected only three refusals for personal hygiene tasks such as combing hair and washing face and hands, and did not include refusals for baths, showers, or oral hygiene during the resident’s stay. There was no documentation in nursing progress notes, behavior monitoring records, or the ADL care plan of any refusals or behavioral issues related to showering or hair washing. Interviews and observations further demonstrated that the resident did not receive the scheduled showers and hair care. The resident and a relative reported that the resident had not received a full body bath/shower or hair wash since admission, and the relative stated that the lack of hair washing for 21 days was very distressing. On observation, the resident’s hair appeared oily with a dry scalp, and the resident reported an itchy scalp. Therapy staff described the resident as alert, oriented, and participatory in care, with some weakness and shortness of breath but able to perform grooming with standby assistance and other ADLs with varying levels of assistance. CNAs acknowledged that the resident should have been showered at least three times per week, admitted they had not provided showers or hair washes, and had not documented refusals or notified nursing. Nursing staff, including the unit manager, confirmed there was no documentation of refusals or care issues, and the DON acknowledged the resident should have received appropriate ADL care.
Unsanitary Wound Care Performed Without Clean Barriers
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and treatment in a sanitary manner, contrary to its own wound management and treatment policies. The Menorah House Wound Management Program policy states that all caregivers are responsible for preventing, caring for, and treating wounds and skin alterations, with an organized approach that includes appropriate local wound care and prevention of skin breakdown. The Menorah House Treatment Procedure requires that a clean field be arranged per facility protocol when performing treatments inside a resident’s room. Despite these policies, surveyors observed wound care being performed without maintaining a clean barrier between open wounds and potentially contaminated surfaces. For one resident with a sacral pressure ulcer and multiple comorbidities including diffuse traumatic brain injury, diabetes mellitus type II, dementia, seizures, hypertension, and atherosclerotic heart disease, the physician’s order directed daily cleansing of the sacral wound with normal saline, patting dry, and applying collagen and calcium alginate with a dry dressing. The resident’s care plan focused on weekly skin checks, documenting wound status and healing, monitoring for signs and symptoms of infection, and encouraging participation in toileting and hygiene. During an observed sacral wound dressing change, an LPN, assisted by a CNA, prepared supplies and washed her hands, but did not place a clean barrier between the resident’s uncovered sacral wound and the diapered bottom. The LPN left the bedside to wash her hands, leaving the bare, exposed wound resting directly on a contaminated diaper and contaminated Hoyer lift net padding. Throughout the procedure, the resident’s uncovered sacral wound repeatedly came into contact with the contaminated diaper and Hoyer lift net padding, with no clean barrier used at any time. For another resident with a mid-upper back pressure ulcer and diagnoses including COPD, hypertension, GERD, and epilepsy, the physician’s order directed cleansing the mid-back wound with normal saline, patting dry, applying Medi-honey to the wound base, and covering with a dry dressing daily. The care plan for this resident also included weekly skin checks, documenting wound status and healing, monitoring for signs and symptoms of infection, and encouraging participation in toileting and hygiene. During an observed mid-upper back wound dressing change, the same LPN, assisted by the CNA, performed the dressing change without placing a clean barrier between the resident’s bare, uncovered back wound area and the contaminated bedding. Throughout the procedure, the resident’s uncovered back wound area was allowed to come into contact with the contaminated bedding while the wound was being cleaned and treated. In interviews, the LPN acknowledged not placing a clean barrier and could not explain why, and the unit manager and DON acknowledged that a clean barrier should have been used and that the dressing changes should have been performed in a safe and sanitary manner.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during one of three visits to the main kitchen. Observations revealed that the walk-in refrigerator on the dairy side had an internal temperature of 49 degrees Fahrenheit, exceeding the acceptable range of 35 to 40 degrees Fahrenheit. Several food items, including an egg platter, a tuna platter, and nutritional juice drinks, were found with internal temperatures above the required 40 degrees Fahrenheit. Additionally, a large container of raw chicken and raw meat in the walk-in meat refrigerator were improperly stored, with one container showing a pool of liquid at the bottom. Further issues were noted in the dry storage room, where dented cans of sliced pineapples and tomato sauce were not segregated with a 'do not use' sign. An opened bottle of extra light amber honey was found without a known opening date. A personal Styrofoam cup of coffee was observed in the food production area, and a large metal container was coated with a dried unidentified substance. The facility's use of sanitation solution was also problematic, as a red bucket tested with Hydrion strips showed an excessive level of 400 parts per million, which the Dietary Manager acknowledged as too much solution.
Plan Of Correction
F812 FOOD PROCUREMENT, STORE/PREPARE/SERVE-SANITARY What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the Walk-in refrigerator on the dairy side was 49° not the necessary 40°. Dietary staff will be in-serviced to check walk-in refrigerator temperatures and ensure it is 40° or below. If not, to inform maintenance to fix/adjust the temperature. In the allegation of the Egg platter from dairy walk-in was 43.7° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of the Scoop of Tuna from the dairy walk-in was 44° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of the Container of nutritional juice drink from the dairy walk-in was 46° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of Another Container of nutritional juice drink from the dairy walk-in was 47.1° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of Raw chicken exposed and dated, Dietary staff will be in-serviced to properly seal and date open items and how long before they need to be disposed of. In the allegation of Raw meat dated, pool of on the bottom of the meat container. Dietary staff will be in-serviced as to the proper storage of raw meat. In the allegation of Bag of unidentified meat dated, Dietary staff will be in-serviced to properly label, date, and store refrigerated items. In the allegation of Red bucket having a reading of 400 parts per million indicating too much sanitation solution in the bucket. Dietary staff will be in-serviced on proper measurements for sanitation solution. In the allegation of Dry storage had a dented can of sliced pineapples that was not placed by the sign "do not use". Dietary staff will be in-serviced where to place and not use dented cans. In the allegation of Dry storage had 2 dented cans of tomato sauce that was not placed by the sign "do not use". Dietary staff will be in-serviced where to place and not use dented cans. In the allegation of Dry storage Open bottle of extra light amber honey was half used and was not dated as to when it was opened. Dietary staff will be in-serviced on proper labeling and storage of open items in the dry storage. In the allegation of Food prep area had a person 20 oz Styrofoam cup of coffee present. Dietary staff will be in-serviced not to have eat or drink or leave personal food in the kitchen. In the allegation of a Large metal container with a dried unidentified substance coating the surface. Dietary Staff will be in-serviced on proper cleaning of metal containers. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Dietary staff will be in-serviced to check walk-in refrigerator temperatures and ensure it is 40° or below. If not, to inform maintenance to fix/adjust the temperature. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. Dietary staff will be in-serviced to properly seal and date open items and how long before they need to be disposed of. Dietary staff will be in-serviced as to the proper storage of raw meat. Dietary staff will be in-serviced to properly label, date, and store refrigerated items. Dietary staff will be in-serviced on proper measurements for sanitation solution. Dietary staff will be in-serviced where to place and not use dented cans. Dietary staff will be in-serviced on proper labeling and storage of open items in the dry storage. Dietary staff will be in-serviced not to eat or drink or leave personal food in the kitchen. Dietary Staff will be in-serviced on proper cleaning of metal containers. Random QA audits will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month, and then monthly for one month or until substantial compliance has been determined. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audits will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month, and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met.
Inadequate Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct diet consistency for residents on pureed diets, as observed during multiple visits to the main kitchen. The pureed meals prepared for residents did not meet the required smooth, pudding-like consistency as per the facility's policy and guidelines set by the National Task Force. Observations revealed that the pureed hamburger had a grainy consistency, and the pureed vegetables were lumpy. Additionally, the pureed turkey contained small pieces, indicating a failure to achieve the necessary texture. Resident #47, who was on a pureed diet due to a medical condition affecting their ability to swallow, received a meal with a pureed roll that was lumpy and grainy. The resident's meal ticket matched the meal tray, but the consistency did not meet the required standards. Interviews with the Registered Dietitian and Speech Therapist confirmed that the pureed diet should be smooth and lump-free, resembling mashed potatoes, which was not the case during the observations. Resident #175 and Resident #77 also received pureed meals that did not meet the required consistency. Resident #175's meal had a loose puree consistency with liquid pooling around the food, leading to a low intake of the meal. Similarly, Resident #77's meal had a loose puree consistency with liquid pooling, and the resident expressed dissatisfaction with the flavor, resulting in a refusal to eat the rest of the meal. These observations indicate a consistent failure to provide pureed meals in the correct form, potentially affecting the nutritional intake and satisfaction of residents on pureed diets.
Plan Of Correction
F805 FOOD IN FORM TO MEET INDIVIDUAL NEEDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the pureed food on the lunch meal tray line, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 2) In the allegation of the pureed food on the lunch meal tray line, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 3) In the allegation of Resident #47, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 4) In the allegation of Resident #175, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 5) In the allegation of Resident #77, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Cooks will be in-serviced as to the proper consistency of pureed food. Random QA audits will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention and control guidelines, particularly concerning Enhanced Barrier Precautions (EBP) for several residents. Resident #103 was observed without proper protective measures in place, as staff did not wear gowns while repositioning the resident, despite the presence of a drainage bag. The Infection Preventionist and Unit Manager acknowledged the oversight, attributing it to the resident's recent room change, which led to the delayed placement of a PPE cart. Resident #175's care also demonstrated lapses in following EBP protocols. Staff members, including a wound care nurse and a hospice aide, were observed providing care without wearing protective gowns, despite the resident's condition requiring such precautions. The staff admitted to being distracted or unaware of the need for gowns, indicating a lack of consistent adherence to the facility's infection control policies. Additionally, Resident #46 and Resident #39 were not provided with appropriate EBP measures. Staff failed to wear gowns during high-contact activities, such as transferring and wound care, and there was a lack of signage and PPE carts outside their rooms. These deficiencies highlight a systemic issue in the facility's implementation of infection control practices, as staff members were either unaware or neglectful of the necessary precautions for residents with specific medical needs.
Plan Of Correction
Corrective action completion date: F880 CONTROL PREVENTION& 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #103. The resident had risk for related to the and interventions did not include Enhanced Barrier Precautions. Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. 2) In the allegation of Resident #175, The Staff left the door open, privacy curtain halfway open and were not wearing proper PPE while doing care on a resident that had Enhanced Barrier Protection. Nursing staff will be in-serviced on dignity, closing door and pulling privacy curtain during care. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. 3) In the allegation of Resident #46, the resident did not have an Enhanced Barrier Protection or care plan. There was no Enhanced Barrier Protection signage on the door and no PPE cart. Staff while transferring resident was not using proper PPE. Staff not wearing proper PPE while caring for resident. Nursing staff will be in-serviced about initiating proper care plans for residents who need care and Enhanced Barrier protection. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. 4) In the allegation of Resident #276, during the staff did not do proper hygiene in between glove changes. Staff will be in-serviced to proper hygiene between glove changes. 5) In the allegation of Resident #278, during the staff did not do proper hygiene in between glove changes. Staff will be in-serviced to proper hygiene between glove changes. 6) In the allegation of Resident #39, during care, Care Staff was not wearing gowns, there was no Enhanced Barrier Precautions signage on the door no isolation cart. Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. - Nursing staff will be in-serviced on dignity, closing doors and pulling privacy curtain during care. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. - Nursing staff will be in-serviced about initiating proper care plans for residents who need care and Enhanced Barrier protection. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. - Staff will be in-serviced to proper hygiene between glove changes. - Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive activities care plan for a resident, identified as Resident #12, who expressed feelings of loneliness and a desire for in-room activities. Despite the resident's expressed preferences for certain activities, such as going outside for fresh air and participating in religious services, there was no documented evidence of an activities care plan in the resident's clinical record. Interviews with the resident and facility staff, including the Activities Director and MDS Coordinator, confirmed the absence of a written care plan and a lack of documentation of activities provided to the resident. Additionally, the facility did not create a care plan for another resident, identified as Resident #39, who had specific medical needs including a right heel and right condition requiring Enhanced Barrier Precautions. The resident's clinical records showed physician orders for wound care and barrier precautions, but there was no corresponding care plan documented. Observations revealed that the necessary precautions were not in place, as there was no sign or isolation cart near the resident's door. Interviews with the MDS Coordinator and a Licensed Practical Nurse confirmed the absence of a care plan for the resident's medical conditions and precautions. The Director of Nursing and the Administrator were informed of these deficiencies, acknowledging that the lack of documentation indicated that the necessary care plans and activities were not implemented. The facility's failure to initiate and document comprehensive care plans for these residents highlights a significant oversight in meeting the residents' individualized care needs.
Plan Of Correction
N072 COMPREHENSIVE CARE PLANS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #12, not having an activities care plan or documentation of activities participation. The Activities Director will be in-serviced about activities care-plans and documentation for activities participation. 2) In the allegation of Resident #39, not having a care plan for right heel or right, and no care plan for Enhanced Barrier Precautions. Missing Enhanced Barrier Precautions signage on the door, missing isolation cart near the resident's door. Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Activities Director will be in-serviced about activities care-plans and documentation for activities participation. Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Inadequate Controlled Drug Record Keeping
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in maintaining accurate records for the dispensing and administration of controlled drugs. This deficiency was identified through interviews and record reviews for three residents. For Resident #487, there was a discrepancy between the Medication Monitoring/Control Record and the Medication Administration Record (MAR), where a medication was signed out as removed from the medication cart but not documented as administered. Similarly, for Resident #28, a medication was removed from the cart but not recorded as administered on the MAR. In contrast, for Resident #82, a medication was documented as administered but not signed out as removed from the medication cart. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) Unit Manager revealed that the Unit Managers are responsible for auditing the medication reconciliation of controlled substances. The LPN Unit Manager stated that she checks the Medication Monitoring/Control Record against the MAR to ensure all entries are signed and match, typically performing this audit three times a week, although it is supposed to be done once a week. These findings indicate a failure in the facility's system to accurately record and reconcile the receipt and disposition of controlled drugs, as required by the consultant pharmacist's established system.
Plan Of Correction
N092 FAC CONTROLLED DRUGS - RECORDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #487, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2) In the allegation of Resident #28, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 3) In the allegation of Resident #82, the resident's medication was not signed out but was documented as administered. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations and interviews. Nine out of 64 rooms were found to have various issues, including stained flooring and walls, disrepair of baseboards, and stained privacy curtains. Specific observations included a dim and blinking bathroom light, a privacy curtain that did not adequately cover a window, and a dresser drawer with a broken piece of wood. Additionally, a TV was connected to a power strip, which could pose a safety hazard. Further environmental concerns were noted during a tour with the Environmental Services Representative and the Housekeeping Director. A strong odor was detected in some bathrooms, and the baseboards were blackened in various sections. The bathroom wall near the door was soft, and the plaster was not smooth. The Environmental Services Representative acknowledged these issues and mentioned that the baseboards had been painted over, but the paint comes off during cleaning and buffing. They also stated that there is a plan to replace all room baseboards and flooring, pending the delivery of new tiles.
Plan Of Correction
N110 PHYSICAL ENVIRONMENT - SAFE, CLEAN, HOMELIKE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of flooring, wall and baseboard behind residents bed where stained and in disrepair. Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. In the allegation of privacy curtain stained, floor stained and baseboard in disrepair. Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. In the allegation of bathroom light dim and blinking and baseboard behind resident's bed in disrepair. Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. In the allegation of privacy curtain does not cover window area. Maintenance staff will fix or replace privacy curtain to ensure it cover the window area. In the allegation of outside of room in disrepair, broken dresser drawer, power strip for the TV. Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. In the allegation of baseboard in disrepair and floor stained behind residents nightstand and bed. Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. In the allegation of strong -like odor in bathroom, room baseboards blackened, bathroom wall near the door soft and plaster not smooth. Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. In the allegation of strong -like odor. Housekeeping will scrub and clean rooms to remove -like odor. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. Maintenance staff will fix or replace privacy curtain to ensure it covers the window area. Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. Housekeeping will scrub and clean rooms to remove -like odor. Random QA audits will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Deficiencies in Resident Care and Support
Penalty
Summary
The facility failed to provide adequate assistance during dining for two residents who required help with their meals. Observations revealed that one resident's meal trays were left untouched or barely eaten, with no staff present to assist, despite the resident's need for partial assistance. Interviews with staff indicated a misunderstanding of the resident's needs, as one CNA believed the resident could eat independently with minimal setup. Another resident also required encouragement and assistance with meals, but staff inconsistently provided the necessary support, as noted by the resident's family member. The facility also failed to maintain an ongoing activities program tailored to a resident's preferences. The resident expressed feelings of loneliness and a lack of engagement in activities, despite having specific interests such as going outside and participating in religious services. The Activities Director admitted to not documenting in-room activities and acknowledged that the resident's care plan lacked evidence of individualized activity planning. This oversight resulted in the resident not receiving the desired level of engagement and support. Additionally, the facility did not ensure timely administration of medications and proper medical care for several residents. One resident did not receive their Pleur-X drainage as ordered, leading to distress and potential health risks. Another resident experienced delays in medication administration, with some medications given up to two hours late. Furthermore, a resident did not have an abduction pillow in place as ordered, and another resident's nutritional needs were not met due to improper administration of enteral feeding. These deficiencies highlight a pattern of inadequate adherence to physician orders and care plans, compromising the residents' health and well-being.
Plan Of Correction
N201 FS RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #1 having multiple meals where trays were not set up for the resident to eat. The resident ate minimal at all the observed meals. Nursing staff will be in-serviced to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. 2) In the allegation of Resident #275 needing help and encouragement during meals. Nursing staff will be in-service to ensure ADLs are followed for meal times for residents that need assistance, i.e. set up, assistance or encouragement with eating. 3) In the allegation of Resident #12, and 1 on 1 activities in room visits not being documented. The Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. 4) In the allegation of Resident #73, and the Pleur-X not being drained on its schedule. And not following medication administration times of an hour prior or an hour post scheduled administration times. The Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. The Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 5) In the allegation of Resident #481 having not received multiple medication at their prescribed times. Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 6) In the allegation of Resident #46, and the resident's abduction pillow not being used. Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. 7) In the allegation of Resident #475, and the facility not receiving an order for almost 20 hours. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 8) In the allegation of Resident #109, not for almost 22 hours and the tube-feeding not running at proper rate. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: In-service will be conducted with nursing staff to ensure ADL are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide eating assistance in a dignified manner for two residents observed for in-room dining. One resident was left unattended with a food tray for approximately 25 minutes without staff assistance, despite needing supervision and assistance during meals. Another resident was referred to as a "feeder" by staff, which is considered undignified language. Additionally, a resident's privacy was compromised as they were left without a privacy pouch for their drainage bag, contrary to their care plan requirements. The facility also failed to maintain privacy during personal care for several residents. One resident was observed with their room door open and privacy curtain partially drawn while receiving care, exposing them to the hallway. Another resident was found with their bed covers off, exposing their disposable brief and tubing, with the room door open, allowing full view from the hallway. These observations indicate a lack of adherence to the facility's dignity policy, which emphasizes maintaining privacy and respectful communication. Furthermore, a resident experienced a delay in receiving their lunch tray, resulting in them waiting 19 minutes after their roommate had already finished eating. This delay in meal service is inconsistent with the facility's policy of treating residents with dignity and ensuring timely assistance. The report highlights multiple instances where the facility's actions or inactions failed to uphold the residents' right to be treated with dignity and respect, as required by the facility's policies and procedures.
Plan Of Correction
N203 RIGHT TO BE TREATED WITH DIGNITY 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #82, being referred to as a "feeder". Staff will be in-serviced regarding dignity, not calling residents "feeders" but as someone who needs assistance with feeding. 2) In the allegation of Resident #103, waiting a long time to be fed. Staff will be in-serviced not to leave trays in the room, but to feed residents in a timely manner as to not cause dignity issues. 3) In the allegation of Resident #103, not having a privacy pouch for bags. Nursing staff will be in-serviced to ensure residents with bags have privacy covers for them. 4) In the allegation of Resident #175, privacy during care. Nursing staff will be in-serviced to provide privacy for residents while they are receiving care. 5) In the allegation of Resident #275, delay in feeding, residents in the same room should be brought their trays at the same time. Staff will be in-serviced to bring food trays to all residents in the same room at the same time not to cause dignity issues. 6) In the allegation of Resident #475, door open no covers (linens) covering resident, resident exposed in only a brief and a shirt. Nursing staff will be in-serviced to ensure residents are dressed or covered for privacy and dignity. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - In-service staff about dignity, not calling residents "feeders" but as someone who needs assistance with feeding. - In-service staff not to leave trays in room, to feed residents in a timely manner as to not cause a dignity issue. - In-service Nursing staff to ensure residents with bags have privacy covers for them. - In-service nursing staff to provide privacy for residents while they are receiving care. - In-service staff to bring food trays to all residents in the same room at the same time not to cause a dignity issue. - In-service nursing staff to ensure residents are dressed or covered for privacy and dignity. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Dignity and Privacy Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide eating assistance in a dignified manner for two residents observed for in-room dining. One resident was left unattended with a food tray for approximately 25 minutes without staff assistance, despite needing supervision and assistance during meals. Another resident was referred to as a "feeder" by staff, which is considered disrespectful and undignified. The facility also failed to maintain privacy and dignity for several residents. One resident was observed without a privacy pouch for a drainage bag, exposing them unnecessarily. Another resident was left with their room door open and privacy curtain partially drawn during personal care, exposing them to the hallway. Additionally, a resident was found lying in bed with their shorts unbuttoned and a disposable brief partially exposed, with the room door open, allowing full view from the hallway. These observations indicate a lack of adherence to the facility's dignity policy, which emphasizes respectful communication and maintaining privacy during personal care activities. The staff's actions and inactions, such as leaving residents exposed or unattended, demonstrate a failure to treat residents with the respect and dignity they are entitled to under federal regulations.
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. F550 RESIDENT RIGHTS/EXERCISE OF RIGHTS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #82, being referred to as a "feeder". Staff will be in-serviced regarding dignity, not calling residents "feeders" but as someone who needs assistance with feeding. 2) In the allegation of Resident #103, waiting a long time to be fed. Staff will be in-serviced not to leave trays in the room, but to feed residents in a timely manner as to not cause dignity issues. 3) In the allegation of Resident #103, not having a privacy pouch for bags. Nursing staff will be in-serviced to ensure residents with bags have privacy covers for them. 4) In the allegation of Resident #175, privacy during care. Nursing staff will be in-serviced to provide privacy for residents while they are receiving care. 5) In the allegation of Resident #275, Delay in feeding, residents in the same room should be brought their trays at the same time. Staff will be in-serviced to bring food trays to all residents in the same room at the same time not to cause dignity issues. 6) In the allegation of Resident #475, Door open no covers (linens) covering resident, resident exposed in only a brief and a shirt. Nursing staff will be in-serviced to ensure residents are dressed or covered for privacy and dignity. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - In-service staff about dignity, not calling residents "feeders" but as someone who needs assistance with feeding. - In-service staff not to leave trays in room, to feed residents in a timely manner as to not cause a dignity issue. - In-service Nursing staff to ensure residents with bags have privacy covers for them. - In-service nursing staff to provide privacy for residents while they are receiving care. - In-service staff to bring food trays to all residents in the same room at the same time not to cause a dignity issue. - In-service nursing staff to ensure residents are dressed or covered for privacy and dignity. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Document Notification of Change in Condition
Penalty
Summary
The facility failed to document the notification of the resident or resident representative for a change in condition for two residents. For Resident #53, the medical record showed no evidence of a Change in Condition Evaluation being completed, nor was there documentation of notifying the resident's representative or emergency contact. The resident was transferred to the hospital due to unstable vitals, but there was no record of the resident leaving for a physician's visit or with whom. The Licensed Practical Nurse (LPN) acknowledged that the resident's wife was present but did not document the change in condition evaluation. Similarly, for Resident #488, the facility did not document notifying the family or representative about the resident's change in condition. The resident was observed to be sluggish with fluctuating oxygen saturation levels, leading to a transfer to the emergency room. The Change in Condition Evaluation section for notifying the family or representative was left blank. The LPN stated that the resident's daughter was present during the change in condition but admitted to not documenting her presence or awareness of the situation.
Plan Of Correction
F580 NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #53, there was no change of condition completed, no notification to family, no documentation as to where or with whom the resident left. Nursing staff will be in-serviced to complete a change of condition for resident when being discharged to the hospital, to notify and document the residents emergency contact/guardian when being sent to the hospital, document to where the resident went and with whom. 2) In the allegation of Resident #488, there was No documentation notification made letting emergency contact/guardian know the resident went to the ER. Nursing staff will be in-serviced to complete a change of condition for resident when being discharged to the hospital, to notify and document the residents emergency contact/guardian when being sent to the hospital, document to where the resident went and with whom. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: In-service Nursing staff to complete a change of condition for residents when being discharged to the hospital, to notify and document the residents emergency contact/guardian when being sent to the hospital, document to where the resident went and with whom. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Deficiencies in Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in 9 out of 64 rooms. Observations revealed various deficiencies, including stained flooring and walls, disrepair of baseboards, and stained privacy curtains. In one instance, a resident's privacy curtain did not adequately cover the window area, and another resident's dresser drawer was broken. Additionally, a TV was connected to a power strip, which could pose a safety risk. The environmental tour further identified strong odors in some rooms, blackened baseboards, and soft bathroom walls with unsmooth plaster. Interviews with residents and staff confirmed these environmental concerns. The Environmental Services Representative acknowledged that the baseboards had been painted over and that the paint comes off during cleaning and buffing. They mentioned a plan to replace all room baseboards and flooring, pending tile delivery. Despite these plans, the current state of the facility did not meet the regulatory requirements for a safe and homelike environment, as evidenced by the observations and resident feedback.
Plan Of Correction
SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of flooring, wall and baseboard behind residents bed where stained and in disrepair. Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. 2) In the allegation of privacy curtain stained, floor stained and baseboard in disrepair. Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. 3) In the allegation of bathroom light dim and blinking and baseboard behind resident's bed in disrepair. Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. 4) In the allegation of privacy curtain does not cover window area. Maintenance staff will fix or replace privacy curtain to ensure it covers the window area. 5) In the allegation of wall outside of room in disrepair, broken dresser drawer, power strip for the TV. Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. 6) In the allegation of baseboard in disrepair and floor stained behind residents nightstand and bed. Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. 7) In the allegation strong-like odor in bathroom, room baseboards blackened, bathroom wall near the door soft and plaster not smooth. Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. 8) In the allegation of strong -like odor. Housekeeping will scrub and clean rooms to remove -like odor. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. - Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. - Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. - Maintenance staff will fix or replace privacy curtain to ensure it covers the window area. - Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. - Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. - Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. - Housekeeping will scrub and clean rooms to remove -like odor. Random QA audits will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee for a period of three months and until substantial compliance is met.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive activities care plan for a resident, identified as Resident #12, who expressed feelings of loneliness and a desire for in-room activities. Despite the resident's cognitive abilities being intact, as indicated by a Brief Interview of Mental Status score of 15, there was no documented activities care plan in the resident's clinical record. The resident expressed that they felt lonely and had lost a workbook during a room transfer, which was not replaced by the facility staff. Interviews with the Activities Director and MDS staff revealed a lack of coordination and documentation regarding the resident's activities care plan. Additionally, the facility did not create a care plan for another resident, identified as Resident #39, who had specific medical needs including a right heel condition and required Enhanced Barrier Precautions. The resident's clinical records showed physician orders for wound care and barrier precautions, but there was no corresponding care plan documented. Observations confirmed the absence of necessary precautions, such as signage and isolation carts, during care procedures. Interviews with the MDS Coordinator and LPN involved in the resident's care highlighted a gap in the creation and implementation of care plans for the resident's identified needs. The deficiencies in care planning for both residents were acknowledged by facility staff, including the Director of Nursing and the Administrator, who confirmed that the lack of documentation indicated that the necessary care plans were not developed or implemented. This failure to document and execute comprehensive care plans for residents' activities and medical needs represents a significant oversight in the facility's care planning processes.
Plan Of Correction
Corrective action completion date: F656 DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #12, not having an activities care plan or documentation of activities participation. The Activities Director will be in-serviced about activities care-plans and documentation for activities participation. 2) In the allegation of Resident #39, not having a care plan for right heel or right, and no care plan for Enhanced Barrier Precautions. Missing Enhanced Barrier Precautions signage on the door, missing isolation cart near the resident's door. Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Activities Director will be in-serviced about activities care-plans and documentation for activities participation. - Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Assist Dependent Residents During Meals
Penalty
Summary
The facility failed to provide necessary assistance during dining for two residents who were dependent on staff for their Activities of Daily Living (ADL). Resident #1, who was assessed as needing partial assistance with eating, was observed multiple times without staff assistance during meals. On several occasions, Resident #1's meal trays were left untouched or barely consumed, indicating a lack of support from staff. Despite the resident's need for help, staff were not present to assist with eating, resulting in the resident consuming only a small portion of their meals. Similarly, Resident #275, who also required partial assistance during meals, was not adequately supported. The resident's assessment indicated a need for observation and assistance to complete meals, yet the facility did not provide the necessary support. Interviews with staff confirmed that both residents required assistance during mealtimes, but the facility failed to ensure staff were available to help, leading to deficiencies in maintaining proper nutrition and hydration for these residents.
Plan Of Correction
F677 ADL CARE PROVIDED FOR DEPENDENT RESIDENTS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #1, having multiple meals where trays were not set up for the resident to eat. The resident ate minimal at all the observed meals. Nursing staff will be in-serviced to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. 2) In the allegation of Resident #275, needing help and encouragement during meals. Nursing staff will be in-service to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - In-service will be conducted with nursing staff to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. - In-service will be conducted with nursing staff to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide an ongoing activities program tailored to the preferences of a resident, identified as Resident #12. The resident's clinical record lacked a written activities care plan, despite the resident expressing preferences for certain activities such as going outside for fresh air and participating in religious services. The resident reported feeling lonely and mentioned that her workbook was lost during a room transfer, which the facility staff could not locate. The Activities Director (AD) admitted to not documenting one-on-one activities or visits, and although the AD claimed to engage with the resident, there was no written evidence to support these interactions. Interviews with the resident and the AD revealed inconsistencies in the activities provided. The AD stated that she conducted one-on-one room visits and offered activities like makeup sessions and reading, but the resident contradicted this by stating that her makeup was only done once. The AD also mentioned that the resident received visits from church friends and was brought to music events, but did not provide magazines or other requested items because the resident had not explicitly asked for them. The lack of documentation and a formal care plan for activities was acknowledged by the facility's Administrator, who noted that if it is not documented, it is considered not done.
Plan Of Correction
F679 ACTIVITIES MEETS INTEREST/NEEDS EACH RESIDENT 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of resident #12, and 1 on 1 activities in room visits not being documented. The Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. Random QA audits will be conducted by the Administrator or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Administrator or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Administrator a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Medication and Equipment Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for three residents. Resident #73 did not receive timely medication administration, with six medications given late by up to an hour and forty-two minutes. Additionally, the resident's Pleur-X tube was not drained as ordered, leading to the resident expressing distress and concern for his health. Interviews with staff revealed a lack of awareness and documentation regarding the Pleur-X drainage, and the attending physician was not informed of the missed drainage. Resident #481 also experienced late medication administration, with medications given late on eight occasions, up to two hours and twenty-nine minutes past the scheduled time. The resident confirmed receiving medications late and expressed awareness of the medication names. Interviews with staff and the consultant pharmacist acknowledged the potential detriment of late medication administration, though not life-threatening. Resident #46 did not have an abduction pillow in place as ordered by the physician. Observations revealed the resident in bed without the required pillow, and interviews with staff indicated a lack of knowledge about the abduction pillow's presence or use. The MDS Coordinator and Unit Manager were unaware of the missing pillow, and staff used regular pillows instead. The resident's care plan included the use of adaptive equipment, but this was not implemented, leading to the deficiency.
Plan Of Correction
QUALITY OF CARE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #73, and the Pleur-X not being drained on its schedule. And not following medication administration times of an hour prior or an hour post scheduled administration times. The Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. The Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 2) In the allegation of Resident #481, having not received multiple medication at their prescribed times. Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 3) In the allegation of Resident #46, and the resident's abduction pillow not being used. Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. - Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. - Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Provide Timely and Adequate Nutritional Support
Penalty
Summary
The facility failed to initiate timely nutritional interventions for Resident #475, who was admitted with acute failure and other conditions. Upon admission, there was no completed Minimum Data Set, and the resident did not have a feeding order until 20 hours later. Observations revealed that the resident was lying in bed with a feeding tube improperly managed, as it had no cover or cap and was merely clamped off. The resident expressed hunger and discomfort, indicating a lack of adequate nutrition. Staff interviews confirmed that the resident had not received the prescribed nutrition in a timely manner, and there was a delay in obtaining necessary physician orders. Resident #109 was readmitted with severe protein-calorie malnutrition and required Jevity 1.5 formula at a specific rate to meet nutritional needs. However, observations showed discrepancies in the administration of the formula, with significantly less being delivered than ordered. The formula was not running as expected, and the volume administered was far below the prescribed amount. Staff interviews and observations confirmed that the formula was not being administered correctly, leading to inadequate nutritional support for the resident. Both cases highlight the facility's failure to follow physician orders and provide appropriate nutritional care. The lack of timely intervention and adherence to prescribed feeding regimens resulted in residents not receiving the necessary nutrition, potentially impacting their health and recovery. The facility's processes for managing feeding orders and ensuring proper nutrition were inadequate, as evidenced by the observations and staff interviews.
Plan Of Correction
MGMT/RESTORE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #475, and the facility not receiving an order for almost 20 hours. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 2) In the instance of Resident #109, not for almost 22 hours and the tube-feeding not running at proper rate. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Pharmaceutical Services Deficiency in Medication Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the accurate dispensing and administration of controlled drugs for three residents. For Resident #487, there was a discrepancy between the Medication Monitoring/Control Record and the Medication Administration Record (MAR), where a 5mg medication was documented as removed from the medication cart but not recorded as administered. Similarly, for Resident #28, a 5mg capsule was signed out as removed but not documented as administered on the MAR. These discrepancies indicate a lack of proper documentation and reconciliation of controlled substances. For Resident #82, the situation was reversed; the medication was documented as administered on the MAR but not signed out as removed from the medication cart. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) Unit Manager revealed that the Unit Managers are responsible for auditing the medication reconciliation of controlled substances. However, the LPN Unit Manager admitted to conducting these audits more frequently than required, yet the discrepancies persisted, indicating a failure in the system of records and reconciliation for controlled drugs.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #487, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2) In the allegation of Resident #28, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 3) In the allegation of Resident #82, the resident's medication was not signed out but was documented as administered. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Meet Resident Dietary Preferences
Penalty
Summary
The facility failed to meet the dietary preferences and needs of two residents, leading to a deficiency in providing food that accommodates resident preferences. Resident #66, who has a moderate cognitive impairment as indicated by a Brief Interview of Mental Status score of 11, was observed during two separate dining occasions to have discrepancies between the meal ticket and the food served. On one occasion, the resident's meal did not include mashed potatoes as requested, and the soft cooked parslied potatoes had skin, which the resident did not want. On another occasion, the resident's meal was missing the ground beef cubes in gravy that were listed on the meal ticket. Similarly, Resident #57, who has no cognitive impairment as indicated by a Brief Interview of Mental Status score of 15, experienced a discrepancy in their meal service. The resident's meal ticket included a large salad with chicken and a Kens salad, neither of which were provided on the tray. The dietary manager/director of food services acknowledged the issue, stating that there are two checkpoints in place to ensure meal tickets match the trays, but these were not effective in preventing the errors observed.
Plan Of Correction
F806 RESIDENT, PREFERENCES, SUBSTITUTES 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #66, not meeting the residents' preference for food, the resident's tray tickets did not match the food on the tray. Dietary staff will be in-serviced to follow the tray tickets. 2) In the allegation of Resident #57, not meeting the residents' preference for food, the resident's tray tickets did not match the food on the tray. Dietary staff will be in-serviced to follow the tray tickets. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Dietary staff will be in-serviced to follow the tray tickets. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Dietary Manager or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Deficient Nurse Call System Maintenance
Penalty
Summary
The facility failed to maintain its nurse call system in accordance with NFPA 99 standards. During a fire safety tour conducted on March 19, 2025, between 12:55 PM and 2:25 PM, it was observed that the nurse call systems in both the Galilee and Masada wings were deficient. Specifically, the Galilee wing had two corridor lights that did not illuminate, and the Masada wing had three corridor lights that failed to illuminate when tested. These observations were made in the presence of the Maintenance Director, who acknowledged the deficiencies. The findings were subsequently reviewed with both the Administrator and the Maintenance Director during the exit conference on the same day at 3:15 PM.
Plan Of Correction
K900 NFPA 99 HEALTH CARE FACILITIES CODE OTHER 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation that the Galilee wing nurse call system having two corridor lights that were allegedly not illuminating and the Masada wing nurse call system having three corridor lights that were allegedly not illuminating. The maintenance staff will check those nurse call light corridor lights allegedly not working and do any necessary repairs to ensure they are illuminating properly. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will check those nurse call light corridor light allegedly not working and do any necessary repairs to ensure they are illuminating properly. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25
Failure to Maintain Essential Electrical System
Penalty
Summary
The facility failed to maintain the Essential Electrical System (EES) in accordance with NFPA 99 standards. During a fire safety tour conducted on March 19, 2025, it was observed that the facility did not have a supply of generator replacement parts for high mortality items on the premises. This deficiency was identified in the presence of the Maintenance Director, who acknowledged the findings during the inspection. The lack of generator replacement parts was discussed with both the Maintenance Director and the Administrator during the exit conference on the same day. The report cites specific sections of NFPA 99, NFPA 101, and NFPA 110 that were not adhered to, indicating a failure to comply with the required maintenance and testing protocols for the facility's essential electrical systems.
Plan Of Correction
K918 NFPA 99 ELECTRICAL SYSTEMS -- ESSENTIAL ELECTRICAL SYSTEM 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the facility not having a supply of generator parts for high mortality items on premises. Maintenance staff will obtain and keep on site generator parts that have a high mortality rate. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will obtain and keep on site generator parts that have a high mortality rate. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K918 ELECTRICAL SYSTEMS - ESSENTIAL ELECTRICAL SYSTEM 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the facility not having a supply of generator parts for high mortality items on premises. Maintenance staff will obtain and keep on site generator parts that have a high mortality rate. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will obtain and keep on site generator parts that have a high mortality rate. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25
Non-compliance with NFPA 101 Egress Door Standards
Penalty
Summary
The facility failed to maintain egress doors equipped with special locking arrangements in accordance with NFPA 101 standards. During a fire safety tour, it was observed that the Main Entrance double exit doors, which were equipped with a delayed egress special locking arrangement, were missing the required signage from both leaves. This lack of signage is a violation of the safety standards as it is essential for ensuring that individuals can identify and understand the function of the delayed egress system in an emergency. Additionally, the Dining Room Patio exit screen door was found to be locked at the latch and with a slide lock located 48 inches above the finished floor. This door had multiple locks engaged, and there was no documentation provided to indicate that the local authority had approved a clinical needs or security special locking arrangement for this setup. The presence of multiple locks without proper authorization or documentation is a breach of the regulations, which typically allow only one locking device unless specific conditions are met. Furthermore, the Rehabilitation double emergency exit doors, also equipped with a delayed egress special locking arrangement, were found to be locked with a hook deadbolt lock. This additional locking mechanism is not compliant with the standards for delayed egress systems, which are designed to allow for safe and timely evacuation. The Maintenance Director acknowledged these findings during the observations, and the issues were reviewed with both the Administrator and the Maintenance Director at the exit conference.
Plan Of Correction
K K222 NFPA 101 EGRESS DOORS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Main Entrance double doors equipped with delayed egress special locking arrangements, not having the required signage on both doors. Maintenance has installed new signage on both of the front doors. 2) In the allegation of the Dining Room patio exit screen door having multiple locks on it. Maintenance has removed the extra lock and there is currently only one. 3) In the allegation of the Rehabilitation double emergency exit doors equipped with delayed egress special locking arrangements being locked with a hook deadbolt lock. Maintenance has disengaged the hook deadbolt lock. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance Director or designee will ensure that proper signage on the Main Entrance double doors is on those doors. - Maintenance Director or designee will ensure that there is only one lock on the Dining Room Patio exit door. - Maintenance Director or designee will ensure that hook deadbolt lock on the Rehabilitation double emergency exit doors is disengaged. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 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. K222 EGRESS DOORS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Main Entrance double doors equipped with delayed egress special locking arrangements, not having the required signage on both doors. Maintenance has installed new signage on both of the front doors. 2) In the allegation of the Dining Room patio exit screen door having multiple locks on it. Maintenance has removed the extra lock and there is currently only one. 3) In the allegation of the Rehabilitation double emergency exit doors equipped with delayed egress special locking arrangements being locked with a hook deadbolt lock. Maintenance has disengaged the hook deadbolt lock. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance Director or designee will ensure that proper signage on the Main Entrance double doors is on those doors. - Maintenance Director or designee will ensure that there is only one lock on the Dining Room Patio exit door. - Maintenance Director or designee will ensure that hook deadbolt lock on the Rehabilitation double emergency exit doors is disengaged. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.
Deficiency in Maintaining Commercial Cooking Facility
Penalty
Summary
The facility failed to maintain their commercial cooking facility in accordance with NFPA 101 standards. During a fire safety tour, it was observed that two gas-powered cooking appliances, a steamer and an oven, located on the dairy side of the kitchen, were on castors without any means to prevent strain on the gas connection. This deficiency was identified for 2 out of 3 sampled gas-powered cooking appliances. The observation was made on March 19, 2025, at 12:33 PM, during a tour with the Maintenance Director. The Maintenance Director acknowledged the findings during an interview conducted concurrently with the observations. The findings were subsequently reviewed with both the Administrator and the Maintenance Director at the exit conference held on the same day at 3:15 PM. Photographic evidence was obtained to support the findings.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the two gas powered appliances on the dairy side of the kitchen, a steamer and an oven, on castors without the means to prevent strain on the gas connection. Maintenance has added restraints to the steamer and the oven to keep them from moving and putting strain on the gas connection. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance Director or designee will put proper restraints on the gas powered steamer and oven on the dairy to keep them from putting strain on the gas connection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K324 COOKING FACILITIES 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the two gas powered appliances on the dairy side of the kitchen, a steamer and an oven, on castors without the means to prevent strain on the gas connection. Maintenance has added restraints to the steamer and the oven to keep them from moving and putting strain on the gas connection. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance Director or designee will put proper restraints on the gas powered steamer and oven on the dairy to keep them from putting strain on the gas connection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.
Fire/Smoke Barrier Deficiency
Penalty
Summary
The facility failed to maintain their fire/smoke barrier construction in accordance with NFPA 101 standards. During a fire safety tour conducted on March 19, 2025, with the Maintenance Director, surveyors observed penetrations in the fire/smoke barriers at two locations within the facility. Specifically, at 12:52 PM, a penetration was found through both sides of a 2-hour fire-rated wall in the Galilee wing near Room 233. Additionally, at 2:09 PM, another penetration was identified through both sides of a smoke wall in the Masada wing near Room 127. The Maintenance Director acknowledged these findings during the tour, and the observations were reviewed with both the Administrator and the Maintenance Director at an exit conference later that day. The report notes that these examples are not exhaustive, suggesting that other unprotected penetrations may exist within the facility's fire/smoke barriers. It emphasizes the importance of conducting a thorough inspection of each barrier along its full length and height to ensure all penetrations are identified and properly sealed. The report underscores the necessity of maintaining the integrity of fire and smoke barriers to restrict the movement of fire and smoke, thereby ensuring the safety of the facility's occupants in the event of a fire emergency. It specifies that any breaches in fire-rated barriers must be repaired using a UL-listed approved system to restore the original fire or smoke-rated integrity of the walls, ceilings, or floors involved.
Plan Of Correction
NFPA 101 SUBDIVISION OF BUILDING SPACES SMOKE BARRIER 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Galilee wing, near room 233 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2) In the allegation of the Masada wing, near room 127 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will seal the alleged penetration in the smoke walls with Red Fire caulk. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K372 SUBDIVISION OF BUILDING SPACES-SMOKE BARRIER 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Galilee wing, near room 233 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2) In the allegation of the Masada wing, near room 127 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will seal the alleged penetration in the smoke walls with Red Fire caulk. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.
Improper Use of Power Strips and Lack of GFCI Protection
Penalty
Summary
The facility was found to have several deficiencies related to the improper use of power strips and the lack of ground-fault circuit-interrupter (GFCI) protection during a fire safety tour conducted on March 19, 2025. Observations revealed that power strips were improperly used in multiple areas, including the Reception desk and the Telecommunication Room, where power strips were plugged into other power strips instead of directly into wall receptacles. Additionally, in the Service Corridor, one of the vending machines lacked GFCI protection, which is a requirement for safety. Further deficiencies were noted in resident rooms, where televisions were plugged into power strips within six feet of the patient care area, which is against the regulations for patient care vicinities. These observations were made in Rooms 122, 123, 128, and 104. The Maintenance Director acknowledged these findings during the tour, and the issues were reviewed with both the Administrator and the Maintenance Director at the exit conference.
Plan Of Correction
K920 NFPA 99 ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENSION CORDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Reception Desk using power strip and not plugging directly into the wall receptacle. Maintenance staff will remove the power strip and plug items directly into the wall receptacle. 2) In the allegation of the Telecommunication Room using power strip and not plugging directly into the wall receptacle. Maintenance staff will remove the power strip and plug items directly into the wall receptacle. 3) In the allegation of the Service Corridor having a vending machine without GFCI protection, maintenance will add GFCI protection for that vending machine. 4) In the allegation of Room 122 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 5) In the allegation of Room 123 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 6) In the allegation of Room 128 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 7) In the allegation of Room 104 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance will ensure that power strips are not being used where they should not be used and items are plugged directly into the wall receptacle. - Maintenance will ensure that items that need GFCI protection have GFCI protection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K920 ELECTRICAL EQUIPMENT...POWER CORDS AND EXTENSION CORDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Reception Desk using power strip and not plugging directly into the wall receptacle. Maintenance staff will remove the power strip and plug items directly into the wall receptacle. 2) In the allegation of the Telecommunication Room using power strip and not plugging directly into the wall receptacle. Maintenance staff will remove the power strip and plug items directly into the wall receptacle. 3) In the allegation of the Service Corridor having a vending machine without GFCI protection, maintenance will add GFCI protection for that vending machine. 4) In the allegation of Room 122 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 5) In the allegation of Room 123 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 6) In the allegation of Room 128 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 7) In the allegation of Room 104 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance will ensure that power strips are not being used where they should not be used and items are plugged directly into the wall receptacle. - Maintenance will ensure that items that need GFCI protection have GFCI protection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25
Failure to Maintain Fire Sprinkler System Documentation
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system in accordance with NFPA 101 standards. During a record review conducted on March 19, 2025, between 10:00 AM and 2:00 PM, it was discovered that there was no documentation available for the 5-year hydrostatic test of the fire department connection (FDC) and the 5-year internal inspection of the fire-line backflow preventer. These deficiencies were identified during a review with the Maintenance Assistant, who acknowledged the findings. The issues were subsequently discussed with the Administrator and the Maintenance Director during the exit conference on the same day at 3:15 PM.
Plan Of Correction
K353 NFPA 101 SPRINKLER SYSTEM - MAINTENANCE AND TESTING 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of having no documentation for the FDC 5-year hydrostatic test. The Maintenance Director or designee will acquire the documentation of proof that the FDC 5-year hydrostatic test was completed. 2) In the allegation of having no documentation for the fire-line backflow preventer 5-year internal inspection. The Maintenance Director or designee will acquire the documentation of proof that the fire-line backflow preventer 5-year internal inspection was completed. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance Director or designee will ensure that there is proper documentation for the FDC 5-year hydrostatic test is up to date and available for inspection. - Maintenance Director or designee will ensure that there is proper documentation for the fire-line backflow preventer 5-year internal inspection documentation is up to date and available for inspection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25
Fire Extinguisher Obstructions and Installation Issues
Penalty
Summary
The facility failed to comply with NFPA 101 standards for portable fire extinguishers, as evidenced by observations made during a fire safety tour. Specifically, three out of twelve sampled portable fire extinguishers were not installed or maintained correctly. At 12:00 PM, a class ABC fire extinguisher in the Telecommunication Equipment Room was obstructed by equipment, and at 12:02 PM, the same room lacked a clean agent fire extinguisher. Additionally, at 12:55 PM and 1:22 PM, fire extinguishers near Rooms 203 and 209 were obstructed by carts, respectively. These deficiencies were confirmed through an interview with the Maintenance Director, who acknowledged the findings during the tour. The issues were further discussed with the Administrator and the Maintenance Director at an exit conference. Photographic evidence was obtained to support these observations, and the facility's non-compliance with NFPA 10 and NFPA 101 standards was documented.
Plan Of Correction
K355 NFPA 101 PORTABLE FIRE EXTINGUISHERS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of ABC fire extinguisher in the Telecommunication Equipment Room being obstructed by equipment. Maintenance has moved items around to ensure that the ABC fire extinguisher is unobstructed. 2) In the allegation of the Telecommunications room not having a clean agent fire extinguisher. Maintenance will place a clean agent fire extinguisher in the Telecommunication room. 3) In the allegation of the fire extinguisher near room 203 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 4) In the allegation of the fire extinguisher near room 209 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will ensure that in the Telecommunication room that the ABC fire extinguisher is not obstructed. Maintenance will put a clean agent fire extinguisher in the Telecommunication room. Maintenance will in-service staff not to place carts in front of fire extinguishers. Maintenance will ensure that carts are not placed in front of fire extinguishers during rounds. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K355 PORTABLE FIRE EXTINGUISHERS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of ABC fire extinguisher in the Telecommunication Equipment Room being obstructed by equipment. Maintenance has moved items around to ensure that the ABC fire extinguisher is unobstructed. 2) In the allegation of the Telecommunications room not having a clean agent fire extinguisher. Maintenance will place a clean agent fire extinguisher in the Telecommunication room. 3) In the allegation of the fire extinguisher near room 203 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 4) In the allegation of the fire extinguisher near room 209 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will ensure that in the Telecommunication room that the ABC fire extinguisher is not obstructed. Maintenance will put a clean agent fire extinguisher in the Telecommunication room. Maintenance will in-service staff not to place carts in front of fire extinguishers. Maintenance will ensure that carts are not placed in front of fire extinguishers during rounds. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.
Failure to Monitor and Document Pain Management
Penalty
Summary
The facility failed to monitor and record a resident's pain level as ordered and did not document the administration of pain medication for one of the sampled residents. The resident was admitted to the facility and had a comprehensive assessment indicating pain, with a care plan in place for pain management. Physician orders required the resident's pain level to be monitored and documented every shift. However, while the resident was monitored for pain, the pain level was not documented in the Medication Administration Record (MAR). Additionally, the Medication Monitoring/Control Record showed that Tramadol was removed for the resident on several occasions, but the MAR did not reflect that the medication was administered on those dates and times. These findings were confirmed during an interview with the Director of Nursing.
Failure to Administer IV Antibiotic as Ordered
Penalty
Summary
The facility failed to verify and administer an IV antibiotic, Vancomycin, for a resident upon admission. The hospital had sent a physician order for Vancomycin IV to be administered with each dialysis session until a specified date. However, this order was intended for Home Health Care and was not included in the discharge orders reconciled by the nurses upon the resident's admission to the facility. The Registered Nurse (RN) responsible for entering hospital orders into the facility's system did not include the Vancomycin IV order, as it was not part of the discharge orders. During a morning meeting involving the Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator, and Social Services, the Vancomycin order was not reviewed or clarified. The Social Services Coordinator noted that the order was intended for Home Health Care and not as a nursing order. Additionally, a Dialysis Center RN reported that the resident's spouse mentioned the need for Vancomycin IV during dialysis, but the on-duty nurse incorrectly stated that the resident was receiving oral Vancomycin. There was no evidence that the Vancomycin IV order was clarified with the physician or reviewed in the morning meeting, leading to a failure in administering the necessary medication.
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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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