Rehab & Healthcare Center Of Cape Coral
Inspection history, citations, penalties and survey trends for this long-term care facility in Cape Coral, Florida.
- Location
- 2629 Del Prado Blvd, Cape Coral, Florida 33904
- CMS Provider Number
- 105342
- Inspections on file
- 23
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rehab & Healthcare Center Of Cape Coral during CMS and state inspections, most recent first.
Multiple residents were found with call lights out of reach, including some who were unaware of their location or unable to summon help. Staff confirmed that call lights should be accessible, and some residents reported long wait times for assistance.
Three residents with significant medical needs did not receive scheduled showers or adequate personal hygiene care, as required by their care plans and facility policy. Documentation was incomplete or missing for multiple shifts, and staff interviews confirmed that care was not consistently provided or recorded, resulting in neglect of residents' hygiene needs.
A resident admitted with left-sided weakness following a stroke was evaluated for PT and OT, with orders for therapy six times per week. However, documentation and staff interviews confirmed that the resident did not receive any therapy sessions as ordered during their short stay, and was discharged to the hospital without receiving the required rehabilitative services.
The facility did not maintain its fire alarm system according to NFPA 101 standards, as 18 duct detectors were not tested during a biennial smoke detector sensitivity test. This was confirmed during a record review and staff interview with the Maintenance Director.
A facility failed to follow physician orders for a resident's tube feeding, as a nurse did not check tube placement or flush it before use. Additionally, two residents' medication administrations were not documented accurately, with missing entries in the MAR. An LPN also did not assess pain scores before administering PRN medications, relying instead on visual assessment, contrary to standard practice.
The facility failed to maintain proper infection control practices during care for two residents. Staff were observed not adhering to hygiene protocols, such as not sanitizing hands or changing gloves between tasks, and using unclean equipment during wound care and medication administration. These actions indicate lapses in infection prevention and control measures.
A deficiency was identified involving improper nursing practices and failure to schedule necessary medical appointments. An LPN failed to flush a feeding tube as required, evidenced by a dry syringe found unused. Additionally, a resident with a new medical device was not scheduled for a necessary specialist appointment due to a breakdown in communication and procedure.
The facility failed to maintain a safe and homelike environment due to damaged drywall and chair rails in several resident rooms, which were not repaired despite being reported. The absence of a full-time Maintenance Director for several months contributed to the oversight, as the damage was not documented in the maintenance system.
The facility failed to maintain personal hygiene for several residents, including those with dementia, quadriplegia, and under hospice care. Residents were observed with unkempt appearances, long fingernails with substances underneath, and requests for care that were not promptly addressed. Scheduled showers and personal hygiene care were not consistently documented or provided, indicating a systemic issue in adhering to care plans.
The facility's medication error rate was 13.79%, exceeding the acceptable threshold. Errors included a nurse administering incorrect Lidocaine patch strength, wrong allergy medication, and incorrect Venlafaxine dosage to a resident. Another nurse gave a resident double the prescribed dose of Torsemide. Both nurses acknowledged their errors.
Two residents in a facility were subject to improper infection control practices during wound care. One resident, with pressure wounds and on Enhanced Barrier Precautions, did not have the required gown worn by staff during care. Another resident, with a surgical wound and pressure injury, experienced lapses in aseptic technique by an RN, including using a contaminated wound cleanser and failing to perform hand hygiene. These actions were against the facility's infection control policies.
The facility failed to document nursing staff's response to changes in condition for two residents, leading to deficiencies in care. One resident experienced multiple instances of reported changes, such as increased assistance needed and shortness of breath, without documented nursing evaluations. Another resident requested hospital transfer due to nausea and vomiting, but the nurse did not contact the physician or document an assessment, leading to a delayed transfer. Both cases highlight a failure in addressing and documenting changes in residents' conditions.
The facility failed to maintain a safe and homelike environment due to drywall damage and broken chair rails in several resident rooms. A resident reported the damage had been present for months without repair. The facility lacked a full-time Maintenance Director for several months, and the new Maintenance Director confirmed the damage was not documented in the maintenance system as required.
The facility failed to document and address changes in health conditions for two residents, leading to deficiencies in care. One resident's condition worsened without proper nursing evaluation or emergency response, while another's request for hospital transfer was ignored by a night shift nurse. Additionally, several residents did not receive adequate personal hygiene care, with observations of unkempt hair and overgrown nails. Staff interviews revealed a lack of communication and documentation regarding care refusals.
A resident with a history of smoking and contractures was unable to smoke due to the facility's failure to provide a specialized chair for transport to the smoking area. This led to significant anxiety and withdrawal symptoms for the resident, as the necessary equipment was not available and the smoking evaluation was delayed. Staff interviews revealed a lack of awareness and communication regarding the resident's needs.
A facility failed to create a comprehensive care plan for a resident with significant medical conditions, including contractures in the lower extremities and left hand. Despite the resident being on hospice and having intact cognitive skills, the care plan lacked interventions such as range of motion exercises or the use of splints and pillows. Interviews with staff revealed a lack of documentation and awareness of the resident's needs, and no restorative program was in place to address the contractures.
A facility failed to provide necessary care for a resident with contractures and ROM limitations. Despite the resident's history of hemiplegia and muscle wasting, and being on hospice, there was no care plan addressing these issues. Observations showed the resident in a fetal position without splints or positioning aids, and staff interviews revealed a lack of documentation and awareness. The facility's restorative program was not implemented, and staff lacked education on managing ROM and contractures.
A resident with an indwelling urinary catheter received improper care, as a CNA used incorrect cleaning techniques, wiping from back to front, contrary to facility protocols. Despite previous training, the CNA's actions were initially praised by the DON, who later admitted the care was inadequate, risking infection.
A resident with a feeding tube was found without the required abdominal binder, which was ordered by the physician to prevent the resident from pulling out the tube. Despite the binder being unavailable due to laundry, nursing staff inaccurately documented its application in the Treatment Administration Record. This discrepancy between the physician's orders and the care provided led to a deficiency.
The facility failed to change IV dressings every 7 days for two residents, as required by policy, risking infection. Observations showed outdated dressings, and MARs inaccurately documented changes. Staff confirmed the lapses, with no evidence of resident refusal.
The facility failed to adhere to physician orders for several residents, resulting in deficiencies. A resident was without a required binder, leading to exposure and leakage at a medical site. Another resident received incorrect medication due to a nurse's misunderstanding of medication orders. Additionally, two residents had outdated medical device covers, contrary to physician instructions. The Director of Nursing confirmed these failures and incorrect documentation.
A facility failed to develop a comprehensive care plan for a resident with significant medical conditions, including limitations in range of motion (ROM). The care plan did not address the resident's needs or preferences, and there was no documentation of interventions or use of supportive devices. Interviews with staff revealed a lack of awareness and documentation regarding the resident's needs, and the absence of a restorative program was noted.
The facility failed to maintain its fire alarm system according to NFPA 101 standards. An annual report revealed that 8 of 12 duct detectors were untested due to being unlocatable, and batteries needed replacement. The smoke detector sensitivity inspection was outdated, and the duct detector air stream test was last conducted months prior. The administrator acknowledged these issues, indicating a need for updated testing by their vendor.
The facility failed to conduct fire drills as required by NFPA 101, with altered dates found on fire drill records. The Maintenance Director, new to the facility, did not conduct the drills prior to the survey. The Administrator acknowledged the alterations and planned further investigation. This deficiency could lead to unprepared staff in a fire emergency.
The facility failed to conduct timely inspections and testing of fire doors and fire and smoke dampers as required by NFPA 80 standards. The last maintenance reports for fire and smoke dampers were over four years old, and the fire door inspection report was outdated. The Director of Maintenance acknowledged a backlog in maintenance tasks. This deficiency could lead to the failure of fire and smoke dampers during fire conditions, affecting all smoke compartments and posing a risk to the safety of the facility's occupants.
The facility failed to document post-disaster analysis for one of its required drills, omitting an After Action Report (AAR) necessary for evaluating and improving its Emergency Preparedness Program. This gap was identified during a review, with the Administrator acknowledging the omission and indicating future compliance.
The facility failed to test electrical equipment according to NFPA 99 and NFPA 110 standards, with no records of main and feeder circuit breaker inspections and exercising. The Maintenance Director, new to the facility, acknowledged the lack of documentation. This deficiency could lead to power loss, equipment fires, or electric shock hazards, endangering the facility's occupants.
The facility's Emergency Preparedness Program was found deficient as it included outdated staff information, risking resident safety during emergencies due to potential lack of medical and support staffing.
The facility's Emergency Preparedness Program failed to include a method for sharing occupancy information with authorities, potentially leaving receiving facilities without necessary information for resident transfers. The EP referenced the ESS website, but the Administrator noted plans to update it to use the 'HFRS' resource.
The facility failed to ensure a safe, clean, and comfortable environment for residents, with observations of live insects, damaged flooring, and unclean ice machines. Staff and residents reported frequent sightings of roaches and ineffective extermination efforts. The Administrator and Regional Director of Maintenance were unaware of the extent of the issues, and there was a lack of documentation for cleaning and maintenance tasks.
The facility failed to provide necessary hygiene care for three residents who required assistance with ADLs. One resident did not receive scheduled showers in March and April 2024, another did not receive any scheduled showers during her stay from October to November 2023, and a third resident did not receive any scheduled showers from late April to early May 2024. CNA documentation was inconsistent, and there was no clear policy or responsibility for ensuring showers were completed.
The facility failed to maintain an effective pest control program, resulting in frequent sightings of large roaches and other insects in resident rooms and common areas. Residents and staff reported ongoing issues, and the pest control measures in place were found to be inadequate.
A resident's grievances about broken furniture and a frayed call light were not addressed by the facility. Despite multiple reports and work orders, the issues remained unresolved for several months. The Regional Director of Maintenance and the Administrator confirmed the deficiencies but admitted to a lack of follow-up and oversight.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of residents' needs by not providing call lights within reach for nine of eighteen sampled residents. During an initial tour, multiple residents were observed in their rooms with call lights either hooked to glove racks behind the bed, on the floor, or otherwise out of reach. Some residents were unaware of the location of their call lights, while others were observed calling out for help or unable to summon assistance due to the call light's placement. Photographic evidence was obtained for several rooms, confirming the call lights were not accessible. Staff interviews corroborated these findings, with a registered nurse acknowledging that call lights should be within residents' reach. Several residents reported not knowing where their call lights were or described long wait times for assistance, sometimes up to an hour. The deficiency was observed across multiple rooms and affected both residents who could communicate and those who could not respond to interview questions.
Failure to Provide Scheduled Showers and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for three of five sampled residents, resulting in neglect as defined by facility policy. For one resident with a history of cerebral vascular accident and chronic kidney disease, documentation did not show that scheduled showers or personal hygiene assistance were provided as required, with several shifts lacking any record of care. Another resident with alcohol abuse, dementia, and multiple sclerosis was observed with poor oral hygiene and reported not remembering the last time he had a shower, with documentation failing to confirm that scheduled showers were given and several days lacking any record of personal hygiene care. A third resident, dependent on dialysis and with multiple comorbidities, stated he had only received four showers in two years and preferred showers over bed baths, but documentation did not show that scheduled showers were provided on multiple occasions. Staff interviews confirmed that showers are scheduled and should be documented, and that refusals should be recorded with alternative care provided. However, there was no evidence that refusals were consistently documented or that care plans were updated accordingly. The facility lacked a specific policy on ADL care, relying only on documentation instructions for CNAs. These failures resulted in residents not receiving scheduled showers or adequate personal hygiene, as required by their care plans and facility policy.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required by the plan of care for a resident who had been admitted with a diagnosis of cerebral vascular accident resulting in left hemiparesis. The resident's care plan included orders for both Occupational Therapy (OT) and Physical Therapy (PT), with specified goals and a frequency of six times per week for eight weeks. Documentation showed that the resident was evaluated by both PT and OT, but there was no evidence that the resident received any therapy sessions as ordered during their short stay. Notes indicated that therapy was withheld or that the resident did not participate, and the resident was ultimately discharged to the hospital after only a few days in the facility. Interviews with facility staff, including the Rehab Director, confirmed that while evaluations were completed, there was no documentation of actual therapy sessions being provided. The Rehab Director was unable to locate any additional therapy notes and stated that the resident did not receive therapy due to the brief duration of their stay. Family members also reported that the resident did not receive therapy during their time at the facility.
Failure to Test Duct Detectors in Fire Alarm System
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with the National Fire Protection Association (NFPA) 101 standards. During a revisit survey, it was found that the biennial smoke detector sensitivity test, conducted on 56 devices on February 26, 2025, did not include the testing of 18 duct detectors. This oversight was confirmed during a record review and staff interview with the Maintenance Director, who acknowledged the findings. The deficiency highlights the facility's failure to ensure the proper operation of the fire alarm system, which is crucial for preventing delayed alarm activation or failure under hazardous conditions. The lack of documentation for the testing of the duct detectors indicates a gap in the facility's compliance with the NFPA 101 and NFPA 72 standards, which could potentially lead to serious consequences in the event of a fire emergency.
Plan Of Correction
K345 Fire Alarm System Testing and Maintenance 1. The fire alarm inspection was conducted for sensitivity test on ducks and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on F345 B. Education with the maintenance department for K345 4. Monthly audits for K345 will be conducted and findings will be brought to QAPI. K345 Fire Alarm System Testing and Maintenance 1. The fire alarm inspection was conducted for sensitivity test on ducks and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on F345 B. Education with the maintenance department for K345 4. Monthly audits for K345 will be conducted and findings will be brought to QAPI.
Deficiencies in Medication Administration and Tube Feeding Practices
Penalty
Summary
The facility failed to ensure that physician orders were followed for a resident who required nutritional support through a feeding tube. During an observation, a registered nurse did not check the placement of the feeding tube, check for residuals, or flush the tube before starting the feeding. This was confirmed by interviews with the LPN and the Director of Nursing, who stated that it is standard nursing practice to flush the tube before and after use. The nurse involved was noted to have a language barrier and was reportedly nervous during the procedure. Additionally, the facility did not accurately document the administration of physician-ordered medications for two residents. The Medication Administration Record (MAR) for one resident showed missing documentation for several scheduled medications. Interviews with the Director of Nursing and the Unit Manager revealed that the nurse responsible for administering the medications did not document them due to being busy, although she confirmed that the medications were given. The facility's policy requires immediate documentation of medication administration, which was not adhered to in this case. Furthermore, during a medication pass observation, an LPN failed to ask two residents for their pain scores before administering as-needed medications. The MAR for these residents showed that pain scores were documented without actually being assessed. The LPN claimed familiarity with the residents allowed her to assess their pain visually, but this was not in line with standard practice, as confirmed by the visiting Director of Nursing. This lack of proper documentation and assessment was a recurring issue noted during the survey.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #2, 3, 4, 5, 6 were assessed with no negative outcomes noted. B. Competencies for medication administration were completed for current licensed nurses and any new licensed nurse hired. C. Feeding competencies were completed for current licensed nurses and any new licensed nurse hired. D. Licensed nurses will document the medication administration on the Medication Administration Record post-administration. Oncoming nurses will verify off-going nurses' Medication Administration Record report prior to taking report. If any discrepancy is noted, the Director of Nursing will be made aware immediately. E. Staff education on the components of F684; this education will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. A. The Director of Nursing/Designee will audit daily the Medication Administration Record to ensure no medications were missed the day prior and if any were missed that appropriate interventions were done. This audit will continue weekly for four weeks then monthly for one quarter. B. The Director of Nursing/Designee will do random audits of licensed nurses and feeding residents to ensure tube placement is checked prior to administration. This audit will continue weekly for four weeks then monthly for one quarter. C. The Director of Nursing/Designee will...
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices during wound care for two residents. During an observation, the Unit Manager and Director of Nursing (DON) were seen performing wound care on a resident without adhering to proper hygiene protocols. The DON retrieved a pair of scissors from a care cart without cleaning them and placed them on a clean barrier. The Unit Manager used these scissors to cut foam dressings for the resident's skin. Additionally, the DON handled a sock from the floor and placed it on the resident without changing gloves or performing hand hygiene before touching the clean dressing. In another instance, a Registered Nurse (RN) was observed preparing to administer medication via a feeding tube for a resident. The RN did not sanitize her hands before putting on gloves and continued to handle medication supplies after dropping them on the floor. She labeled a medication container and connected new tubing to the resident's feeding tube without changing gloves or sanitizing her hands throughout the process. The facility's lack of specific care policies and failure to adhere to existing infection control protocols contributed to these deficiencies. The observations revealed lapses in hand hygiene, improper handling of medical equipment, and inadequate use of personal protective equipment, which are critical components of infection prevention and control in a healthcare setting.
Plan Of Correction
F 880- Prevention & Control 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #1 and 6 have had no negative outcomes. 2: How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; A. A complete audit of residents with care and feeding was done to ensure appropriate orders and interventions are in place and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. The Director of Nursing and Unit Managers were educated on control and proper change procedure. B. License nurses were educated on proper feeding administration and change procedures/techniques. C. Competencies for changes are completed on current license nurses and will be completed on any new license nurses hired. D. Nursing Managers will do weekly rounds to ensure appropriate treatment and healing of is followed. E. Education of staff on the components of F880 this will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. A. The Director of Nursing/Designee will do random audits of care, and feeding administration to ensure proper procedure/techniques are being utilized weekly for four weeks then monthly for one quarter. B. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Deficiency in Nursing Practice and Medical Appointment Scheduling
Penalty
Summary
The deficiency involves improper handling and documentation of medical procedures and orders for residents in the facility. Staff D, an LPN, highlighted a failure to adhere to standard nursing practices, specifically regarding the flushing of feeding tubes. It was noted that a syringe, which should have been used for flushing, was found dry and unused in a Styrofoam cup, indicating that the procedure may not have been performed as required. This was corroborated by Staff F, another LPN, who confirmed that the standard practice is to flush the tube before and after use. The Director of Nursing attempted to address the issue by educating the involved nurse, who claimed to have flushed the tube, but the physical evidence suggested otherwise. Additionally, there was a failure in scheduling and documenting necessary medical appointments for a resident who had a new medical device placed prior to their arrival at the facility. Staff E, an RN, and Staff D, an LPN, both confirmed that there was no record of the resident being scheduled to see a specialist, despite an order being present in the resident's chart. This oversight was attributed to a breakdown in communication and procedure, as the medical records clerk was not informed of the need to schedule the appointment, and the order was not followed up on in a timely manner.
Plan Of Correction
4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. A. The Director of Nursing/Designee will audit daily the Medication Administration Record to ensure no medications were missed the day prior and if any were missed that appropriate interventions were done. This audit will continue weekly for four weeks then monthly for one quarter. B. The Director of Nursing/Designee will do random audits of licensed nurses and feeding residents to ensure tube placement is checked prior to administration of the medication. This audit will continue weekly for four weeks then monthly for one quarter. C. The Director of Nursing/Designee will do random audits of licensed nurses during medication administration to residents to ensure an accurate scale is obtained and documented. This audit will continue weekly for four weeks then monthly for one quarter. D. The Director of Nursing/Designee will submit a report of the findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Facility Fails to Maintain Safe and Homelike Environment Due to Maintenance Oversight
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for residents on Unit 1, as evidenced by damage to drywall and chair rails in 8 out of 31 rooms. Observations during an initial tour revealed that the drywall and chair-rails behind residents' beds in rooms 6, 9, 14, 18, 21, 35, 37, and 39 were damaged, with chair-rails found on the floor. Additionally, holes were observed in the drywall next to the bathroom doors in rooms 6, 9, 14, 21, and 39. A resident reported that the damage had been present for several months and that staff had been informed, but no repairs had been made. The facility had been without a full-time Maintenance Director for several months, and the newly hired Maintenance Director confirmed the damage during a tour. The Maintenance Director noted that the damage was not documented in the facility's maintenance computer system as required by their Work Orders policy. The Administrator confirmed the absence of a full-time Maintenance Director and acknowledged that the responsibilities of the Maintenance Director included ensuring minor repairs and supervising day-to-day maintenance to prevent deterioration of the facility's physical condition.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. # ,18,21,35,37,39 findings were fixed and addressed. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A. A Complete audit of all room was conducted, and findings were noted and put on a schedule to be completed. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. Staff was educated on the TELS system. B. Facility Maintenance department and the staff was educated on the components of F584. C. The Maintenance director will check the TELS system daily. D. During morning meeting any environmental concerns will be relayed. E. Department heads concierge rounds were added to report any environmental concerns. F. Education on the components of F584 will be provided annually and upon new hires. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Nursing Home Administrator/Designee will audit the Tels system for timely resolution of work orders along with random room rounds to ensure adequate safe environment is maintained weekly for four weeks then monthly for one quarter. The Nursing Home Administrator/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Maintain Personal Hygiene for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for several residents, as observed and documented in the report. Resident #24, who was readmitted with diagnoses including dementia and anxiety, required substantial assistance with personal hygiene. Despite this, the resident was observed with greasy, matted hair, long fingernails with a brown and black substance underneath, and a pungent body odor. The resident repeatedly requested a diaper change, but the call light was on the floor, and the request was not promptly addressed by the staff. Resident #69, diagnosed with quadriplegia and anxiety, was dependent on staff for showers and personal hygiene. The resident's fingernails were observed to be long with a brown substance underneath, and the resident expressed an inability to cut them himself. Despite the resident's dependency, there was no documentation of care being provided or refusals being recorded, indicating a lack of adherence to the care plan. Resident #72, who was under hospice care with severely impaired cognitive skills, required total assistance for ADLs. The resident was observed with unkempt appearance, facial hair growth, and long fingernails with a brown substance. Scheduled showers were not documented as provided, and refusals were not consistently recorded. Similarly, Resident #83, also under hospice care, was observed with greasy, matted hair, long fingernails, and a need for water and a change of clothes. The resident's refusals of care were not documented, and the staff failed to provide necessary hygiene care. Resident #271 expressed a desire for a shower and shave, but there was no documentation of care being provided or refusals being recorded, highlighting a systemic issue in maintaining personal hygiene for residents.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #24, grooming was completed, #69, nails were cut, #271, was shaved and showered, #72, was shaved and cut and clean, #83 was shaved, and were cut and cleaned. B. Rn staff J, CNA staff G, Unit Manager staff E, CNA staff C, CAN staff A, ADON, LPN staff W, Unit manager LPN staff M, CNA staff Q and CNA staff O were all educated on F677. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. A complete audit was done on all residents for proper grooming and ADL care and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Licensed staff was educated on the components of F677. B. Nursing managers will review POC documentation the following business day for any refusal and completion of ADL care and follow up as needed. C. Nursing managers will review 24-hour report for any refusal or care and follow up as needed. D. Licensed staff was educated on documentation of care provided and refusal of care. E. Concierge rounds will include resident appearance, and any abnormal findings will be brought to morning stand up for further follow up. F. Education on F677 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will audit the resident appearance and random audits of the 24-hour report and POC for documentation weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. F 677
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 13.79% during the observation of 29 medication administration opportunities involving five residents and four nurses. One significant error involved RN Staff R, who administered medications to a resident without adhering to the physician's orders. Specifically, RN Staff R applied Lidocaine patches with a 5% concentration instead of the prescribed 4%, administered Loratadine 10 mg without a physician's order instead of the prescribed Cetirizine 10 mg, and failed to administer the correct dosage of Venlafaxine, omitting the additional 37.5 mg required to meet the total prescribed dose of 112.5 mg. Another error was observed with RN Staff K, who administered Torsemide 10 mg to a resident instead of the prescribed 5 mg for the treatment of Congestive Heart Failure and edema. Both nurses acknowledged their errors during interviews, with RN Staff R expressing confusion between Loratadine and Cetirizine and not realizing the discrepancy in Lidocaine patch strength. These errors highlight a lack of adherence to physician orders and medication administration protocols, contributing to the facility's elevated medication error rate.
Plan Of Correction
A. License Nurses was educated on F759 documentation and medication administration. This education will be provided annually and upon new hire orientation. B. Nursing Managers will audit medication administration for any documentation of such as but not limited to not available, holes/blanks in the MAR, and ensure that appropriate follow-up was completed. C. Medication competency was completed for current license nurses and any new license nurse hired. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of license nurses during medication administration to ensure proper procedure/techniques is being utilized weekly for four weeks, then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for two residents, leading to deficiencies in infection prevention and control. Resident #53, who had a medical history of senile degeneration, dementia, weight loss, and pressure wounds, was on Enhanced Barrier Precautions (EBP) due to her condition. Despite the presence of signs indicating the need for gown and gloves, Licensed Practical Nurse (LPN) Staff M and Registered Nurse (RN) Staff L only used gloves during wound care, acknowledging afterward that gowns should have been worn as per the EBP policy. Resident #107, who was bedbound and dependent on staff for all activities of daily living, had a surgical wound and a stage 3 pressure injury. During wound care, RN Staff K failed to maintain aseptic technique by using a bottle of wound cleanser that had fallen on the floor, not changing gloves after touching personal items, and not performing hand hygiene between tasks. These actions were contrary to the facility's aseptic dressing change protocol, which requires hand hygiene and glove changes between different stages of wound care. The Director of Nursing and the Regional DON confirmed that the facility's policy required the use of gowns and gloves during wound care under EBP. The Assistant Director of Nursing also acknowledged that using a contaminated bottle of wound cleanser was unacceptable. These lapses in infection control practices placed the residents at risk for potential wound infections, as noted by RN Staff K during an interview.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #53 and Resident #107 had no negative outcome. B. LPN staff M, RN staff L, RN staff K, and evening supervisor staff B was educated on control and proper change procedure. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with care to ensure appropriate orders and interventions are in place and any abnormal findings was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License nurses was educated on proper change procedure/technique. B. Competency for change completed on current license nurses and will be completed on any new License nurse hire. Nursing managers to do weekly rounds to ensure appropriate treatment and healing of is followed. Education of staff on the components of F880 this will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of care to ensure proper procedure/techniques is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Document and Address Changes in Resident Conditions
Penalty
Summary
The facility failed to document nursing staff's response to reported changes in condition for two residents, leading to deficiencies in care. Resident #46 experienced multiple instances where staff observed and reported changes in his condition, such as increased assistance needed for transfers, shortness of breath, and confusion. Despite these observations, there was a lack of documented nursing evaluations or actions taken in response to these reports. The Director of Nursing acknowledged the absence of documentation and noted that the resident should have been assessed and the physician notified. Resident #66 also experienced a deficiency in care when she requested to be transferred to the hospital due to nausea and vomiting. Despite her request and symptoms, RN Staff X did not contact the physician or document an assessment. The resident's condition worsened, and she was eventually transferred to the hospital the following day after being seen by a practitioner. The Risk Manager was unaware of the incident until later, and RN Staff X was suspended pending investigation. Both cases highlight a failure in the facility's process for addressing and documenting changes in residents' conditions. The lack of timely nursing assessments and communication with physicians contributed to delays in appropriate care and interventions for the residents involved.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #66 and resident #46 are no longer in the facility. B. PTA staff F, COTA staff Y, LPN staff W, staff AA, CNA staff N, RN staff R, PTA staff Z, Evening supervisor RN staff B, RN staff X, LPN staff M was educated on F684. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A. A complete audit of residents with a change of condition and residents requesting to go to the hospital was completed and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Licensed nurses were educated on resident requests to be sent to the hospital and documentation of change in condition. B. Nursing managers will review the 24-hour report the following morning for any documentation of change in condition to ensure appropriate interventions were taken, including but not limited to sending the resident out to the hospital. C. All concerns of change in condition will be brought to the morning meeting for follow-up by the nurse management team. D. Licensed nurses will document and assess any concerns brought to them by any staff members regarding a change in condition, and they must notify the physician in a timely manner to obtain further interventions. If nurses are unable to get ahold of the physician, they can contact the medical director. In an emergent case, such as distress, licensed nurses will call 911 and have the resident sent to the hospital, then document entirely on the findings and interventions. E. Staff will use the INTERACT Stop and Watch program/form to relay any change in condition noted by any resident at the facility. A copy of the Stop and Watch form will also be brought to the morning clinical meeting to be reviewed by nurse managers/ADT to ensure appropriate measures were taken and followed. F. Staff education on the components of F684 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will audit the follow-up for any change of condition or request to go to the hospital to ensure timely assessment, documentation, and notification is obtained. The audit communication for change in condition will occur weekly for four weeks, then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance, and Compliance Committee monthly for one quarter.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment as required by regulations. Observations during an initial tour of Unit 1 revealed drywall damage and broken chair rails in several resident rooms, specifically rooms 18, 21, 35, 37, and 39. Holes were also noted in the drywall next to the bathroom doors in rooms 21 and 39. A resident reported that the chair rail molding behind beds had been damaged for several months and that staff had been informed, but no repairs had been made. The facility had been without a full-time Maintenance Director for several months, and the newly hired Maintenance Director confirmed the damage during a tour. The Maintenance Director also noted that the damage was not documented in the facility's maintenance computer system as required by their policy. The Administrator confirmed the absence of a full-time Maintenance Director and acknowledged the responsibility of the Maintenance Director to ensure minor repairs and day-to-day maintenance to prevent deterioration of the facility's physical condition.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. # 18,21,35,37,39 findings were fixed and addressed. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. A Complete audit of all room was conducted, and findings were noted and put on a schedule to be completed. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Staff was educated on the TELS system. B. Facility Maintenance department and the staff was educated on the components of F584. C. The Maintenance director will check the TEL.S system daily. D. During morning meeting any environmental concerns will be relayed. Department heads concierge rounds were added to report any environmental concerns. E. Education on the components of F584 will be provided annually and upon new hires. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Nursing Home Administrator/Designee will audit the Tels system for timely resolution of work orders along with random room rounds to ensure adequate safe environment is maintained weekly for four weeks then monthly for one quarter. The Nursing Home Administrator/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Deficiencies in Health Care and Personal Hygiene Documentation
Penalty
Summary
The facility failed to adequately document and address changes in the health conditions of two residents, leading to a deficiency in providing appropriate health care. For one resident, multiple staff members, including a Certified Occupational Assistant and a Physical Therapy Assistant, reported changes in the resident's condition, such as not feeling well and being unable to obtain clear vital signs. Despite these reports, there was a lack of documentation of a nursing evaluation or appropriate response, such as calling 911 when the resident's condition appeared critical. The Director of Nursing acknowledged the absence of documentation and the need for a proper assessment. Another resident requested to be transferred to the hospital due to feeling unwell, but the request was not acted upon by the night shift nurse, who failed to contact a physician or document an assessment. The resident expressed dissatisfaction with the care received and was eventually transferred to the hospital the following day after a practitioner deemed the resident medically unstable. The facility's risk manager was unaware of the incident until later, and the nurse involved was suspended pending investigation. Additionally, the facility did not maintain personal hygiene for several residents, as evidenced by observations of residents with long, unkempt hair, overgrown nails, and body odor. The facility's policy required showers twice a week, but documentation showed inconsistencies in providing scheduled showers and personal care. Staff interviews revealed a lack of communication and documentation regarding residents' refusals of care, contributing to the deficiency in maintaining personal hygiene.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A. #24. grooming was completed, #69, nails were cut, #271, was shaved and showered, #72, was shaved and cut and clean, #83 was shaved, and were cut and cleaned. B. Rn staff J, CNA staff G, Unit Manager staff E, CNA staff C, CAN staff A, ADON, LPN staff W, Unit manager LPN staff M CNA staff Q and CNA staff O were all educated on F677. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A. A Complete audit were done on all resident for proper grooming and adi care and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on the components of F677. B. Nursing managers will review POC documentation the following business day for any refusal and completion of ADL care and follow up as needed. C. Nursing managers will review 24-hour report for any refusal or care and follow up as needed. D. License staff was educated on documentation of care provided and refusal of care. E. Concierge rounds will include resident appearance, and any abnormal findings will be brought to morning stand up for further follow up. F. Education on F677 will be provided annually and upon new hire orientation. What systematic changes you will make to ensure that the deficient practice does not recur: A. License nurses was educated on resident request to be sent to the hospital and documentation of change in condition. B. Nursing managers will review 24 hour report the following morning for any documentation of change in condition to ensure appropriate interventions were taken including but not limited to sending the resident out to the hospital. C. is to bring all concerns of change in condition to the morning meeting for re follow up by the nurse management team. D. License nurses will document and assess any concerns brought to them by any staff members regarding a change in condition and they must notify physician in a timely manner to obtain further interventions and if nurses are unable to get ahold of the physician they can contact the medical director. If in an emergent case such as distress, or license nurses will call 911 and have resident sent to the hospital and then document entirely on the findings and interventions. E. Staff will use the interact stop and watch program/ form to relay any change in condition noted by any resident at the facility. A copy of the stop and watch form will also be brought to morning clinical meeting to be reviewed by nurse managers/IDT to ensure appropriate measures were taken and followed. F. Staff education on the components of F684 this education will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing /Designee will audit the follow up for any change of condition or request to go to the hospital to ensure timely assessment, documentation and notification is obtained and audit communication for change in condition weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Accommodate Resident's Smoking Needs
Penalty
Summary
The facility failed to accommodate the smoking needs and preferences of a resident who required a specialized chair for transport to the designated smoking area. The resident, who had a history of smoking and was not interested in a smoking cessation program, was unable to smoke due to the absence of the necessary equipment. This situation caused the resident significant anxiety and withdrawal symptoms, as she was unable to leave her room to smoke. The resident was admitted to the facility with a history of right cerebrovascular accident (CVA) with left side affected, hypertension, atrial fibrillation, and depression. Upon admission, it was noted that the resident had contractures and required a specialized chair for mobility. Despite this, the facility did not have the appropriate equipment available, and the resident's smoking evaluation was delayed. The resident expressed her distress and withdrawal symptoms to staff, but the issue remained unresolved for several days. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's needs. The Nursing Home Administrator and other staff members were not informed of the requirement for a specialized chair, and the resident's smoking evaluation was not completed in a timely manner. The facility's failure to provide the necessary equipment and support resulted in the resident's inability to smoke, leading to unnecessary anxiety and distress.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #470 was assessed, and appropriate chair was provided, smoking assessment completed. B. Education was given to CNA O, SSD, LPN W, Admission Director, Unit manager LPN M. C. Director of Rehab is no longer at the facility. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Audit of all current residents who want to smoke and who currently smokes was completed to ensure they are able to smoke and abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Education to staff regarding the components of F558. B. Nursing management is to review new admission the following business day to ensure resident who wants to smoke has accommodation to do so. C. Nursing managers will review 24 hour report for any documentation or changes to resident smoking preferences. D. Education for smoking accommodation and F558 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of nursing/Designee will audit the 24 hour report and review new smoking residents for accommodation and assessment weekly for four weeks then monthly for one quarter. The Nursing Home Administrator/Director of nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Develop Comprehensive Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident, identified as Resident #83, who was on hospice services and had significant medical conditions including hemiplegia, hemiparesis, anxiety, major depressive disorder, and muscle wasting. The resident was observed in a fetal position with contractures in his lower extremities and left hand, yet there were no splints or positioning devices in place to assist with his condition. Despite the resident's cognitive skills being intact, the care plan did not address the management of his contractures or include interventions such as range of motion exercises or the use of splints and pillows. Interviews with facility staff, including the Director of Rehab, Registered Nurse Staff B, the Director of Nursing, and Care Plan Coordinators, revealed a lack of documentation and awareness regarding the resident's contractures and the absence of a restorative program. The staff confirmed that there was no care plan addressing the resident's lower leg contractures, and no documentation of therapy or interventions for the resident's condition. The facility's failure to document and implement a care plan for the resident's contractures was evident, as staff were unaware of the resident's needs and there was no evidence of education provided to direct care staff on how to manage the resident's condition.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #83 care plan was updated to reflect resident current status. B. Education for F656 provided to RN staff B, care plan coordinator Staff L and Care plan coordinator RN staff H. C. Director of Rehab is no longer at the facility. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with contractors and limited ROM was conducted and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on the components of F656. B. Nursing management will review 24 hour report and follow up on any new limited ROM or contractors and update care plan as needed. C. All New residents will be reviewed and reassessed if needed and review by the IDT team the following business day for any limited ROM or contractors to ensure appropriate interventions are in place. D. Education on F656 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Care Plans /Designee will audit new residents chart and any change of condition charts to ensure that care plans are appropriate to reflect the status of the resident with emphasis on contractor or limited ROM weekly for four weeks then monthly for one quarter. The Director of Care Plans/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Address Contractures and ROM Limitations
Penalty
Summary
The facility failed to provide appropriate services and interventions for a resident with contractures and limitations in range of motion (ROM). The resident, a male with a history of hemiplegia, hemiparesis, anxiety, major depressive disorder, and muscle wasting, was on hospice services. Despite being identified as having limitations in ROM in both lower extremities and one upper extremity, the facility did not implement a care plan to address these issues. Observations revealed the resident in a fetal position with no splinting devices or positioning aids in place, and staff interviews confirmed a lack of documentation and awareness regarding the resident's contractures. The resident had previously been on and off therapy caseloads, but consistently refused evaluations and services. Occupational and physical therapy records indicated attempts to manage the resident's condition with splints and exercises, but these were met with resistance from the resident. Despite the resident's refusal, there was no documentation of these refusals or any alternative strategies to manage the contractures. Interviews with staff, including the Director of Rehab and the Director of Nursing, revealed a lack of communication and coordination in addressing the resident's needs. The facility's policy on Restorative Nursing Programs was not effectively implemented, as there was no restorative program in place, and staff had not received education on ROM, contractures, or splints. The care plan coordinator confirmed the absence of a care plan for the resident's lower leg contractures, and the Director of Nursing was unaware of the resident's condition. The lack of a coordinated approach and documentation contributed to the failure to provide necessary care for the resident's contractures and ROM limitations.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #83 was assessed, and care plan was updated. B. RN unit manager E, Hospice CNA, RN staff B, CNA staff C, care plan coordinator Staff 1, CNA staff A, RN care plan coordinator staff H was educated. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete audit of resident with Limited ROM and was completed any abnormal findings was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License staff was educated on the documentation of refusal of care, limited ROM and B. Nursing management will review 24-hour report for any refusal of care documentation and ensure and or contractor management are being followed and follow up with any concerns noted. C. Nurse managers will review POC (point of Care) documentation for any refusal or blanks and follow up as needed. D. Nurse Managers will review new admitted residents the following day for any limited ROM and or contractors and ensure appropriate interventions are in place. E. Education for F688 will be provided annually and upon new hire orientation. F. Resident will be screen upon admission and then quarterly by for any decrease in ROM or contractors and appropriate interventions and care plans will be put in place for those residents identified. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will audit identified residents with limited ROM or contractors to ensure adequate interventions are followed weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who had a history of recurrent urinary tract infections and was on antibiotics and prophylactic methenamine, was observed receiving improper catheter care. During the care, a CNA used soapy water from a hand soap dispenser and did not follow the correct procedure for cleaning, wiping from back to front instead of front to back, which is against the facility's protocol. The Director of Nursing initially praised the CNA's performance, but later acknowledged that the care provided did not adhere to the facility's guidelines, placing the resident at risk for infection. The CNA had previously completed competency training and attended an in-service on perineal and catheter care, yet failed to apply the correct techniques during the observed care session.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #107 has no complication with her. B. CNA staff BB and CNA staff CC was reeducated on F590 and care. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with to ensure appropriate interventions are in place and any abnormal findings were corrected. B. Audit of CNA competency for care completed and any abnormal findings was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on care. B. Competency for care was completed for current CNADs and will be obtained for any new hires. C. Education on F690 will be completed for staff, upon new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of care to ensure proper procedure/techniques is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Apply Abdominal Binder for Resident with Feeding Tube
Penalty
Summary
The facility failed to adhere to physician's orders regarding the use of an abdominal binder for a resident with a feeding tube, leading to a deficiency. Resident #26, who was readmitted to the facility with conditions including dysphagia and delusional disorders, had a history of pulling out her feeding tube. The physician's order required an abdominal binder to be in place to prevent the resident from pulling out the tube, with instructions to remove it only for skin integrity checks and feeding tube care every shift. However, during observations, the resident was found without the abdominal binder, and the feeding tube was exposed and leaking. Despite the absence of the abdominal binder, the Treatment Administration Record (TAR) was signed by nursing staff, indicating that the binder was applied as per the physician's order. Staff interviews revealed that the binder was unavailable as it was sent to the laundry, and alternative measures such as using a sheet were employed. The RN Unit Manager confirmed that the binder was not applied as ordered, and the documentation on the TAR was inaccurate. This discrepancy between the physician's orders and the actual care provided, along with inaccurate documentation, led to the deficiency identified in the report.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #26 binder use was corrected. B. RN staff K educated on documentation. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete audit of resident and any specialty device used for their tube was completed and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License Nurses was educated on documentation with emphasis on services not provided/physician orders not carried out and the process of documentation. B. Nurse Manager to review 24 hour report and order detail summary the following business day for any refusal or care, supplies not available and any new order for specialty equipment and follow up to ensure appropriate interventions were implemented. C. Staff was educated on the components of F693 and this education will be provided upon new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of resident and any specialty equipment used on their is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Change IV Dressings Timely
Penalty
Summary
The facility failed to ensure the timely change of short peripheral catheter cover dressings for two residents, leading to a potential risk of local and systemic infection. The policy for Vascular Access Devices and Infusion Therapy Procedures requires that short peripheral catheter dressings be changed every 7 days or when the integrity of the dressing is compromised. However, observations revealed that the dressing for one resident was dated 1/22, and for another resident, it was dated 1/31, both exceeding the 7-day requirement. The Medication Administration Records (MAR) for both residents inaccurately documented that the dressings were changed according to the schedule, despite evidence to the contrary. Interviews with staff, including an LPN Supervisor and the Director of Nursing (DON), confirmed that the dressings were not changed as per the physician's orders and facility policy. The DON acknowledged that the MARs were incorrect and that the nurses documented completion of dressing changes that were not performed. There was no documentation indicating that either resident refused the dressing changes, suggesting a lapse in adherence to the established protocols for IV catheter care.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #271 and #23 was changed. B. LPN staff V was educated on change. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with lines and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License Nurses was educated on changes. B. Nursing Management will review 24-hour report and order listing report for any new placement and any refusal of care related to change and follow up to ensure appropriate interventions are being followed. C. License nurses was educated on F694, documentation of care and services provided and refusal of care and services, this education will also be provided during new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do audits of resident receiving 's has received their change weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. RN staff R and RN staff K was educated on medication administration. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Audit was completed to ensure residents was receiving correct medications and abnormal finding was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur:
Failure to Follow Physician Orders and Medication Errors
Penalty
Summary
The facility failed to follow physician orders for multiple residents, leading to several deficiencies. Resident #26 was observed without a required binder, which was supposed to be applied to prevent her from pulling out a medical device. Despite the absence of the binder, the Treatment Administration Record (TAR) was signed off by nursing staff as if the binder had been applied. The binder was reportedly sent to the laundry, and alternative measures were inadequately implemented, resulting in the resident being exposed and the insertion site leaking. Resident #470 received incorrect medication administration, where the nurse administered a medication not ordered by the physician and failed to administer the correct dosage of another medication. The nurse was unaware of the differences in medication strengths and mistakenly believed two medications were the same. This error was confirmed during an interview with the nurse, who acknowledged the mistake in medication administration. Residents #271 and #23 had issues with the timely changing of their medical device covers. The covers were not changed as per the physician's orders, which required changes every seven days. The Medication Administration Records (MAR) inaccurately reflected that the covers were changed, despite photographic evidence and staff interviews confirming otherwise. The Director of Nursing acknowledged the failure to follow physician orders and the incorrect documentation in the MARs.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A. RN staff R and RN staff K was educated on medication administration. B. Residents #26, #23, #271, #470 and #60 no negative outcome was noted. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Audit was completed to ensure residents was receiving correct medications and abnormal finding was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License Nurses was educated on F759 documentation and medication administration this education will be provided annually and upon new hire orientation. B. Nursing Managers will audit medication administration for any documentation of such as but not limited to not available, holes/blanks in the MAR and ensure that appropriate follow up was completed. C. Medication competency was completed for current license nurses and any new license nurse hired. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of license nurses during medication administration to ensure proper procedure/techniques is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A. Resident #26 binder use was corrected. B. RN staff K educated on documentation. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete audit of resident and any specialty device used for their tube was completed and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License Nurses was educated on documentation with emphasis on services not provided/ physician orders not carried out and the process of documentation. B. Nurse Manager to review 24 hour report and order detail summary the following business day for any refusal or care, supplies not available and any new order for specialty equipment and follow up to ensure appropriate interventions were implemented. C. Staff was educated on the competence of F693 and this education will be provided upon new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of resident and any specialty equipment used on their is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #271 and #23 was changed. B. LPN staff V was educated on change. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with lines and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License Nurses was educated on changes. B. Nursing Management will review 24-hour report and order listing report for any new placement and any refusal of care related to change and follow up to ensure appropriate interventions are being followed. C. License nurses was educated on F694, documentation of care and services provided and refusal of care and services, this education will also be provided during new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do audits of resident receiving s has received their change weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for Resident #83, as required by the regulation. The care plan did not adequately describe the resident's medical, physical, mental needs, and preferences, nor did it outline how the facility would assist in meeting these needs. Resident #83, a male with a history of significant medical conditions including limitations in range of motion (ROM) on both sides of the lower extremities and one side of the upper extremity, was observed without necessary positioning devices or interventions to assist with his condition. Despite being on hospice services, there was no documentation or care plan addressing his ROM limitations or the use of supportive devices like pillows. Interviews with facility staff, including the Director of Rehab, Registered Nurse (RN) Staff B, and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding the resident's needs and the absence of a restorative program. The Care Plan Coordinator confirmed that there were no interventions documented for the resident's lower extremity limitations, and the resident's refusal of care was not properly documented. The deficiency was further highlighted by the absence of a care plan addressing the resident's ROM limitations, despite the resident's significant change in condition being noted in the Minimum Data Set (MDS) assessment.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #83 care plan was updated to reflect resident current status. B. Education for F656 provided to RN staff B, care plan coordinator Staff L and Care plan coordinator RN staff H. C. Director of Rehab is no longer at the facility. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with contractors and limited ROM was conducted and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on the components of F656. B. Nursing management will review 24 hour report and follow up on any new limited ROM or contractors and update care plan as needed. C. All New residents will be reviewed and reassessed if needed and review by the IDT team the following business day for any limited ROM or contractors to ensure appropriate interventions are in place. D. Education on F656 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Care Plans/Designee will audit new residents' charts and any change of condition charts to ensure that care plans are appropriate to reflect the status of the resident with emphasis on contractor or limited ROM weekly for four weeks then monthly for one quarter. The Director of Care Plans/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 101 standards, as evidenced by a review of records and interviews. On February 11, 2025, it was found that the annual fire alarm report from November 4, 2023, indicated that 8 out of 12 duct detectors could not be located for testing. Additionally, the report noted that the batteries required replacement. Furthermore, the smoke detector sensitivity inspection report was outdated, with the last inspection dated February 19, 2021, and the duct detector air stream test was last conducted on September 6, 2023. The facility's administrator acknowledged these findings and mentioned that their vendor would need to provide updated testing. The failure to maintain the fire alarm system as per NFPA 101 standards could potentially delay alarm activation during hazardous conditions, although this risk is not explicitly stated in the report. The deficiency highlights lapses in the facility's adherence to required testing and maintenance schedules for critical safety equipment.
Plan Of Correction
K345 Fire Alarm System - Testing and Maintenance 1. The fire alarm inspection was conducted and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on regulatory requirements. B. Maintenance director educated on K345. 4. Maintenance Director will do monthly audits of Fire alarm testing and Maintenance to monthly QAPI. K345 Fire Alarm System Testing and Maintenance 1. The fire alarm inspection was conducted and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on regulatory requirements. B. Maintenance director educated on K345. 4. Maintenance Director will do monthly audits of Fire alarm testing and Maintenance to monthly QAPI.
Fire Drill Record Alterations
Penalty
Summary
The facility failed to conduct fire drills as required by NFPA 101, which mandates that fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. These drills are to be held at unexpected times under varying conditions, at least quarterly on each shift. During a review of the facility's fire drill records, it was found that the sign-in sheets for the drills did not have matching dates, and some dates were altered. Specifically, the fire drills dated 8/14/24 and 7/25/24 had matching sign-in sheets, but the dates were changed. Similarly, the drills on 11/29/24 and 10/31/24 had matching sign-in sheets, but the dates were removed from the sheets. The Maintenance Director, who had recently started working at the facility, stated that he did not conduct the drills prior to the survey. The Administrator, upon reviewing the drills, acknowledged the visible alterations in the records and indicated that further investigation would be conducted. This deficiency could result in staff not being prepared to address and respond to a fire emergency, thereby endangering the occupants of the building.
Plan Of Correction
K712 Fire Drills 1. Fire Drills are current and up to date. 2. Audit was completed on fire drills; any abnormal finding was noted. 3. A. Fire Drill will be conducted monthly. B. Staff educated on fire drills. 4. Administrator will audit monthly to ensure fire drills are completed, and findings will be brought to QA.
Failure to Conduct Timely Fire Door and Damper Inspections
Penalty
Summary
The facility failed to conduct timely inspections and testing of fire doors and fire and smoke dampers as required by NFPA 80 standards. During a records review, it was found that the last maintenance and testing reports for fire and smoke dampers were dated over four years ago, on 3/5/20, which exceeds the maximum interval of four years for testing these devices. Additionally, the inspection report for fire doors was dated 7/4/22, indicating a lapse in the annual inspection requirement. The Director of Maintenance acknowledged the backlog in maintenance tasks, attributing it to the previous maintenance director. This deficiency in maintenance practices could lead to the failure of fire and smoke dampers during fire conditions, potentially allowing the spread of fire, smoke, and gases throughout the building's smoke compartments. This oversight affects all smoke compartments within the facility, posing a risk to the safety of its occupants. The individuals responsible for performing these inspections and tests are required to have the necessary knowledge, training, or experience, and written records of these activities must be maintained and available for review.
Plan Of Correction
K761 Maintenance Inspection & Testing - Doors 1. Fire doors and fire and smoke dampers were inspected and current. 2. All fire doors and dampers were audited and inspected. 3. A. Cintas has been retained, and inspection has been placed on their schedule to maintain compliance with regulatory guidelines. B. Maintenance director and maintenance staff educated on K761. 4. Maintenance director will audit to ensure facility remains in compliance and report findings to QAPI. K761 Maintenance Inspection & Testing - Doors 1. Fire doors and fire and smoke dampers were inspected and current. 2. All fire doors and dampers were audited and inspected. 3. A. Cintas has been retained, and inspection has been placed on their schedule to maintain compliance with regulatory guidelines. B. Maintenance director and maintenance staff educated on K761. 4. Maintenance director will audit to ensure facility remains in compliance and report findings to QAPI.
Lack of Post-Disaster Analysis Documentation
Penalty
Summary
The facility failed to provide documentation of post-disaster analysis, including potential areas of improvement and revision of the Emergency Preparedness Program (EP). This deficiency was identified during a review of disaster drills conducted by the facility. Specifically, one of the required two drills did not include an After Action Report (AAR), which is essential for evaluating the facility's response to emergencies and identifying areas for improvement. During the review, it was noted that the absence of an AAR could leave the facility unprepared for unexpected situations that might arise during an actual emergency. The AAR is a critical component of the emergency preparedness process, as it allows the facility to document its response to drills and real events, analyze the effectiveness of its emergency plan, and make necessary revisions to address any shortcomings. The deficiency was confirmed through an interview with the Administrator, who acknowledged the omission and indicated that future drills would include an AAR. However, the lack of documentation for the drill in question highlights a gap in the facility's emergency preparedness efforts, which could potentially impact its ability to respond effectively to real emergencies.
Plan Of Correction
3/12/25 1. Drills were updated to meet the requirements of E039. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E39. 4. Audit for compliance for E39 will be completed by administrator or designee monthly and report to QAPI for one quarter.
Failure to Test Electrical Equipment as per NFPA Standards
Penalty
Summary
The facility failed to test electrical equipment in accordance with NFPA 99 and NFPA 110 standards. During a review of the facility's maintenance and testing documents, it was found that there were no records of main and feeder circuit breaker inspections and exercising. The only available record was a thermal imaging report dated May 13, 2022. This lack of documentation was acknowledged by the Maintenance Director, who had recently started working at the facility and was unsure of the current status of the records. The deficiency could result in a loss of power to the facility, energized equipment fires, or fires resulting from devices failing to perform as designed. This poses a risk to the occupants of the building from electric shock hazards or the loss of power providing life support and life safety features of the facility. The report highlights the importance of exercising these breakers to ensure their reliability in the event of a fault or overload situation, as per NFPA 99 (2012 edition) and NFPA 110 (2010 edition).
Plan Of Correction
3/12/25 **Electrical Systems - Essential Electric System** 1. Main and feeder circuit breaker inspection and exercising was completed. 2. Audit was conducted to ensure all other inspections were completed; any abnormal findings were corrected. 3. A. The facility has placed in TELS system a schedule to do the inspection according to the regulatory guidelines to maintain compliance. B. Maintenance director and maintenance staff educated on K918. 4. Maintenance Director will do monthly audit to ensure facility maintain compliance with its inspection and report findings to QAPI.
Deficient Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain an up-to-date communication plan as part of their Emergency Preparedness Program (EP). During a review conducted on February 11, 2025, it was found that the list of staff included individuals who no longer worked at the facility. This deficiency was identified through a record review and interview process, where the Administrator acknowledged that the plan had been reviewed through the Quality Assurance and Performance Improvement (QAPI) process but still required several updates, including current staffing information. The absence of an accurate communication plan, particularly in the context of an emergency, poses a risk to residents as it could lead to a lack of medical and support staffing during a transfer to other facilities. The deficiency highlights the facility's failure to ensure that the communication plan includes the necessary names and contact information of staff and residents' physicians, which is crucial for effective emergency response and resident safety.
Plan Of Correction
1. Name and contact information was updated to reflect current contacts and employees. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E030. 4. Audit for compliance for E30 will be completed by administrator or designee monthly and reported to QAPI for one quarter.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to provide a method for sharing occupancy information and needs as part of their Emergency Preparedness Program (EP). This deficiency was identified during a record review and interview, where it was found that the facility's EP did not include a clear method for communicating occupancy needs to the authority having jurisdiction. This lack of communication could potentially leave receiving facilities and caregivers without the necessary information for accommodating transferred residents. During the review, it was noted that the facility's EP referenced the Emergency Status System (ESS) and included a link to the ESS website. However, the Administrator acknowledged that they would use the online resource 'HFRS' and update the EP to reflect this new website. This indicates that the current EP did not adequately address the requirement for sharing occupancy information, which is crucial for maintaining continuity of care during transfers or intakes of residents.
Plan Of Correction
3/12/25 1. The link was updated to reflect HFRS instead of the old site ESS. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E033. 4. Audit for compliance for E33 will be completed by administrator or designee monthly and report to QAPI for one quarter.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and sanitary environment for residents, as evidenced by multiple observations and interviews. During an initial tour, surveyors observed a large live insect behind an oxygen concentrator, a wash basin stored on the floor of a shared bathroom, exposed wires of a call light, missing closet drawers, damaged vinyl flooring, and missing baseboards exposing cracked drywall. Additionally, the ice machine in the main dining room was found to have a white substance and dust, indicating it was not being cleaned as per facility policy. Staff interviews confirmed the presence of roaches and bugs, with multiple staff members stating that while they reported these issues, the extermination efforts were ineffective, and maintenance requests were often delayed or ignored for weeks. Residents and their families also reported frequent sightings of roaches and expressed concerns about the facility's cleanliness and maintenance. The Administrator admitted to not touring the facility to observe these concerns and acknowledged a lack of oversight in ensuring that maintenance and cleaning tasks were completed. The Regional Director of Maintenance was unaware of the ongoing issues and declined to conduct a joint tour of the facility. The Certified Dietary Manager confirmed that there was no documentation to verify that the ice machines and coolers were being cleaned and sanitized as required. Housekeeping staff also reported seeing roaches daily and indicated that they only cleaned the outside of the ice coolers, not the inside. These observations and interviews highlight significant deficiencies in the facility's ability to maintain a safe, clean, and comfortable environment for its residents.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide necessary care and services to maintain hygiene for three residents who required assistance with activities of daily living (ADLs). Resident #24, who had diagnoses including depression, chronic obstructive pulmonary disease, and type 2 diabetes mellitus, did not receive scheduled showers on multiple occasions in March and April 2024. The CNA documentation showed inconsistencies and lack of proper documentation for the scheduled showers, with the resident receiving only one shower in March and none in April. The resident's representative confirmed the lack of scheduled showers during a telephone interview. Resident #999, who had diagnoses including chronic kidney disease, metastatic breast cancer, and type 2 diabetes mellitus, did not receive any scheduled showers during her stay from October 2023 to November 2023. The CNA documentation indicated that the resident received partial bed baths instead of scheduled showers, with no documentation of shower refusals. Additionally, Resident #750, who required substantial to maximum assistance with personal care, did not receive any scheduled showers from the time of admission on April 29, 2024, to May 7, 2024. The CNA staff and the Director of Nursing confirmed the lack of a policy on ADLs or bathing of residents and the absence of a clear responsibility for ensuring showers were completed as assigned.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program and a sanitary environment free from pests for residents residing in the skilled nursing facility. On multiple occasions, residents and staff reported the presence of large roaches and other insects in resident rooms and common areas. Observations included a live brown insect in a resident's room and a dead bug on a conference room table. Residents expressed concerns about bugs crawling on walls and even on them at night, while staff confirmed the frequent presence of pests and their attempts to manage the situation by stepping on the bugs and logging sightings for the exterminator. However, the pest control measures in place were ineffective, as evidenced by the recurring pest sightings and the exterminator's admission that the previous pest control reports indicated no pest activity despite the ongoing issues reported by residents and staff. Interviews with the pest control exterminator revealed that this was his first visit to the facility, and he had not received any prior reports of pest activity from the previous exterminator. The exterminator noted that the large roaches likely originated from old sewer lines and outside mulch areas. Despite regular spraying, the pest control measures were insufficient, particularly after rain, leading to the persistent presence of pests. The facility's pest log was also found to be inadequate, with no documented pest activity on several dates, contradicting the numerous reports and observations of pests by residents and staff.
Failure to Address Grievances Related to Maintenance Issues
Penalty
Summary
The facility failed to address grievances related to broken furniture and a frayed call light for a resident. The resident's representative reported these issues to the facility Administrator, and work orders were filed, but the repairs were not completed. The resident's closet drawer was missing, and the call light had exposed wiring, which was confirmed through photographic evidence and observations by the surveyor. The issues had been reported multiple times over several months, but no corrective action was taken. The Regional Director of Maintenance was unaware of the maintenance concerns and confirmed the deficiencies during a tour of the resident's room. The Administrator admitted that the Maintenance Director, who had recently left the facility, was responsible for repairs but did not ensure the completion of the tasks. The Administrator acknowledged that he did not follow up to verify that the repairs were made, assuming they were taken care of by the Maintenance Director.
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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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