Terrace Of St Cloud, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Cloud, Florida.
- Location
- 3855 Old Canoe Creek Road, Saint Cloud, Florida 34769
- CMS Provider Number
- 105528
- Inspections on file
- 27
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Terrace Of St Cloud, The during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and high care needs did not receive care in accordance with their documented care plans. Staff frequently provided one-person assistance for ADLs and transfers when two-person assistance was required, and care plans were inconsistently documented and difficult for staff to access or interpret. This led to confusion among CNAs and care that did not align with the residents' assessed needs.
Surveyors found that three residents with vascular access devices did not receive care and services consistent with professional standards and physician orders. Issues included undated and improperly maintained dressings, lack of documentation for monitoring and maintenance, and absence of physician orders for care and removal. Nursing staff and the DON confirmed these deficiencies, including failure to change dressings as required and to ensure proper documentation.
Surveyors found that staff failed to follow infection control protocols, including improper placement of a biohazard waste container for a resident on contact isolation and an LPN not using gloves or cleaning equipment during blood glucose monitoring and injectable medication administration. These actions did not comply with facility policies for infection prevention and control.
Three residents with central lines or similar devices did not receive care and services according to standards of practice and physician orders. Dressings were found undated or improperly maintained, and in one case, there were no physician orders for monitoring or maintenance. Staff acknowledged the omissions, and facility policy requiring dating and documentation was not followed.
Surveyors found that the facility did not have the most recent 'Nursing Home Inspections Ratings' page available in the survey binder for residents and visitors. The Administrator, who was responsible for updating the binder, was unaware of the requirement to include this page and did not know how to access the information.
The facility did not maintain up-to-date annual testing records for emergency battery back-up exit lighting, with the last documented test occurring over a year ago. This deficiency was confirmed by the Assistant Director of Maintenance and reconfirmed with facility leadership during the survey.
Surveyors identified that the facility did not maintain required annual testing of the fire alarm system, specifically the duct detector differential testing, with the last documented test occurring nearly a year prior. The deficiency was acknowledged by facility leadership during the survey.
Surveyors found that external wiring was improperly loaded onto fire sprinkler piping during an above-ceiling inspection near the Dietary Department. The Assistant Director of Maintenance was unaware of this issue, and both the Administrator and Assistant Director of Maintenance confirmed the finding during the exit conference. Photographic evidence was provided.
A resident with multiple medical conditions fell during a transfer due to the use of an incorrect and oversized sling by CNAs. The resident, dependent on staff for transfers, slipped through the sling and sustained a head injury. The facility's policy on mechanical lift use was not followed, as staff failed to ensure the correct sling size and type.
The facility failed to implement their abuse policy and provide education for an injury of unknown origin for a resident with multiple diagnoses. Despite initiating an investigation, the facility's DON revealed conflicting information and was unable to provide a Root Cause Analysis or a completed timeline. Not all staff received the required in-service education, and there was no written evidence that the necessary steps were completed.
Failure to Implement and Communicate Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with severe cognitive impairment and significant care needs. For one resident with vascular dementia, diabetes, end stage renal disease, and other conditions, the care plan required two-person assistance for transfers and activities of daily living (ADLs) due to her fragility and risk of injury. Despite this, multiple CNAs admitted to providing care alone, contrary to the care plan, and could not recall if they had assistance on the day the resident was found with a bruise on her face. The care plan interventions were not consistently followed, and staff could not provide a reason for not adhering to the two-person assistance requirement. Another resident with congestive heart failure, colon cancer, Alzheimer's disease, and dementia was also dependent on staff for ADLs and at risk for skin breakdown and bruising due to fragile skin and combative behaviors. The care plan for this resident was inconsistent with the MDS assessment, listing one-person assistance for transfers and ADLs despite the assessment indicating a need for two or more staff. Staff reported difficulty accessing or understanding the electronic care plan system, often relying on verbal reports rather than documented care plans to determine the level of assistance required. Interviews with CNAs and facility leadership revealed that staff were not consistently able to access or interpret care plan information in the electronic system, leading to confusion and inconsistent care. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but these were not effectively implemented or communicated to staff, resulting in care that did not meet the documented needs of the residents.
Failure to Follow Standards for Vascular Access Device Care and Documentation
Penalty
Summary
Surveyors identified that the facility failed to provide care and services according to professional standards and physician orders for three residents with vascular access devices. For one resident, a vascular access dressing was observed to be undated, contrary to the physician's order requiring weekly changes and dating of the dressing. The assigned RN confirmed the omission and acknowledged the importance of dating to prevent infection and complications. The Director of Nursing (DON) also confirmed that dressings should always be dated. Another resident was found with a vascular access dressing that was undated and loose, with the edges lifting from the skin. The resident could not recall when the dressing was last changed. A nurse later wrote a date on the existing dressing without changing it, despite the dressing being loose and undated. The DON confirmed that the dressing should have been changed, not just dated, and that the facility protocol required dating upon insertion and changing every Tuesday. A third resident had a vascular access device placed, but there were no physician orders for monitoring or maintenance, and no documentation in the medical or treatment administration records to indicate that the site had been monitored or maintained. The dressing was initially undated and later dated without evidence of proper monitoring or maintenance. The DON confirmed that there should have been physician orders for care, maintenance, and removal, and acknowledged that without such orders, nurses would not be prompted to check or document the site.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: Resident #106 and #466 were immediately changed on . On a physician's order was obtained to remove Resident #520's, . No adverse consequences were identified at that time. On an in-service for all licensed nurses was initiated by the Staff Development Coordinator which addressed Central Care changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents with Central and/or have the potential to be affected by this deficient practice. On a facility-wide audit was conducted for all residents with Central and/or to ensure that accurate and were appropriate physicians' orders were in place; and that appropriately dated and were being appropriately maintained. All other residents were found to have appropriately maintained site and appropriate orders in place. On , an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and C) What measures will be put in place or what system change will be made to ensure this will not recur: On , an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and Unit Managers, or designee will audit admission/readmission orders for any resident with a Central and/or to ensure that there are physician orders in place for care and maintenance of the. Audits will be completed with every new admission and/or order for times 4 weeks. Any identified problems will be addressed immediately. Audits will be submitted to the DON, or designee weekly. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly times 3 months, then quarterly x 4 quarters. maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and. Unit Managers, or designee will audit admission/readmission orders for any resident with a Central and/or to ensure that there are physician orders in place for care and maintenance of the. Audits will be completed with every new admission and/or order for times 4 weeks. Any identified problems will be addressed immediately. Audits will be submitted to the DON, or designee weekly. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly times 3 months, then quarterly x 4 quarters. F 694
Deficiencies in Infection Control and Isolation Precautions
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices. In one instance, a resident placed on contact isolation for a staph infection had a biohazard waste receptacle for used personal protective equipment (PPE) located in the middle of the room, between the beds of two residents. This placement required staff to walk past the resident's bed and dresser to dispose of soiled PPE, rather than having the disposal container near the exit as required by facility policy and standard infection control practices. The infection preventionist confirmed that this setup constituted a break in isolation protocol, as it increased the risk of transmitting the organism to other residents. Another deficiency was observed during medication administration for a resident with diabetes and other medical conditions. An LPN performed a blood glucose check and administered an injectable medication without donning gloves, despite the potential for exposure to blood. The LPN also failed to sanitize his hands before and after the procedure and did not clean the glucometer before placing it back into the medication cart. The Director of Nursing confirmed that the facility's policy required the use of gloves and cleaning of equipment between residents, and acknowledged that the LPN did not follow these procedures. Facility policies reviewed by surveyors indicated that staff were required to wear gloves during procedures involving potential exposure to blood or body fluids, and to clean reusable equipment after each use. The observed failures to adhere to these policies during both isolation precautions and medication administration led to the cited deficiencies in infection prevention and control.
Plan Of Correction
F 880 A) What corrective action will be accomplished for these residents found to be effective: On Resident #56, biohazard waste receptacle for used PPE was moved to the appropriate location near the exit of the resident's room. On Resident #64, was assessed and no adverse side effects were noted at that time. On LPN A, received education from the ADON on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents with isolation precautions or who require monitoring. On no other residents were able to be identified upon review of LPN A's assigned residents. On LPN A, received education from the ADON on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On the ADON, initiated education for all licensed nurses on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On biohazard waste receptacles in isolation rooms were moved to the appropriate location near the exit of the resident rooms. Staff have been educated on the appropriate placement of the waste receptacles. C) What measures will be put in place or what system change will be made to ensure this will not recur: On LPN A, received education from the ADON on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On the ADON, initiated education for all licensed nurses on appropriate handwashing, appropriate use of PPE, isolation precautions, and how to appropriately clean multi-use items. On staff, initiated education on handwashing, implementation of appropriate isolation precautions, and appropriate use of PPE. On biohazard waste receptacles in isolation rooms were moved to the appropriate location near the exit of the resident rooms. Staff have been educated on the appropriate placement of the waste receptacles. The Unit Managers, or designee, will randomly audit, 3 times a week, across all shifts, staff handwashing, implementation of appropriate isolation precautions, appropriate placement of biohazard waste receptacles, medication administration for appropriate use of PPE, and use and cleaning of multi-use items. Audits will be submitted to the DON weekly. Any identified problems will be addressed immediately. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly for 3 months, then quarterly for 4 quarters.
Failure to Maintain and Document Central Line Care per Standards and Orders
Penalty
Summary
The facility failed to provide care and services according to standards of practice and the plan of care for three residents who had central lines or similar devices. For one resident, a central line was present in the right upper arm for medication administration, but the dressing was undated, contrary to physician orders and facility policy requiring weekly changes and dating. The assigned RN confirmed the omission and acknowledged the importance of dating the dressing to prevent complications. The Director of Nursing (DON) also confirmed that dressings should always be dated. Another resident had a line in the left upper arm for medication administration, with physician orders specifying weekly dressing changes and monitoring for signs of infection. The dressing was found to be undated and loose, with the edges lifting from the skin. The resident could not recall when the dressing was last changed. An RN later wrote a date on the dressing without changing it, and the DON acknowledged that the dressing should have been changed, not just dated, as the duration it had been in place was unknown. Facility policy required labeling dressings with initials and date at the time of application. A third resident had a line placed in the left arm, but there were no physician orders for monitoring or maintenance of the line, nor documentation in the medical or treatment administration records indicating that the site had been monitored or maintained. The dressing was undated initially, and staff could not locate orders for care or removal of the line. The DON confirmed that there should have been physician orders for monitoring, maintenance, and removal, and acknowledged that without such orders, nurses would not be prompted to check or document the site.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: Resident #106 and #466 were immediately changed on a physician’s order was obtained to remove Resident #520’s. No adverse consequences were identified at that time. On an in-service for all licensed nurses was initiated by the Staff Development Coordinator which addressed Central and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central Care. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents with Central have the potential to be affected by this deficient practice. On a facility-wide audit was conducted for all residents with Central and/or to ensure that accurate and appropriate physicians orders were in place; and that were appropriately dated and were being appropriately maintained. All other residents were found to have appropriately maintained site and appropriate orders in place. On an, an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and. C) What measures will be put in place or what system change will be made to ensure this will not recur: On, an in-service for all licensed nurses was initiated by the ADON which addressed Central Care and changes and care and maintenance. The in-service addressed the need to obtain physician orders for appropriate care, maintenance, and removal of Central and Unit Managers, or designee will audit admission/readmission orders for any resident with a Central to ensure that there are physician orders in place for care and maintenance of the. Audits will be completed with every new admission and/or order for times 4 weeks. Any identified problems will be addressed immediately. Audits will be submitted to the DON, or designee weekly. D) How the corrective action will be monitored to ensure the potential will not occur: The DON, or designee, will report the findings of the audits to the QA and QAPI committees monthly times 3 months, then quarterly x 4 quarters.
Nursing Home Guide Not Posted as Required
Penalty
Summary
The facility failed to ensure that the most recent version of the Nursing Home Guide, specifically the 'Nursing Home Inspections Ratings' page, was available and accessible to residents and visitors in the survey binder located in the front lobby. During the survey, it was observed that this required page was not printed or placed in the binder for review. An interview with the Administrator revealed that she was responsible for updating the survey binder but was unaware that the inspection ratings page needed to be included quarterly and did not know how to access the necessary information from the appropriate website. This deficiency was identified through both record review and staff interview, and it was determined that the facility did not meet the statutory requirement to post all pages listing the facility in the most recent version of the Nursing Home Guide in prominent positions accessible to residents and the public.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents had the potential to be affected by this deficient practice. The new Administrator of the facility was educated by the Consultant Administrator on the need to post the most recent Nursing Home Guides in a location(s) accessible to all residents, staff, and visitors and how to access the information. The most recent Nursing Home Guide was placed in the Nursing Home Inspection Ratings binder in the front lobby. Information was shared at Resident Council regarding what information is available in the binder containing the Nursing Home Guide. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents had the potential to be affected by this deficient practice. The new Administrator of the facility was educated on the need to post the most recent Nursing Home Guides in a location(s) accessible to all residents, staff, and visitors and how to access the information. On [date], the most recent Nursing Home Guide was placed in the Nursing Home Inspection Ratings binder in the front lobby. Information was shared at Resident Council regarding what information is available in the binder containing the Nursing Home Guide. C) What measures will be put in place or what system change will be made to ensure this will not recur: All residents had the potential to be affected by this deficient practice. The new Administrator of the facility was educated on the need to post the most recent Nursing Home Guides in a location(s) accessible to all residents, staff, and visitors and how to access the information. On [date], the most recent Nursing Home Guide was placed in the Nursing Home Inspection Ratings binder in the front lobby. Information was shared at Resident Council regarding what information is available in the binder containing the Nursing Home Guide. The Administrator, or designee, will audit the Nursing Home Inspection Ratings binder and website weekly to ensure that the most recent Nursing Home Guide is in the binder. Any identified concerns will be immediately addressed. D) How the corrective action will be monitored to ensure the potential will not occur: The Administrator, or designee, will report the findings of the audits to the QA and QAPI committees monthly for 3 months, then quarterly for 4 quarters.
Failure to Maintain Annual Emergency Lighting Testing
Penalty
Summary
The facility failed to maintain yearly testing of the emergency battery back-up exit lighting as required by NFPA 101. During a record review, surveyors found that the most recent documented test of the emergency lighting was performed on 7/12/23, and there was no evidence of a more recent annual test. This deficiency was confirmed through interviews with the Assistant Director of Maintenance, who acknowledged the lack of complete records for the required testing. The absence of up-to-date annual testing records for the emergency lighting was further reconfirmed with both the Administrator and the Assistant Director of Facilities during the exit conference. The deficiency was supported by photographic evidence, and no specific individual was identified as solely responsible for the deficient practice.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents, employees, and visitors have the potential to be affected by this deficient practice; however, a specific individual was not identified in this deficiency. On 7/17/24, a testing of the emergency battery back-up exit lighting was completed. No concerns were identified at that time. On 4/28/2025, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct testing of the emergency battery back-up exit lighting yearly. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents, employees, and visitors have the potential to be affected by this practice. On 7/17/24, a testing of the emergency battery back-up exit lighting was completed. No concerns were identified at that time. On 4/28/2025, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct testing of the emergency battery back-up exit lighting yearly. C) What measures will be put in place or what system change will be made to ensure this will not recur: On 7/17/24, a testing of the emergency battery back-up exit lighting was completed. No concerns were identified at that time. On 4/28/2025, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct testing of the emergency battery back-up exit lighting yearly. The Administrator Consultant developed a tracking schedule for the yearly testing of the emergency battery back-up exit lighting. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director on the tracking schedule. The schedule noted the date on which the Maintenance Director is to complete the yearly testing of the emergency battery back-up exit lighting. The Maintenance Director is to provide documentation to the Administrator of the date of the inspection and testing. Upon completion of the inspection and testing, the Maintenance Director is to provide a copy of the report to the Administrator. D) How the corrective action will be monitored to ensure the potential will not occur: The Maintenance Director, or designee, will report the findings of yearly testing of the emergency battery back-up exit lighting to the QA and QAPI committee monthly x 12 months.
Failure to Maintain Annual Fire Alarm System Testing
Penalty
Summary
The facility failed to maintain annual testing of the fire alarm system, specifically the annual duct detector differential testing. During a record review, surveyors found that the most recent documented testing was completed nearly a year prior, and no evidence was provided to show that the required annual testing had been performed since then. The Assistant Director of Facilities was present during the review and acknowledged the deficiency. This finding was confirmed during the exit conference with both the Administrator and the Assistant Director of Facilities. The lack of current documentation for the annual duct detector differential testing was the sole focus of the deficiency, and no additional patient or resident details were provided in the report.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents have the potential to be affected by this deficient practice; however, a specific individual was not identified in this deficiency. On 3/12/25, duct detector differential testing was completed. Any identified problems were immediately corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct the annual duct detector differential testing. B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents have the potential to be affected by this practice. On 3/12/25, duct detector differential testing was completed. Any identified problems were immediately corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct the annual duct detector differential testing. C) What measures will be put in place or what system change will be made to ensure this will not recur: On 3/12/25, duct detector differential testing was completed. Any identified problems were immediately corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct the annual duct detector differential testing. The Administrator Consultant developed a tracking schedule for the completion of the testing of the duct detector differential. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director on the tracking schedule. The schedule notes the dates on which the Maintenance Director is to have the annual duct detector differential completed. The Maintenance Director is to provide documentation to the Administrator of the date of the testing. Upon completion of the testing, the Maintenance Director is to provide a copy of the report to the Administrator. D) How the corrective action will be monitored to ensure the potential will not occur: The Maintenance Director, or designee, will report the findings of the annual duct detector differential testing to the QA and QAPI committee monthly for 12 months.
Improper External Loading on Fire Sprinkler Piping
Penalty
Summary
During a facility inspection, surveyors conducted an above-ceiling inspection in the corridor outside of the Dietary Department. They observed that external wiring was loaded onto the fire sprinkler piping, which is not compliant with NFPA 101 and NFPA 25 standards for the maintenance and testing of automatic fire sprinkler systems. The Assistant Director of Maintenance, who was present during the inspection, confirmed that he was not aware of the issue prior to the surveyors' findings. The deficiency was acknowledged and confirmed by both the Administrator and the Assistant Director of Maintenance during the exit conference. The report includes photographic evidence of the deficiency. No information regarding specific residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
A) What corrective action will be accomplished for these residents found to be effective: All residents have the potential to be affected by this deficient practice; however, a specific individual was not identified in this deficiency. On 4/28/25, the external loading of wiring on the fire sprinkler piping noted above the ceiling in the corridor outside the Dietary Department was corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct inspections above the ceiling to ensure that there is no wiring touching or around the automatic fire sprinkler system and is maintained in compliance with the regulations (NFPA Code 101). B) How will you identify other residents having potential to be affected and what corrective actions will be taken: All residents have the potential to be affected by this practice. On 4/28/25, the external loading of wiring on the fire sprinkler piping noted above the ceiling in the corridor outside the Dietary Department was corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct inspections above the ceiling to ensure that there is no wiring touching or wrapped around the automatic fire sprinkler system and is maintained in compliance with the regulations (NFPA Code 101). On 4/28/25, the Maintenance Director and Assistant Maintenance Director completed an inspection of the wiring for the fire sprinkler in the area above the ceiling. Any concerns were addressed. C) What measures will be put in place or what system change will be made to ensure this will not recur: On 4/28/25, the external loading of wiring on the fire sprinkler piping noted above the ceiling in the corridor outside the Dietary Department was corrected. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director of the need to conduct inspections above the ceiling to ensure that there is no wiring touching or wrapped around the automatic fire sprinkler system and is maintained in compliance with the regulations (NFPA Code 101). On 4/28/25, the Maintenance Director and Assistant Maintenance Director completed an inspection of the wiring for the fire sprinkler in the area above the ceiling. Any concerns were addressed. The Administrator Consultant developed a tracking schedule for the completion of inspections of the wiring for the fire sprinkler in the area above the ceiling. On 4/28/25, the Administrator Consultant in-serviced the Administrator, Maintenance Director, and Assistant Maintenance Director on the tracking schedule. The schedule notes the dates on which the Maintenance Director is to complete inspections of the wiring for the fire sprinkler in the area above the ceiling. The Maintenance Director is to provide documentation to the Administrator of the date of the inspections. Upon completion of the inspections, the Maintenance Director is to provide a copy of the report to the Administrator. D) How the corrective action will be monitored to ensure the potential will not occur: The Maintenance Director, or designee, will report the findings of the inspections to the QA and QAPI committee monthly x 12 months.
Inadequate Supervision and Incorrect Sling Use Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment to prevent accidents for a resident who was dependent on staff for transfers and required the use of a Hoyer lift. The resident, who had multiple medical conditions including atrial fibrillation and dementia, was involved in a fall incident during a transfer from a wheelchair to a bed. The incident occurred because the nursing staff used an incorrect type of sling, specifically a shower/toilet sling, which was also too large for the resident. This resulted in the resident slipping through the sling and sustaining a head injury. The incident was documented in a progress note, which revealed that two CNAs were involved in the transfer. One CNA admitted to not ensuring the sling was the correct size and type for the resident. The resident fell and hit her head on the floor, resulting in a laceration that required evaluation and treatment at an emergency room. The hospital evaluation showed no acute diagnoses, and the resident returned to the facility the same day. The facility's policy on using mechanical lifts was not followed, as it requires staff to visually check the size of the sling to ensure it is appropriate for the resident. The CNAs involved in the incident did not adhere to this policy, leading to the resident's fall and injury. The Director of Nursing conducted follow-up interviews with the CNAs, confirming the misuse of the sling and the lack of knowledge regarding the correct sling size and type.
Failure to Implement Abuse Policy and Provide Education
Penalty
Summary
The facility failed to implement their abuse policy to fully investigate and provide education for an injury of unknown origin for one resident. The resident, who had multiple diagnoses including type 2 diabetes mellitus, heart failure, stroke, dementia, and left-hand contracture, was found with a purple discoloration on the right hand and later a swollen right arm with a faint yellowish discoloration. An X-ray revealed an acute spiral fracture of the right proximal humerus. Despite initiating an investigation, the facility's Director of Nursing (DON) revealed conflicting information regarding the timing and cause of the injury, and the facility was unable to provide a Root Cause Analysis or a completed timeline of the investigation. The DON admitted that not all staff received the required in-service education following the incident, and there was no written evidence that the necessary steps were completed. The facility's investigation included obtaining statements and performing record reviews, but the information gathered was inconsistent. The DON confirmed that the expectation was for the Administrator to write up the report and conduct an in-service for all staff, which did not occur in this case.
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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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