Valencia Hills Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakeland, Florida.
- Location
- 1350 Sleepy Hill Rd, Lakeland, Florida 33810
- CMS Provider Number
- 105301
- Inspections on file
- 34
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Valencia Hills Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to consistently provide and document ordered 1:1 supervision and enhanced monitoring for multiple residents with dementia, suicidal ideation, elopement risk, aggression, and sexually inappropriate behavior. Several residents were documented in progress notes and psychiatric evaluations as being on 1:1, continuous observation, or EM following behavioral incidents, yet CNA assignment sheets for numerous shifts showed no staff assigned for 1:1, or listed a single CNA responsible for 1:1 while also caring for a full group of rooms, or assigned one staff member to EM for two residents in different rooms. Staff interviews confirmed that CNAs were sometimes expected to perform 1:1 while maintaining regular assignments, that 1:1 duties were rotated without clear documentation responsibility, and that definitions of 1:1, EM, and continuous monitoring, as well as whether a physician order was required, varied among the DON, unit managers, and nurses.
The facility failed to consistently notify practitioners and document abnormal lab results for multiple residents. One resident with hypothyroidism had a markedly elevated TSH level reported, but the record lacked documentation that the practitioner was notified when the result was received, despite a care plan requiring lab monitoring and MD notification. Another resident with hypothyroidism had abnormal urinalysis findings after a change in mental status, with only a brief note that results were sent to the ARNP and no clear evidence of timely notification. A third resident with gout had repeated abnormal hematologic and BUN values, with documentation that initial results were sent to the physician but no entry indicating that subsequent abnormal labs were communicated, and the designated area for new labs in the daily note was left blank. Staff interviews confirmed that facility expectations require prompt practitioner notification and documentation of abnormal labs, which did not occur in these cases.
A resident with dementia, behavioral disturbances, and anxiety was involved in a reported sexual incident with a female peer. The care plan was updated to note that the resident could be sexually inappropriate and to include enhanced monitoring by staff, but progress notes contained no documentation of 1:1 supervision, enhanced monitoring, or continuous monitoring during the relevant period. Interviews with the DON, ADON, and an RN/UM showed conflicting understandings of the terms 1:1 supervision and enhanced monitoring, and differing views on whether a physician order was required, while all indicated that such supervision should be reflected in the care plan and documented in progress notes. This inconsistency and lack of documentation demonstrated that the comprehensive care plan interventions for supervision were not effectively implemented.
A cognitively intact, wheelchair-dependent resident who was always incontinent of bowel and totally dependent on staff for toileting reported multiple instances of having a BM without timely staff response for needed care. Review of bowel elimination task records showed numerous shifts over several months with no incontinence or toileting care documented, despite a care plan stating the resident was totally dependent on staff to meet toileting needs and required bowel management interventions. Facility leaders, including an RN/unit manager, an LPN, and the DON, confirmed that CNAs are expected to document toileting and incontinence care and that undocumented care is considered not done, while facility policies and job descriptions require regular toileting checks, assistance, and accurate ADL documentation, which were not consistently reflected in the resident’s record.
Surveyors found that the facility failed to maintain accurate, complete, and legible shift-to-shift controlled substance count records for several medication carts. Narcotic binders for multiple carts showed missing shift entries, unexplained increases and decreases in total narcotic card counts, incorrect math after plus/minus entries, illegible notations, and missing explanations in comment sections. Staff described a process requiring two nurses to count and sign at each shift change and to keep discontinued narcotics locked in the cart until removal by the DON with a witness, but practice did not consistently match these expectations. One RN handed off cart keys to another nurse during a break and did not document a narcotic count upon return. Leadership acknowledged inaccuracies in the ledgers, while facility policies require strict shift-to-shift inventory of controlled substances and proper documentation of all administrations and remaining amounts.
The facility failed to ensure its QAPI Committee effectively implemented and sustained corrective actions for controlled medication documentation. After prior citation and staff education on narcotic shift-to-shift documentation and use of Controlled Medication Inventory Sheets (CMIS), surveyors found ongoing incomplete and inaccurate entries on multiple medication carts. An RN acknowledged missing medication names, an LPN stated there was no need to record resident names, another RN reported not receiving recent narcotic education, and a UM’s cart showed a discrepancy between documented and actual narcotic card counts. Although internal audits reported 100% compliance and QAPI meetings reviewed deficiencies and corrective actions, direct observations and record reviews demonstrated that the documented processes and the facility’s own QAPI policy were not effectively translated into consistent practice on the units.
A resident with mood and anxiety disorders was discharged from the hospital with an active order for the antipsychotic Lurasidone (Latuda) 20 mg with supper, but upon readmission the facility did not enter this medication into the EMR or physician orders and did not administer it for two days. Admission documentation incorrectly indicated no medications were recommended by the hospital, and the expected process for medication reconciliation—verifying discharge medications with the physician and documenting any changes—was not followed. The psychiatrist was not informed of the missed doses, despite the facility’s policy requiring review and clarification of hospital medication orders with the physician at admission and after returns from outside care.
The facility did not promptly notify physicians of laboratory results for two residents, including a case where a stat D-dimer result was significantly elevated and not communicated until the following day. In both cases, required documentation of provider notification was missing, despite facility policy and federal regulations mandating timely communication of lab findings. Staff interviews and record reviews confirmed these lapses.
Two residents did not receive timely and appropriate healthcare services due to delays in notifying providers of critical laboratory results. In one case, a resident with respiratory symptoms had a stat D-dimer test with elevated results that were not communicated to the physician until the next day. In another case, a resident's lab results were not documented as reviewed or communicated to the provider. Staff interviews and record reviews revealed inconsistent processes and documentation for lab result notification.
Two residents did not have their laboratory results promptly communicated to their physicians as required. In one case, a resident with fractures and respiratory symptoms had a critical D-dimer result that was not reported to the physician for two days. In another case, a resident with multiple chronic conditions had a valproic acid level result that was not documented as reviewed or communicated to the provider. Staff interviews and record reviews revealed inconsistent processes and lack of documentation regarding timely physician notification of lab results.
The facility did not maintain a pest-free environment, as live insects such as spiders, cockroaches, and ants were observed in multiple wings and common areas. Several residents with intact cognition reported seeing pests in their rooms, and staff confirmed occasional sightings. Pest logs documented ongoing issues, and the administrator acknowledged increasing pest reports and inadequate pest control services.
A resident with multiple serious diagnoses was found to have a low potassium level and was started on potassium supplementation, but the family was not notified of this change in condition or the new medication, contrary to facility policy and expectations as confirmed by the DON.
A resident with severe cognitive impairment was abused by a CNA who pinched the resident in retaliation after being hit. The incident resulted in bruising on the resident's arms and was witnessed by another staff member. Despite the resident's care plan and recent abuse training for the CNA, the facility failed to prevent the abuse, indicating a deficiency in their abuse prevention measures.
A resident with a history of cognitive impairment and past molestation alleged abuse by a volunteer. Despite the family confirming the resident's history, the facility did not conduct a required trauma screening. The facility's policy mandated rescreening for trauma indicators, which was not followed, highlighting a communication gap among staff.
Failure to Provide and Assign Required 1:1 and Enhanced Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required 1:1 supervision, enhanced monitoring (EM), or continuous monitoring (CM) for multiple residents who had behavioral symptoms, suicidal ideation, or elopement risk. For one resident with dementia and behavioral disturbance who had pushed another resident, nursing notes documented placement on 1:1 monitoring after the altercation, but CNA assignment sheets for several subsequent shifts showed no resident listed or staff assigned for 1:1. On another date, a CNA was listed as assigned to 1:1 supervision without any resident name or room number, and on other shifts there was no 1:1 assignment at all, despite progress notes indicating the resident was on 1:1 or enhanced monitoring. A second resident with dementia, psychosis, and depression had an order for continuous observation for elopement. Progress notes described wandering, agitation, and increased supervision due to elopement risk. However, CNA assignment sheets for multiple shifts showed no resident documented or staff assigned for 1:1 supervision, and on one shift a CNA was assigned 1:1 supervision for two residents in the same room. A third resident with Alzheimer’s disease and documented suicidal ideation had physician orders for 1:1 supervision and continuous observation for suicide ideation. Progress notes repeatedly stated the resident remained on 1:1 or continuous observation, yet CNA assignment sheets showed staff assigned to 1:1 while also responsible for a full group of rooms, and on later dates there were no residents documented or staff assigned for 1:1 on any shift, even while notes continued to reference continuous observation. Another resident with depression and active suicidal thoughts had multiple physician orders for 1:1 observation and continuous observation for suicidal ideation following a behavioral incident. Progress notes documented a 24‑hour sitter, ongoing 1:1, and continued close observation, but CNA assignment sheets for several dates and shifts showed no staff assigned for 1:1, including entire days with no 1:1 assignment despite notes indicating the resident continued on 1:1. A further resident with vascular dementia, agitation, and a history of wandering and resident‑to‑resident altercations was described in progress notes and psychiatric documentation as being on 1:1 supervision or enhanced monitoring after aggressive incidents, yet CNA assignment sheets and staffing records showed multiple shifts with no 1:1 assignment, shifts where EM was assigned to one CNA for two residents in different rooms, and night shifts with no EM or 1:1 documented for this resident. A final resident with dementia and sexually inappropriate behavior had a care plan intervention for enhanced monitoring after a sexual incident with a peer. Progress notes did not document 1:1, EM, or CM, and CNA assignment sheets showed shifts with no staff assigned for 1:1 or EM, as well as shifts where one staff member was assigned EM for this resident and another resident in different rooms. Interviews with nursing and CNA staff revealed inconsistent understanding and implementation of 1:1 and EM: one LPN stated staff should not have both a regular assignment and a 1:1 due to safety concerns, while CNAs reported being instructed to provide 1:1 while also caring for other residents, sometimes rotating the 1:1 among staff and bringing the supervised resident along while performing other care. Leadership interviews showed conflicting definitions of 1:1, EM, and continuous monitoring, disagreement about whether physician orders were required, and reliance on verbal reporting and care plans rather than consistent written assignments and documentation, despite multiple residents being described as on 1:1 or EM at the time.
Failure to Notify Practitioners and Document Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify practitioners of abnormal laboratory results and to document such notifications as required by facility policy and resident care plans. For one resident with a primary diagnosis of a left ilium fracture and a care plan for hypothyroidism, a TSH level of 26.99 (reference range 0.45–5.33 uIU/mL) was reported by the lab on 3/7/26 at 5:55 p.m. The record later showed an order on 3/9/26 to increase Levothyroxine to 200 mcg daily and to repeat the lab in a week, and a nursing note that the resident’s son was informed of the medication increase and repeat lab. However, the documentation did not show that the practitioner was notified of the abnormal TSH result at the time it was reported, despite the care plan intervention to obtain and monitor labs and report results to the MD. Another resident with hypothyroidism had increased confusion documented, and the ARNP was notified with a request for labs. A urinalysis with microscopic exam was ordered and later reported with abnormal findings for urine blood, protein, mucus, and calcium oxalate crystals; the only documentation was that urine results were sent to the ARNP, without clear evidence of timely practitioner notification consistent with facility expectations. A third resident with idiopathic gout had multiple abnormal lab values (low RBC, Hgb, HCT; elevated Hemoglobin A1c and BUN) reported on 3/5/26, with a nursing note the next day stating results were sent to the physician. Subsequent labs on 3/7/26 again showed abnormal BUN and hematologic values, but the daily Medicare Managed Care note section for new labs was left blank, and there was no documentation that the physician was notified of these later abnormal results. Interviews with the DON, RN Unit Manager, and an LPN confirmed that staff are expected to notify practitioners of abnormal results as soon as possible and document this in the medical record, which was not consistently done for these residents.
Failure to Implement and Document Enhanced/1:1 Supervision After Sexual Behavior Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document a comprehensive care plan intervention for enhanced or one-to-one supervision for a resident with known behavioral and cognitive impairments. The resident was admitted with multiple dementia-related diagnoses, including Alzheimer’s disease, vascular dementia with behavioral disturbances, anxiety disorders, and major depressive disorder. The facility’s reportable incident log documented a sexual allegation involving this resident and another resident. Following this, the resident’s comprehensive care plan identified that he could be sexually inappropriate at times related to his dementia diagnosis, and an intervention of “enhanced monitoring by staff as necessary” was added. However, review of progress notes from the days surrounding the incident showed no documentation of 1:1 supervision, enhanced monitoring, or continuous monitoring being provided. Interviews with facility staff revealed inconsistent understanding and implementation of supervision interventions. The DON stated that enhanced supervision was different from 1:1 supervision and that enhanced supervision did not require a physician order and was communicated verbally between nurses, with documentation expected in progress notes. In contrast, an RN/UM reported that 1:1 supervision and enhanced monitoring were the same and that an order would be in place for nurses to document, with the intervention reflected on the care plan and Kardex. The ADON stated that a physician order was needed for 1:1 supervision and that the expectation for residents on 1:1 or enhanced monitoring was implementation of a care plan and documentation in progress notes. Despite these expectations and the facility’s policy requiring care plans to be updated and implemented based on resident assessments and condition changes, there was no evidence in the record that the enhanced or 1:1 supervision interventions were consistently implemented or documented for this resident after the incident.
Failure to Provide and Document Required Incontinence and Toileting Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document incontinence and toileting care for a dependent, cognitively intact resident. The resident, admitted with multiple diagnoses including Type 2 diabetes mellitus, anemia, paroxysmal atrial fibrillation, legal blindness, gastrointestinal hemorrhage, and adjustment disorder with anxiety, reported many instances where they had a bowel movement and staff did not come in a timely manner to provide needed care. The resident’s Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and documented that the resident was always incontinent of bowel, used a wheelchair, had impaired lower extremity range of motion, and was dependent or required substantial/maximal assistance for toileting hygiene and toilet transfers. Record review of the resident’s bowel elimination task documentation revealed multiple shifts across January, February, and March where no care was marked, despite the resident’s total dependence on staff for toileting. Specifically, there were numerous 7 AM–3 PM, 3 PM–11 PM, and 11 PM–7 AM shifts with no documentation of bowel care provided. The resident’s care plan identified impaired physical mobility and self-care deficit, with interventions stating the resident was totally dependent on staff to meet toileting needs and would be toileted in bed with staff assistance, and also identified constipation related to opioid use, decreased mobility, and fear of pain, with interventions including encouraging the resident to sit on the toilet and following the facility bowel protocol. There were no physician orders specific to incontinence care and no progress notes documenting refusals of incontinence care during the review period. Interviews with nursing leadership and licensed staff confirmed that the facility’s expectation is that CNAs document toileting and incontinence care, including whether a resident voided, and that if care is not documented, it is considered not done. The RN/unit manager, an LPN, and the DON all stated there is no way to verify that toileting or incontinence care occurred if it was not charted. Position descriptions for RNs, LPNs, and CNAs require monitoring and documenting care, reporting changes in condition, and ensuring compliance with care plans and facility policies. The facility’s bowel and bladder/incontinence care policy requires that residents with any incontinence episodes be assisted with toileting or checked for incontinence at specified times (upon rising, before/after meals, activities, therapy, at bedtime, and as needed) and that CNAs document toileting as part of ADL care. Despite these policies and role expectations, the documentation gaps and the resident’s report of delayed care demonstrate that required incontinence and toileting care was not consistently provided or recorded for this resident.
Inaccurate and Incomplete Documentation of Controlled Substance Counts on Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and consistent documentation of controlled substances on shift-to-shift narcotic count sheets for multiple medication carts. Surveyors observed that the narcotic count sheet for cart 200-A had no entry for the current morning’s count, even though the assigned LPN stated the count itself was correct and that she had simply forgotten to record the total number of narcotic cards. During interviews, nursing staff described the facility’s process: at each shift change, the off‑going and oncoming nurses are required to count narcotic cards together, verify each resident’s narcotic medications, and both sign the Shift-to-Shift Controlled Medication Count. Staff also reported that discontinued or discharged narcotic cards remain in the locked narcotic box in the cart until the DON removes them with another nurse as witness. Further review of the narcotic binders for carts 100/A, 100/B, and 200/A revealed numerous discrepancies and incomplete or illegible entries. For cart 100/B, surveyors noted multiple instances where the total number of narcotic cards changed between shifts without any explanatory comments, as well as sequences of plus and minus entries that did not mathematically match the documented totals. Some entries showed beginning counts that did not align with the prior shift’s ending count, and there were illegible notations and unclear corrections. Similar issues were found in the 100/A narcotic ledger, including unexplained changes in total card counts, incorrect totals after documented additions and removals, missing shift counts, and entries written in the comments section instead of the total column. In several cases, the total number of cards increased or decreased without any corresponding explanation in the comment section. The 200/A narcotic count sheets also contained multiple inconsistencies. Surveyors identified shifts where the total narcotic card count decreased or increased from one shift to the next with no documentation in the comment section to explain the change, as well as a missing total entry for an entire shift. There were instances where a new count sheet was started without carrying over the prior total, resulting in a new starting count that did not match the previous ending count. Some entries contained illegible numbers and scratched-out totals before a final number was recorded. During interviews, the ADON and unit manager acknowledged that there were areas for improvement and inaccuracies in the ledgers, and one RN reported that when he left his cart keys with another nurse during a break, he did not document the narcotic count upon his return because the binder was in the ADON’s office. The facility’s own policies require that controlled substances be inventoried at each shift change by both incoming and outgoing nurses, that keys remain in the possession of a licensed nurse, and that all alleged misappropriation be reported, but the observed documentation practices and omissions did not consistently follow these requirements. Interviews with leadership and pharmacy personnel further clarified the existing processes and expectations but also underscored the documentation gaps. The ADON stated that when pharmacy delivers narcotics, the receiving nurse verifies the prescription with the delivery person, signs the delivery documentation, places the prescription in the narcotic book with a witness, and adjusts the shift-to-shift count. The ADON also stated that if a nurse relinquishes keys to another nurse for a break, the expectation is that narcotics are counted before and after the break, yet the RN who handed off his keys did not document a count upon return. Staff referenced at least one prior incident of a missing narcotic pill that was reportedly resolved, but the ADON indicated she had not had concerns about narcotic diversion during her tenure and believed pharmacy would alert the facility if there were issues. The consultant pharmacist reported that their role includes monthly medication review, checking for expiration dates, and verifying destruction of medications, but not checking narcotic counts beyond destruction processes. These combined observations and interviews demonstrate that the facility did not consistently maintain accurate, complete, and legible controlled substance count records as required by its own policies and regulatory expectations. The facility’s written policy on Schedule II controlled substances requires that when a controlled medication is administered, the nurse must document on the declining inventory sheet the date, quantity administered, amount remaining, and initials, and that an inventory count of all controlled medications on each unit be performed at each shift change by both incoming and outgoing nurses, with both signing the inventory form. The policy on abuse, neglect, exploitation, and misappropriation states that the facility will maintain an inventory of residents’ property and report alleged misappropriation in accordance with federal and state law. Despite these written requirements, the survey findings show repeated failures to document shift-to-shift narcotic counts accurately, to reconcile changes in total card counts, and to ensure that all required entries and signatures were present on the narcotic ledgers for multiple carts over an extended period.
QAPI Committee Failed to Sustain Corrective Actions for Narcotic Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure its Quality Assurance and Performance Improvement (QAPI) Committee effectively implemented and monitored corrective actions to prevent recurrence of previously identified problems with controlled medication documentation. The facility had been cited earlier under F755 for issues related to narcotic management and had developed a Plan of Correction with specific education and auditing processes. Education on narcotic shift-to-shift documentation, including requirements for count sheets, comment sections, signatures at the time of count, and counts when medications are received from the pharmacy, was initiated for nursing staff. Audit tools were also created with the stated goal of ensuring compliance with proper documentation on narcotic shift count sheets, and audit results showed 100% compliance on paper. Despite these measures, direct observations and record reviews showed that the corrective actions were not consistently carried out in practice. Review of Controlled Medication Inventory Sheets (CMIS) on multiple medication carts revealed incomplete and inaccurate documentation of narcotic counts over several days. On one cart, incomplete documentation of narcotic counts was found, and the RN present acknowledged that someone had forgotten to write down the name of the medication. On another cart, incomplete documentation was also identified, and the LPN stated there was no need to complete the resident’s name on the CMIS, indicating a misunderstanding or disregard of documentation requirements. Further review of additional carts showed similar issues. On one cart, an RN reported not having received recent education about narcotic management, despite the facility’s claim that all nurses had been educated. On another cart, the CMIS documented a total of 23 narcotic cards, while only 22 cards were physically present, and the RN Unit Manager acknowledged that the resident’s name should be documented and later reported that staff had told her they forgot to document the removal of one narcotic card. Another LPN described the expected process for narcotic counts and documentation, including documenting when medication cards are received or removed and ensuring all entries are complete and accurate, but the documented deficiencies showed that this process was not consistently followed. These findings, combined with QAPI meeting records that focused on reviewing the CMS Form 2567 and discussing corrective actions, demonstrate that the QAPI Committee did not effectively ensure that the planned corrective actions for narcotic documentation were fully implemented and sustained. The facility’s own QAPI policy describes a comprehensive, data-driven program intended to involve all departments and staff, focus on systems and processes, and use root cause analysis and performance improvement projects to achieve sustained improvement. It states that the Administrator is responsible for the Quality Assessment and Assurance Committee, which is to meet at least monthly, obtain data from multiple sources, and monitor and evaluate changes. However, the continued presence of incomplete and inaccurate narcotic documentation on multiple medication carts after the prior citation and Plan of Correction shows that the systems and monitoring described in the policy were not effectively applied to this issue. The deficiency centers on the gap between the facility’s written QAPI framework and the actual implementation and oversight of narcotic documentation practices on the units.
Failure to Reconcile and Administer Antipsychotic Medication on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to accurately reconcile and continue an antipsychotic medication upon a resident’s readmission. The resident had diagnoses including major depressive disorder, generalized anxiety disorder, and other specified persistent mood disorders, and was discharged from the hospital with an active order for Lurasidone (Latuda) 20 mg to be given orally with supper. On readmission, the hospital discharge medication list clearly showed this Latuda order, but the facility’s electronic medical record and Order Summary Report for the readmission did not include Latuda, and the admission progress note section for medication reconciliation indicated there were no medications recommended by the hospital. As a result, the Latuda order was not entered into the physician orders on readmission and was not administered on the first two days after the resident returned. The medication was not started at the facility until two days after readmission, when it was initiated based on the hospital discharge paperwork. Interviews revealed that the DON expected the admitting nurse to call the physician, verify medications from the hospital discharge paperwork, review readmit medications, obtain new orders, and document any changes, but this process did not occur correctly for this resident’s Latuda order. An interview with the resident’s psychiatrist confirmed that he was not notified that the resident had missed two days of the antipsychotic medication and that it was important for medications to be administered as ordered. The facility’s medication reconciliation policy required reviewing hospital medication orders, noting any that needed clarification, and reviewing all medications with the physician when obtaining admission orders, as well as reviewing medications when residents return from ER visits or physician appointments, but this process was not followed for the Latuda prescription in this case.
Failure to Promptly Notify Physicians of Laboratory Results
Penalty
Summary
The facility failed to promptly notify physicians of laboratory results for two residents, as required by federal regulations and the facility's own policies. For one resident, who had a history of a motor vehicle accident resulting in fractures and was experiencing respiratory symptoms, a stat D-dimer test was ordered by the physician. The laboratory result, which was significantly elevated, was received by the facility in the evening, but there was no documentation that the physician was notified until the following morning. Interviews with nursing staff and the Director of Nursing confirmed that the result was not communicated to the physician in a timely manner, and the delay was attributed to a lack of notification by the nurse on duty over the weekend. For another resident, laboratory results were received and reviewed by staff, but there was no documentation that the physician was notified or that the results were reviewed by the provider. The resident had a complex medical history, including diabetes, behavioral disturbances, and recent medication changes. Progress notes and provider documentation did not indicate that the abnormal lab results were communicated or addressed, despite facility policy requiring prompt notification and documentation of such communication. The facility's policy outlines a process for tracking, receiving, and notifying providers of laboratory results, including the use of a lab log and documentation of notification and any new orders. However, in both cases, the required steps were not followed, and there was a lack of documentation to show that physicians were promptly informed of critical or abnormal laboratory findings. This failure was confirmed through record review and staff interviews, demonstrating noncompliance with both regulatory requirements and internal procedures.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F773 Lab Services Physician Order/Notify of Results 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, the lab was reviewed by the physician no changes made to current order. Physician progress note completed that labs were reviewed for resident #1 and no changes made. Resident #2 discharged from 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. Other current residents with lab orders in the last 30 days from were reviewed by the DON/Nursing Administration team to ensure review of lab results and physician notification with documentation was completed. 3. What measures will be put in place or what systematic changes will you make to ensure that deficient practice does not occur. Nurse leadership staff will be educated by the DON/designee regarding daily lab order review, and timely notification to physicians of results with supporting documentation by. Education completed by DON/designee to the licensed nurses regarding daily review of lab orders and timely notification of lab results reported to the physician of results with supporting documentation by. Education completed by the DON/designee to physicians for review of labs and notation that the lab was reviewed by. 4. How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? Random audits of lab orders, physician notification of lab results, and supporting documentation will be completed by the DON/designee on 20 residents, weekly x4 weeks then monthly x2 months. The results of the random audits will be presented to the QAPI committee monthly x3 months and as needed for review and follow-up recommendations as indicated. DON/designee regarding daily lab order review, and timely notification to physicians of results with supporting documentation by. Education completed by DON/designee to the licensed nurses regarding daily review of lab orders and timely notification of lab results reported to the physician of results with supporting documentation by. Education completed by the DON/designee to physicians for review of labs and notation that the lab was reviewed by. 4. How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? Random audits of lab orders, physician notification of lab results, and supporting documentation will be completed by the DON/designee on 20 residents, weekly x4 weeks then monthly x2 months. The results of the random audits will be presented to the QAPI committee monthly x3 months and as needed for review and follow-up recommendations as indicated.
Delayed Provider Notification of Laboratory Results
Penalty
Summary
The facility failed to ensure that two residents received appropriate and adequate healthcare services due to delays in notifying the ordering provider of laboratory results. For one resident, who had a history of a motor vehicle accident resulting in fractures and was experiencing respiratory symptoms, a stat D-dimer test was ordered by the physician. The lab specimen was collected and the results, which were significantly elevated, were reported to the facility in the evening. However, there was no documentation that the physician was notified of these results until the following morning, resulting in a delay in further medical evaluation and intervention. For another resident, laboratory tests were ordered and completed, with results received and reviewed by staff. Despite this, there was no documentation that the physician or provider was notified of the results or that the results were reviewed by the provider. Progress notes and interviews confirmed the absence of documentation regarding provider notification or review of the lab results, even though the resident had a complex medical and behavioral history and was undergoing medication changes that warranted close monitoring. Interviews with nursing staff and the Director of Nursing revealed inconsistencies and gaps in the process for tracking, documenting, and communicating laboratory results to providers. Staff described reliance on verbal handoffs and incomplete use of lab tracking logs, and acknowledged that results were sometimes not promptly communicated to physicians. The facility's own policy required prompt notification of lab results to providers, but this was not consistently followed, as evidenced by the delays and lack of documentation in these two cases.
Plan Of Correction
N201 Right to Adequate and Appropriate Health Care Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F773 Lab Services Physician Order/Notify of Results 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, the lab was reviewed by the physician no changes made to current order. Physician progress note completed that labs were reviewed for resident #1 and no changes made. Resident #2 discharged from 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. Other current residents with lab orders in the last 30 days from , were reviewed by the DON/Nursing Administration team to ensure review of lab results and physician notification with documentation was completed. 3. What measures will be put in place or what systematic changes will you make to ensure that deficient practice does not occur. Nurse leadership staff will be educated by the DON/designee regarding daily lab order review, and timely notification to physicians of results with supporting documentation by. Education completed by DON/designee to the licensed nurses regarding daily review of lab orders and timely notification of lab results reported to the physician of results with supporting documentation by. Education completed by the DON/designee to physicians for review of labs and notation that the lab was reviewed by. 4. How will the corrective actions be monitored to ensure the practice will not recur, what quality measures will be put into place? Random audits of lab orders, physician notification of lab results, and supporting documentation will be completed by the DON/designee on 20 residents, weekly x4 weeks then monthly x2 months. The results of the random audits will be presented to the QAPI committee monthly x3 months and as needed for review and follow-up recommendations as indicated. N0201
Failure to Promptly Notify Physicians of Laboratory Results
Penalty
Summary
The facility failed to promptly notify physicians of laboratory results for two residents, resulting in a deficiency. For one resident with a history of fractures and essential hypertension, a stat D-dimer test was ordered after the resident experienced shortness of breath and was placed on oxygen. The D-dimer result, which was significantly elevated, was received by the facility but not communicated to the physician until two days later. During this period, there was no documentation of physician notification or follow-up regarding the abnormal result, despite the resident's ongoing symptoms and the critical nature of the test. In the second case, a resident with multiple diagnoses including diabetes, heart disease, and mood disorders had a valproic acid level ordered and collected. The laboratory result was received and reviewed in the system, but there was no documentation that the physician or psychiatric provider was notified of the result or that it was reviewed, despite facility policy requiring such notification and documentation. Progress notes and psychiatric notes did not reference the lab result, and the Director of Nursing confirmed the absence of documentation regarding review or notification. Interviews with nursing staff and the DON revealed inconsistencies in the process for tracking and communicating lab results. Staff described reliance on shift-to-shift communication and lab books, but there was no consistent use of a daily log or clear documentation of physician notification. Facility policy required prompt notification of lab results to physicians and documentation of such actions, but these procedures were not followed in the cases reviewed, leading to delays in physician awareness and potential delays in care.
Failure to Maintain Pest-Free Environment Across Facility Wings
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment due to ongoing pest sightings across all five wings. During a tour, live insects, including spiders and cockroaches, were observed in resident areas such as the dining room and linen closet. Multiple residents with intact cognition reported seeing pests, including roaches, in their rooms. Staff interviews confirmed occasional sightings of roaches, flying pests, and ants, with staff trained to record these in pest logs. Review of pest sighting logs documented numerous pest sightings in resident rooms and common areas over several months, including cockroaches, ants, and other bugs. The facility's pest control policy requires regular pest control services, food storage in airtight containers, daily trash removal, and prompt reporting and investigation of pest sightings. However, the Nursing Home Administrator acknowledged that pest reporting had increased and that the current pest control contractor was not meeting expectations. The absence of a housekeeping supervisor placed the responsibility for monitoring pest control on the administrator. Despite ongoing pest control efforts, the facility continued to experience pest issues, as confirmed by both staff and residents.
Failure to Notify Family of Change in Condition and New Medication
Penalty
Summary
The facility failed to inform the family of a resident's change in condition, specifically regarding a low potassium level and the initiation of potassium supplementation. The resident, who was admitted for respite and hospice care, had multiple diagnoses including transient ischemic accident, congestive heart failure, cerebrovascular accident, stage 4 chronic kidney disease, and hypertension. Laboratory results showed a potassium level below the acceptable range, and the resident was subsequently started on potassium as ordered by the physician. However, there was no documentation in the progress notes indicating that the family was notified of the abnormal lab result or the new medication. During interviews, the DON confirmed that the facility's policy requires prompt notification of the resident's representative when there is a significant change in the resident's condition or when new medications are started. The DON acknowledged that the family should have been notified of the low potassium and the initiation of potassium therapy. Review of the facility's policy further supported the expectation for family notification and documentation in the medical record, which was not observed in this case.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by a staff member, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with severe cognitive impairment. The resident, who had a history of dementia, anxiety, and psychosis, was observed to have been pinched by a staff member after an altercation. The incident was reported by another staff member who witnessed the CNA pinching the resident in retaliation after the resident had hit the CNA. This resulted in visible bruising on the resident's arms, which was consistent with the reported abuse. The resident's medical history included severe cognitive impairment, aggressive behavior, and a tendency to wander, which required supervision and specific interventions to ensure safety. The resident's care plan highlighted the need for staff to intervene to protect the rights and safety of others, and to approach the resident in a calm manner. Despite these measures, the incident occurred, indicating a failure in adhering to the care plan and abuse prevention policies. The facility's policy on abuse prevention mandates immediate reporting of any alleged violations to the appropriate authorities. However, the incident involving the resident and the CNA was not prevented, and the staff member involved was only suspended after the fact. The facility's records showed that the CNA had received abuse training approximately one month prior to the incident, yet the abusive behavior still occurred, highlighting a deficiency in the facility's ability to prevent and address abuse effectively.
Failure to Provide Trauma-Informed Care After Abuse Allegation
Penalty
Summary
The facility failed to provide trauma-informed care for a resident following an allegation of abuse. The resident, who had a history of moderate cognitive impairment and a previous molestation experience, reported feeling molested by a volunteer. Despite the resident's family confirming a history of molestation, the facility did not conduct a trauma screening after the allegation, which was a requirement according to their policy. The resident had been admitted with diagnoses including Parkinson's disease, dementia, and anxiety disorders. Prior to the incident, the resident had expressed concerns about being drug tested or molested during a urine collection procedure. The facility's records showed that the last PTSD/Trauma Screening was conducted nine months before the allegation, and it did not indicate PTSD at that time. However, the facility's policy required rescreening when new trauma indicators arose, which was not done in this case. Interviews with facility staff, including the Risk Manager, Director of Nursing, and Social Service Director, revealed a lack of awareness and communication regarding the resident's history and the need for a trauma screening. The facility's policy on trauma-informed care emphasized the importance of addressing past trauma and developing individualized care plans, but these steps were not taken following the resident's allegation.
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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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