Vivo Healthcare Lakeland
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakeland, Florida.
- Location
- 1919 Lakeland Hills Blvd, Lakeland, Florida 33805
- CMS Provider Number
- 105354
- Inspections on file
- 26
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Vivo Healthcare Lakeland during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical conditions reported ongoing dental pain, altered eating habits, and longstanding difficulty obtaining dental care, stating that appointments were delayed, had to be initiated by the resident, and were sometimes cancelled without explanation. Records showed a prior in-house dental visit documenting a mobile root fragment causing discomfort and the resident’s interest in extraction, but there was no evidence of follow-up, no documentation of tooth pain or dental issues in progress notes, and no Social Services documentation of offering or arranging dental services or explaining the lack of access. The SSD confirmed the absence of follow-up despite a later on-site visit by the dental provider and cited the resident’s low income and inability to cover dental liability, while the facility’s policy committed to assisting residents in obtaining routine and emergency dental care for damaged teeth and other urgent oral problems.
Surveyors found deficiencies in infection control, including improper storage and disposal of toileting items in two resident rooms, staff with artificial nails exceeding policy length, and a CNA failing to perform hand hygiene during meal service after coughing and wiping her face before feeding a resident.
Two residents with cognitive and physical impairments were observed with their briefs exposed and visible from the hallway, in violation of facility policy and staff training on resident dignity and privacy.
Surveyors found that several resident rooms had environmental deficiencies, including a picture hanging off the wall, a high-rise toilet seat with dirty tape, and torn drywall behind a bed. Additionally, a shower room was used to store equipment such as a bed, walker, and reclining chairs. Staff interviews revealed that these issues were not reported or addressed as required by facility policy.
A resident with severe cognitive impairment sustained bruising and swelling around the eye after another resident mistakenly entered her bed, resulting in head-to-head contact. Although staff witnessed the incident and documented the injury, the DON and NHA did not report the event to state agencies, citing lack of intent or aggression, despite facility policy requiring such reporting.
Two residents with dementia and additional mental health diagnoses did not have updated PASRR assessments, as required. The Social Services Director, responsible for PASRR screenings, was unfamiliar with regulatory requirements and did not consistently identify when a Level II PASRR was needed, resulting in incomplete assessments.
The facility did not ensure comprehensive, person-centered care plans for three residents with severe cognitive impairment, resulting in repeated falls, unaddressed injuries, and unmanaged behavioral issues. Staff interviews revealed a lack of awareness and understanding of care plan interventions, and care plans were not consistently updated or communicated following significant changes in residents' conditions.
Two residents did not receive necessary assistance with ADLs, including bathing and grooming. One resident, dependent for bathing and needing supervision for oral hygiene, was left with unwanted facial hair, while another, requiring full assistance for bathing, missed multiple showers and was noted to have a foul odor. Staff did not consistently offer or document required care, despite facility policy and resident care plans indicating these needs.
The facility failed to schedule a stat urology consult and follow up on an MRI with sedation for a resident with complex medical needs, and did not administer medications on time for two other residents. Staff interviews revealed a lack of awareness and communication regarding appointment scheduling, and medication passes were routinely late due to staffing and workflow issues, contrary to facility policy.
A resident with multiple psychiatric diagnoses was prescribed several psychotropic and other medications, but side effect monitoring for antipsychotic use was discontinued while the medications continued. The care plan and facility policy required ongoing monitoring and documentation of side effects, but this was not maintained, as confirmed by the DON.
A registered nurse was observed making two medication errors while administering medications to a resident, resulting in a medication error rate of 7.14%. The nurse incorrectly measured and mixed MiraLAX with other medications and dispensed an extra Losartan tablet, actions that did not align with the resident's orders or facility policy.
Surveyors found improper food storage practices and expired food items in kitchen areas, including a non-functioning walk-in freezer containing food, a fridge with spoiled produce and expired pickles, and a trailer freezer with open boxes. The CDM confirmed food was stored incorrectly and that expired items were not discarded, contrary to facility policy.
Two residents with severe cognitive impairment and known elopement risk were able to leave the facility unsupervised due to lapses in staff supervision, unsecured exit areas, and delayed notification of law enforcement. One resident walked a significant distance and was found on a highway, requiring hospitalization for dehydration and acute kidney injury, while another was found outside the building after triggering an exit alarm.
Two residents with severe cognitive impairment and a history of wandering were able to exit the facility unsupervised, with one resident found walking away from the building after triggering a door alarm and another resident leaving through a damaged patio screen and being found on a highway. Staff interviews revealed lapses in supervision, communication, and timely response, and the facility lacked an effective QAPI plan to prevent such elopements.
A facility failed to address flooring hazards in a memory care unit, leading to a resident's injury. The resident, who had difficulty walking, was injured due to an uneven walkway caused by a concrete patch left by plumbers. The DOM delayed repairs, opting for temporary fixes that were inadequate, resulting in the resident requiring surgical intervention and experiencing a decline in mobility and daily living activities.
A resident in a memory care unit suffered a significant injury after tripping over an unrepaired clean-out drain in a high-traffic area. The facility failed to promptly address the flooring hazard, relying on inadequate temporary measures. This oversight resulted in the resident's decreased ability to walk independently and perform daily activities, requiring surgical intervention.
A flooring hazard in the memory care unit of a facility led to a resident tripping and sustaining a serious injury. The issue involved a missing clean-out cover that was inadequately repaired with a metal sheet and tape, causing the resident to fall. The resident, who had difficulty walking, required hospitalization and surgery. The facility's maintenance records indicated a delay in addressing the hazard, which was in a high-traffic area, placing others at risk.
A facility failed to protect resident privacy when a staff member posted unauthorized videos of residents on social media. The videos, featuring residents from the secure memory care unit, were shared without consent, violating their dignity and privacy. Many residents were unable to provide informed consent due to cognitive impairments, and the facility's social media policy was not followed.
A facility failed to protect resident privacy and confidentiality when videos of residents, many with severe cognitive impairments, were posted on social media without consent. The videos, initially shared by an Admissions Coordinator, were widely disseminated, and family members were not informed or asked for consent. The facility's policy prohibits such actions, yet the breach went unnoticed by administration until it was reported.
The facility failed to maintain admission paperwork, including agreements and consents, for four residents. The Administrator confirmed the absence of these documents and was unsure of their whereabouts, prompting the facility to begin obtaining new paperwork.
A facility failed to maintain accurate and complete medical records for a resident who experienced a change in condition. Despite the initiation of emergency procedures and notification of EMT, the clinical record did not reflect these actions. The Director of Nursing confirmed the documentation was incomplete, violating the facility's policy on timely and accurate record-keeping.
A resident in the memory care unit suffered a major injury due to a fall caused by an unsafe environment with uneven flooring. The facility failed to report the incident as required by policy, and the Director of Nursing did not consider it adverse since the plan of care was followed. The Director of Maintenance addressed the flooring issue only after the incident, highlighting a lack of prompt action to ensure resident safety.
A resident in a memory care unit suffered a major injury due to a fall in a high-traffic area with uneven flooring. The facility failed to report the incident as required, despite the resident's care plan indicating a risk for falls. Temporary fixes to the flooring hazard were inadequate, and staff did not adhere to reporting policies.
A resident with acute failure and supplemental support dependence was found unresponsive after a room transfer. Despite emergency measures being initiated, the facility failed to document these actions in the clinical record, as confirmed by the DON. This omission violated the facility's policy requiring accurate and timely documentation of resident care.
A facility failed to provide timely access to medical records for a resident with Alzheimer's and other conditions, despite a request from the family made nearly 11 months prior. The Medical Records Director delayed the release due to instructions from the new company ownership and lack of contact with company attorneys. The facility's policy requires timely access to records, which was not adhered to in this case.
A resident who had undergone a renal transplant did not receive physician-ordered laboratory tests, including weekly Creatinine levels and Vitamin B12/Folate levels. The facility's staff failed to ensure these tests were completed due to a lack of awareness and understanding of the process for confirming and entering laboratory orders. The facility's policy emphasized the need for timely laboratory services, but the deficiency was evident as the orders were not properly entered or confirmed, leading to missed tests.
Failure to Provide Timely Dental Services for Resident with Documented Tooth Fragment
Penalty
Summary
Failure to ensure dental services were provided occurred when a resident with intact cognition and documented dental needs did not receive timely follow-up care. The resident, admitted with diagnoses including muscle wasting, legal blindness, and anemia, reported that obtaining dental care at the facility had always been a problem. He stated his mouth felt "weird," he had ongoing dental pain when eating, and he therefore mainly ate soft foods. He reported seeing the dentist only once and not thereafter, and described repeated issues with scheduling, including the facility attributing delays to insurance or paperwork, the resident having to initiate appointments himself, and last-minute cancellations without explanation. Despite these complaints, the resident’s MDS oral/dental section showed no responses indicating mouth or facial pain, chewing difficulty, or problems with teeth or dentures. Record review showed a dental order from an outside dental service documenting that the resident had a mobile root fragment on tooth #8 causing slight discomfort and that the resident was interested in extraction. However, there was no evidence in the progress notes of documentation of tooth pain, a broken tooth, or any follow-up dental services. Social Services notes contained no documentation of offering dental services or any rationale for the lack of access to dental care. The Social Services Director confirmed that the resident had been seen by an in-house dentist for the root fragment and expressed interest in extraction, but could not explain why no follow-up occurred and acknowledged that the resident had not been seen when the dental company was later on-site. The SSD also stated the resident’s income was very low and that he did not have enough to cover patient liability for dental services, and that attempts were being made to contact family about payment responsibility. The facility’s dental policy stated it would assist residents in obtaining routine and emergency dental care, including treatment of broken or damaged teeth or other oral problems requiring immediate attention.
Infection Control Deficiencies in Sanitation, Staff Grooming, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. In two resident rooms, improper storage and disposal of toileting items were observed: a plastic urinal was left open on the floor under a bed with a wet area present, and an adult brief with visible soiling was found on the bathroom floor in front of the toilet. These observations were supported by photographic evidence. Additionally, three staff members, including two RNs and one CNA, were observed with artificial nails longer than the facility's policy limit of 1/4 inch, in violation of the dress code and infection control standards. During a meal service, a CNA was observed serving multiple meal trays and assisting a resident with feeding without performing hand hygiene at any point. The CNA was also seen coughing into her hand and wiping her face, then using the same hand to feed a resident, again without hand hygiene. Interviews with facility leadership confirmed that these actions were not in line with facility policy, which requires hand hygiene when entering or exiting resident rooms, between resident care activities, and specifically while feeding residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
Two residents were observed in situations that failed to maintain their dignity and privacy as required by facility policy. One resident, with severe cognitive impairment and multiple diagnoses including Parkinson's disease and dementia, was seen from the hallway sitting on the side of his bed, sleeping, and wearing only a T-shirt and a brief, with his brief visible from the hallway. Another resident, who had moderate cognitive impairment and required substantial assistance with dressing, was observed in her wheelchair with her nightgown pulled up and her briefs exposed, also visible from the hallway. Interviews with staff, including CNAs and the DON, confirmed that residents should not be visible in their briefs from the hallway and that maintaining resident privacy is part of their dignity training. The facility's policy emphasizes the importance of protecting and promoting resident rights, including maintaining privacy. Despite this, both residents were left exposed in a manner that did not uphold their dignity, as observed by surveyors.
Failure to Maintain Homelike and Safe Environment in Resident Rooms and Shower Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in several rooms and a shower area. During a facility tour, surveyors observed multiple deficiencies: pictures hanging off the wall over a resident's bed, a high-rise toilet seat with dirty tape attached in a resident's bathroom, and torn, unfinished drywall behind a resident's bed. Additionally, one of two shower rooms was being used to store a bed, walker, and reclining chairs, rather than being maintained for resident use. Interviews with staff revealed a lack of awareness and reporting regarding these environmental issues. The RN/Unit Manager was not aware of the specific deficiencies and stated that such issues should have been reported during daily room rounds. The Director of Maintenance also indicated he was unaware of the problems and expected staff to report them through the maintenance system. The Nursing Home Administrator confirmed that managers are assigned to monitor rooms and report concerns, but acknowledged that these issues were not reported as expected. The facility's policy requires housekeeping and maintenance to maintain a sanitary and comfortable environment and for unresolved concerns to be reported to the Administrator.
Failure to Report Resident-to-Resident Incident Resulting in Injury
Penalty
Summary
The facility failed to report an alleged resident-to-resident incident to the appropriate state agencies as required by law. A resident with severe cognitive impairment and multiple diagnoses, including anoxic brain damage and aphasia, was observed with significant bruising and swelling around her left eye. Documentation and staff interviews revealed that another resident mistakenly entered her bed, resulting in physical contact between the two residents' heads. The incident was witnessed by staff, and both residents were assessed, with the affected resident later showing visible injury. The incident was documented in progress notes and communicated to the families of both residents. Despite the presence of injury and the facility's own policy identifying physical marks as possible indicators of abuse, the DON and NHA did not report the incident to state agencies or law enforcement. The DON stated that the event was not considered reportable because there was no intent or physical aggression involved. This decision was made even though the facility's policy requires reporting all alleged violations, including those resulting in injury, within specified time frames.
Failure to Update PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were properly updated for two residents with mental health diagnoses. For one resident admitted with unspecified dementia, mood disorder, major depressive disorder, and insomnia, the Level I PASRR indicated no suspicion of serious mental illness or intellectual disability, and a Level II PASRR was not completed, despite the presence of secondary mental health diagnoses. Similarly, another resident admitted with unspecified dementia, mood disorder, major depressive disorder, and generalized anxiety disorder had a Level I PASRR that did not trigger a Level II evaluation, even though the resident had a primary diagnosis of dementia and additional mental health conditions. Interviews and record reviews revealed that the Social Services Director was responsible for reviewing diagnoses and completing PASRR screenings but was not familiar with the specific regulatory requirements. The process relied on information from psychiatry and GDR meetings to identify new diagnoses, but there was a lack of understanding regarding when a Level II PASRR was required. The facility's policy stated that all applicants should be screened according to state Medicaid rules, with the Social Services Director responsible for tracking PASRR status, but this was not consistently followed, leading to the deficiency.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed the medical, physical, mental, and psychosocial needs of three residents with severe cognitive impairment. For one resident with Parkinson's Disease and a history of frequent falls, observations revealed repeated unsafe situations, such as being left unsupervised in a high bed with cluttered surroundings and having multiple falls since admission. The care plan included several interventions, but staff interviews indicated a lack of awareness and understanding of these interventions, with some staff unable to access or describe the care plan. Despite ongoing falls, there was no evidence that the effectiveness of interventions was evaluated or that staff were consistently informed of changes. Another resident with anoxic brain damage and aphasia was observed with significant facial bruising, but the care plan did not include any focus, goals, or interventions related to the injury or its monitoring. Staff interviews revealed that the incident was known among staff, but there was no documentation in the care plan to address the injury or prevent recurrence. The lack of care plan updates following significant changes in the resident's condition demonstrated a failure to ensure comprehensive and responsive care planning. A third resident with severe cognitive impairment and behavioral issues had a care plan that addressed a single aggressive incident but did not include additional focuses, goals, or interventions for subsequent behavioral episodes, such as confusion and entering another resident's bed. Staff responsible for updating care plans relied on daily order reports and verbal communication, but there was no systematic process to ensure all relevant staff were informed of care plan changes. The facility's policy required measurable objectives and timely updates, but interviews and documentation showed these requirements were not consistently met.
Failure to Provide Assistance with ADLs: Bathing and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents. One resident, admitted with multiple diagnoses including neuromuscular dysfunction and multiple sclerosis, was observed with long white facial hair and expressed a desire for help with its removal. Her records indicated she required supervision or assistance for oral hygiene and was dependent on staff for bathing. A CNA confirmed she had not offered assistance with facial hair removal, and the DON stated that staff should offer help with unwanted facial hair during showers or baths. Another resident, dependent on staff for bathing due to muscle wasting and immunodeficiency, was noted to have a foul odor emanating from his side of the room. Staff discussed not providing a shower due to concerns about covering his neck, and documentation showed that bathing was missed on four out of five opportunities. The resident's care plan indicated a preference for showers with one-person assistance, but records showed refusals were not consistently documented or signed by nursing staff. Facility policy required provision of ADL care based on assessment and resident needs, including bathing and grooming, but these services were not consistently provided or documented for the residents involved.
Failure to Schedule Specialist Appointments and Timely Medication Administration
Penalty
Summary
The facility failed to provide appropriate nursing care and services for several residents, as evidenced by missed specialist appointments and delayed medication administration. One resident with a history of cerebral infarction, benign prostatic hyperplasia, mood disorder, major depressive disorder, and dementia was not scheduled for a stat urology consult as ordered, and there was no evidence of follow-up for an MRI with sedation as requested by the family and recommended by the neurologist. Multiple interviews with staff revealed a lack of awareness regarding the need for these appointments, and the transportation coordinator was not informed of the required consults. The Director of Nursing acknowledged that insurance issues may have contributed to the delay, but this was not documented in the resident's chart, and there was no facility policy available for review regarding appointment scheduling. Additionally, two residents did not receive their medications within the required time frame. One resident with chronic obstructive pulmonary disease, diabetes mellitus, and hypokalemia had multiple medications, including antihypertensives, diuretics, steroids, and inhalers, administered several hours after the scheduled time. Another resident with Parkinson's disease, mood disorder, anemia, major depressive disorder, and neurocognitive disorder with Lewy bodies received gabapentin for pain significantly later than scheduled. Staff interviews confirmed that late medication administration was a recurring issue, attributed to staffing challenges and difficulties locating residents at the time of medication pass. The facility's medication administration policy requires medications to be given within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. Despite this, audit reports and staff interviews confirmed that medications were routinely administered outside of this window. The Director of Nursing stated that late medication administration is not acceptable and that nurses should receive assistance if they are unable to complete medication passes on time.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
A deficiency was identified when the facility failed to ensure that side effect monitoring was in place for a resident receiving multiple psychotropic medications. The resident, who had diagnoses including dementia, psychotic disorder with delusions, mood disorder, major depressive disorder, and generalized anxiety disorder, was prescribed Divalproex Sodium, Olanzapine, Lasix, Potassium Chloride, and Hydralazine. Review of the resident's records showed that behavior and antipsychotic side effect monitoring were discontinued on 06/10/25, despite ongoing use of these medications. The care plan indicated that staff should monitor and document for side effects and effectiveness, but there was no evidence of continued side effect monitoring after the specified discontinue date. During an interview, the DON confirmed that side effect monitoring should be documented in the medical record and that the admitting nurse is responsible for entering this information. The facility's medication administration policy also requires staff to report and document adverse side effects. However, the lack of ongoing documentation for side effect monitoring for this resident demonstrated noncompliance with both facility policy and regulatory requirements for unnecessary medications.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5.00%, as evidenced by two errors identified out of twenty-eight medication administration opportunities, resulting in a 7.14% error rate. During observation, a registered nurse dispensed medications for a resident, including Losartan, Lidocaine patch, Zonisamide, Nifedipine, and MiraLAX. The nurse placed a Losartan tablet and an unspecified amount of MiraLAX powder into the same medicine cup, then transferred both into a larger drinking cup. An additional Losartan tablet was dispensed separately, and other medications were added to the cup. Before administration, the process was stopped when it was noticed that an extra Losartan tablet had been mixed with the MiraLAX, and the nurse removed the tablet with a spoon, acknowledging the error. A review of the resident's medication orders showed that only one Losartan tablet and one packet of MiraLAX were to be administered daily. The nurse's method of measuring MiraLAX was inconsistent with the order, as she used an estimated capful rather than a specified packet, and mixed it with other medications, contrary to facility policy and the DON's expectations. The facility's policy required verification of medication name, form, dose, route, and time against the MAR, which was not followed in this instance.
Improper Food Storage and Expired Food Found in Kitchen Areas
Penalty
Summary
Surveyors observed multiple instances of improper food storage and the presence of expired and deteriorating food items in the facility's kitchen areas. In the walk-in freezer, there were several boxes of food, containers, and a bag of ice, along with unidentifiable debris, despite the freezer not being in use due to a malfunctioning door. The walk-in fridge contained a box with a bottle of green liquid, a yellow rag, wrinkled green bell peppers with gray and black bio growth, an open can, a box of tomatoes with yellow string particles, a container of boiled eggs with ripped plastic wrap, and a bucket of pickles labeled with an expiration date that had already passed. The trailer freezer was also found to have multiple open cardboard boxes stacked on top of each other. Interviews with the Certified Dietary Manager (CDM) confirmed that the walk-in freezer was not supposed to be used and that food items had been improperly stored there. The CDM acknowledged that staff may have placed food in the freezer out of convenience, and that expired or poor condition food should have been discarded. The Nursing Home Administrator, upon reviewing photographic evidence, stated an expectation for proper food storage and cleanliness. The facility's own policy requires regular sanitation inspections to ensure compliance with state and federal regulations, which was not followed in these instances.
Failure to Prevent Elopement and Neglect of Residents at Risk
Penalty
Summary
The facility failed to protect two residents identified as being at risk for elopement from neglect, resulting in serious harm to one resident. One resident, with severe cognitive impairment and multiple psychiatric and neurological diagnoses, was able to leave the facility unnoticed. This resident exited through a screened patio door, after removing part of the screen, and walked unsupervised for eight miles along high-traffic streets, eventually being found by the State Highway Patrol on an interstate highway. The resident was subsequently hospitalized for dehydration and acute kidney injury. Interviews and records revealed that the resident was known to wander, had a history of impulsivity and agitation, and was assessed as an elopement risk, but was allowed unsupervised access to an unsecured patio area. Staff were unaware of the resident's whereabouts for an extended period, and there was a delay in notifying law enforcement after the resident was discovered missing. Another resident, also with severe cognitive impairment and a history of wandering, was able to exit the facility through an emergency exit door. The alarm on the door was triggered, and the resident was found 10-15 feet from the building, attempting to leave. This incident was identified as an isolated event by the facility, but it demonstrated a failure to provide adequate supervision and secure the environment for residents at risk of elopement. Both residents had care plans indicating their elopement risk and interventions such as allowing safe wandering on secure units, but these interventions were not effectively implemented. Facility policies required the identification, assessment, and monitoring of residents at risk for elopement, as well as the maintenance and inspection of exit doors and alarms. However, the report documents lapses in staff supervision, communication, and adherence to protocols, including delayed notification of police and failure to secure areas accessible to high-risk residents. These failures resulted in one resident suffering serious harm and created the likelihood of serious injury or death.
Failure to Implement Effective QAPI Plan to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan to prevent elopement among residents identified as at risk. One resident with severe cognitive impairment and a history of wandering was able to exit the facility through a door with an alarm, which was heard by staff after the resident had already left the building. The resident was found ambulating away from the facility and stated an intention to leave. The medical director was not familiar with the resident and did not consider the incident to be an elopement, and there was no indication of heightened concern about resident supervision from leadership at that time. Another resident, also with severe cognitive impairment and multiple medical diagnoses, was able to leave the facility unnoticed, walk a significant distance along high-traffic streets, and was eventually found on an interstate highway by law enforcement. This resident was admitted to a higher level of care for evaluation and treatment of dehydration. Staff interviews revealed that the resident was known to walk throughout the building and sit in the patio area, which was previously left unlocked and unsupervised. On the day of the incident, the resident was last seen in the dining room, and staff searched for an extended period before notifying police. The resident exited through a patio screen door by removing part of the screen, which was later found damaged. Facility policies required regular assessment and supervision of residents at risk for elopement, as well as functioning door alarms and prompt staff response to alarms. However, staff interviews and documentation indicated lapses in supervision, communication, and timely response to a missing resident. The facility's QAPI committee did not have an effective plan in place to prevent these incidents, and there was a lack of clear documentation of a comprehensive QAPI policy at the time of the survey.
Failure to Address Flooring Hazards Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate and appropriate protective and support services to prevent accident hazards, resulting in an injury to a resident in the memory care unit. Specifically, the facility did not replace a clean-out drain located in a high-traffic area and failed to address flooring issues promptly and effectively, creating an unsafe walkway. This negligence led to a resident sustaining an injury that required transfer to a higher level of care and surgical intervention. The resident involved had a history of difficulty walking and was independent in some activities of daily living but required supervision for others. The incident occurred near the nursing station and outside the resident's room, where the flooring was uneven due to a concrete patch left by plumbers. The Director of Maintenance (DOM) acknowledged the issue but delayed repairs, attempting temporary fixes that proved inadequate. This resulted in a significant decline in the resident's ability to ambulate and perform daily activities at their prior functional level.
Plan Of Correction
Immediate action(s) taken for the resident(s) found to have been affected include: Flooring was repaired to prevent further accidents. Resident # 6 is no longer resides in the facility. Identification of other residents having the potential to be affected: NHA and Director of Maintenance performed rounds of the facility to identify any hazardous areas. Identified hazards removed and/or repaired. Actions taken/ systems put in place to reduce the risk of future occurrence include: DCS/Designee provided education on Accidents and Supervision policy, redirecting residents with from environmental hazards, and recognizing and reporting potential environmental hazards. An additional staff member has been assigned to memory care unit as Hall Monitor to increase supervision. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will complete facility assessment rounds to make certain.
Failure to Address Flooring Hazards Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for its residents, particularly in the memory care unit, where a clean-out drain in a high-traffic area was not properly repaired. This oversight led to an unsafe walkway, resulting in a resident tripping and suffering a significant injury. The resident, who had a history of difficulty walking and other medical conditions, was ambulating in the hallway when she tripped over the uneven flooring and tape that was not adequately securing the area. This incident caused a significant change in the resident's ability to walk independently and perform activities of daily living, necessitating surgical intervention. The facility's maintenance records revealed that a work order was created to address the missing clean-out cover, but the issue was not resolved promptly. Instead, temporary measures such as placing a metal sheet and tape over the area were used, which proved inadequate. The Director of Maintenance acknowledged the delay in obtaining the necessary materials to fix the problem and admitted to attempting to handle the repair in-house before calling in professional plumbers. This delay in addressing the hazard contributed to the resident's fall and subsequent injury. Interviews with staff members indicated that the area was known to be a hazard, yet it remained unrepaired for an extended period. The staff, including the Director of Nursing and Certified Nursing Assistants, were aware of the incident and the resident's condition post-fall. The facility's failure to promptly and effectively address the flooring issues and provide adequate supervision and assistance devices placed the resident and others at risk for serious injury.
Plan Of Correction
Immediate action(s) taken for the resident(s) found to have been affected include: Flooring was repaired to prevent further accidents. Resident # 6 is no longer resides in the facility. 2. Identification of other residents having the potential to be affected: NHA and Director of Maintenance performed rounds of the facility to identify any hazardous areas. Identified hazards removed and/or repaired. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: DCS/Designee provided education on Accidents and Supervision policy, redirecting residents with from environmental hazards, and recognizing and reporting potential environmental hazards. An additional staff member has been assigned to memory care unit as Hall Monitor to increase supervision. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will complete facility assessment rounds to make certain facility is free of hazards once weekly x 8 weeks; then every w weekly x 4 weeks and will continue weekly rounds ongoing. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Removal Plan
- Immediate Action: Environmental rounds completed, identified areas of concern noted.
- Summoned Corporate Plant Operations support team for assistance.
- Quality review completed for all current residents sustaining a fall to ensure plan of care is in place, no discrepancies noted.
- Medical Record Review of all residents with falls with major injury conducted: no discrepancies noted.
- 99.5% of all facility staff were educated.
- Initiated and assigned direct care staff member as 'Hallway Safety Monitor' on secure unit for additional supervision.
- Identification of others at risk was accomplished by reassessing all residents residing in the facility for fall risk via Fall Risk Evaluation.
- Facility implemented Activities Invitation Rounds for residents identified at risk for falls.
- The Care Plan Coordinator(s) completed review of care plans to ensure all residents identified as 'at risk' for falls had safety measures, as well as resident specific interventions in place.
- Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards.
- Identified environmental concerns addressed by priority level, initiated repairs and ongoing.
- Record review of Resident #6 completed.
- Actions to Prevent Occurrence/Recurrence: NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion.
- Regional DCS educated the DCS on the facility's Fall Prevention Program, all facility related policies, how to conduct an RCA, and how to ensure incident investigations are timely and complete.
- DCS/designee re-educated staff on facility Fall Prevention Program guidelines, following care plan/Kardex interventions, as well as all facility related policies.
- DCS/Designee re-educated staff on Abuse, Neglect, and Exploitation Policy.
- DCS/Designee re-educated staff on Residents' Rights.
- DCS/Designee re-educated staff on Accidents and Supervision Policy.
- DCS/Designee re-educated staff on Recognizing & Reporting Hazards.
- DCS/Designee re-educated staff on Redirecting Residents with Dementia from Environmental Hazards.
- DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm.
- The Director of Clinical Services/designee to conduct quality monitoring of new admission fall risk evaluation completion to ensure that risk factors, safety measures, and resident specific interventions are reflected on the care plan and Kardex.
- A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures.
- NHA/Plant Ops/Designee will round to ensure facility is free of hazards.
- DON/designee will review all falls at the clinical meeting with the IDT (interdisciplinary) to ensure appropriate interventions are implemented, the resident's care plan has been reviewed and revised, and the Kardex has been updated.
- Regional DCS will review to ensure a RCA (root cause analysis) has been conducted and that resident specific interventions are reflected in the care plan as well as updated on the Kardex.
- Verification of the facility's removal plan was conducted by the survey team.
Flooring Hazard in Memory Care Unit Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and visitors, particularly in the secure memory care unit, where a flooring hazard was present. This hazard was due to an incomplete floor repair in the 200 hallway, which was a high-traffic area. The flooring issue involved a missing clean-out cover that was temporarily covered with a metal sheet and tape, but not properly repaired. This inadequate repair led to a resident tripping and sustaining a serious injury, requiring hospitalization and surgical intervention. The injured resident, who had a history of difficulty walking and other medical conditions, was attempting to detach herself from tape on the floor when she lost her balance and fell. The incident was witnessed by a Certified Nursing Assistant (CNA), who reported that the tape was not holding anything down, and the resident's foot got caught on it. The fall resulted in a significant decline in the resident's ability to ambulate and perform activities of daily living at her prior functional level. The facility's maintenance records showed that the flooring issue was known and documented, but the repair was delayed. The Director of Maintenance (DOM) had attempted temporary fixes and was researching a permanent solution, but the repair was not completed until after the resident's injury. The facility's failure to address the flooring hazard in a timely manner placed other residents, staff, and visitors at risk for serious injury.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Administrator and Director of Maintenance performed environmental rounds, identified areas of concern noted and reported in Electronic Maintenance System. Repairs on all items identified were completed prior to survey exit on Resident # 6 no longer resides in the facility. 2. Identification of other residents having the potential to be affected: Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards. Administrator/Designee rounded facility to survey for environmental hazards; identified environmental concerns reported via Electronic Maintenance System, addressed by priority level, and completed. 3. Actions taken/systems put in place to reduce the risk of future occurrence include: Administrator/Director of Clinical Services/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion; Director of Clinical Services/Designee re-educated staff on Accidents and Supervision Policy; Director of Clinical Services/Designee re-educated staff on Recognizing & Reporting Hazards; Director of Clinical Services/Designee re-educated staff on Redirecting Residents from Environmental Hazards; Director of Clinical Services/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm; initiation and assignment of direct care staff member as Hallway Safety Monitor for secure unit (200 Hall) for additional supervision and hazard identification. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will round to ensure facility is free of hazards twice weekly x 8 weeks; then weekly ongoing. Quality reviews will be completed once a week x 8 weeks and then every 2 weeks x 1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Removal Plan
- NHA and Plant Operations Director performed environmental rounds, identified areas of concern, and reported them in the electronic maintenance records system.
- Work orders started in order of priority for hazards causing uneven surfaces, risk hazards, and items with potential to risk resident safety.
- Summoned Corporate Plant Operations support team for assistance.
- Initiated repairs of identified areas of concern.
- Tiles in high traffic area of secure unit (200 Hall) repaired.
- 400 Hall ramp missing carpet tiles replaced with one solid carpet piece.
- Surveyors and NHA completed environmental rounds of the facility noting areas of continued concern.
- List compiled of concerns from environmental tour, all items entered in the electronic maintenance records system.
- 300 Hall clean out with uneven surface repaired.
- 99.5% of all facility staff were educated.
- Initiated and assigned direct care staff member as 'Hallway Safety Monitor' on secure unit (200 Hall) for additional supervision.
- Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards.
- NHA/Designee rounded facility to survey for environmental hazards.
- Identified environmental concerns reported via electronic maintenance records system, addressed by priority level, and repairs initiated and will be ongoing.
- NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion.
- DCS/Designee re-educated staff on Accidents and Supervision Policy.
- DCS/Designee re-educated staff on Recognizing & Reporting Hazards.
- DCS/Designee re-educated staff on Redirecting Residents with from Environmental Hazards.
- DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm.
- Initiation and Assignment of direct care staff member as 'Hallway Safety Monitor' for secure unit (200 Hall) for additional supervision and hazard identification.
- A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures.
- NHA/Plant Ops/Designee will round to ensure facility is free of hazards; then twice weekly; then weekly and PRN (as needed) as indicated.
- These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors.
Unauthorized Social Media Posts Violate Resident Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by unauthorized videos of residents being posted on social media platforms. These videos, which included residents dancing or appearing in the background, were recorded by a staff member, the Admissions Coordinator, without obtaining consent from the residents or their legal representatives. The videos were shared widely, garnering significant views and interactions online, which violated the residents' rights to privacy and confidentiality. The report highlights that 10 out of 16 sampled residents were affected by this breach of privacy. Many of these residents resided in the secure memory care unit and had diagnoses that impaired their ability to provide informed consent. For instance, Resident #10, who was featured in the videos, had been diagnosed with conditions affecting her cognitive abilities, and her admission record indicated she was unable to make willful and knowing health decisions. Similarly, Resident #14's Health Care Surrogate confirmed that no consent was given for the social media postings, and Resident #13's records showed she was incapable of communicating health decisions. Interviews with facility staff, including the Nursing Home Administrator and the Regional Nurse Consultant, revealed that the videos were discovered inadvertently through social media. The staff involved did not inform the administration about the recordings, and it was only after the videos were identified online that the issue was addressed. The facility's policy on social media use explicitly prohibits unauthorized recordings and postings, yet this policy was not adhered to, leading to the violation of residents' rights.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Facility contacted residents responsible parties/representatives/families of residents #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 to notify them that the residents were posted on social media by a staff member, without the facility's knowledge. Staff members were advised to remove all resident-related content from social media. All videos found were reported to the social media to remove videos. The legal department at Tik Tok was contacted to remove videos. Staff member was terminated. 2. Identification of other residents having the potential to be affected: Multiple social media platforms reviewed to identify any postings of facility residents. Facility-wide audit of all residents currently residing in the facility to verify photo consents are signed and present in the medical record. The photo consent form. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure personal privacy and confidentiality for ten of sixteen sampled residents, as evidenced by videos posted on social media platforms without consent. These videos, which included residents dancing or appearing in the background, were recorded in various locations within the facility, including the secure memory care unit and hallways. The videos were originally posted by the Admissions Coordinator and subsequently reposted and edited by unknown users, leading to widespread dissemination across social media platforms. Several residents involved in the videos had severe cognitive impairments, as indicated by their medical records and assessments. For instance, one resident had a severe cognitive impairment score and was unable to communicate a willful and knowing health decision. Family members of these residents were not informed or asked for consent prior to the posting of the videos. Interviews with family members revealed that they were unaware of the social media postings and would not have consented to their loved ones being featured in such videos. The facility's policy on social media use explicitly prohibits the unauthorized taking, keeping, or distributing of photographs or recordings of residents, emphasizing the need to maintain resident privacy and confidentiality. Despite this policy, the Nursing Home Administrator and Regional Nurse Consultant were unaware of the videos until they were brought to their attention. The Admissions Coordinator, who was responsible for the original postings, was identified and subsequently suspended, with plans for termination. This incident highlights a significant breach of privacy and confidentiality protocols within the facility.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Facility contacted residents responsible parties/representatives/families of residents #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 to notify them that the residents were posted on social media by a staff member, without the facility's knowledge. Staff members were advised to remove all resident-related content from social media. All videos found were reported to the social media to remove videos. The legal department at Tik Tok was contacted to remove videos. Staff member was terminated. 2. Identification of other residents having the potential to be affected: Multiple social media platforms reviewed to identify any postings of facility residents. Facility-wide audit of all residents currently residing in the facility to verify photo consents are signed and present in the medical record. The photo consent form was revamped to include social media posting. The consent form does not permit staff to post on their personal pages. The consent clearly states for use on Lakeland Nursing and Rehab OPCO, LLC's official social media accounts. 3. Actions taken/systems put in place to reduce the risk of future occurrence include: RDCS/DCS/Designee re-educated staff on facility policies to include Neglect, Resident Rights, Social Media, and Personal Cell Phone Use. NHA has since created an official social media page for authorized facility-related content and is the authorized administrator of the page. Resident records will be reviewed for photo and social media consent prior to any posting of content. No phones are allowed to be out in patient care areas. Nursing Home Administrator/Designee will search social media weekly for postings related to our facility. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Admissions Director/Designee will conduct an audit of new admission records to make certain records contain Photo Consent Form five times a week for 4 weeks, 3 times a week for 4 weeks, twice weekly for 4 weeks, then weekly and PRN as indicated. The Administrator/Designee will conduct reviews of social media (Tik Tok, Facebook, Instagram) weekly for 8 weeks and every 2 weeks for 1 month, then monthly for 3 months and quarterly or PRN as indicated. Quality reviews will be completed once a week for 8 weeks and then every 2 weeks for 1 month. Quality reviews will be reviewed by the QAPI committee monthly for 3 months or until substantial compliance is met along with quarterly reviews.
Missing Admission Paperwork for Residents
Penalty
Summary
The facility failed to ensure that admission paperwork, including admission agreements and consents, was present in the resident records for four of the sixteen sampled residents. During a review of the records for these residents, it was found that there was no documentation of the necessary admission paperwork, which includes admission consents and admission agreements/contracts. The deficiency was confirmed by the Administrator, who acknowledged that the admission paperwork for these four residents could not be located. The Administrator expressed uncertainty about what happened to the documents and indicated that the facility was in the process of obtaining new admission paperwork for the affected residents.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Facility contacted resident/representative and obtained new admission agreement for residents #7, #9, #11 and #15. 2. Identification of other residents having the potential to be affected: A facility wide audit was completed for all in-house residents. Review of medical records to verify and ensure admissions agreements were completed for all residents. Any resident found not to have an agreement was completed. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Admissions department staff were educated to ensure admission agreements are completed and signed in a timely manner. Audits will be put in place. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Admissions/designee will conduct quality review of resident records to ensure admission agreements are completed and uploaded into resident records. Records of newly admitted residents will be monitored for Admission agreements completion and upload. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Deficiency in Accurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident, leading to a deficiency in maintaining medical records. The resident, who had been admitted with diagnoses including idiopathic conditions, acute failure, and dependence on supplemental support, experienced a change in condition related to decreased food and fluid intake. Despite the situation being assessed and the provider being notified, the clinical record did not accurately reflect the events that transpired, including the initiation of emergency procedures and the calling of Emergency Medical Transport (EMT). The Director of Nursing (DON) confirmed that the clinical record and transfer form did not document the emergency intervention that was administered. The facility's policy on documentation requires that each resident's medical record accurately represent their experiences and include timely and complete information. However, in this case, the documentation was not completed in accordance with the facility's policy, as it failed to capture the critical interventions and notifications made during the resident's change in condition.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Review of resident #4s clinical record. Resident #4 was transferred out to Lakeland Regional Medical Center. Upon record review resident #4 was transferred out and expired, therefore, she no longer resides at Lakeland Nursing and Rehab. Late entry regarding the event was input in Resident #4s clinical record. 2. Identification of other residents having the potential to be affected: Quality review of code blue events to ensure record contains documentation of per advance directive order. Review of code blue events for the past 90 days to ensure change of condition, transfer forms, if applicable, MD notification, and resident representative notification. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Director of Clinical Services reeducated on documentation policy. All licensed nurses educated on proper documentation protocols, code blue events, change of condition and transfer forms. Code blue events, change of conditions, and transfer forms will be reviewed in the morning clinical meeting with follow-up as necessary. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing/ Designee to complete quality review of any code blue event to make certain record reflects proper documentation. Audits of code blue events, change of condition, transfer forms, if applicable, MD notification, and resident representative notification. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Failure to Report Neglect and Ensure Safe Environment
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who suffered a major injury due to an unsafe environment. The incident involved a resident in the memory care unit who experienced an unwitnessed fall in the hallway, resulting in a significant injury that required surgical intervention. The facility's policy mandates immediate reporting of such incidents, especially when they involve serious bodily injury, but this was not adhered to. The resident, who had a history of poor safety awareness and was residing in the memory care unit, tripped and fell in a hallway with rough and uneven concrete. This area was a known high-traffic zone and had a raised drain cap, which posed a hazard. Despite the known risk, the facility did not take timely action to repair the flooring hazard, which contributed to the resident's fall and subsequent injury. Interviews with facility staff, including the Director of Nursing and the Director of Maintenance, revealed a lack of prompt reporting and inadequate measures to ensure a safe environment. The Director of Nursing did not report the incident, believing the plan of care was followed, while the Director of Maintenance acknowledged the flooring issue but only addressed it after the incident occurred. The facility's failure to report the incident and address the environmental hazard in a timely manner led to the deficiency.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Nursing Home Administrator/Coordinator re-educated on ensuring that allegations of neglect or mistreatment are reported according to federal guidelines time frame. Late report completed for Resident # 6. Resident #6 no longer resides at the facility. 2. Identification of other residents having the potential to be affected: Care Plan Coordinator/Designee completed quality review of residents who sustained in past 6 months. No newly affected residents identified. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Education for all staff on Neglect and a position has been created for a facility risk manager, and we are currently recruiting for the position. A daily Risk Management Meeting initiated at daily clinical meeting, to include attendance of the interdisciplinary team with NHA oversight. Risk events including alleged violations involving possible neglect, mistreatment, injuries of unknown source and misappropriation will be reviewed by Administrator/Risk Manager/Designee to ensure all reportable events meet the time frame guidelines for reporting. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Administrator/Risk Manager/Designee will conduct an audit of risk events to monitor all risk events for alleged violations including possible neglect, mistreatment, injuries of unknown source and misappropriation and make certain violations are reported five times a week X 4 weeks, 3 times a week X 4 weeks, twice weekly X 4 weeks, then weekly and as indicated. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Failure to Report Allegation of Neglect and Maintain Safe Environment
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who suffered a major injury due to an unsafe environment. The incident involved a resident in the memory care unit who was ambulating in the hallway and experienced a fall, resulting in a significant injury that required surgical intervention. The resident's care plan indicated a risk for falls due to poor safety awareness and other factors, yet the environment was not maintained free of hazards, contributing to the incident. The investigation revealed that the resident tripped in a high-traffic area with rough and uneven concrete, which had a raised drain cap. This area was located near the dining room, nurses' station, and the resident's room. Despite being a known hazard, the facility did not adequately address the flooring issue in a timely manner. The Director of Maintenance had attempted temporary fixes, but the area remained a risk, and the facility's response was insufficient to prevent the incident. Interviews with staff indicated that the incident was not reported as an adverse event because the plan of care was followed, despite the resident suffering a significant change in condition. The facility's policy required immediate reporting of such incidents, but this was not adhered to. The Director of Nursing and other staff members were aware of the incident but failed to report it to the appropriate authorities within the required timeframe.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Nursing Home Administrator/Coordinator re-educated on ensuring that allegations of neglect or mistreatment are reported according to federal guidelines time frame. Late report completed for Resident # 6. Resident #6 no longer resides at the facility. 2. Identification of other residents having the potential to be affected: Care Plan Coordinator/Designee completed quality review of residents who sustained in past 6 months. No newly affected residents identified. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Education for all staff on Neglect and a position has been created for a facility risk manager, and we are currently recruiting for the position. A daily Risk Management Meeting initiated at daily clinical meeting, to include attendance of the Interdisciplinary team with NHA oversight. Risk events including alleged violations involving possible neglect, mistreatment, injuries of unknown source and misappropriation will be reviewed by Administrator/Risk Manager/Designee to ensure all reportable events meet the time frame guidelines for reporting. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Administrator/Risk Manager/Designee will conduct an audit of risk events to monitor all risk events for alleged violations including possible neglect, mistreatment, injuries of unknown source and misappropriation and make certain violations are reported five times a week X 4 weeks, 3 times a week X 4 weeks, twice weekly X 4 weeks, then weekly and as indicated. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Incomplete Documentation of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident who experienced a change in condition. The resident, who had been admitted with diagnoses including idiopathic acute failure and dependence on supplemental support, was found unresponsive after being transferred to another room. Despite the emergency medical transport being called and the physician and family being notified, the clinical record and transfer form did not document that emergency measures were initiated. An interview with the Director of Nursing (DON) revealed that the expectation was for staff to document the initiation of emergency measures and the calling of EMTs in the clinical record. However, the DON confirmed that this documentation was missing. The facility's policy on medical record documentation requires that each resident's medical record accurately represent their experiences and include timely documentation of assessments, observations, and services provided. This policy was not adhered to in this instance, leading to incomplete documentation of the resident's care during a critical event.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Review of resident #4s clinical record. Resident #4 was transferred out to Lakeland Regional Medical Center. Upon record review resident #4 was transferred out and expired, therefore, she no longer resides at Lakeland Nursing and Rehab. Late entry regarding the event was input in Resident #4s clinical record. 2. Identification of other residents having the potential to be affected: Quality review of code blue events to ensure record contains documentation of per advance directive order. Review of code blue events for the past 90 days to ensure change of condition, transfer forms, if applicable, MD notification, and resident representative notification. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Director of Clinical Services reeducated on documentation policy. All licensed nurses educated on proper documentation protocols, code blue events, change of condition and transfer forms. Code blue events, change of conditions, and transfer forms will be reviewed in the morning clinical meeting with follow-up as necessary. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing/ Designee to complete quality review of any code blue event to make certain record reflects proper documentation. Audits of code blue events, change of condition, transfer forms, if applicable, MD notification, and resident representative notification. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a resident whose family had requested them. The resident, who had been admitted with conditions including Alzheimer's disease, peripheral vascular disease, heart disease, and edema, had their medical records requested by a family member on July 28, 2023. The Medical Records Director (MRD) acknowledged the request but delayed fulfilling it due to instructions from the new company that acquired the facility in June 2023. The MRD was told to hold off on legal cases and sending charts, pending contact with company attorneys, which the facility did not have at the time. Despite communication with the family member, the MRD did not release the records, citing the absence of a response from the family's attorney since October 2023. The facility's policy on the release of information, revised in November 2009, states that residents or their legal representatives can access their medical records upon written consent. The policy also specifies that records should be accessible within a certain number of hours and that photocopies can be obtained with 48 hours' notice, excluding weekends and holidays. However, the MRD admitted that the request made by the resident's Power of Attorney for clinical summaries, lab and diagnostics, and the entire medical record had not been fulfilled approximately 11 months after the initial request. This failure to provide the requested records in a timely manner constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed for a resident who had undergone a renal transplant. The resident was informed by the provider that blood work was to be done, but it had not been completed. The resident was supposed to have weekly Creatinine levels checked and avoid nephrotoxic agents, including diuretics, as per the provider's notes. Additionally, the provider planned for Vitamin B12/Folate levels to be checked with the next blood draw, but these orders were not reflected in the laboratory orders. The review of the resident's laboratory results and physician orders showed that several tests, including a Basic Metabolic Panel (BMP) with glomerular filtration rate (GFR), Complete Blood Count (CBC) with differential, Complete Metabolic Panel (CMP), and Magnesium (Mag), were not completed as ordered. The Treatment Administration Record (TAR) indicated that some orders were discontinued while pending confirmation, and the Medication Administration Record (MAR) did not include any laboratory tests. Interviews with staff revealed a lack of awareness and understanding of the process for confirming and entering laboratory orders, contributing to the oversight. The Interim Director of Nursing (DON) and other staff members acknowledged the issue with the laboratory orders not being entered correctly into the system. The facility's policy on laboratory services and reporting emphasized the need for timely provision of laboratory services and prompt notification of results outside the clinical reference range. However, the deficiency in ensuring the completion of physician-ordered laboratory tests for the resident was evident, as the orders were not properly entered or confirmed, leading to missed tests.
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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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