Vivo Healthcare Winter Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in Winter Haven, Florida.
- Location
- 2701 Lake Alfred Rd, Winter Haven, Florida 33881
- CMS Provider Number
- 105998
- Inspections on file
- 24
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vivo Healthcare Winter Haven during CMS and state inspections, most recent first.
The facility did not submit required PBJ staffing data for a full quarter, as confirmed by review of CMS reports. The NHA was unaware of the missed submission, citing reliance on a third-party company, and the facility lacked a policy or procedure for PBJ reporting expectations.
The facility did not develop or implement action plans to address quality deficiencies, failed to track and analyze medical errors and adverse events, and did not conduct required annual Performance Improvement Plans. Despite claims of regular QAPI/QAA meetings with the DON, Medical Director, and other department heads, the facility could not provide any documentation or signature pages to verify these activities, as the QAPI/QAA book was missing.
The facility did not implement effective infection control measures, including failing to initiate contact precautions for a resident treated for a contagious GI condition, not properly cleaning and storing shared medical equipment, and allowing direct care staff to have long or artificial fingernails, contrary to CDC guidance and facility policy.
The facility did not maintain an effective antibiotic stewardship program, as infection control logs were incomplete, lacking key information such as onset and resolution dates, culture results, and infection site details. The DON confirmed that antibiotics were sometimes prescribed without proper cultures or adherence to established protocols, and the Infection Preventionist had not consistently applied required criteria or maintained necessary documentation. These actions and omissions resulted in the facility's failure to follow its own antibiotic stewardship policy.
Multiple resident rooms and common areas were found with bio growth, soiled and damaged surfaces, missing or broken equipment, and incomplete maintenance, while the facility lacked comprehensive maintenance policies and tracking. The Director of Maintenance relied on an electronic work order system without scheduled surveys or specific protocols for bio growth, resulting in unresolved environmental deficiencies.
Surveyors identified a medication error rate of 34.15% during observed medication passes, with errors including missed doses, administration of expired medications, and failure to follow physician orders. LPNs were observed searching for unavailable medications, attempting to administer incorrect or expired drugs, and not following proper procedures for medication reconciliation or documentation. The DON confirmed that staff did not always notify physicians or the pharmacy when medications were unavailable, and several ordered medications were not administered to residents following hospital readmission.
Live bugs and insect feces were observed in multiple rooms and common areas, with both staff and a resident reporting frequent pest sightings. The pest log showed repeated pest activity over several months, and the Director of Maintenance lacked a comprehensive written maintenance policy, relying instead on an electronic work order system and biweekly pest control services.
The facility did not promptly resolve or document grievances related to delayed call light responses and inadequate staff assistance, as repeatedly raised by residents in council meetings and individual complaints. Despite ongoing concerns, the formal grievance process was not consistently followed, and investigations were incomplete or not documented, leaving residents' issues unresolved.
The facility did not ensure accurate PASRR screenings for several residents with mental health or intellectual disability diagnoses, resulting in missing or incomplete documentation of conditions such as depression, bipolar disorder, cerebral palsy, and dementia. In multiple cases, PASRR forms were not updated to reflect new diagnoses or were left incomplete, and the interdisciplinary team did not consistently review or correct these records as required by facility policy.
Three residents did not receive care as outlined in their care plans, including failures to properly administer and monitor oxygen therapy, supervise nebulizer treatments, and provide prescribed splints/orthotics for contracture management. Staff did not consistently follow physician orders or document required interventions, resulting in unmet care needs.
Four resident bathrooms were found without accessible call light pull strings, as confirmed by direct observation and staff interviews. The maintenance process relied on an electronic work order system, but no work orders were placed to address the missing call lights in the affected rooms, despite facility policy requiring immediate reporting and resolution of such issues.
Several residents who required assistance with ADLs were observed with visible facial hair, despite documentation showing that care was provided and no refusals were recorded. Interviews with residents, their representatives, and staff confirmed that facial grooming was expected and should be included in daily care, but it was not performed as required by care plans and facility policy.
Two residents did not receive multiple ordered medications following admission or readmission due to failures in medication reconciliation, ordering, and administration. Staff did not consistently notify physicians or the pharmacy when medications were unavailable, and documentation of these actions was lacking, despite facility policy requiring such steps.
Two residents on pureed diets were served meals with unidentifiable food items, and staff were unable to inform them about what they were eating due to missing information on meal tickets. One resident, with multiple health conditions, was assisted by staff who could not identify the foods, while another cognitively intact resident reported receiving the same foods daily and not being offered alternatives. The dietary manager also struggled to identify the foods served, and facility policies requiring resident involvement and information about meals were not followed.
Two residents independently self-administered nebulizer treatments without physician orders, assessments, or care plan interventions addressing self-administration. Nursing staff did not remain present during treatments, and required documentation and interdisciplinary team assessments were not completed, despite facility policy mandating these steps for self-medication.
A resident's care plan was not updated to reflect the removal of an indwelling urinary catheter, resulting in outdated interventions and goals remaining in place. Staff interviews and documentation confirmed the catheter had been removed weeks prior, but the care plan continued to address catheter care despite the resident no longer having one.
A resident with a history of multiple fractures and recent surgery was found with a mesh pad covering a black area on the left ankle that had not been assessed, documented, or treated for about a month. Staff interviews and record reviews revealed no physician orders or monitoring of the site, and the care plan lacked specific instructions for its care, resulting in a deficiency in appropriate wound management.
A resident with severe upper extremity contractures and cognitive impairment was not provided with the ordered splints and orthotics for contracture management over several days. Staff were unaware of the splinting requirements, and there was no documentation or evidence that the prescribed interventions were implemented, despite clear physician orders and care plan directives.
A resident with multiple complex diagnoses, including neuromuscular bladder dysfunction and quadriplegia, did not have proper physician orders specifying the diagnosis, Foley or balloon size, or instructions for catheter changes. The DON confirmed the absence of required documentation and orders, despite facility policy requiring appropriate catheter care.
A resident with severe cognitive impairment and a history of swallowing difficulties was observed coughing during meals and was served foods inconsistent with prescribed diet orders, such as garlic bread instead of appropriate mechanically soft options. Despite multiple changes in diet orders and recommendations for supervision, staff did not consistently implement or monitor dietary interventions, and failed to obtain or review key hospital records related to swallowing assessments. The resident also accessed unsafe foods from other sources, and staff did not adequately address these issues.
Two residents did not receive oxygen therapy as ordered, with oxygen concentrators set at incorrect levels and incomplete documentation of administration and monitoring. Additionally, two other residents had nebulizer masks left unbagged on bedside tables after use, contrary to facility policy requiring proper storage of respiratory equipment. Staff interviews confirmed that physician orders and facility procedures were not consistently followed.
A resident with dementia and multiple psychiatric diagnoses exhibited frequent yelling and self-hitting behaviors, but staff did not consistently monitor, document, or address these behaviors through behavioral health services. Staff interviews revealed uncertainty about documentation requirements, and records showed no evidence of behavioral monitoring or interventions, despite facility policy requiring such care.
The facility did not maintain accurate medical records for two residents, including repeated identical and missing vital sign entries, incomplete documentation of medication administration, and continued documentation of catheter care after a catheter had been removed. Staff recorded care and observations that did not occur, contrary to facility policy requiring factual and complete documentation.
A resident with a history of falls and multiple medical conditions experienced a fall, but the facility did not notify the resident's representative or family at the time of the incident. Documentation showed the notification section was left blank and there was no record of timely communication. The family was only informed after the resident was sent to the ER for further treatment.
Failure to Submit PBJ Staffing Data for Required Quarter
Penalty
Summary
The facility failed to submit the required Payroll Based Journal (PBJ) staffing data for the first quarter of Fiscal Year 2025, covering the period from October 1 to December 31. Review of the CMS PBJ Staffing data report (CASPER Report 1705D) confirmed that no staffing data was submitted for this timeframe. During an interview, the Nursing Home Administrator (NHA) stated he was not involved with PBJ submissions and was unaware that the facility had failed to report the data, noting that a third-party company was responsible for submitting their PBJ staffing hours. The NHA also mentioned that he could access the relevant report but rarely reviewed it. Additionally, the facility did not have a policy or procedure outlining the expectations for reporting PBJ staffing hours.
Failure to Implement and Document QAPI Program Activities
Penalty
Summary
The facility failed to develop and implement action plans to correct identified quality deficiencies, as well as to measure the success of actions taken and track performance to ensure improvements were realized and sustained. The facility also did not track medical errors and adverse events, analyze their causes, or implement preventive actions and mechanisms. Additionally, the facility did not conduct at least one Performance Improvement Plan (PIP) annually that focused on high-risk or problem-prone areas, as required by their own policies and federal regulations. Record review revealed that the facility's Quality Assurance and Performance Improvement (QAPI) program policy required the establishment of a Quality Assessment and Assurance (QAA) Committee, regular meetings, data collection and analysis, and the development and implementation of corrective action plans. The policy also required the QAA Committee to regularly review and analyze data, including data from drug regimen reviews, and to act on this data to make improvements. However, there was no documentation available to demonstrate that these activities were being carried out as required. During an interview, the Nursing Home Administrator stated that the QAPI/QAA program met at least once a month and included the DON, Medical Director, and other interdisciplinary team members. Despite this, the Administrator was unable to provide signature pages or any other documentation related to the meetings, as the QAPI/QAA book was missing and its whereabouts were unknown. This lack of documentation meant there was no evidence to support that the facility was following its own QAPI policies or federal requirements regarding quality assurance and performance improvement activities.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program in several key areas. For one resident who was suspected and treated for a highly contagious gastrointestinal condition, staff did not initiate contact precautions as required. Despite the resident experiencing multiple episodes of diarrhea and being treated with antibiotics for possible Clostridioides difficile (C. diff), there was no signage or personal protective equipment (PPE) outside the resident's room, and no documentation of transmission-based precautions in the facility records. Staff interviews revealed that precautions were not implemented while awaiting laboratory confirmation, contrary to facility policy, which allows for empiric precautions based on symptoms. Additionally, staff did not consistently clean and store shared medical equipment in a sanitary manner. During medication administration, an LPN was observed wiping a glucometer and blood pressure cuff with disinfectant wipes but then placing them directly on the resident's over-bed table without a barrier. The same staff member also failed to clean a thermometer after use and stored it with other equipment without proper disinfection. These actions were not in accordance with the facility's policy on routine cleaning and disinfection, which requires proper cleaning to prevent the development and transmission of infections. The facility also failed to promote good hand hygiene practices among direct care staff. Multiple staff members, including two LPNs and the DON, were observed with artificial and/or long fingernails extending beyond the fingertips, some of which were painted or acrylic. The DON acknowledged that anyone providing care should have clean, short fingernails, but the facility did not provide a dress code policy when requested. CDC guidance referenced in the report states that natural nails should not extend past the fingertip and artificial nails should not be worn when providing direct care, as germs can persist under artificial nails even after hand hygiene.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an effective antibiotic stewardship program, as evidenced by incomplete and inconsistent documentation of infection events and antibiotic use. Infection control logs for February and March 2025 showed missing onset and resolution dates for most infections, incomplete information on whether infections were healthcare-associated, and lack of documentation regarding isolation requirements. Many infections, including urinary tract infections (UTIs) and respiratory infections, lacked culture results or evidence of appropriate diagnostic testing, and the logs did not consistently indicate whether infections were community-acquired or nosocomial. Additionally, the logs did not break down infections by site or report dates to the Infection Control/Performance Improvement Committee as required. Interviews with the Director of Nursing (DON) revealed that the facility did not consistently follow its own antibiotic stewardship protocols. The DON acknowledged that not all infections were cultured before antibiotics were prescribed, and that antibiotics were sometimes ordered prophylactically without clear documentation of appropriateness. The DON also confirmed that the Infection Preventionist (IP) had not been applying McGeer criteria during her tenure, and there was no evidence of follow-up or documentation regarding antibiotic use reviews with physicians or the Quality Assurance committee. The facility's process for reviewing antibiotic appropriateness upon admission or readmission was inconsistently applied, and there was no clear tracking of antibiotic utilization rates. A review of the facility's written policy on antibiotic stewardship outlined specific responsibilities for the IP, DON, and administrator, as well as protocols for laboratory testing, monitoring, and documentation. However, the observed practices did not align with these policies. Required documentation, such as action plans, assessment forms, data collection forms, and meeting minutes, was not maintained or was incomplete. Data from antibiotic stewardship monitoring activities was not consistently discussed in QAPI meetings, and there was a lack of feedback reports and records related to staff education. These deficiencies contributed to the facility's failure to implement an effective antibiotic stewardship program.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment in 16 out of 52 resident rooms and in three common areas across multiple wings. Observations over several days revealed multiple deficiencies, including bio growth on ceilings near fire sprinkler heads, brown rough surfaces over toilet seats, unfinished and unpainted walls, missing baseboards, broken drawers, broken toilets, pest feces in showers, and the absence of call light systems or lights in some bathrooms. Common areas also exhibited bio growth, loose ceiling tiles, and bio growth in lighting fixtures. Photographic evidence was obtained to document these findings. Interviews and record reviews indicated that the Director of Maintenance (DOM) did not conduct comprehensive facility surveys or submit reports to the Nursing Home Administrator. Maintenance issues were addressed through an electronic work order system, but there was no written policy for scheduled maintenance or for addressing bio growth. Facility documents showed that many maintenance issues, such as patched but unpainted walls and missing floorboards, were not tracked or addressed in the work order system. The facility's cleaning policy required cleaning of visibly soiled surfaces, but there was no specific policy for bio growth. No work orders were found addressing the observed deficiencies.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with observations revealing a 34.15% error rate during medication administration. Surveyors observed 41 medication administration opportunities and identified 14 errors involving four residents. These errors included missed doses, administration of expired medications, incorrect medication preparation, and failure to follow physician orders and facility policies. One incident involved a nurse searching for a prescribed calcium supplement and instead attempting to administer a different formulation before realizing the error. The nurse informed the resident that the correct medication was owed, but the medication order had been changed shortly after the observation. In another case, a nurse attempted to administer Midodrine to a resident despite the resident's blood pressure being above the hold parameter, only stopping after being prompted to review the order. The same nurse also prepared to administer expired insulin before obtaining a replacement from the emergency drug kit, but did not properly prime the insulin pen according to facility policy. Additional deficiencies included a nurse being unable to administer a prescribed antidepressant due to its unavailability, and another nurse failing to provide multiple ordered medications to a recently hospitalized resident due to missing medications and lack of reconciliation upon the resident's return. In several cases, staff did not follow procedures for obtaining or documenting unavailable medications, and there was a lack of timely communication with the pharmacy and physicians regarding medication availability. These actions and inactions directly contributed to the high medication error rate identified during the survey.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control management system, as evidenced by the presence of live crawling bugs and insect feces in nine resident rooms and common areas. Observations were made on multiple occasions, and both staff and a resident reported frequent sightings of pests such as roaches and ants throughout the facility. The pest log documented repeated occurrences of roaches, ants, flies, spiders, and fleas across various wings over several months. A resident specifically pointed out pest droppings under her nightstand, confirming ongoing pest activity in her room. Interviews with staff revealed that while the Director of Maintenance (DOM) conducted daily walkthroughs and addressed issues as they arose, there was no comprehensive survey or written policy outlining daily, weekly, monthly, or annual maintenance procedures. The DOM relied on an electronic maintenance work order system for tracking and resolving pest issues, and pest control services were scheduled biweekly. The facility's pest control policy required a written agreement with an outside service and a reporting system for pest issues, but the observed and documented pest activity indicated that these measures were not effectively implemented.
Failure to Promptly Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances voiced by residents, particularly those raised during Resident Council meetings over a period of several months. Resident Council minutes from three separate months documented ongoing concerns about delayed call light responses and inadequate staff assistance, especially during evening and weekend shifts. Despite these recurring complaints, a review of the facility's grievance logs revealed no corresponding entries or documentation of these issues being formally addressed as grievances. Two residents, both cognitively intact, reported continued difficulties in receiving staff assistance. One resident filed a grievance regarding lack of staff assistance, but the investigation only noted the nurse aide's location at the time and did not document notification of the resident's representative. The other resident filed a grievance about both staff assistance and maintenance of an air mattress; the investigation only addressed the mattress issue, leaving the staff assistance concern unresolved and the resolution date section blank. Both residents continued to report ongoing problems with staff assistance during interviews. Interviews with facility staff, including the Activity Director and Social Service Director (who also served as the Grievance Coordinator), confirmed that while concerns were discussed in meetings and some actions were taken, the formal grievance process was not consistently followed. The facility's own policy requires that all grievances, including those voiced during Resident Council meetings, be documented, investigated, and resolved promptly, with appropriate follow-up and communication to the resident. However, the absence of documentation and incomplete investigations indicate that these procedures were not adhered to in these cases.
Failure to Maintain Accurate PASRR Screenings for Residents with Mental Disorders or Intellectual Disabilities
Penalty
Summary
The facility failed to maintain accurate Pre-admission Screening and Resident Review (PASRR) screenings for eight residents out of a sample of 52. In several cases, residents were admitted with mental health or intellectual disability diagnoses that were not accurately reflected in their PASRR Level I screenings. For example, one resident with diagnoses of Bipolar Disorder and Major Depressive Disorder had a PASRR that did not include these conditions, and no rescreen was performed to determine if a Level II evaluation was needed. Another resident with multiple mental health diagnoses and behavioral issues had a PASRR that did not indicate any mental illness or history of mental health services, nor did it reflect the primary diagnosis of Alzheimer's disease. Additional deficiencies were noted where residents' PASRR screenings failed to include relevant diagnoses such as cerebral palsy, depression, anxiety, and mood disorders. In some cases, the PASRR forms were outdated or incomplete, with sections left blank or failing to address significant mental health or intellectual disability conditions. For instance, one resident's PASRR did not mention a diagnosis of cerebral palsy, and another's did not address a mood disorder despite it being present in the medical record. There were also instances where the PASRR was not updated to reflect new or changed diagnoses after admission. Interviews with facility leadership confirmed that the expectation is for the interdisciplinary team to review PASRR documentation upon admission and complete a new PASRR if the information is incorrect or incomplete. The facility's policy requires accurate and timely coordination with the PASRR program, including maintaining up-to-date records and referring residents for Level II evaluations when necessary. However, the findings indicate that these procedures were not consistently followed, resulting in inaccurate or incomplete PASRR screenings for multiple residents.
Failure to Follow Comprehensive Care Plans for Respiratory, Oxygen, and Contracture Management
Penalty
Summary
The facility failed to follow comprehensive, person-centered care plans for three residents, resulting in deficiencies related to respiratory care, oxygen therapy, and contracture management. For one resident with COPD, observations revealed that the nebulizer mask was left unbagged on the overbed table, and the resident self-administered nebulizer treatments without a physician's order or assessment for self-medication. The nurse did not remain with the resident during the treatment, and the oxygen concentrator was set below the physician-ordered rate on multiple occasions. The care plan required staff to administer medications and oxygen as ordered, and to monitor lung sounds, but these interventions were not consistently followed. Another resident receiving oxygen therapy via nasal cannula was observed multiple times with the oxygen concentrator set below the physician-ordered rate of 2 liters per minute. Documentation in the Treatment Administration Record was incomplete, with several shifts lacking evidence that oxygen therapy was monitored as required. The care plan for this resident included interventions to provide oxygen as ordered, but these were not consistently implemented, as confirmed by staff interviews and record review. A third resident with severe cognitive impairment and upper extremity contractures was not observed wearing prescribed splints or orthotics during multiple visits, and no such devices were visible in the room. Staff interviews revealed a lack of awareness regarding the resident's need for splints/orthotics, and review of the care plan and physician's orders confirmed that the resident was to wear specific splints and a palm guard for a set duration each week. There was no documentation of the resident receiving assistance with these devices or of any refusals, indicating that the care plan interventions were not followed.
Failure to Maintain Accessible Call System in Resident Bathrooms
Penalty
Summary
The facility failed to maintain an effective resident call system in four specific resident rooms, as evidenced by the absence of call light pull strings in the bathrooms of rooms #204, #207, #403, and #609. Observations conducted on two separate dates confirmed that the call light pull strings were missing in these locations. Interviews with the Nursing Home Administrator revealed that he was aware of the broken call light pull strings in these rooms. The Director of Maintenance stated that while he conducts daily walkthroughs and addresses issues as they arise, there is no comprehensive survey or written policy for regular maintenance checks, and the process is managed through an electronic maintenance work order system. A review of facility documentation showed that although the electronic maintenance work order system includes a weekly task to test the nurse call system, there were no work orders placed for call light parts to address the concerns in the affected rooms during the relevant period. The facility's policy requires that call systems be accessible to residents at each toilet and bathing facility, and that staff report problems immediately to supervisors or maintenance. However, the lack of work orders and missing call light pull strings indicate that these procedures were not followed in the identified rooms.
Failure to Provide Facial Grooming Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming assistance, specifically shaving facial hair, for four residents who required help with activities of daily living (ADL). Observations revealed that these residents had visible facial hair, such as white or gray patches on their chins, despite documentation indicating that ADL care was provided and no refusals of care were recorded. Interviews with the affected residents and their representatives confirmed that the presence of facial hair was undesirable and that assistance was expected but not provided. Review of care plans for these residents showed that they required varying levels of assistance with personal hygiene, ranging from supervision to total dependence. None of the care plans documented any behaviors or refusals related to personal grooming, and staff interviews indicated that facial grooming should be part of daily ADL care for both male and female residents. Staff members, including CNAs and LPNs, stated that female residents should not have facial hair and that grooming was expected to be completed during morning care and on bath/shower days. The facility's policy on grooming facial hair outlined specific procedures for assisting residents with shaving to maintain proper hygiene. However, despite these policies and staff expectations, the observed residents continued to have facial hair, and there was no documentation of refusal or behavioral issues that would have prevented grooming. This indicates a failure to follow through with the required assistance for personal grooming as outlined in the residents' care plans and facility policy.
Failure to Reconcile and Provide Medications as Ordered for New Admissions
Penalty
Summary
The facility failed to reconcile, obtain, and provide medications as ordered for two residents who were recently admitted or readmitted. For one resident with a history of seizures, brain neoplasm, myasthenia gravis, and chronic pain syndrome, multiple scheduled medications were not administered as ordered following admission. The resident's medication administration record (MAR) showed missed doses of several critical medications, including those for seizure control, pain management, and chronic conditions. The facility did not document physician notification or obtain orders to hold or adjust medications when they were unavailable, and some medications were not available in the facility's stock or electronic dispenser. For another resident with chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension, the MAR indicated that several prescribed medications were not administered after readmission. During medication administration, an LPN was observed unable to provide multiple ordered medications, including antibiotics, antihypertensives, and medications for heart failure and nausea. The staff member did not document that the pharmacy or physician was notified about the missing medications, despite facility policy requiring such notification when medications are unavailable or late. Facility policies reviewed indicated that medications should be administered as ordered and that the physician must be contacted if medications are unavailable or delayed. The policies also outlined procedures for medication reconciliation and ordering upon admission or readmission. However, in both cases, there was a lack of timely reconciliation, ordering, and administration of medications, as well as insufficient documentation of communication with physicians or the pharmacy regarding unavailable medications.
Failure to Provide Identifiable Pureed Foods and Inform Residents of Meal Contents
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence and self-determination by not serving identifiable foods to two residents on pureed diets. In both cases, meal tickets did not specify the food items being served, and staff members assisting with feeding were unable to identify the pureed foods on the residents' trays. Staff expressed uncertainty about the contents of the meals and acknowledged that they would not be able to inform residents or their families about what was being served, nor could they confirm the absence of allergens. One resident with Alzheimer's disease, severe protein-calorie malnutrition, dysphagia, and adult failure to thrive was observed being assisted with meals where neither the assisting staff nor the dietary manager could identify the pureed food items. The menu for the day listed specific items, but these were not reflected on the meal ticket or easily identifiable on the plate. Staff confirmed that the meal ticket lacked information about the food items, and the dietary manager verified the unidentified foods after checking in the kitchen and with the resident's tray. Another resident with COPD, hypertension, dysphagia, and anemia, who was cognitively intact, reported eating the same foods daily and not being offered alternatives. This resident was observed eating only oatmeal, stating that the other pureed items were unidentifiable and unappealing. The dietary manager was also unable to immediately identify the foods served and confirmed that one item (sausage) was not on the menu. Facility policies reviewed indicated that residents' preferences should be assessed and that they should be informed about their meals, but these practices were not followed.
Failure to Assess and Care Plan for Resident Self-Administration of Nebulizer Treatments
Penalty
Summary
The facility failed to obtain physician orders, conduct assessments, or develop care plans for two residents who were self-administering nebulizer treatments. Observations revealed that both residents independently managed their nebulizer treatments without nursing staff remaining present during administration, as required by facility policy. In both cases, the nebulizer equipment was left un-bagged on bedside tables after use, and the residents reported that nurses provided the medication and set up the equipment but did not stay in the room during the treatment. Review of the medical records for both residents showed no physician orders authorizing self-administration of nebulizer treatments, no documentation of assessments to determine their ability to self-administer, and no care plan interventions addressing self-administration. Both residents had diagnoses including COPD and required respiratory treatments, with cognitive assessments indicating intact cognition. However, their care plans only addressed general respiratory care and did not include any provisions for self-administration of medications or storage arrangements for nebulizer equipment. Interviews with staff, including an LPN and the DON, confirmed that the facility did not have any residents formally assessed or care planned for self-administration of nebulizer treatments. The DON stated that the process for nebulizer treatments required nursing staff to remain with the resident throughout the procedure, and that any resident self-administering should have an order, assessment, and care plan in place. Facility policies also required interdisciplinary team assessment and documentation before allowing self-administration, none of which were completed for the residents involved.
Failure to Revise Care Plan After Catheter Removal
Penalty
Summary
The facility failed to accurately revise the care plan and related interventions for a resident with a history of an indwelling urinary catheter. The resident's care plan continued to include interventions and goals related to catheter care, even after the catheter had been removed. Observations and interviews confirmed that the resident did not have a urinary catheter at the time of the survey, and the resident reported that the catheter had come out approximately three weeks prior. Documentation review showed that the catheter was found on the bed with the balloon deflated, and the physician had ordered it to be left out to monitor the resident's condition without it. Despite the removal of the catheter and the absence of a current physician order for catheter use, the care plan was not updated in a timely manner to reflect the resident's current status. Staff interviews revealed confusion regarding the resident's catheter status, with some staff initially believing the resident still had a catheter. The facility's policy requires that comprehensive care plans be developed and revised to reflect the resident's current needs, but this was not followed in this case.
Failure to Assess, Document, and Treat Surgical Wound
Penalty
Summary
The facility failed to assess, document, and treat a surgical wound for one resident with a history of multiple fractures and recent surgical interventions. The resident was observed with a mesh pad covering a black area on the left ankle, which had reportedly been in place for about a month. Despite the presence of this surgical site, there were no physician or surgeon orders regarding its care, and the site was not mentioned in weekly skin checks or documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The care plan referenced potential or actual skin impairment but did not include specific interventions or follow-up instructions for the left ankle surgical site. Interviews with staff, including the DON and an LPN, confirmed that the area had not been recently assessed or monitored, and the wound specialist had not provided recent recommendations. The facility's documentation policy requires accurate and complete records of resident care, but the medical record lacked sufficient detail about the left ankle surgical site. This lack of assessment, documentation, and treatment for the surgical wound constituted a deficiency in providing appropriate care according to orders, resident preferences, and goals.
Failure to Implement Contracture Management Program with Splints/Orthotics
Penalty
Summary
A deficiency occurred when a resident with severe upper extremity contractures and cognitive deficits was not provided with the prescribed splints and orthotics as part of her contracture management program. Over a three-day observation period, the resident was repeatedly seen lying in bed with contracted hands and fingers, and at no time were splints or orthotics observed on her or present in her room. Multiple staff members, including CNAs and an LPN, were unaware of any splint or orthotic use for the resident, and there was no documentation on the CNA task sheet or care plan indicating their application. Further investigation revealed that the resident had physician orders and care plan interventions specifying the use of a right elbow extension splint, right resting hand splint, and left palm guard for six hours per day, five days a week, to be applied and removed by nursing staff. Occupational therapy records confirmed the need for orthotic management, and the resident had been referred to Restorative Nursing for ongoing contracture management after being discharged from OT. However, staff interviews and record reviews indicated that these interventions were not being implemented, and there was no documentation of the resident receiving assistance with splints or orthotics, nor any record of refusal. The resident's medical history included diagnoses of dysphagia, contractures in multiple joints, chronic pain, anxiety, and dementia, with substantial assistance required for most ADLs. The facility's own policies required nursing staff to provide restorative services, including splint or brace assistance, and for licensed nurses to oversee and document the effectiveness of such interventions. Despite these requirements, the prescribed contracture management program was not carried out, and the resident did not receive the ordered splinting interventions during the period reviewed.
Lack of Physician Orders and Documentation for Foley Catheter
Penalty
Summary
The facility failed to ensure that proper physician orders were in place for a resident with a Foley catheter. Upon review, it was found that the resident, who had multiple diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and quadriplegia, did not have a documented physician order specifying the diagnosis, Foley or balloon size, or instructions for catheter changes. The care plan referenced catheter use and related interventions, but the physician orders lacked essential details such as the reason for the catheter and specific directions for its management. Additionally, there was no documentation of recent catheter changes, despite the DON stating that a change had occurred about two weeks prior. The facility's own policy requires that residents with indwelling catheters receive appropriate care, including maintaining dignity and privacy, but the lack of clear physician orders and documentation did not meet these standards. The DON confirmed the absence of necessary orders and documentation, and acknowledged that not all residents with neuromuscular bladder dysfunction require a catheter, further highlighting the need for individualized and documented medical justification.
Failure to Implement and Monitor Dietary Interventions for Resident with Swallowing Difficulties
Penalty
Summary
A deficiency occurred when the facility failed to identify, implement, monitor, and modify appropriate interventions for a resident who experienced coughing during meals. The resident, who had a history of metabolic encephalopathy, protein-calorie malnutrition, muscle wasting, acute respiratory failure, and dementia, was observed coughing and with watery eyes while eating spaghetti, meatballs, and garlic toast in the dining room. Staff intervened by removing the plate, but the resident's family member reported ongoing concerns about the lack of assistance with eating and stated that the resident was supposed to be on a pureed diet. The facility did not address the family member's concerns, citing a lack of documentation from the hospital regarding the need for assistance. Review of the resident's records revealed multiple changes in diet orders, including regular, pureed, and mechanically soft diets, as well as recommendations for thickened liquids and supervision during meals. Despite these orders and the resident's severe cognitive impairment, there were instances where the resident was served inappropriate food items, such as garlic bread, which were not consistent with her prescribed diet. Staff interviews confirmed that residents on mechanically altered diets should not receive foods with crusts or hard textures, yet the dietary manager admitted to serving garlic bread to all residents due to a lack of bread sticks. The resident was also noted to be non-compliant with her diet, obtaining snacks from vending machines and other residents, and required education and supervision to prevent consumption of unsafe foods. Speech therapy and nursing documentation indicated ongoing issues with swallowing and coughing during meals, with recommendations for diet modifications and supervision. However, there was a lack of consistent follow-up, as the facility did not have a full-time speech therapist, and the results of a hospital-ordered swallow study were not obtained or reviewed. The care plan and progress notes highlighted the need for a mechanically altered diet and close monitoring, but these interventions were not reliably implemented or adjusted in response to the resident's changing needs and observed difficulties during meals.
Failure to Provide and Document Ordered Oxygen Therapy and Proper Respiratory Equipment Storage
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with professional standards and physician orders for two residents. One resident with COPD, hypertension, and anemia was observed multiple times with an oxygen concentrator set at levels inconsistent with the physician's order of 2 liters per minute via nasal cannula. Documentation in the Medication Administration Record was incomplete, with several shifts lacking evidence that the ordered oxygen therapy was provided. The resident's care plan required oxygen administration as ordered, but observations and staff interviews confirmed the prescribed settings were not consistently followed. Another resident receiving oxygen therapy was also observed with the concentrator set below the ordered 2 liters per minute on several occasions. The Treatment Administration Record showed multiple shifts where monitoring of oxygen therapy was not documented as required. The care plan for this resident included interventions to provide oxygen as ordered, but staff interviews and record reviews confirmed that these interventions were not consistently implemented. Additionally, the facility failed to ensure proper storage of respiratory equipment for two other residents. Nebulizer masks were observed left unbagged on bedside tables after use, contrary to facility policy requiring such equipment to be bagged when not in use. Staff interviews confirmed awareness of the policy, and facility procedures outlined the need for proper cleaning and storage of respiratory equipment, which was not followed in these instances.
Failure to Provide Behavioral Health Services and Documentation
Penalty
Summary
The facility failed to provide necessary behavioral health care services to a resident with a complex medical and psychiatric history, including vascular dementia, mood and psychotic disturbances, and anxiety. Observations revealed the resident frequently yelled out and hit her leg, behaviors that were not addressed through behavioral health interventions. The resident was unable to communicate about her care, and her care plan identified ongoing behavioral issues such as screaming, banging, and agitation, with interventions to monitor and document behaviors and attempt to determine underlying causes. However, there were no physician orders for behavior monitoring, and no documentation of behaviors was found in the Treatment Administration Record or progress notes. Interviews with staff indicated uncertainty about the need to monitor or document the resident's behaviors, and the DON described the behaviors as a form of communication rather than behavioral health issues. Despite the facility's policy requiring person-centered behavioral health services and documentation, there was no evidence that the resident's behaviors were being consistently monitored, documented, or addressed through appropriate behavioral health care services.
Failure to Accurately Document Vital Signs, Medication Administration, and Catheter Care
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, specifically regarding documentation of vital signs, medication administration, and indwelling catheter care. For one resident, review of the Medication Administration Record (MAR) revealed repeated documentation of identical vital signs across multiple shifts and days, as well as missing entries for required vital sign monitoring on several shifts. Additionally, the MAR did not include blood pressure readings at the time of administration for a medication that required withholding if systolic blood pressure exceeded a certain threshold, and there were missed medication administration times. For another resident, documentation inconsistencies were found related to the presence and care of a Foley catheter. Although the resident's catheter was removed and not reinserted per physician orders, nursing staff continued to document catheter care and the use of a privacy bag for a drainage bag for several days after the catheter had been discontinued. This was despite multiple clinical notes indicating the resident no longer had a catheter and was incontinent of urine. Facility policy required that all documentation in the medical record be factual, objective, accurate, and complete, reflecting the actual experiences and care provided to the resident. However, staff documented care and observations that did not occur, including false entries for catheter care and vital signs, which was confirmed by the Director of Nursing, who acknowledged that such documentation was incorrect.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify the resident representative following an accident involving a resident who had a history of repeated falls and multiple medical diagnoses, including urinary tract infection, osteoporosis, leukemia, hypertension, rheumatoid arthritis, muscle wasting and atrophy, and difficulty walking. The resident experienced a fall in the early morning hours, as documented in the Change in Condition Evaluation, but the section for resident or representative notification was left blank. Review of progress notes also showed no documentation that the family was informed of the fall at the time it occurred. Subsequently, the resident was sent to the emergency room for treatment after expressing increased pain and being found to have a left hip fracture. The family was only notified about the fall and the transfer to the hospital several hours after the incident. During interviews, facility leadership confirmed that there was no documentation of family notification immediately following the fall, and acknowledged that the family should have been informed at that time.
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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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