Westminster Towers
Inspection history, citations, penalties and survey trends for this long-term care facility in Orlando, Florida.
- Location
- 70 West Lucerne Circle, Orlando, Florida 32801
- CMS Provider Number
- 105757
- Inspections on file
- 25
- Latest survey
- March 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Westminster Towers during CMS and state inspections, most recent first.
A resident with multiple health conditions was administered Hydralazine outside of prescribed parameters for heart rate, despite physician orders to hold the medication if the heart rate was less than 65. The LPN involved was unaware of the updated parameters, and the DON acknowledged the oversight. Facility policies on medication administration were not followed, leading to this deficiency.
Two residents were found self-administering medications without physician orders, contrary to facility policy. One resident used Neosporin ointment for a rash, while another used Voltaren cream for arthritis pain. Both residents were cognitively intact but had not been evaluated or authorized to self-administer medications, as required by the facility's policy.
The facility failed to provide timely written summaries of baseline care plans to two residents. One resident did not receive a copy of his care plan, and another's care plan was not completed within the required 48-hour timeframe. The ADON acknowledged these oversights, which were contrary to the facility's policy.
A resident who required assistance for personal hygiene did not receive showers as scheduled, despite expressing a preference for them. Facility records showed missed showers, and staff interviews revealed inconsistencies in documentation and communication regarding the resident's care. The facility's policy to provide showers as per request or schedule was not consistently followed.
A resident with quadriplegia and mild vascular dementia experienced ongoing eye discomfort and was prescribed artificial tears, which were ineffective. Despite a request for an eye specialist appointment, the facility failed to coordinate care due to insurance issues and lack of follow-up by the Social Services Director, leaving the resident without necessary specialist care.
A facility failed to document an incident involving a 98-year-old resident with dementia who wandered into another resident's bathroom. Despite family reports and increased private care, no record of the incident was found in the resident's clinical records or incident log. Interviews with staff confirmed awareness of the incident but revealed a lack of documentation, contrary to facility policy.
A resident receiving hospice care was found unresponsive, and staff failed to verify her Full Code status, leading to a lack of resuscitative measures. Despite clear documentation of her wishes, RN A assumed a DNR status and did not call for emergency assistance, resulting in Immediate Jeopardy. The incident highlighted a critical lapse in following facility procedures for verifying code status.
A resident receiving hospice care was found unresponsive, and staff failed to verify her Full Code status, leading to the omission of life-saving measures. RN A and RN C did not initiate CPR, assuming the resident was a DNR due to her hospice status. The RN Supervisor also did not verify the code status, resulting in Immediate Jeopardy as the resident's wishes were not honored.
A resident with Alzheimer's and moderate cognitive impairment left the facility unsupervised and was found at a nearby hospital. The facility's administrator filed the neglect report late, acknowledging the delay to ensure the investigation was complete. Facility policy requires reporting alleged violations within 24 hours if no serious injury occurred.
A resident with Alzheimer's and a history of elopement left a facility unsupervised after removing her wander alarm and swapping her walker. Staff failed to monitor her adequately, allowing her to follow a dietary aide into an elevator and exit the facility. She was later found at a nearby hospital. The facility's policy required more frequent checks, which were not performed.
A resident with multiple health conditions, including stage III pressure ulcers, was found with medications at their bedside without a physician's order for self-administration or storage. The LPN, ADON, and DON confirmed the lack of necessary orders, contrary to facility policy requiring an interdisciplinary team assessment and care plan for such arrangements.
Two residents in the facility did not receive wound care as per physician's orders. One resident with a stage IV pressure wound on the coccyx and another with stage III pressure ulcers on the buttocks had missing entries in their Treatment Administration Records (TAR), indicating incomplete wound care. The DON and Wound Care RN acknowledged these omissions during a review.
A resident with a PICC line did not have their dressing changed as per physician's orders, which required a change every seven days. The dressing was observed to be dated incorrectly, and both the LPN and ADON confirmed the discrepancy. The DON acknowledged the issue, noting confusion due to multiple orders in the system, and confirmed the dressing was not changed as required by facility policy.
A resident with multiple health issues had a PICC line dressing that was not changed as per the physician's order, despite documentation indicating otherwise. The dressing was observed to be dated incorrectly, and staff confirmed the discrepancy. An LPN admitted to signing off on the TAR without performing the dressing change, contrary to the facility's documentation policy.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders and implement the comprehensive care plan for a resident with a history of atrial fibrillation, hypertension, type 2 diabetes, and stroke. The resident was prescribed Hydralazine 100 mg three times a day for hypertension, with specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 65. Despite these orders, the medication was administered outside of the prescribed parameters multiple times in February and March 2025, as documented in the Medication Administration Record (MAR). The Licensed Practical Nurse (LPN) involved admitted to administering the medication even when the heart rate was below the specified threshold, citing a lack of awareness of the updated order parameters. The Director of Nursing (DON) acknowledged that the nurses were not correctly following the physician's orders for the resident's medication. The facility's policies on Medication Regimen Review and Medication Administration, which emphasize the importance of adhering to physician orders and professional standards, were not followed. The failure to act upon the pharmacist's recommendations and ensure that the nursing staff was aware of and adhered to the current medication parameters contributed to the deficiency.
Plan Of Correction
Resident #43 was assessed by the physician upon notification of the medication concern. The medication was discontinued, and a new order written for a different medication. An audit of current residents with medications with parameters for administration was completed by the DON and/or designee to ensure medications were administered within the parameters. The physician was notified of any discrepancies. The licensed staff were in-serviced by the DON and/or designee on medication administration guidelines to follow the physician orders, including medication parameters. Weekly audits will be completed by the DON and/or designee for a minimum of three months or until significant compliance has been met to ensure licensed nurses are following the physician orders, including medication parameters. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain compliance.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure proper self-administration of medication for two residents. Resident #57, who was cognitively intact with a BIMS score of 13/15, was found with Neosporin ointment on his nightstand, which he used for a rash on his thigh. However, there were no physician orders for this medication, and the resident's assessment indicated he was not to self-administer medications. The primary RN acknowledged the presence of the ointment and explained that medications unknown to the nurse could cause interactions with other medicines. Similarly, Resident #83, also cognitively intact with a BIMS score of 13/15, was found using Voltaren cream for arthritis pain in her knees, which her daughter had brought for her. The cream was discovered in her nightstand drawer, and there were no physician orders for its use. The RN supervisor acknowledged the absence of orders and removed the cream for safekeeping. The DON confirmed that both residents were assessed as not being permitted to self-administer medications, as per facility policy, which requires an interdisciplinary team evaluation and physician orders for self-administration.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both federal and State laws. F554 Self Admin of meds Medications were immediately removed from rooms for residents #83 and resident #57. Self-administration of medication assessment was completed for resident #57 on Resident #57 was reviewed for the c/o to right side on Skin assessment completed on for resident #57 with no integrity issues. #83 was reassessed for Resident #83 MD was contacted, and new order was obtained cream to. Resident #83 for on discharged home on. An audit of the residents rooms completed by nursing management team did not reveal any additional on over the counter medications or treatments stored at the bedside. All resident self-administration of medications were reviewed to ensure accuracy of self-administration and found to be correct. Resident #57 and the family were educated regarding not having medication at bedside on and to notify the nurse if the resident needs a specific product, so staff is able to assess and to update the physician. Resident #83 discharged home. The licensed staff were in-serviced by the DON and/or designee regarding self-administration of medications, including families should not bring in any over the counter medications and they are required to report to the charge nurse any medications found at bedside. The education will be completed to staff on. Facility will provide education to residents and families via the Monthly Activities Newsletter regarding not to bring in any medications and to notify the nurse if you feel a specific medication is needed so the physician may be notified. This will notify all existing residents. A new process was put in place adding a notice to new admissions packet requesting outside medications not to be brought in and notifying the nurse if something specific is needed. Staff who complete Angel rounds were educated to focus on monitoring for medications at bedside during rounds and to report to the charge nurse any found. Staff also educated to ask the resident if they have any medication not obviously visible in the room. Angel rounds audits will be submitted to the NHA for review upon completion for any reports of medication at bedside. Random weekly audits of 5 resident rooms per floor will be conducted four times a week by the DON and/or designee to ensure any medications are not stored in the residents room without a physicians order. The room audits will be conducted for a minimum of 3 months or until significant compliance is met. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain compliance.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure a written summary of the baseline care plan was provided to two residents within the required timeframe. Resident #390, a male with diagnoses including right ankle osteomyelitis and asthma, was admitted to the facility and did not receive a written summary of his initial care plan. The Baseline Care Plan Assessment for this resident was completed and signed by staff, but there was no signature from the resident or his representative, and no documentation was found to confirm that a copy was provided to the resident. The Assistant Director of Nursing (ADON) acknowledged the oversight and could not confirm if the resident received the required documentation. Resident #546, admitted with diagnoses including aftercare following surgery on the digestive system, also did not receive a timely written summary of her baseline care plan. Although the resident was admitted on a Friday, the baseline care plan was not completed and signed until several days later, beyond the 48-hour requirement. The ADON admitted that the baseline care plan should have been completed and signed within the required timeframe to ensure the resident was informed of her care plan. The facility's policy mandates that a baseline care plan be developed and provided to the resident within 48 hours of admission, which was not adhered to in these cases.
Plan Of Correction
F655 Baseline Care Plan Resident #390 baseline care plan was completed and reviewed with the resident on Resident #546 baseline care plan was completed and reviewed with the resident on An audit of current residents records for the baseline care plans was completed by nursing management on Baseline care plans were completed as appropriate. The licensed staff will be in-serviced by the DON and/or designee regarding providing a written summary of the baseline care plan within the required time frame. Newly admitted resident baseline care plan will be reviewed and updated with 48-hour time frame. Nursing staff will review baseline care plan completion date with resident daily to ensure completion within 48-hours. Weekly audits of all new admissions will be completed by the DON and/or designee for three months then until significant compliance has been met to ensure the baseline care plan has been completed within the required time frame. The results of the audits will be reviewed and discussed at the monthly QAPE committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain compliance.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers per resident preference and as scheduled for a resident who was dependent on staff for activities of daily living. The resident, who had intact cognition and required extensive assistance for personal hygiene, preferred showers three times a week. However, the facility did not adhere to this schedule, as evidenced by the resident's report of not receiving showers as scheduled and the facility's records showing missed showers on multiple occasions. The resident expressed that he was not asked if he wanted a shower on scheduled days and sometimes received a bed bath instead, which was not his preference. Interviews with staff revealed inconsistencies in the documentation and communication regarding the resident's care. Certified Nursing Assistants (CNAs) stated they informed nurses when the resident refused showers and provided bed baths instead, but there was no documentation of refusals in the resident's progress notes. The Registered Nurse and Unit Manager were unaware of any refusals, and the Director of Nursing expected refusals to be documented, which was not done. The facility's policy required showers to be provided as per request or schedule, but this was not consistently followed, leading to the deficiency.
Plan Of Correction
Resident #75 received a shower per his preference and receives showers as scheduled. If he refuses his scheduled shower, the CNAs will document the refusal and notify the nurse. Resident's care plan was updated to offer a bed bath if the resident declines a shower. An audit was completed to ensure showers were completed per the resident preference and as scheduled, with refusals documented. Any discrepancies were corrected as appropriate. The DON and/or designee will in-service the CNAs and licensed staff to provide showers per resident preference and as scheduled, including documentation of resident refusal and notification of the nurse. Staff will honor resident preferences for showers. Resident preferences will be care planned. Random weekly audits of five residents for each floor/unit will be completed by the DON/designee to provide showers per resident preference and as scheduled, including documentation of resident refusal. The audits will be completed weekly for a minimum of three months or until significant compliance has been met. The results of the audits will be forwarded to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain compliance.
Failure to Coordinate Eye Care for Resident
Penalty
Summary
The facility failed to coordinate necessary eye care for a resident with quadriplegia, slurred speech, polyneuropathy, and mild vascular dementia. The resident had a medical order for vision consults as needed, starting from June 2022, and was experiencing eye irritation, for which artificial tears were prescribed. Despite the resident's ongoing complaints of eye discomfort and the ineffectiveness of the artificial tears, the facility did not arrange for an eye specialist consultation. The resident's condition included watering eyes and reddened conjunctivas, and the resident reported significant pain in the right eye. The Assistant Director of Nursing had requested an eye specialist appointment for the resident in January 2025, but the Social Services Director did not follow through with the coordination of care. The in-house eye specialist was out of network for the resident's insurance, and the resident could not afford to pay out of pocket. Despite being aware of these issues, the Social Services Director did not seek alternative arrangements or request facility assistance to cover the cost, resulting in the resident not receiving the necessary specialist care.
Plan Of Correction
Resident #45 was seen by the optometrist on and new orders received. An audit was completed on by Social services of current residents and any additional resident referrals were followed up on. The facility has contacted an outside to ensure that the resident's new insurance was covered by an optometrist for any future needs completed by. On Social services was educated on the process for ensuring that all referrals are submitted on a timely basis by the Administrator. The Social service team has been educated on the importance of documenting each step of the referral and any roadblocks that they are trying to overcome. Social services will perform weekly audits of residents' referral orders to ensure are obtained and follow up on timely. Audits will continue weekly for a minimum of 3 months or until significant compliance has been met after. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain compliance.
Failure to Document Resident Incident and Care
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a 98-year-old male resident with multiple diagnoses, including dementia and impaired mobility. The resident was admitted to the facility and required assistance with transfers and toileting due to his cognitive and physical impairments. An incident occurred where the resident was found wandering without his walker and ended up in another resident's bathroom. Despite the family reporting this incident and increasing private sitter care to 24/7, there was no documentation of the incident in the resident's clinical records or the facility's incident log. Interviews with facility staff, including the Administrator and the Director of Nursing (DON), revealed that the incident was known but not documented. The Administrator acknowledged the incident and stated it was reported to the night shift nurse, but no record of this was found. The DON confirmed that no documentation could be identified regarding the incident or any subsequent assessments or monitoring of the resident's condition. The facility's policy requires timely and accurate documentation of residents' experiences, which was not adhered to in this case.
Plan Of Correction
Resident #55 was seen by the nurse practitioner on and and into no adverse effects of another resident room were noted. An audit was conducted with staff nursing on each shift to determine if any unusual occurrences or behaviors have occurred and verified if documentation has occurred. Licensed nurses were provided education by regarding documentation of resident experience to include any unusual occurrences or incidents that have occurred on the shift. If there is an unusual occurrence, staff should assess the patient and implement appropriate interventions if necessary. DON and/or designee will complete 4 random interviews with staff on each shift weekly for 3 months to determine if any unusual occurrences or behaviors have been observed, and then DON and/or designee will audit resident records to ensure this has been appropriately reflected in the resident record. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain compliance.
Failure to Verify Code Status in Emergency
Penalty
Summary
The deficiency involved a failure by licensed nurses to follow the facility's policy and procedure regarding the verification of a resident's code status in an emergency situation. A resident, who was receiving hospice care, was found unresponsive in her bed by RN A. Despite the resident's documented status as a Full Code, RN A did not verify this information and failed to initiate life-saving measures. Instead, RN A assumed the resident was a Do Not Resuscitate (DNR) due to her hospice care status and proceeded with postmortem care without calling Emergency Medical Services or a Code Blue. The resident's medical records clearly indicated her Full Code status, which had been confirmed in discussions with her husband and documented in her care plan and physician orders. However, RN A, along with RN C and RN Supervisor B, did not verify the resident's code status as per the facility's procedure. This oversight led to the resident not receiving the resuscitative measures she had requested, as her wishes were not honored due to the staff's failure to check her chart and confirm her code status. The incident placed all residents receiving hospice care at risk of not having their wishes honored, resulting in Immediate Jeopardy. The facility's policy required staff to provide basic life support in accordance with the resident's advance directives, but this was not followed. The deficiency was identified as having the potential for more than minimal harm, although it was not considered Immediate Jeopardy after the initial finding.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both federal and State laws. 1. Resident #1 expired on Nurse A and Nurse B were suspended immediately. 2. Residents who, in house in the past 3 months were reviewed to ensure all advanced directives were followed. This was completed by and no discrepancies were noted. All Code statuses were followed as ordered. Social services validated all current residents' code status and validated the status is correct according to their individual wishes on Nurse A is no longer employed at the facility and the results of the investigation were reported to the board of nursing. Education was provided to Nurse B prior to returning to work. 3. Facility completed code blue drills each shift 72 hours post incident and re-educated staff on our code blue policies. Completed by Staff received an electronic communication with immediate education on resident rights, advanced directives, and validating residents' code status in their chart prior to calling a code blue on. The nursing supervisors were re-educated by the ADON and/or designee regarding verifying code status on any resident found without vital signs or unresponsive prior to having contact with residents. Licensed nurses have been in-serviced by the ADON and/or designee that residents receiving hospice service does not equate to the resident being a full code and staff must check all residents' code status when they are found unresponsive. This was completed prior to having contact with residents. A new process was put into place where the Facility will add residents' full code status order to the MAR to be signed off every shift by the nurse if the patient is on hospice and is a full code to increase visibility to nursing staff. Written Code blue competency tests were administered to the licensed staff and CNAs and validated by the DON/Designee. Regularly scheduled staff completed by and PRN staff will complete testing prior to having contact with residents. Any new staff members will receive code blue education and competency testing during their orientation days before working the floor alone ongoing. Facility staff were re-educated by the ADON and/or designee of the advance directive processes; neglect and; resident's rights regarding treatment and advance directives; communication of code status; and physician notification of changes. Regularly scheduled staff completed by and PRN staff will complete education prior to having contact with residents. 4. Facility completed ad hoc QAPI on and continued with ad hoc QAPI for the following three weeks on and Code blue drills varying day/shift will continue weekly for one month, followed by three drills a month varying day/shift monthly thereafter to be completed by DON/designee. Random weekly checks will be completed by DON and/or designee for three months to ensure the nurses & CNAs are competent with checking the residents' code status when a resident is found unresponsive, regardless of status, i.e., Hospice, STR, etc. ADON and/or designee will complete weekly audits of current hospice residents to ensure there is a separate order being signed off stating the resident's full code status if appropriate. Audits will be completed weekly for one month, followed by monthly for two months. DON and/or Designee will audit any new hires to ensure a code blue competency test has been satisfactorily completed monthly x3 months. Incident was reviewed during QAPI meeting on and the committee agrees with this corrective action. Results of the previously mentioned audits including checking the code status, code blue drills, auditing of hospice resident orders, physician notification of change of condition for full code hospice residents, and new hire competencies will be submitted to the Administrator and brought to QAPI for review and evaluation monthly. Audits will continue for a minimum of 3 months or until significant compliance has been met as deemed by the QAPI committee.
Failure to Verify Code Status Leads to Unmet Resident Wishes
Penalty
Summary
Licensed nurses at the facility failed to adhere to the policy and procedure for verifying code status in an emergency situation for a resident who was receiving hospice care. The resident, who had a history of severe cognitive impairment and was on hospice care, had a documented Full Code status, which was not honored when she was found unresponsive. The failure to verify the resident's code status led to the omission of life-saving measures, as the staff assumed she was a Do Not Resuscitate (DNR) due to her hospice status. On the evening of the incident, the resident was found unresponsive in her bed by RN A, who did not verify the resident's code status and failed to initiate cardiopulmonary resuscitation (CPR) as per the resident's wishes. RN A, along with RN C, provided postmortem care without calling a Code Blue or contacting emergency medical services. RN A later acknowledged that she was unaware of the resident's Full Code status and admitted that she did not check the resident's chart, which would have indicated the need for resuscitative measures. The RN Supervisor B, who was informed of the resident's passing, also assumed the resident was a DNR due to her hospice care and did not verify the code status. This assumption was incorrect, as the resident's husband had confirmed her desire to be a Full Code. The facility's failure to ensure staff followed procedures related to honoring an advance directive resulted in Immediate Jeopardy, as it placed all residents receiving hospice care at risk of not having their wishes honored.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both federal and State laws. 1. Resident #1 expired on Nurse A and Nurse B were suspended immediately. 2. Residents who , in house in the past 3 months were reviewed to ensure all advanced directives were followed. This was completed by and no discrepancies were noted. All Code statuses were followed as ordered. Social services validated all current residents code status and validated the status is correct according to their individual wishes on Nurse A is no longer employed at the facility and the results of the investigation were reported to the board of nursing. Education was provided to Nurse B prior returning to work. 3. Facility completed code blue drills each shift 72 hours post incident and re-educated staff on our code blue policies. Completed by Staff received an electronic communication with immediate education on resident rights, advanced directives, and validating residents code status in their chart prior to calling a code blue on The nursing supervisors were re-educated by the ADON and/or designee by regarding verifying code status on any resident found without vital signs or unresponsive prior to having contact with residents. Licensed nurses have been in serviced by the ADON and/or designee by that residents receiving hospice service does not equate to the resident being a and staff must check all residents code status when they are found unresponsive. This was completed prior to having contact with residents. A new process was put into place where the Facility will add residents full code status order to the MAR to be signed off every shift by the nurse if the patient is on hospice and is a full code to increase visibility to nursing staff on. Written Code blue competency tests were administered to the licensed staff and CNAs and validated by the DON/Designee. Regularly scheduled staff completed by and PRN staff will complete testing prior to having contact with residents. Any new staff members will receive code blue education and competency testing during their orientation days before working the floor alone ongoing. Facility staff were re-educated by the ADON and/or designee of the advance directive processes; neglect and; resident's rights regarding treatment and advance directives; communication of code status; and physician notification of changes. Regularly scheduled staff completed by and PRN staff will complete education prior to having contact with residents. 4. Facility completed ad hoc QAPI on and continued with ad hoc QAPI for the following three weeks on and Code blue drills varying day/shift will continue weekly for one month, followed by three drills a month varying day/shift monthly thereafter to be completed by DON/designee. Random weekly checks will be completed by DON and/or designee for three months to ensure the nurses & CNAs are competent with checking the residents code status when a resident is found unresponsive, regardless of status, ie Hospice, STR, etc. ADON and/or designee will complete Weekly audits of current hospice residents to ensure there is a separate order being signed off stating the resident full code status if appropriate. Audits will be completed weekly for one month, followed by monthly for two months. DON and/or Designee will audit any new hires to ensure a code blue competency test has been satisfactorily completed monthly x3 months. Incident was reviewed during QAPI meeting on and committee agrees with this corrective action. Results of the previously mentioned audits including checking the code status, code blue drills, auditing of hospice resident orders, physician notification of change of condition for full code hospice residents and new hire competencies will be submitted to the Administrator and brought to QAPI for review and evaluation monthly. Audits will continue for a minimum of 3 months or until significant compliance has been met as deemed by the QAPI committee.
Removal Plan
- Administrator and DON initiated an investigation into discrepancies in resident #1's chart regarding her passing.
- The facility completed an in-house audit for code status of all residents.
- Licensed nurses were educated on the facility's policy and procedure for verifying code status prior to initiating or withholding lifesaving procedures including Code Blue drills to validate comprehension.
- Resident #1's husband was notified regarding discrepancies found and investigation.
- Law enforcement and elderly affairs were notified out of abundance of caution. An immediate report was filed with the state agency.
- A record review of resident #1 was completed by the DON.
- Social Service Director completed an audit of all current residents' code status.
- RN Supervisor B and RN A received personal training from the DON on checking residents' code status and starting Code Blue procedures. Both nurses were suspended pending investigation.
- Nursing Supervisors received individual education on checking code status when residents were unresponsive and initiating Code Blue procedures from the DON.
- A text was sent to all nursing staff containing education regarding if a resident was found unresponsive, it was the responsibility of the nurse to verify code status in the chart and initiate if Full Code.
- 64 of 81 total licensed nurses received education.
- 48 out of 81 nurses completed the education.
- An additional 10 of 81 nurses completed their education.
- An additional 6 of 81 nurses completed their education.
- Remaining licensed nurses would receive education prior to working next shift.
- New hire nurses at the facility would receive the above education during orientation and prior to working an assignment.
- Mock Code Blue drills were conducted to validate education received was retained.
- Starting weekly code blue drills to be conducted on varying shifts and days to include all shifts.
- Random weekly audits to be completed to ensure staff follow facility procedure for verifying residents' code status prior to initiating or withholding.
- New hire nurses at the facility to participate in a mock code drill during orientation and prior to working an assignment.
- Ad Hoc Quality Assurance and Performance Improvement (QAPI) held to review the recommendations made from the investigation. The QAPI committee reviewed education in progress and code blue drills.
Failure to Timely Report Alleged Neglect
Penalty
Summary
The facility failed to report an alleged violation of neglect in a timely manner for a resident with Alzheimer's disease, dementia, and other conditions. The resident, who had a moderate cognitive impairment and used a wander/elopement alarm daily, was admitted to the facility with a care plan for wandering and at risk for elopement. On the morning of August 7, 2024, the resident was found missing during rounds by the 7:00 AM - 3:00 PM nurse, prompting a facility search. The resident was eventually located at a nearby hospital after leaving the facility unsupervised. The facility's administrator, responsible for filing reports of allegations of abuse or neglect, confirmed that the immediate report of neglect was filed late, on August 8, 2024, around 3:00 PM. The administrator acknowledged the delay, stating he wanted to ensure the investigation was complete before submitting the report. According to the facility's policy and procedure for Abuse, Neglect, and Exploitation, alleged violations should be reported no later than 24 hours after the allegation if the event did not involve abuse and did not result in serious bodily injury.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with Alzheimer's disease and dementia. The resident, who had a history of wandering and elopement, was equipped with a wander/elopement alarm. However, on the night of the incident, the resident managed to cut off the alarm and hide it in her dresser drawer. She then swapped her walker with another resident's walker, which did not have an alarm, and left the facility unsupervised. The staff on duty, including a registered nurse, a certified nursing assistant, and a dietary aide, did not adequately monitor the resident. The dietary aide allowed the resident to follow him into an elevator without realizing she was a resident, as no alarm sounded. The resident exited the facility through the employee entrance and walked to a nearby hospital, where she was admitted. The staff did not notice her absence until the next morning, despite the facility's policy requiring staff to check on residents at least every two hours. Interviews with staff revealed a lack of communication and assumption that the resident was in her room or on leave. The facility's investigation confirmed that the resident was seen on camera leaving the facility. The administrator acknowledged that alarms are not a substitute for supervision and that staff should have checked on the resident more frequently, especially given her risk for elopement.
Failure to Obtain Physician's Order for Bedside Medication Storage
Penalty
Summary
The facility failed to ensure a physician's order was obtained for medications at the bedside for a resident who was reviewed for pressure ulcer care. The resident, a male with multiple diagnoses including cellulitis, diabetes type II, lymphedema, anxiety disorder, and stage III pressure ulcers, was observed with a tube of Ammonium lactate 12% cream and a tube of Santyl ointment on his tray table. The resident's Minimum Data Set (MDS) admission assessment indicated intact cognition and functional limitations in range of motion. However, there was no physician's order for self-administration or bedside storage of these medications. The Licensed Practical Nurse (LPN) confirmed the presence of the medications at the resident's bedside and acknowledged that they should not be left there without a physician's order. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed that a physician's order was necessary for medications or treatments to be stored at the bedside. The facility's policy required an interdisciplinary team assessment and a care plan reflecting the resident's self-administration and storage arrangements, which were not in place for this resident.
Failure to Provide Ordered Wound Care for Pressure Ulcers
Penalty
Summary
The facility failed to provide wound care for pressure ulcers as per physician's orders for two residents. The first resident, a male with a history of malignant neoplasm of the tongue, gastrostomy, and pneumonia, had an unstageable pressure ulcer on his sacrum and stage IV pressure wound on his coccyx. The treatment plan included specific applications of Gentamicin, Santyl, and Dakin's solution, but the Treatment Administration Record (TAR) showed missing entries on several dates, indicating that wound care was not consistently provided as ordered. The Director of Nursing (DON) and the Wound Care Registered Nurse (RN) acknowledged these omissions during a review of the TAR. The second resident, an 86-year-old male with cellulitis, diabetes, lymphedema, anxiety disorder, and stage III pressure ulcers on his buttocks, also did not receive wound care as ordered. The resident's physician orders included specific wound care treatments for multiple wounds, but the TAR lacked documentation for wound care on certain dates. The Wound Care RN confirmed the absence of documentation for wound care on specific dates, and the DON stated that clinical records, including TARs, were reviewed for completeness during morning clinical meetings, acknowledging that there should not be any blank entries.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure the timely change of a Peripheral Inserted Central Catheter (PICC) line dressing for a resident, as per physician's orders and professional standards. The resident, a male with multiple diagnoses including cellulitis, diabetes, lymphedema, anxiety disorder, and stage III pressure ulcers, was admitted with a central line for intravenous access. The physician's order required the PICC line dressing to be changed every seven days on the evening shift. However, on observation, the dressing was found to be dated 5/04/24, indicating it had not been changed by the due date of 5/11/24. The Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) both confirmed the discrepancy between the documented dressing change dates and the actual date on the dressing. The Medication Administration Record and Treatment Administration Record indicated that the dressing was changed on 5/03/24 and 5/10/24, but the physical evidence contradicted these records. The Director of Nursing (DON) acknowledged the issue, noting confusion due to two different orders in the system and confirmed that the dressing was not changed as required. The facility's policy mandates weekly dressing changes to minimize infection risk, which was not adhered to in this instance.
Inaccurate Documentation of PICC Line Dressing Change
Penalty
Summary
The facility failed to ensure accurate medical records regarding the dressing of a Peripheral Inserted Central Catheter (PICC) line for a resident. The resident, a male with multiple diagnoses including cellulitis, diabetes type II, lymphedema, anxiety disorder, and stage III pressure ulcers, had a physician order to change the PICC line dressing every seven days. However, upon observation, the dressing was dated 5/04/24, indicating it had not been changed as per the order. The Medication Administration Record and Treatment Administration Record (TAR) showed signatures indicating the dressing was changed on 5/03/24 and 5/10/24, which was inconsistent with the actual date on the dressing. The RN Supervisor and the Assistant Director of Nursing confirmed the discrepancy between the documented dates and the actual date on the dressing. A Licensed Practical Nurse (LPN) admitted to signing off on the TAR without changing the dressing, mistakenly believing she was confirming the standing order. The facility's policy on documentation requires that each resident's medical record accurately reflect their experiences, and false information should not be documented. This incident highlights a failure to adhere to this policy, resulting in inaccurate medical records for the resident.
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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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