Cayuga Nursing And Rehabilitation Center

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe environment free from accident hazards for Resident #171, who had a physician order for a regular dysphagia pureed texture diet. The resident was served and fed ground vegetables instead of pureed, leading to a choking incident. The resident, who had diagnoses including dementia and oropharyngeal dysphagia, began to cough and was subsequently sent to the hospital. The resident's care plan and dietary orders were not followed, resulting in the resident receiving the wrong food consistency. The incident occurred when Certified Nurse Aide #3 fed the resident the incorrect consistency of Brussels sprouts, which were chopped and not pureed as required. The dietary server was responsible for plating the food according to the meal ticket, but the unit staff, including the aide, failed to verify the meal ticket against the food served. The resident showed signs of choking, and although the airway was cleared without the Heimlich Maneuver, the resident was sent to the hospital with breathing issues due to aspiration. Interviews with staff revealed a lack of adherence to protocols for verifying meal tickets and food consistencies. The dietary aide and unit staff were expected to check the meal ticket and ensure the correct food consistency was served, but this did not occur. The facility's policies required staff to follow diet orders and ensure safe dining practices, which were not followed in this instance, leading to Immediate Jeopardy past non-compliance for Resident #171.

Removal Plan

• Certified Nurse Aide #3 was reeducated on following resident care plans regarding appropriate diet and consistency as ordered.
• All dietary staff were educated on diet consistencies.
• All nursing staff were educated on diet consistencies.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #49 received treatment and care in accordance with professional standards of practice. Specifically, the resident was administered 14 doses of expired levetiracetam, a seizure medication, from January 10, 2025, to January 17, 2025. The facility's policy on medication administration required that the individual administering the medication verify the expiration date had not been exceeded. However, the medication card for levetiracetam had an expiration date of December 30, 2024, and was not checked by the nurses before administration. Licensed Practical Nurse #31 admitted to administering the expired medication without realizing it was expired, and there was no documentation that the attending physician was notified of the error. Resident #49 had a history of convulsions, dementia, and heart failure, with a documented severe cognitive impairment and seizure disorder. Despite the administration of expired medication, nursing progress notes from January 10 to January 16, 2025, did not document any seizure activity for the resident. Interviews with nursing staff and the Director of Nursing revealed a lack of consistent checking of medication expiration dates and a failure to notify the physician when expired medication was administered. The Director of Nursing acknowledged that nurses were not regularly checking expiration dates and that expired medications should not have been administered due to potential changes in efficacy.

Plan Of Correction

Plan of Correction: Approved February 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident identified as #49’s [MEDICATION NAME] level will be checked. The expired medication was removed and the MD was notified. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The medication carts were all audited for expired medications and no further expired medications were found. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All licensed nurses will receive education on the medication administration policy. An updated 11p-7a nursing checklist will include removal of all expired medications from the medication cart nightly. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: Medication carts will be audited weekly for three months, monthly for three months, and quarterly for six months. Audits will be reported to QAPI monthly. The date for correction and the title of the person responsible for correction of each deficiency: Director of Quality Management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the building was fully protected by an approved automatic sprinkler system, as required by CMS regulation º 483.90(a) for multiple locations. Observations revealed mixed sprinkler coverage in the stairwells and boiler room, with both standard and quick response sprinklers present. Additionally, there was a lack of sprinkler coverage in an outdoor storage area under the building's roof, where two propane tanks and a gas grill were stored. During an interview, the Director of Facility Services acknowledged awareness of the regulation but was unaware of the mixed sprinklers and stated that the propane tanks would be relocated to a proper storage location.

Plan Of Correction

Plan of Correction: Approved March 7, 2025 (Sprinkler System - Installation) The Facility Services Director is currently in the process of scheduling to have the incorrect sprinklers replaced in the following areas: - Stairwell on 2nd floor North East side by double doors that had one standard response head that should have been quick response. - The stairwell by kitchen that had one standard response head that should have been quick response. - 1st floor Boiler room/Mechanical room that had one standard response head that should have been quick response. (Two Propane tanks stored under exterior overhang): Both tanks have been removed. Missing spare sprinkler heads: The Facility Services Director is in the process of adding the following spare sprinkler heads: Green vertical spare heads, Blue pendant standard heads. The Facility Services Director or designee will conduct a facility-wide audit of all compartments with sprinklers. This will include auditing the exterior of the building and, in addition, the spare sprinklers cabinets. The Facility Services Director or designee on a quarterly basis will conduct a facility-wide audit of all compartments with sprinklers. This will include auditing the exterior of the building and, in addition, the spare sprinkler cabinets. Any deficiencies found will be corrected in a timely manner. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/25. The Facility Services Director will be responsible for this plan of correction.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the views, grievances, or recommendations voiced by residents during Resident Council meetings were considered, acted upon, and responded to with a rationale. During a recertification survey, 10 anonymous residents reported that they did not receive responses to topics or concerns addressed in prior meetings. The facility's policy stated that the Resident Council would serve as a liaison between residents and facility administration, addressing concerns or complaints regarding facility operations, policies, and resident experiences. However, there was no documented evidence that residents' voiced concerns were investigated, and rationales or responses were provided to the residents. The Resident Council meeting minutes from August to December 2024 documented recurring issues such as call bells not being answered timely, medications not being available, noise levels during certain shifts, and staff using offensive language. Despite these concerns being raised repeatedly, there was a lack of documented staff responses or actions taken to address them. The Recreation Leader and Activities Director both noted that the issues were not being resolved, and the residents expressed frustration that their concerns were not being addressed, leading to a perception that attending the meetings was futile. Interviews with facility staff revealed a lack of structured follow-up on the residents' concerns. The Recreation Leader stated that they documented issues and delivered them to each department, but they were unsure why the same concerns persisted without resolution. The Activities Director, who started in November, noticed the lack of structure in the meeting minutes and recurring unresolved issues. The Administrator acknowledged seeing repeated concerns in the minutes and attributed the lack of clear follow-up to inadequate documentation, which made it appear as though the residents' concerns were not being addressed.

Plan Of Correction

Plan of Correction: Approved February 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A memo addressing cell phone use, playing music, wearing ear buds and inappropriate language will be sent to all staff directly through the employee payroll system. All old business noted on the latest resident council minutes will be addressed and responded to accordingly. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A survey will be conducted to all residents and/or responsible parties regarding concerns, potential grievances or complaints. Each topic will be addressed and brought to the appropriate department head to respond. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: Education was completed to all Department head level staff for addressing and responding to resident council concerns. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Director of Therapeutic Recreation will report compliance at QAPI monthly for 6 months and quarterly thereafter. The date for correction and the title of the person responsible for correction of each deficiency: Director of Therapeutic Recreation.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for a resident who required two-person assistance with a mechanical lift for transfers. A Certified Nurse Aide (CNA) attempted to transfer the resident alone, resulting in the resident nearly falling. Despite the care plan violation, the resident was not assessed by a qualified professional following the incident, and was later found with skin tears on both legs. The resident, who had diagnoses including atrial fibrillation, long-term use of anticoagulants, and progressive neuropathy, was care planned for two-person assistance with a mechanical lift. However, CNA #29 attempted a one-person transfer, which was against the care plan. The CNA reported that the resident became combative during the transfer, nearly resulting in a fall. Despite the incident, there was no documented evidence that the resident was assessed by a qualified professional immediately following the transfer. Subsequently, the resident was found with skin tears and a bruise, but the origin of these injuries was unknown. The facility's investigation did not determine when the injuries occurred, and there was no documentation of an assessment following the improper transfer. The Director of Nursing was not immediately notified of the incident, and the registered nurse on duty was not informed, which was against the facility's protocol for handling such incidents.

Plan Of Correction

Plan of Correction: Approved March 4, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident identified as #371 has since been discharged from the facility. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Reviewed and investigated the previous 30 days of accidents/incidents regarding skin impairments. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Educate administrative nursing staff on the Recognizing and reporting elder abuse/neglect criteria policy, as well as education on conducting thorough investigations. The policy addresses completion of an assessment of the resident for injuries and has been updated to include documentation of the assessment in the accident/incident report. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? All skin impairments of unknown origin will be reviewed by the Director of Quality Management and reported on during QAPI monthly for three months and quarterly thereafter. The date for correction and the title of the person responsible for correction of each deficiency: Administrator.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #473 had physician orders for immediate care consistent with their physical status upon admission. The resident's hospital discharge orders and summary contained conflicting information regarding diet consistency, which was not clarified at the time of admission. The hospital discharge summary indicated the resident had thin liquid dysphagia and required a thickened liquid diet, while the nursing home transfer documented a regular diet. This discrepancy was not addressed, leading to the resident being admitted on a regular diet with thin liquids. During a lunch observation, the resident was found consuming thin liquids, which prompted a visitor to question the appropriateness of the diet. A speech language pathologist intervened and removed the thin liquids, indicating a need to verify the resident's evaluation. The facility's triple check system, which involved the Director of Admissions, Director of Nursing, and Nurse Manager, failed to identify and clarify the conflicting diet information. The Director of Nursing and Nurse Practitioner involved in the admission process did not review the discharge summary thoroughly, missing the dysphagia diagnosis. Interviews with facility staff revealed that the admission process involved reviewing hospital orders and summaries, but the conflicting information was overlooked. The Director of Nursing admitted to not reviewing the discharge summary unless new medications were involved, and the Nurse Practitioner did not recall addressing the diet discrepancy. The failure to clarify the resident's diet consistency upon admission posed a risk of choking or aspiration, which could lead to complications.

Plan Of Correction

Plan of Correction: Approved February 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident identified as #473 diet order was corrected immediately. Resident #473 has since been discharged to a lower level of care. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All new admissions from the previous three months discharge summaries, and physician orders [REDACTED]. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The policy medication physicians orders management has been updated to include reconciliation of hospital discharge orders with the discharge summary and discrepancies to be clarified by physician order. All nursing staff will be educated on policy revisions and changes. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? A weekly audit of the reconciliations will be completed for three months, followed by monthly for three months and quarterly for six months. All audit results will be reported at QAPI. The date for correction and the title of the person responsible for correction of each deficiency: Director of Nursing.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with a significant mental illness was referred for a Level II Preadmission Screening and Resident Review (PASRR), as required by federal regulations. Resident #66, who had diagnoses including schizophrenia, hallucinations, and delusional disorder, exhibited a change in behavior that necessitated medication intervention. Despite these changes, there was no documentation of a new Level I screen or a Level II referral being initiated, which is a requirement when a resident is newly diagnosed with a mental illness or experiences a significant change in condition. The resident's comprehensive care plan documented ongoing issues with psychosis, delusions, and non-compliance with care and medications. The resident had a history of being verbally and physically violent towards staff, making accusations of abuse, and exhibiting behaviors such as throwing objects and refusing medications. Despite these significant behavioral changes, the facility did not complete the necessary PASRR evaluations to determine the specialized services required by the resident. Interviews with facility staff revealed a lack of awareness and adherence to the PASRR requirements. The Administrator admitted that the facility did not have a policy regarding PASRR, and the Director of Social Work was identified as responsible for maintaining and updating PASRR documentation. A social worker from a sister facility noted that the resident's significant change in mental illness should have prompted a new screen, highlighting a gap in the facility's compliance with federal requirements.

Plan Of Correction

Plan of Correction: Approved February 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Identified resident #66 will be screened and referred for a level II PASARR. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A 100% audit of all current residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions will be referred for a level II PASARR. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Education will be provided to the Director of Admissions and Social Work department on level II PASARR requirements. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? A monthly audit of all admissions and newly diagnosed serious mental disorders will be completed to ensure level II PASARR is completed. Audit results will be reported to QAPI monthly. The date for correction and the title of the person responsible for correction of each deficiency: Director of Social Work.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a proper discharge planning process for Resident #105, who expressed a desire to return to their prior living situation. Despite the resident's goal to be discharged back to their apartment, the facility did not assist with discharge planning or provide updates on the status of their discharge goal. The facility's policies required collaboration with the resident to ensure a smooth transition of care, including resident education and participation in discharge planning, but these were not adhered to in this case. Resident #105 had a history of metabolic encephalopathy and repeated falls, and their Minimum Data Set assessments indicated a goal to return to the community. The resident was independent in most activities of daily living, as documented in therapy discharge summaries. However, there was no evidence of an interdisciplinary care plan meeting to discuss the resident's discharge potential and goals. Interviews with staff revealed a lack of communication and documentation regarding the resident's discharge plan, and the resident expressed concern about not being able to go home. Interviews with various staff members, including CNAs, LPNs, and the Director of Quality Management, highlighted a lack of awareness and involvement in the resident's discharge planning. The resident had been cut from therapy, which should have triggered a care plan meeting, but this did not occur. The resident's mental health and functionality were at risk due to the delay in discharge planning, and the resident was left without clear communication or a plan to return home, resulting in them slipping through the cracks of the facility's discharge process.

Plan Of Correction

Plan of Correction: Approved February 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #105 has met with the Social work department and a discharge plan is being developed with the residents input as well as the IDT. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A 100% audit of all residents wishing to discharge for an active discharge plan will be completed. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? IDT will be educated on the discharge planning policy and procedure. A discharge planning meeting will be scheduled upon admission. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? An audit will be conducted by the MDS Coordinator or representative assigned to confirm discharge planning meeting has occurred by the completion of the comprehensive MDS. The date for correction and the title of the person responsible for correction of each deficiency: MDS Coordinator.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure consistent communication and collaboration with a community-based dialysis center for a resident requiring hemodialysis, leading to incomplete documentation of vital signs and weights for 25 out of 34 dialysis sessions. The facility's policy required that a hemodialysis report be completed and sent with the resident to the dialysis center, and upon the resident's return, the report should be reviewed, and any new recommendations confirmed with the primary physician. However, the dialysis report sheets frequently lacked complete documentation, and there was no evidence of follow-up communication with the dialysis center regarding these omissions. Resident #65, who had diagnoses of end-stage renal disease, diabetes, and hypertension, was affected by this deficiency. Despite the facility's policy and physician orders requiring vital signs and weights to be documented before and after dialysis, the interdisciplinary progress notes did not reflect any communication with the dialysis center to address the incomplete reports. Interviews with facility staff revealed that the process for reviewing and following up on dialysis reports was not consistently followed, and there was an assumption that if the dialysis center did not call, everything was fine, even if the report sheet was blank.

Plan Of Correction

Plan of Correction: Approved February 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident identified as #65 continues on [MEDICAL TREATMENT] treatment. Resident #65’s order for the [MEDICAL TREATMENT] communication book to be returned and completed and advised to contact [MEDICAL TREATMENT] office directly if incomplete. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Currently no other residents require [MEDICAL TREATMENT]. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: LPN and RN staff to be educated on [MEDICAL TREATMENT] policy. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: An audit to monitor [MEDICAL TREATMENT] communication book will be completed weekly for three months, monthly for three months, and quarterly for six months and reported to QAPI. The date for correction and the title of the person responsible for correction of each deficiency: Director of Nursing.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a medication error rate below 5 percent, resulting in a significant deficiency during the recertification survey. Specifically, two residents were affected by medication administration errors. Resident #27, who had diagnoses including cerebral infarction, type 2 diabetes, depression, and hyperlipidemia, was administered five medications over an hour late. Additionally, their sliding scale insulin dose was given after breakfast instead of before, as ordered, and the insulin pen was not primed, potentially affecting the insulin dosage received. The Licensed Practical Nurse (LPN) responsible for administering the medications admitted to being behind on their medication pass and did not follow the facility's protocol for reporting such delays. Resident #110, who had a gastrostomy tube and dysphagia, was administered four medications orally instead of via the gastrostomy tube as ordered. The LPN involved attempted to administer the medications by mouth to see if the resident could swallow them, despite not having a physician's order to change the route of administration. This action was taken without consulting the physician or waiting for the speech language pathologist to assess the resident's ability to swallow safely. The medications were also administered over an hour late, and the LPN did not seek approval from the physician for the delay. The facility's medication administration policy required that any errors be reported immediately to the attending physician and nursing administration. However, there was no documented evidence of such reporting or any facility policy on blood glucose monitoring and insulin administration. The Registered Nurse Educator and Licensed Practical Nurse Manager confirmed that the actions taken by the LPNs were not in accordance with the facility's protocols, highlighting a lack of adherence to established procedures and communication failures within the facility.

Plan Of Correction

Plan of Correction: Approved March 4, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents identified as #27 and #110 medication errors were identified and discussed with the Medical Director. LPN #24's agency was notified of errors. LPN has not returned to the facility. LPN #10 was provided education on correct medication administration. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Medication administration observations will be completed on all diabetic residents receiving insulin. Medication documentation audit will be reviewed to identify late medication administration. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Medication administration education and post test will be completed by all licensed nurses. Medication administration observation audit will be completed. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Medication administration reports will be reviewed daily for two weeks. A random daily report weekly will be completed for three months. Further audits will be conducted dependent on results of observations and audits completed. The date for correction and the title of the person responsible for correction of each deficiency: Nurse Educator.

Penalty

Fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During the recertification survey, it was observed that the kitchen had unclean areas, including a drain behind the oven that was full and backing up with a strong, foul odor, and food debris was found under and around the equipment. Additionally, potentially hazardous foods were not maintained at safe temperatures. A deep hotel pan of crab cake mix was found in the cooler at 48 degrees Fahrenheit, which was above the recommended storage temperature. The crab cake mix was prepared the previous day, and the Director of Dietary acknowledged that food could be out of temperature for 2 hours, but the mix was made the previous day by the night cook. Interviews with staff revealed that there were issues with the cooling process of food items. The Director of Dietary stated that cooling should not be done in large quantities and that they documented cooling temperatures of items like roasts. However, the crab cake mix was not cooled properly, as it was placed in a hotel pan instead of shallower pans for faster cooling. The Facility Services Director mentioned that the drain issue had been ongoing, and a contractor had been called to address it months ago. The Registered Dietitian emphasized the importance of proper food preparation, cooling, and storage to prevent bacterial growth and foodborne illness. The facility's policies on cooling and food storage were not adhered to, leading to these deficiencies.

Plan Of Correction

Plan of Correction: Approved February 28, 2025 F812 D What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Food identified was discarded immediately. The drain behind the oven was immediately reported to the Facility Services Director. The drain was unclogged and cleaned immediately, as well as the food debris under and around the equipment were cleaned immediately. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Additional food items were checked for appropriate temperature. No other drains were identified with a similar issue. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? PM cook #43 was provided education on 1/16/25 on policy Cooling of food items. All cooks were inserviced on the policy and procedure of cooling food items on 1/27/25. All dietary staff were inserviced on food storage policy and procedure on 2/6/25. Under all equipment cleaning will be added to the cooks daily cleaning schedule. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Dietary Manager or designee will audit all food items in the cooler and the cooling log three times a week for three months, weekly for three months, and quarterly thereafter. Drains will change from a monthly cleaning rotation to weekly cleaning and/or as needed. Two audits a week will be conducted to confirm no food debris is under or around equipment. All audits will be reported and reviewed at monthly QAPI meetings. The date for correction and the title of the person responsible for correction of each deficiency: Dietary Manager.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the kitchen hood fire suppression system was maintained in accordance with the National Fire Protection Association (NFPA) 96 Standard. During the survey, it was found that 2 out of 3 kitchen staff members interviewed were not aware of how to activate the kitchen hood fire suppression system in the main kitchen. Specifically, one cook mentioned they would use a fire extinguisher and pull the fire alarm but were unsure about the location of the emergency button for the suppression system. Similarly, the Dietary Supervisor was unaware of the kitchen fire suppression system and would also resort to using a fire extinguisher and pulling the fire alarm. The Director of Facility Services stated that kitchen staff were trained annually on the fire suppression system and the use of K-type fire extinguishers, indicating that all dietary staff should have been familiar with the system.

Plan Of Correction

Plan of Correction: Approved March 7, 2025 (Cooking Facilities – Staff Training on the Kitchen Fire Suppression system) The Facility Services Director will train all the Kitchen staff on how to properly use the Kitchen Fire Suppression system and where the pull switch is located to operate it. The Facility Services Director or a properly trained designee will train all dietary staff, nursing supervisors, maintenance staff, and custodial staff on how to properly use the Kitchen Fire Suppression system and where the pull switch is to operate it. This will also include all newly hired employees within the identified departments. The Facility Services Director or properly trained designee will conduct periodic audits to ensure staff knowledge of the kitchen fire suppression system and report results to QAPI. The audits will be monitored and reported to the QAPI committee on a quarterly basis for one year and annually thereafter. The deficiency will be corrected no later than 3/25/25. The Facility Services Director will be responsible for this plan of correction.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that corridor doors were properly maintained, specifically the server room door, which did not close and latch properly. This deficiency was identified during an observation on January 16, 2025, at 1:11 PM, when the server room door was tested and found not to latch. During an interview on January 24, 2025, at 3:23 PM, the Director of Facility Services acknowledged awareness of the requirement for corridor doors to close and latch but was not aware of the specific issue with the server room door.

Plan Of Correction

Plan of Correction: Approved March 7, 2025 (Corridor Doors) The Corridor door to the server room has been repaired. The door was repaired on: 1/24/25. The Facility Services Director or designee will conduct a facility-wide audit of all corridor doors throughout the building. Any deficiencies found will be corrected in a timely manner. The Facility Services Director or designee will conduct an audit for all corridor doors throughout the building on a quarterly basis. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than: 3/25/25. The Facility Services Director will be responsible for this plan of correction.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper electrical installations in the sensory room, as observed during the Life Safety Code recertification survey. On January 16, 2025, at 3:06 PM, it was noted that four power strips were mounted to the walls and used as a substitute for fixed wiring to power various lights. This setup was not compliant with the required standards. During an interview on January 24, 2025, the Director of Facility Services admitted to being unaware that the use of power strips in this manner was not permitted and acknowledged that additional outlets could be installed as needed.

Plan Of Correction

Plan of Correction: Approved March 7, 2025 The power strips will be removed from the wall in the sensory room. The Facility Services Director or designee will conduct a facility-wide audit throughout the facility. This audit will be added to the PCREE and non-PCREE audit. Any deficiencies found will be corrected. This audit will be conducted on a quarterly basis. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than: 3/25/25. The Facility Services Director will be responsible for this plan of correction.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper labeling of exit signs in accordance with the National Fire Protection Association (NFPA) 101 standards. During the Life Safety Code recertification survey, it was observed that the double doors to the upper courtyard and the single door from the second-floor lounge area to the upper courtyard were not labeled as either an exit or a non-exit. This lack of labeling could lead to confusion, as these doors might be mistaken for exits. The Director of Facility Services acknowledged during an interview that the doors should have been labeled 'No Exit' to ensure the safe egress of residents and staff.

Plan Of Correction

Plan of Correction: Approved March 7, 2025 (Exit Signage) The Facility Services Director has installed the proper signage to read (No Exit) on the following doors: The double doors to the upper courtyard, second-floor lounge, and 3 east middle hall door to the roof. The Facility Services Director or designee will conduct a Facility wide audit of all (No Exit) doors throughout the facility to ensure that there are no other non-exit doors that are out of compliance and if there are any other doors found to be deficient they will be corrected in a timely manner. The Facility Services Director or designee will conduct a Facility wide audit of all Non Exit doors throughout the facility on a quarterly basis to ensure that signage remains on the doors. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/25. The Facility Services will be responsible for this plan of correction.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that hazardous areas were maintained according to safety standards during a Life Safety Code recertification survey. Specifically, the housekeeping office was converted into a resident storage room without being properly rated as a hazardous storage area. During an observation, it was noted that the room, approximately 80 square feet in size, lacked a fire-rated and self-closing door assembly. In an interview, the Director of Facility Services admitted uncertainty about when the conversion occurred but acknowledged awareness of the requirement for hazardous storage rooms to be properly rated.

Plan Of Correction

Plan of Correction: Approved March 7, 2025 The Facility Services Director or designee will remove the temporary stored items from the Housekeeping office and returning it to be an office. The Facility Services Director or designee will conduct a facility wide audit to ensure there are no other storage areas in the building that are out of compliance and if any are found to be out of compliance the storage area will be corrected in a timely manner to meet the standard. The Facility Services Director or designee will conduct an audit on a quarterly basis to inspect all storage areas in the building to ensure all other storage rooms remain in compliance with the standard. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/25. The Facility Services Director will be responsible for this plan of correction.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its automatic sprinkler system by not having spare sprinklers for each type and temperature rating present in the facility. During observations conducted on January 16, 2025, it was noted that the boiler room and laundry room had green vertical standard response sprinkler heads, while the server room had blue pendant standard response sprinkler heads. However, upon reviewing the spare sprinklers, only quick response sprinklers were available, and no standard response spares were present. The Director of Facility Services acknowledged the requirement to have a spare for each type of sprinkler in the facility but was unaware that their supply lacked standard response sprinklers.

Plan Of Correction

Plan of Correction: Approved March 7, 2025 (Missing Spare Sprinklers) The Facility Services Director is currently in the process of ordering the following spare sprinkler heads and will be added to the spare sprinkler cabinet: Green vertical standard heads, Blue vertical standard heads, Red vertical standard heads, Green pendant standard heads, Blue pendant standard heads, Red pendant standard heads. The Facility Services Director will conduct an audit of all the spare sprinkler heads stored in the spare sprinkler cabinets to ensure there are no other spare heads missing from the cabinets. If there are any spare heads missing, they will be replaced in a timely manner. The Facility Services Director or designee will conduct an audit of the spare heads on a quarterly basis. The audit will be included in the Sprinkler audit form. Any deficiencies found will be corrected in a timely manner. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than 3/25/25. The Facility Services Director will be responsible for this plan of correction.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that electrical equipment had approved wiring and electrical outlets in accordance with NFPA 70, 2011 Edition, in two specific rooms: the physical therapy room and the admissions office. During an observation, it was noted that the physical therapy room had two pieces of equipment plugged into regular outlets that were not protected by a ground fault circuit interrupter (GFCI). Additionally, the admissions office had a power strip located directly on the floor, which was not protected from water when the floor was mopped. During an interview, the Director of Facility Services acknowledged awareness of the requirement for outlets to be protected from water but was unaware that the equipment and power strip were not properly protected.

Plan Of Correction

Plan of Correction: Approved March 7, 2025 (Physical Therapy room and Admissions office) The standard electrical outlets will be replaced with a Ground fault circuit interrupter that will meet NFPA 70 standards. The power strip in the Admissions office will be mounted to the wall 12” off the floor. The Facility Services Director will conduct a Facility wide audit of all electrical outlets throughout the building to ensure that no electrical devices that contain water or could come in contact with water or liquid. If there are any deficiencies found, the deficiency will be corrected in a timely manner. This will be done on a quarterly basis. The audits will be monitored and reported to the QAPI committee on a quarterly basis. The deficiency will be corrected no later than: 3/25/25. The Facility Services Director will be responsible for this plan of correction.