Menorah House
Inspection history, citations, penalties and survey trends for this long-term care facility in Boca Raton, Florida.
- Location
- 9945 Central Park Blvd N, Boca Raton, Florida 33428
- CMS Provider Number
- 105685
- Inspections on file
- 25
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Menorah House during CMS and state inspections, most recent first.
A resident with COPD, hypertension, GERD, epilepsy, and intact cognition was care planned to receive assistance with ADLs, including bathing and personal hygiene, and was scheduled for showers three times per week. Despite this, documentation for weekly showers and skin observations was left blank, and there were no nursing notes or behavior monitoring entries indicating refusals of showers or hair care. The resident and a relative reported that the resident had not received a full body bath or hair wash since admission, and observation showed oily hair, a dry scalp, and complaints of itchiness. Therapy staff described the resident as alert, oriented, and participatory in grooming with standby assistance, while CNAs and nursing staff acknowledged that showers and hair washes had not been provided, refusals were not consistently documented, and nursing was not notified of missed care.
Two residents with pressure ulcers received wound care that was not performed in a sanitary manner. For a resident with a sacral pressure ulcer and multiple comorbidities, an LPN, assisted by a CNA, conducted a dressing change without placing a clean barrier between the open sacral wound and a contaminated diaper and Hoyer lift net padding, allowing the uncovered wound to rest on and repeatedly contact these contaminated surfaces during the procedure. For another resident with a mid-upper back pressure ulcer and chronic conditions including COPD, hypertension, GERD, and epilepsy, the same LPN and CNA performed a dressing change without a clean barrier between the uncovered back wound and contaminated bedding, allowing the wound area to contact the bedding throughout the treatment. The LPN later acknowledged not using a clean barrier, and leadership confirmed that the dressing changes should have been done in a safe and sanitary manner.
The facility failed to maintain food safety standards, with a refrigerator exceeding temperature limits and improperly stored food items. Dented cans were not marked, and sanitation solution levels were too high. Personal items were found in the food production area.
The facility failed to provide pureed meals with the correct consistency for residents requiring such diets. Observations revealed grainy and lumpy textures in pureed foods, contrary to the smooth, pudding-like consistency required. Residents expressed dissatisfaction with the meals, leading to low intake. Interviews with staff confirmed the inconsistency with guidelines.
The facility failed to follow infection control guidelines, particularly Enhanced Barrier Precautions (EBP), for several residents. Staff did not wear protective gowns during high-contact activities for residents with specific medical needs, and there was a lack of signage and PPE carts. These lapses were observed in the care of multiple residents, indicating a systemic issue in the facility's infection control practices.
The facility failed to develop and document comprehensive care plans for two residents. One resident expressed loneliness and a desire for activities, but no activities care plan was documented. Another resident required specific medical care and precautions, but no care plan was created for their needs. Staff interviews confirmed the absence of these care plans, and the facility's leadership acknowledged the oversight.
The facility failed to maintain accurate records for controlled drugs for three residents. Medications were either removed from the cart without being documented as administered or documented as administered without being signed out. The DON and an LPN Unit Manager indicated that audits are conducted to reconcile these records, but discrepancies were still found.
The facility failed to provide a safe, clean, and homelike environment in nine resident rooms. Observations included stained flooring and walls, disrepair of baseboards, and stained privacy curtains. A dim bathroom light, inadequate privacy curtain coverage, and a broken dresser drawer were also noted. Strong odors and blackened baseboards were found during an environmental tour.
The facility failed to provide adequate dining assistance, maintain an activities program, and ensure timely medication and medical care for residents. Two residents did not receive necessary help during meals, leading to inadequate nutrition. Another resident lacked engagement in activities, feeling lonely and unsupported. Additionally, medication administration was delayed, and medical orders were not followed, compromising residents' health and well-being.
The facility failed to maintain resident dignity and privacy, as evidenced by undignified language, lack of eating assistance, and exposure during personal care. Two residents were left without proper meal assistance, and another was referred to as a "feeder." Privacy was compromised for several residents, with open doors and inadequate coverage during care. Additionally, a resident experienced a delay in receiving their meal, highlighting a failure to adhere to dignity policies.
The facility failed to provide dignified eating assistance and maintain privacy for residents. One resident was left unattended with a food tray for 25 minutes, while another was referred to as a "feeder". Privacy issues included a resident without a privacy pouch for a drainage bag, another with an open door during personal care, and a resident exposed in bed with the door open.
The facility failed to document the notification of two residents' representatives regarding changes in their conditions. One resident was transferred to the hospital due to unstable vitals without a documented Change in Condition Evaluation or notification of the representative. Another resident, observed to be sluggish with fluctuating oxygen levels, was transferred to the ER, but the notification section was left blank. The LPN acknowledged the presence of family members but did not document their awareness.
The facility failed to maintain a safe, clean, and homelike environment in 9 out of 64 rooms. Observations included stained flooring and walls, disrepair of baseboards, and stained privacy curtains. Some rooms had strong odors, and a resident's privacy curtain did not cover the window area. The Environmental Services Representative acknowledged these issues and mentioned plans to replace baseboards and flooring.
The facility failed to develop comprehensive care plans for two residents, one of whom expressed loneliness and lacked an activities care plan, while the other required specific medical care and Enhanced Barrier Precautions without corresponding care plans. Interviews and observations revealed a lack of documentation and coordination among staff, leading to these deficiencies.
The facility failed to assist two residents who required partial assistance during meals, resulting in inadequate consumption of their meals. Observations showed that staff were not present to help the residents, despite their assessed needs for support with eating.
A resident's preferences for activities were not met due to the lack of a written care plan and documentation of activities. The resident expressed feelings of loneliness and reported missing personal items, while the Activities Director admitted to not documenting one-on-one visits or activities. Despite claims of engagement, inconsistencies were noted between the resident's and the AD's accounts.
The facility failed to provide proper care for three residents, including late medication administration and missing equipment. A resident did not receive timely medications, and their Pleur-X tube was not drained as ordered, causing distress. Another resident experienced late medication administration on multiple occasions. A third resident lacked an abduction pillow as ordered, with staff unaware of its absence.
A facility failed to provide timely and adequate nutritional support for two residents. One resident was admitted without a feeding order for 20 hours, and observations showed improper management of the feeding tube. Another resident received significantly less formula than prescribed, with discrepancies in administration. Staff interviews confirmed delays and errors in following physician orders, leading to inadequate nutrition.
The facility failed to ensure accurate dispensing and administration of controlled drugs for three residents. A resident's medication was removed from the cart but not documented as administered, while another's was documented as administered but not removed. The DON and an LPN Unit Manager acknowledged the responsibility for auditing medication reconciliation, but discrepancies persisted.
The facility failed to provide meals that matched the dietary preferences of two residents, leading to a deficiency. One resident with moderate cognitive impairment did not receive mashed potatoes and had unwanted potato skins, while another resident did not receive the salads listed on their meal ticket. The dietary manager acknowledged the issue, despite having checkpoints to ensure meal accuracy.
The facility's nurse call systems in the Galilee and Masada wings were found deficient during a fire safety tour, with several corridor lights failing to illuminate as required by NFPA 99 standards. The Maintenance Director acknowledged these deficiencies.
The facility did not maintain its Essential Electrical System (EES) as per NFPA 99 standards, lacking a supply of generator replacement parts for high mortality items. This was observed during a fire safety tour with the Maintenance Director, who acknowledged the deficiency. The issue was discussed with the Administrator and Maintenance Director during the exit conference.
The facility was found non-compliant with NFPA 101 standards for egress doors. Observations revealed missing signage on main entrance doors with delayed egress locks, unauthorized multiple locks on the Dining Room Patio exit, and improper locking mechanisms on Rehabilitation emergency exit doors. The Maintenance Director acknowledged these deficiencies.
The facility failed to maintain their commercial cooking facility according to NFPA 101 standards. During a fire safety tour, it was observed that two gas-powered appliances, a steamer and an oven, were on castors without means to prevent strain on the gas connection. The Maintenance Director acknowledged the findings, which were reviewed with the Administrator.
The facility failed to maintain fire/smoke barriers as per NFPA 101 standards, with penetrations found in a 2-hour fire-rated wall and a smoke wall during a fire safety tour. The Maintenance Director acknowledged these findings, which were reviewed with the Administrator. The report highlights the need for thorough inspections to ensure all penetrations are sealed to maintain safety.
During a fire safety tour, a facility was found to have improper use of power strips and lack of GFCI protection. Power strips were plugged into other power strips at the Reception desk and Telecommunication Room, and a vending machine lacked GFCI protection. Additionally, televisions in several resident rooms were plugged into power strips within six feet of the patient care area, violating safety regulations. The Maintenance Director acknowledged these findings.
The facility did not maintain documentation for the 5-year hydrostatic test of the fire department connection and the 5-year internal inspection of the fire-line backflow preventer, as required by NFPA 101. This was identified during a record review with the Maintenance Assistant, who acknowledged the findings, and discussed with the Administrator and Maintenance Director.
The facility failed to maintain portable fire extinguishers according to NFPA 101 standards, with three out of twelve extinguishers either obstructed or improperly installed. The Telecommunication Equipment Room had an obstructed class ABC extinguisher and lacked a clean agent extinguisher, while extinguishers near Rooms 203 and 209 were blocked by carts. These issues were confirmed by the Maintenance Director and discussed with the Administrator.
A facility failed to monitor and document a resident's pain level as ordered and did not record the administration of pain medication. The resident had a care plan for pain management, but the MAR lacked documentation of pain levels and medication administration, despite records showing Tramadol was removed for the resident. These issues were confirmed by the DON.
A facility failed to verify and administer an IV antibiotic, Vancomycin, for a resident upon admission. The hospital's order for Vancomycin IV during dialysis was intended for Home Health Care and was not included in the discharge orders reconciled by the nurses. The order was not reviewed or clarified in a morning meeting with the DON, ADON, Administrator, and Social Services. A Dialysis Center RN reported that the resident's spouse mentioned the need for Vancomycin IV, but the on-duty nurse incorrectly stated that the resident was receiving oral Vancomycin. There was no evidence that the order was clarified with the physician.
Failure to Provide Scheduled Showers and Hair Care for a Cognitively Intact Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate ADL care, specifically bathing and hair care, to a cognitively intact resident despite an existing ADL policy and individualized care plan. The facility’s policy required a consistent and effective approach to ADL care, including bathing, hygiene, hair care, and regular monitoring and documentation of ADL needs and outcomes. The resident’s ADL care plan, initiated shortly after admission, identified a need for assistance with ADLs due to weakness and decreased mobility following a recent hospitalization, and directed staff to encourage and assist with all ADL tasks, including bathing and personal hygiene, while observing for changes in capabilities. Record review showed that the resident was admitted with COPD, hypertension, GERD, and epilepsy, and had a BIM score of 14, indicating intact cognition. The resident was scheduled on the unit’s shower list to receive showers three times per week, but the computerized CNA task section for weekly showers/skin observation and the paper shower schedule form were left blank and not completed. CNA documentation reflected only three refusals for personal hygiene tasks such as combing hair and washing face and hands, and did not include refusals for baths, showers, or oral hygiene during the resident’s stay. There was no documentation in nursing progress notes, behavior monitoring records, or the ADL care plan of any refusals or behavioral issues related to showering or hair washing. Interviews and observations further demonstrated that the resident did not receive the scheduled showers and hair care. The resident and a relative reported that the resident had not received a full body bath/shower or hair wash since admission, and the relative stated that the lack of hair washing for 21 days was very distressing. On observation, the resident’s hair appeared oily with a dry scalp, and the resident reported an itchy scalp. Therapy staff described the resident as alert, oriented, and participatory in care, with some weakness and shortness of breath but able to perform grooming with standby assistance and other ADLs with varying levels of assistance. CNAs acknowledged that the resident should have been showered at least three times per week, admitted they had not provided showers or hair washes, and had not documented refusals or notified nursing. Nursing staff, including the unit manager, confirmed there was no documentation of refusals or care issues, and the DON acknowledged the resident should have received appropriate ADL care.
Unsanitary Wound Care Performed Without Clean Barriers
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and treatment in a sanitary manner, contrary to its own wound management and treatment policies. The Menorah House Wound Management Program policy states that all caregivers are responsible for preventing, caring for, and treating wounds and skin alterations, with an organized approach that includes appropriate local wound care and prevention of skin breakdown. The Menorah House Treatment Procedure requires that a clean field be arranged per facility protocol when performing treatments inside a resident’s room. Despite these policies, surveyors observed wound care being performed without maintaining a clean barrier between open wounds and potentially contaminated surfaces. For one resident with a sacral pressure ulcer and multiple comorbidities including diffuse traumatic brain injury, diabetes mellitus type II, dementia, seizures, hypertension, and atherosclerotic heart disease, the physician’s order directed daily cleansing of the sacral wound with normal saline, patting dry, and applying collagen and calcium alginate with a dry dressing. The resident’s care plan focused on weekly skin checks, documenting wound status and healing, monitoring for signs and symptoms of infection, and encouraging participation in toileting and hygiene. During an observed sacral wound dressing change, an LPN, assisted by a CNA, prepared supplies and washed her hands, but did not place a clean barrier between the resident’s uncovered sacral wound and the diapered bottom. The LPN left the bedside to wash her hands, leaving the bare, exposed wound resting directly on a contaminated diaper and contaminated Hoyer lift net padding. Throughout the procedure, the resident’s uncovered sacral wound repeatedly came into contact with the contaminated diaper and Hoyer lift net padding, with no clean barrier used at any time. For another resident with a mid-upper back pressure ulcer and diagnoses including COPD, hypertension, GERD, and epilepsy, the physician’s order directed cleansing the mid-back wound with normal saline, patting dry, applying Medi-honey to the wound base, and covering with a dry dressing daily. The care plan for this resident also included weekly skin checks, documenting wound status and healing, monitoring for signs and symptoms of infection, and encouraging participation in toileting and hygiene. During an observed mid-upper back wound dressing change, the same LPN, assisted by the CNA, performed the dressing change without placing a clean barrier between the resident’s bare, uncovered back wound area and the contaminated bedding. Throughout the procedure, the resident’s uncovered back wound area was allowed to come into contact with the contaminated bedding while the wound was being cleaned and treated. In interviews, the LPN acknowledged not placing a clean barrier and could not explain why, and the unit manager and DON acknowledged that a clean barrier should have been used and that the dressing changes should have been performed in a safe and sanitary manner.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during one of three visits to the main kitchen. Observations revealed that the walk-in refrigerator on the dairy side had an internal temperature of 49 degrees Fahrenheit, exceeding the acceptable range of 35 to 40 degrees Fahrenheit. Several food items, including an egg platter, a tuna platter, and nutritional juice drinks, were found with internal temperatures above the required 40 degrees Fahrenheit. Additionally, a large container of raw chicken and raw meat in the walk-in meat refrigerator were improperly stored, with one container showing a pool of liquid at the bottom. Further issues were noted in the dry storage room, where dented cans of sliced pineapples and tomato sauce were not segregated with a 'do not use' sign. An opened bottle of extra light amber honey was found without a known opening date. A personal Styrofoam cup of coffee was observed in the food production area, and a large metal container was coated with a dried unidentified substance. The facility's use of sanitation solution was also problematic, as a red bucket tested with Hydrion strips showed an excessive level of 400 parts per million, which the Dietary Manager acknowledged as too much solution.
Plan Of Correction
F812 FOOD PROCUREMENT, STORE/PREPARE/SERVE-SANITARY What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the Walk-in refrigerator on the dairy side was 49° not the necessary 40°. Dietary staff will be in-serviced to check walk-in refrigerator temperatures and ensure it is 40° or below. If not, to inform maintenance to fix/adjust the temperature. In the allegation of the Egg platter from dairy walk-in was 43.7° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of the Scoop of Tuna from the dairy walk-in was 44° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of the Container of nutritional juice drink from the dairy walk-in was 46° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of Another Container of nutritional juice drink from the dairy walk-in was 47.1° not the necessary 40°. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. In the allegation of Raw chicken exposed and dated, Dietary staff will be in-serviced to properly seal and date open items and how long before they need to be disposed of. In the allegation of Raw meat dated, pool of on the bottom of the meat container. Dietary staff will be in-serviced as to the proper storage of raw meat. In the allegation of Bag of unidentified meat dated, Dietary staff will be in-serviced to properly label, date, and store refrigerated items. In the allegation of Red bucket having a reading of 400 parts per million indicating too much sanitation solution in the bucket. Dietary staff will be in-serviced on proper measurements for sanitation solution. In the allegation of Dry storage had a dented can of sliced pineapples that was not placed by the sign "do not use". Dietary staff will be in-serviced where to place and not use dented cans. In the allegation of Dry storage had 2 dented cans of tomato sauce that was not placed by the sign "do not use". Dietary staff will be in-serviced where to place and not use dented cans. In the allegation of Dry storage Open bottle of extra light amber honey was half used and was not dated as to when it was opened. Dietary staff will be in-serviced on proper labeling and storage of open items in the dry storage. In the allegation of Food prep area had a person 20 oz Styrofoam cup of coffee present. Dietary staff will be in-serviced not to have eat or drink or leave personal food in the kitchen. In the allegation of a Large metal container with a dried unidentified substance coating the surface. Dietary Staff will be in-serviced on proper cleaning of metal containers. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Dietary staff will be in-serviced to check walk-in refrigerator temperatures and ensure it is 40° or below. If not, to inform maintenance to fix/adjust the temperature. Dietary staff will be in-serviced not to use refrigerated food with a temperature above 40°. Dietary staff will be in-serviced to properly seal and date open items and how long before they need to be disposed of. Dietary staff will be in-serviced as to the proper storage of raw meat. Dietary staff will be in-serviced to properly label, date, and store refrigerated items. Dietary staff will be in-serviced on proper measurements for sanitation solution. Dietary staff will be in-serviced where to place and not use dented cans. Dietary staff will be in-serviced on proper labeling and storage of open items in the dry storage. Dietary staff will be in-serviced not to eat or drink or leave personal food in the kitchen. Dietary Staff will be in-serviced on proper cleaning of metal containers. Random QA audits will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month, and then monthly for one month or until substantial compliance has been determined. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audits will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month, and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met.
Inadequate Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct diet consistency for residents on pureed diets, as observed during multiple visits to the main kitchen. The pureed meals prepared for residents did not meet the required smooth, pudding-like consistency as per the facility's policy and guidelines set by the National Task Force. Observations revealed that the pureed hamburger had a grainy consistency, and the pureed vegetables were lumpy. Additionally, the pureed turkey contained small pieces, indicating a failure to achieve the necessary texture. Resident #47, who was on a pureed diet due to a medical condition affecting their ability to swallow, received a meal with a pureed roll that was lumpy and grainy. The resident's meal ticket matched the meal tray, but the consistency did not meet the required standards. Interviews with the Registered Dietitian and Speech Therapist confirmed that the pureed diet should be smooth and lump-free, resembling mashed potatoes, which was not the case during the observations. Resident #175 and Resident #77 also received pureed meals that did not meet the required consistency. Resident #175's meal had a loose puree consistency with liquid pooling around the food, leading to a low intake of the meal. Similarly, Resident #77's meal had a loose puree consistency with liquid pooling, and the resident expressed dissatisfaction with the flavor, resulting in a refusal to eat the rest of the meal. These observations indicate a consistent failure to provide pureed meals in the correct form, potentially affecting the nutritional intake and satisfaction of residents on pureed diets.
Plan Of Correction
F805 FOOD IN FORM TO MEET INDIVIDUAL NEEDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the pureed food on the lunch meal tray line, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 2) In the allegation of the pureed food on the lunch meal tray line, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 3) In the allegation of Resident #47, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 4) In the allegation of Resident #175, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 5) In the allegation of Resident #77, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Cooks will be in-serviced as to the proper consistency of pureed food. Random QA audits will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention and control guidelines, particularly concerning Enhanced Barrier Precautions (EBP) for several residents. Resident #103 was observed without proper protective measures in place, as staff did not wear gowns while repositioning the resident, despite the presence of a drainage bag. The Infection Preventionist and Unit Manager acknowledged the oversight, attributing it to the resident's recent room change, which led to the delayed placement of a PPE cart. Resident #175's care also demonstrated lapses in following EBP protocols. Staff members, including a wound care nurse and a hospice aide, were observed providing care without wearing protective gowns, despite the resident's condition requiring such precautions. The staff admitted to being distracted or unaware of the need for gowns, indicating a lack of consistent adherence to the facility's infection control policies. Additionally, Resident #46 and Resident #39 were not provided with appropriate EBP measures. Staff failed to wear gowns during high-contact activities, such as transferring and wound care, and there was a lack of signage and PPE carts outside their rooms. These deficiencies highlight a systemic issue in the facility's implementation of infection control practices, as staff members were either unaware or neglectful of the necessary precautions for residents with specific medical needs.
Plan Of Correction
Corrective action completion date: F880 CONTROL PREVENTION& 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #103. The resident had risk for related to the and interventions did not include Enhanced Barrier Precautions. Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. 2) In the allegation of Resident #175, The Staff left the door open, privacy curtain halfway open and were not wearing proper PPE while doing care on a resident that had Enhanced Barrier Protection. Nursing staff will be in-serviced on dignity, closing door and pulling privacy curtain during care. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. 3) In the allegation of Resident #46, the resident did not have an Enhanced Barrier Protection or care plan. There was no Enhanced Barrier Protection signage on the door and no PPE cart. Staff while transferring resident was not using proper PPE. Staff not wearing proper PPE while caring for resident. Nursing staff will be in-serviced about initiating proper care plans for residents who need care and Enhanced Barrier protection. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. 4) In the allegation of Resident #276, during the staff did not do proper hygiene in between glove changes. Staff will be in-serviced to proper hygiene between glove changes. 5) In the allegation of Resident #278, during the staff did not do proper hygiene in between glove changes. Staff will be in-serviced to proper hygiene between glove changes. 6) In the allegation of Resident #39, during care, Care Staff was not wearing gowns, there was no Enhanced Barrier Precautions signage on the door no isolation cart. Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. - Nursing staff will be in-serviced on dignity, closing doors and pulling privacy curtain during care. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. - Nursing staff will be in-serviced about initiating proper care plans for residents who need care and Enhanced Barrier protection. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. - Staff will be in-serviced to proper hygiene between glove changes. - Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive activities care plan for a resident, identified as Resident #12, who expressed feelings of loneliness and a desire for in-room activities. Despite the resident's expressed preferences for certain activities, such as going outside for fresh air and participating in religious services, there was no documented evidence of an activities care plan in the resident's clinical record. Interviews with the resident and facility staff, including the Activities Director and MDS Coordinator, confirmed the absence of a written care plan and a lack of documentation of activities provided to the resident. Additionally, the facility did not create a care plan for another resident, identified as Resident #39, who had specific medical needs including a right heel and right condition requiring Enhanced Barrier Precautions. The resident's clinical records showed physician orders for wound care and barrier precautions, but there was no corresponding care plan documented. Observations revealed that the necessary precautions were not in place, as there was no sign or isolation cart near the resident's door. Interviews with the MDS Coordinator and a Licensed Practical Nurse confirmed the absence of a care plan for the resident's medical conditions and precautions. The Director of Nursing and the Administrator were informed of these deficiencies, acknowledging that the lack of documentation indicated that the necessary care plans and activities were not implemented. The facility's failure to initiate and document comprehensive care plans for these residents highlights a significant oversight in meeting the residents' individualized care needs.
Plan Of Correction
N072 COMPREHENSIVE CARE PLANS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #12, not having an activities care plan or documentation of activities participation. The Activities Director will be in-serviced about activities care-plans and documentation for activities participation. 2) In the allegation of Resident #39, not having a care plan for right heel or right, and no care plan for Enhanced Barrier Precautions. Missing Enhanced Barrier Precautions signage on the door, missing isolation cart near the resident's door. Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Activities Director will be in-serviced about activities care-plans and documentation for activities participation. Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Inadequate Controlled Drug Record Keeping
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in maintaining accurate records for the dispensing and administration of controlled drugs. This deficiency was identified through interviews and record reviews for three residents. For Resident #487, there was a discrepancy between the Medication Monitoring/Control Record and the Medication Administration Record (MAR), where a medication was signed out as removed from the medication cart but not documented as administered. Similarly, for Resident #28, a medication was removed from the cart but not recorded as administered on the MAR. In contrast, for Resident #82, a medication was documented as administered but not signed out as removed from the medication cart. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) Unit Manager revealed that the Unit Managers are responsible for auditing the medication reconciliation of controlled substances. The LPN Unit Manager stated that she checks the Medication Monitoring/Control Record against the MAR to ensure all entries are signed and match, typically performing this audit three times a week, although it is supposed to be done once a week. These findings indicate a failure in the facility's system to accurately record and reconcile the receipt and disposition of controlled drugs, as required by the consultant pharmacist's established system.
Plan Of Correction
N092 FAC CONTROLLED DRUGS - RECORDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #487, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2) In the allegation of Resident #28, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 3) In the allegation of Resident #82, the resident's medication was not signed out but was documented as administered. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations and interviews. Nine out of 64 rooms were found to have various issues, including stained flooring and walls, disrepair of baseboards, and stained privacy curtains. Specific observations included a dim and blinking bathroom light, a privacy curtain that did not adequately cover a window, and a dresser drawer with a broken piece of wood. Additionally, a TV was connected to a power strip, which could pose a safety hazard. Further environmental concerns were noted during a tour with the Environmental Services Representative and the Housekeeping Director. A strong odor was detected in some bathrooms, and the baseboards were blackened in various sections. The bathroom wall near the door was soft, and the plaster was not smooth. The Environmental Services Representative acknowledged these issues and mentioned that the baseboards had been painted over, but the paint comes off during cleaning and buffing. They also stated that there is a plan to replace all room baseboards and flooring, pending the delivery of new tiles.
Plan Of Correction
N110 PHYSICAL ENVIRONMENT - SAFE, CLEAN, HOMELIKE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of flooring, wall and baseboard behind residents bed where stained and in disrepair. Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. In the allegation of privacy curtain stained, floor stained and baseboard in disrepair. Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. In the allegation of bathroom light dim and blinking and baseboard behind resident's bed in disrepair. Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. In the allegation of privacy curtain does not cover window area. Maintenance staff will fix or replace privacy curtain to ensure it cover the window area. In the allegation of outside of room in disrepair, broken dresser drawer, power strip for the TV. Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. In the allegation of baseboard in disrepair and floor stained behind residents nightstand and bed. Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. In the allegation of strong -like odor in bathroom, room baseboards blackened, bathroom wall near the door soft and plaster not smooth. Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. In the allegation of strong -like odor. Housekeeping will scrub and clean rooms to remove -like odor. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. Maintenance staff will fix or replace privacy curtain to ensure it covers the window area. Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. Housekeeping will scrub and clean rooms to remove -like odor. Random QA audits will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Deficiencies in Resident Care and Support
Penalty
Summary
The facility failed to provide adequate assistance during dining for two residents who required help with their meals. Observations revealed that one resident's meal trays were left untouched or barely eaten, with no staff present to assist, despite the resident's need for partial assistance. Interviews with staff indicated a misunderstanding of the resident's needs, as one CNA believed the resident could eat independently with minimal setup. Another resident also required encouragement and assistance with meals, but staff inconsistently provided the necessary support, as noted by the resident's family member. The facility also failed to maintain an ongoing activities program tailored to a resident's preferences. The resident expressed feelings of loneliness and a lack of engagement in activities, despite having specific interests such as going outside and participating in religious services. The Activities Director admitted to not documenting in-room activities and acknowledged that the resident's care plan lacked evidence of individualized activity planning. This oversight resulted in the resident not receiving the desired level of engagement and support. Additionally, the facility did not ensure timely administration of medications and proper medical care for several residents. One resident did not receive their Pleur-X drainage as ordered, leading to distress and potential health risks. Another resident experienced delays in medication administration, with some medications given up to two hours late. Furthermore, a resident did not have an abduction pillow in place as ordered, and another resident's nutritional needs were not met due to improper administration of enteral feeding. These deficiencies highlight a pattern of inadequate adherence to physician orders and care plans, compromising the residents' health and well-being.
Plan Of Correction
N201 FS RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #1 having multiple meals where trays were not set up for the resident to eat. The resident ate minimal at all the observed meals. Nursing staff will be in-serviced to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. 2) In the allegation of Resident #275 needing help and encouragement during meals. Nursing staff will be in-service to ensure ADLs are followed for meal times for residents that need assistance, i.e. set up, assistance or encouragement with eating. 3) In the allegation of Resident #12, and 1 on 1 activities in room visits not being documented. The Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. 4) In the allegation of Resident #73, and the Pleur-X not being drained on its schedule. And not following medication administration times of an hour prior or an hour post scheduled administration times. The Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. The Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 5) In the allegation of Resident #481 having not received multiple medication at their prescribed times. Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 6) In the allegation of Resident #46, and the resident's abduction pillow not being used. Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. 7) In the allegation of Resident #475, and the facility not receiving an order for almost 20 hours. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 8) In the allegation of Resident #109, not for almost 22 hours and the tube-feeding not running at proper rate. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: In-service will be conducted with nursing staff to ensure ADL are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide eating assistance in a dignified manner for two residents observed for in-room dining. One resident was left unattended with a food tray for approximately 25 minutes without staff assistance, despite needing supervision and assistance during meals. Another resident was referred to as a "feeder" by staff, which is considered undignified language. Additionally, a resident's privacy was compromised as they were left without a privacy pouch for their drainage bag, contrary to their care plan requirements. The facility also failed to maintain privacy during personal care for several residents. One resident was observed with their room door open and privacy curtain partially drawn while receiving care, exposing them to the hallway. Another resident was found with their bed covers off, exposing their disposable brief and tubing, with the room door open, allowing full view from the hallway. These observations indicate a lack of adherence to the facility's dignity policy, which emphasizes maintaining privacy and respectful communication. Furthermore, a resident experienced a delay in receiving their lunch tray, resulting in them waiting 19 minutes after their roommate had already finished eating. This delay in meal service is inconsistent with the facility's policy of treating residents with dignity and ensuring timely assistance. The report highlights multiple instances where the facility's actions or inactions failed to uphold the residents' right to be treated with dignity and respect, as required by the facility's policies and procedures.
Plan Of Correction
N203 RIGHT TO BE TREATED WITH DIGNITY 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #82, being referred to as a "feeder". Staff will be in-serviced regarding dignity, not calling residents "feeders" but as someone who needs assistance with feeding. 2) In the allegation of Resident #103, waiting a long time to be fed. Staff will be in-serviced not to leave trays in the room, but to feed residents in a timely manner as to not cause dignity issues. 3) In the allegation of Resident #103, not having a privacy pouch for bags. Nursing staff will be in-serviced to ensure residents with bags have privacy covers for them. 4) In the allegation of Resident #175, privacy during care. Nursing staff will be in-serviced to provide privacy for residents while they are receiving care. 5) In the allegation of Resident #275, delay in feeding, residents in the same room should be brought their trays at the same time. Staff will be in-serviced to bring food trays to all residents in the same room at the same time not to cause dignity issues. 6) In the allegation of Resident #475, door open no covers (linens) covering resident, resident exposed in only a brief and a shirt. Nursing staff will be in-serviced to ensure residents are dressed or covered for privacy and dignity. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - In-service staff about dignity, not calling residents "feeders" but as someone who needs assistance with feeding. - In-service staff not to leave trays in room, to feed residents in a timely manner as to not cause a dignity issue. - In-service Nursing staff to ensure residents with bags have privacy covers for them. - In-service nursing staff to provide privacy for residents while they are receiving care. - In-service staff to bring food trays to all residents in the same room at the same time not to cause a dignity issue. - In-service nursing staff to ensure residents are dressed or covered for privacy and dignity. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Dignity and Privacy Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide eating assistance in a dignified manner for two residents observed for in-room dining. One resident was left unattended with a food tray for approximately 25 minutes without staff assistance, despite needing supervision and assistance during meals. Another resident was referred to as a "feeder" by staff, which is considered disrespectful and undignified. The facility also failed to maintain privacy and dignity for several residents. One resident was observed without a privacy pouch for a drainage bag, exposing them unnecessarily. Another resident was left with their room door open and privacy curtain partially drawn during personal care, exposing them to the hallway. Additionally, a resident was found lying in bed with their shorts unbuttoned and a disposable brief partially exposed, with the room door open, allowing full view from the hallway. These observations indicate a lack of adherence to the facility's dignity policy, which emphasizes respectful communication and maintaining privacy during personal care activities. The staff's actions and inactions, such as leaving residents exposed or unattended, demonstrate a failure to treat residents with the respect and dignity they are entitled to under federal regulations.
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. F550 RESIDENT RIGHTS/EXERCISE OF RIGHTS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #82, being referred to as a "feeder". Staff will be in-serviced regarding dignity, not calling residents "feeders" but as someone who needs assistance with feeding. 2) In the allegation of Resident #103, waiting a long time to be fed. Staff will be in-serviced not to leave trays in the room, but to feed residents in a timely manner as to not cause dignity issues. 3) In the allegation of Resident #103, not having a privacy pouch for bags. Nursing staff will be in-serviced to ensure residents with bags have privacy covers for them. 4) In the allegation of Resident #175, privacy during care. Nursing staff will be in-serviced to provide privacy for residents while they are receiving care. 5) In the allegation of Resident #275, Delay in feeding, residents in the same room should be brought their trays at the same time. Staff will be in-serviced to bring food trays to all residents in the same room at the same time not to cause dignity issues. 6) In the allegation of Resident #475, Door open no covers (linens) covering resident, resident exposed in only a brief and a shirt. Nursing staff will be in-serviced to ensure residents are dressed or covered for privacy and dignity. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - In-service staff about dignity, not calling residents "feeders" but as someone who needs assistance with feeding. - In-service staff not to leave trays in room, to feed residents in a timely manner as to not cause a dignity issue. - In-service Nursing staff to ensure residents with bags have privacy covers for them. - In-service nursing staff to provide privacy for residents while they are receiving care. - In-service staff to bring food trays to all residents in the same room at the same time not to cause a dignity issue. - In-service nursing staff to ensure residents are dressed or covered for privacy and dignity. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Document Notification of Change in Condition
Penalty
Summary
The facility failed to document the notification of the resident or resident representative for a change in condition for two residents. For Resident #53, the medical record showed no evidence of a Change in Condition Evaluation being completed, nor was there documentation of notifying the resident's representative or emergency contact. The resident was transferred to the hospital due to unstable vitals, but there was no record of the resident leaving for a physician's visit or with whom. The Licensed Practical Nurse (LPN) acknowledged that the resident's wife was present but did not document the change in condition evaluation. Similarly, for Resident #488, the facility did not document notifying the family or representative about the resident's change in condition. The resident was observed to be sluggish with fluctuating oxygen saturation levels, leading to a transfer to the emergency room. The Change in Condition Evaluation section for notifying the family or representative was left blank. The LPN stated that the resident's daughter was present during the change in condition but admitted to not documenting her presence or awareness of the situation.
Plan Of Correction
F580 NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #53, there was no change of condition completed, no notification to family, no documentation as to where or with whom the resident left. Nursing staff will be in-serviced to complete a change of condition for resident when being discharged to the hospital, to notify and document the residents emergency contact/guardian when being sent to the hospital, document to where the resident went and with whom. 2) In the allegation of Resident #488, there was No documentation notification made letting emergency contact/guardian know the resident went to the ER. Nursing staff will be in-serviced to complete a change of condition for resident when being discharged to the hospital, to notify and document the residents emergency contact/guardian when being sent to the hospital, document to where the resident went and with whom. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: In-service Nursing staff to complete a change of condition for residents when being discharged to the hospital, to notify and document the residents emergency contact/guardian when being sent to the hospital, document to where the resident went and with whom. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Deficiencies in Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in 9 out of 64 rooms. Observations revealed various deficiencies, including stained flooring and walls, disrepair of baseboards, and stained privacy curtains. In one instance, a resident's privacy curtain did not adequately cover the window area, and another resident's dresser drawer was broken. Additionally, a TV was connected to a power strip, which could pose a safety risk. The environmental tour further identified strong odors in some rooms, blackened baseboards, and soft bathroom walls with unsmooth plaster. Interviews with residents and staff confirmed these environmental concerns. The Environmental Services Representative acknowledged that the baseboards had been painted over and that the paint comes off during cleaning and buffing. They mentioned a plan to replace all room baseboards and flooring, pending tile delivery. Despite these plans, the current state of the facility did not meet the regulatory requirements for a safe and homelike environment, as evidenced by the observations and resident feedback.
Plan Of Correction
SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of flooring, wall and baseboard behind residents bed where stained and in disrepair. Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. 2) In the allegation of privacy curtain stained, floor stained and baseboard in disrepair. Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. 3) In the allegation of bathroom light dim and blinking and baseboard behind resident's bed in disrepair. Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. 4) In the allegation of privacy curtain does not cover window area. Maintenance staff will fix or replace privacy curtain to ensure it covers the window area. 5) In the allegation of wall outside of room in disrepair, broken dresser drawer, power strip for the TV. Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. 6) In the allegation of baseboard in disrepair and floor stained behind residents nightstand and bed. Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. 7) In the allegation strong-like odor in bathroom, room baseboards blackened, bathroom wall near the door soft and plaster not smooth. Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. 8) In the allegation of strong -like odor. Housekeeping will scrub and clean rooms to remove -like odor. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Maintenance/Housekeeping staff will fix, and or clean flooring, wall and baseboard behind resident's bed. - Maintenance/Housekeeping staff will change privacy curtain, fix, and or clean flooring, wall and baseboard behind resident's bed. - Maintenance/Housekeeping staff will change or fix the bathroom light, and or clean/fix baseboard behind resident's bed. - Maintenance staff will fix or replace privacy curtain to ensure it covers the window area. - Maintenance staff will repair the wall outside of the room, they will fix or place the dresser drawer, and they will remove the power strip from the TV. - Maintenance/Housekeeping staff will fix, and or clean flooring, and baseboard behind resident's bed and nightstand. - Maintenance/Housekeeping staff will clean the bathroom to remove the -like odor, baseboards will be repaired or replaced, and the wall will be repaired and smoothed out. - Housekeeping will scrub and clean rooms to remove -like odor. Random QA audits will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Maintenance or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee for a period of three months and until substantial compliance is met.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive activities care plan for a resident, identified as Resident #12, who expressed feelings of loneliness and a desire for in-room activities. Despite the resident's cognitive abilities being intact, as indicated by a Brief Interview of Mental Status score of 15, there was no documented activities care plan in the resident's clinical record. The resident expressed that they felt lonely and had lost a workbook during a room transfer, which was not replaced by the facility staff. Interviews with the Activities Director and MDS staff revealed a lack of coordination and documentation regarding the resident's activities care plan. Additionally, the facility did not create a care plan for another resident, identified as Resident #39, who had specific medical needs including a right heel condition and required Enhanced Barrier Precautions. The resident's clinical records showed physician orders for wound care and barrier precautions, but there was no corresponding care plan documented. Observations confirmed the absence of necessary precautions, such as signage and isolation carts, during care procedures. Interviews with the MDS Coordinator and LPN involved in the resident's care highlighted a gap in the creation and implementation of care plans for the resident's identified needs. The deficiencies in care planning for both residents were acknowledged by facility staff, including the Director of Nursing and the Administrator, who confirmed that the lack of documentation indicated that the necessary care plans were not developed or implemented. This failure to document and execute comprehensive care plans for residents' activities and medical needs represents a significant oversight in the facility's care planning processes.
Plan Of Correction
Corrective action completion date: F656 DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #12, not having an activities care plan or documentation of activities participation. The Activities Director will be in-serviced about activities care-plans and documentation for activities participation. 2) In the allegation of Resident #39, not having a care plan for right heel or right, and no care plan for Enhanced Barrier Precautions. Missing Enhanced Barrier Precautions signage on the door, missing isolation cart near the resident's door. Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Activities Director will be in-serviced about activities care-plans and documentation for activities participation. - Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Assist Dependent Residents During Meals
Penalty
Summary
The facility failed to provide necessary assistance during dining for two residents who were dependent on staff for their Activities of Daily Living (ADL). Resident #1, who was assessed as needing partial assistance with eating, was observed multiple times without staff assistance during meals. On several occasions, Resident #1's meal trays were left untouched or barely consumed, indicating a lack of support from staff. Despite the resident's need for help, staff were not present to assist with eating, resulting in the resident consuming only a small portion of their meals. Similarly, Resident #275, who also required partial assistance during meals, was not adequately supported. The resident's assessment indicated a need for observation and assistance to complete meals, yet the facility did not provide the necessary support. Interviews with staff confirmed that both residents required assistance during mealtimes, but the facility failed to ensure staff were available to help, leading to deficiencies in maintaining proper nutrition and hydration for these residents.
Plan Of Correction
F677 ADL CARE PROVIDED FOR DEPENDENT RESIDENTS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #1, having multiple meals where trays were not set up for the resident to eat. The resident ate minimal at all the observed meals. Nursing staff will be in-serviced to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. 2) In the allegation of Resident #275, needing help and encouragement during meals. Nursing staff will be in-service to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - In-service will be conducted with nursing staff to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. - In-service will be conducted with nursing staff to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide an ongoing activities program tailored to the preferences of a resident, identified as Resident #12. The resident's clinical record lacked a written activities care plan, despite the resident expressing preferences for certain activities such as going outside for fresh air and participating in religious services. The resident reported feeling lonely and mentioned that her workbook was lost during a room transfer, which the facility staff could not locate. The Activities Director (AD) admitted to not documenting one-on-one activities or visits, and although the AD claimed to engage with the resident, there was no written evidence to support these interactions. Interviews with the resident and the AD revealed inconsistencies in the activities provided. The AD stated that she conducted one-on-one room visits and offered activities like makeup sessions and reading, but the resident contradicted this by stating that her makeup was only done once. The AD also mentioned that the resident received visits from church friends and was brought to music events, but did not provide magazines or other requested items because the resident had not explicitly asked for them. The lack of documentation and a formal care plan for activities was acknowledged by the facility's Administrator, who noted that if it is not documented, it is considered not done.
Plan Of Correction
F679 ACTIVITIES MEETS INTEREST/NEEDS EACH RESIDENT 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of resident #12, and 1 on 1 activities in room visits not being documented. The Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. Random QA audits will be conducted by the Administrator or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Administrator or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Administrator a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Medication and Equipment Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for three residents. Resident #73 did not receive timely medication administration, with six medications given late by up to an hour and forty-two minutes. Additionally, the resident's Pleur-X tube was not drained as ordered, leading to the resident expressing distress and concern for his health. Interviews with staff revealed a lack of awareness and documentation regarding the Pleur-X drainage, and the attending physician was not informed of the missed drainage. Resident #481 also experienced late medication administration, with medications given late on eight occasions, up to two hours and twenty-nine minutes past the scheduled time. The resident confirmed receiving medications late and expressed awareness of the medication names. Interviews with staff and the consultant pharmacist acknowledged the potential detriment of late medication administration, though not life-threatening. Resident #46 did not have an abduction pillow in place as ordered by the physician. Observations revealed the resident in bed without the required pillow, and interviews with staff indicated a lack of knowledge about the abduction pillow's presence or use. The MDS Coordinator and Unit Manager were unaware of the missing pillow, and staff used regular pillows instead. The resident's care plan included the use of adaptive equipment, but this was not implemented, leading to the deficiency.
Plan Of Correction
QUALITY OF CARE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #73, and the Pleur-X not being drained on its schedule. And not following medication administration times of an hour prior or an hour post scheduled administration times. The Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. The Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 2) In the allegation of Resident #481, having not received multiple medication at their prescribed times. Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 3) In the allegation of Resident #46, and the resident's abduction pillow not being used. Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. - Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. - Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Provide Timely and Adequate Nutritional Support
Penalty
Summary
The facility failed to initiate timely nutritional interventions for Resident #475, who was admitted with acute failure and other conditions. Upon admission, there was no completed Minimum Data Set, and the resident did not have a feeding order until 20 hours later. Observations revealed that the resident was lying in bed with a feeding tube improperly managed, as it had no cover or cap and was merely clamped off. The resident expressed hunger and discomfort, indicating a lack of adequate nutrition. Staff interviews confirmed that the resident had not received the prescribed nutrition in a timely manner, and there was a delay in obtaining necessary physician orders. Resident #109 was readmitted with severe protein-calorie malnutrition and required Jevity 1.5 formula at a specific rate to meet nutritional needs. However, observations showed discrepancies in the administration of the formula, with significantly less being delivered than ordered. The formula was not running as expected, and the volume administered was far below the prescribed amount. Staff interviews and observations confirmed that the formula was not being administered correctly, leading to inadequate nutritional support for the resident. Both cases highlight the facility's failure to follow physician orders and provide appropriate nutritional care. The lack of timely intervention and adherence to prescribed feeding regimens resulted in residents not receiving the necessary nutrition, potentially impacting their health and recovery. The facility's processes for managing feeding orders and ensuring proper nutrition were inadequate, as evidenced by the observations and staff interviews.
Plan Of Correction
MGMT/RESTORE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #475, and the facility not receiving an order for almost 20 hours. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 2) In the instance of Resident #109, not for almost 22 hours and the tube-feeding not running at proper rate. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Pharmaceutical Services Deficiency in Medication Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the accurate dispensing and administration of controlled drugs for three residents. For Resident #487, there was a discrepancy between the Medication Monitoring/Control Record and the Medication Administration Record (MAR), where a 5mg medication was documented as removed from the medication cart but not recorded as administered. Similarly, for Resident #28, a 5mg capsule was signed out as removed but not documented as administered on the MAR. These discrepancies indicate a lack of proper documentation and reconciliation of controlled substances. For Resident #82, the situation was reversed; the medication was documented as administered on the MAR but not signed out as removed from the medication cart. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) Unit Manager revealed that the Unit Managers are responsible for auditing the medication reconciliation of controlled substances. However, the LPN Unit Manager admitted to conducting these audits more frequently than required, yet the discrepancies persisted, indicating a failure in the system of records and reconciliation for controlled drugs.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #487, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2) In the allegation of Resident #28, the resident's medication was shown as signed out, but no documentation that it had been administered to the resident. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 3) In the allegation of Resident #82, the resident's medication was not signed out but was documented as administered. Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Nursing staff will be in-serviced to sign out medication and to also document the administration of the medication. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Failure to Meet Resident Dietary Preferences
Penalty
Summary
The facility failed to meet the dietary preferences and needs of two residents, leading to a deficiency in providing food that accommodates resident preferences. Resident #66, who has a moderate cognitive impairment as indicated by a Brief Interview of Mental Status score of 11, was observed during two separate dining occasions to have discrepancies between the meal ticket and the food served. On one occasion, the resident's meal did not include mashed potatoes as requested, and the soft cooked parslied potatoes had skin, which the resident did not want. On another occasion, the resident's meal was missing the ground beef cubes in gravy that were listed on the meal ticket. Similarly, Resident #57, who has no cognitive impairment as indicated by a Brief Interview of Mental Status score of 15, experienced a discrepancy in their meal service. The resident's meal ticket included a large salad with chicken and a Kens salad, neither of which were provided on the tray. The dietary manager/director of food services acknowledged the issue, stating that there are two checkpoints in place to ensure meal tickets match the trays, but these were not effective in preventing the errors observed.
Plan Of Correction
F806 RESIDENT, PREFERENCES, SUBSTITUTES 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #66, not meeting the residents' preference for food, the resident's tray tickets did not match the food on the tray. Dietary staff will be in-serviced to follow the tray tickets. 2) In the allegation of Resident #57, not meeting the residents' preference for food, the resident's tray tickets did not match the food on the tray. Dietary staff will be in-serviced to follow the tray tickets. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Dietary staff will be in-serviced to follow the tray tickets. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Dietary Manager or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Deficient Nurse Call System Maintenance
Penalty
Summary
The facility failed to maintain its nurse call system in accordance with NFPA 99 standards. During a fire safety tour conducted on March 19, 2025, between 12:55 PM and 2:25 PM, it was observed that the nurse call systems in both the Galilee and Masada wings were deficient. Specifically, the Galilee wing had two corridor lights that did not illuminate, and the Masada wing had three corridor lights that failed to illuminate when tested. These observations were made in the presence of the Maintenance Director, who acknowledged the deficiencies. The findings were subsequently reviewed with both the Administrator and the Maintenance Director during the exit conference on the same day at 3:15 PM.
Plan Of Correction
K900 NFPA 99 HEALTH CARE FACILITIES CODE OTHER 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation that the Galilee wing nurse call system having two corridor lights that were allegedly not illuminating and the Masada wing nurse call system having three corridor lights that were allegedly not illuminating. The maintenance staff will check those nurse call light corridor lights allegedly not working and do any necessary repairs to ensure they are illuminating properly. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will check those nurse call light corridor light allegedly not working and do any necessary repairs to ensure they are illuminating properly. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25
Failure to Maintain Essential Electrical System
Penalty
Summary
The facility failed to maintain the Essential Electrical System (EES) in accordance with NFPA 99 standards. During a fire safety tour conducted on March 19, 2025, it was observed that the facility did not have a supply of generator replacement parts for high mortality items on the premises. This deficiency was identified in the presence of the Maintenance Director, who acknowledged the findings during the inspection. The lack of generator replacement parts was discussed with both the Maintenance Director and the Administrator during the exit conference on the same day. The report cites specific sections of NFPA 99, NFPA 101, and NFPA 110 that were not adhered to, indicating a failure to comply with the required maintenance and testing protocols for the facility's essential electrical systems.
Plan Of Correction
K918 NFPA 99 ELECTRICAL SYSTEMS -- ESSENTIAL ELECTRICAL SYSTEM 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the facility not having a supply of generator parts for high mortality items on premises. Maintenance staff will obtain and keep on site generator parts that have a high mortality rate. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will obtain and keep on site generator parts that have a high mortality rate. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K918 ELECTRICAL SYSTEMS - ESSENTIAL ELECTRICAL SYSTEM 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the facility not having a supply of generator parts for high mortality items on premises. Maintenance staff will obtain and keep on site generator parts that have a high mortality rate. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will obtain and keep on site generator parts that have a high mortality rate. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25
Non-compliance with NFPA 101 Egress Door Standards
Penalty
Summary
The facility failed to maintain egress doors equipped with special locking arrangements in accordance with NFPA 101 standards. During a fire safety tour, it was observed that the Main Entrance double exit doors, which were equipped with a delayed egress special locking arrangement, were missing the required signage from both leaves. This lack of signage is a violation of the safety standards as it is essential for ensuring that individuals can identify and understand the function of the delayed egress system in an emergency. Additionally, the Dining Room Patio exit screen door was found to be locked at the latch and with a slide lock located 48 inches above the finished floor. This door had multiple locks engaged, and there was no documentation provided to indicate that the local authority had approved a clinical needs or security special locking arrangement for this setup. The presence of multiple locks without proper authorization or documentation is a breach of the regulations, which typically allow only one locking device unless specific conditions are met. Furthermore, the Rehabilitation double emergency exit doors, also equipped with a delayed egress special locking arrangement, were found to be locked with a hook deadbolt lock. This additional locking mechanism is not compliant with the standards for delayed egress systems, which are designed to allow for safe and timely evacuation. The Maintenance Director acknowledged these findings during the observations, and the issues were reviewed with both the Administrator and the Maintenance Director at the exit conference.
Plan Of Correction
K K222 NFPA 101 EGRESS DOORS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Main Entrance double doors equipped with delayed egress special locking arrangements, not having the required signage on both doors. Maintenance has installed new signage on both of the front doors. 2) In the allegation of the Dining Room patio exit screen door having multiple locks on it. Maintenance has removed the extra lock and there is currently only one. 3) In the allegation of the Rehabilitation double emergency exit doors equipped with delayed egress special locking arrangements being locked with a hook deadbolt lock. Maintenance has disengaged the hook deadbolt lock. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance Director or designee will ensure that proper signage on the Main Entrance double doors is on those doors. - Maintenance Director or designee will ensure that there is only one lock on the Dining Room Patio exit door. - Maintenance Director or designee will ensure that hook deadbolt lock on the Rehabilitation double emergency exit doors is disengaged. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 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. K222 EGRESS DOORS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Main Entrance double doors equipped with delayed egress special locking arrangements, not having the required signage on both doors. Maintenance has installed new signage on both of the front doors. 2) In the allegation of the Dining Room patio exit screen door having multiple locks on it. Maintenance has removed the extra lock and there is currently only one. 3) In the allegation of the Rehabilitation double emergency exit doors equipped with delayed egress special locking arrangements being locked with a hook deadbolt lock. Maintenance has disengaged the hook deadbolt lock. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance Director or designee will ensure that proper signage on the Main Entrance double doors is on those doors. - Maintenance Director or designee will ensure that there is only one lock on the Dining Room Patio exit door. - Maintenance Director or designee will ensure that hook deadbolt lock on the Rehabilitation double emergency exit doors is disengaged. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.
Deficiency in Maintaining Commercial Cooking Facility
Penalty
Summary
The facility failed to maintain their commercial cooking facility in accordance with NFPA 101 standards. During a fire safety tour, it was observed that two gas-powered cooking appliances, a steamer and an oven, located on the dairy side of the kitchen, were on castors without any means to prevent strain on the gas connection. This deficiency was identified for 2 out of 3 sampled gas-powered cooking appliances. The observation was made on March 19, 2025, at 12:33 PM, during a tour with the Maintenance Director. The Maintenance Director acknowledged the findings during an interview conducted concurrently with the observations. The findings were subsequently reviewed with both the Administrator and the Maintenance Director at the exit conference held on the same day at 3:15 PM. Photographic evidence was obtained to support the findings.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the two gas powered appliances on the dairy side of the kitchen, a steamer and an oven, on castors without the means to prevent strain on the gas connection. Maintenance has added restraints to the steamer and the oven to keep them from moving and putting strain on the gas connection. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance Director or designee will put proper restraints on the gas powered steamer and oven on the dairy to keep them from putting strain on the gas connection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K324 COOKING FACILITIES 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the two gas powered appliances on the dairy side of the kitchen, a steamer and an oven, on castors without the means to prevent strain on the gas connection. Maintenance has added restraints to the steamer and the oven to keep them from moving and putting strain on the gas connection. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance Director or designee will put proper restraints on the gas powered steamer and oven on the dairy to keep them from putting strain on the gas connection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.
Fire/Smoke Barrier Deficiency
Penalty
Summary
The facility failed to maintain their fire/smoke barrier construction in accordance with NFPA 101 standards. During a fire safety tour conducted on March 19, 2025, with the Maintenance Director, surveyors observed penetrations in the fire/smoke barriers at two locations within the facility. Specifically, at 12:52 PM, a penetration was found through both sides of a 2-hour fire-rated wall in the Galilee wing near Room 233. Additionally, at 2:09 PM, another penetration was identified through both sides of a smoke wall in the Masada wing near Room 127. The Maintenance Director acknowledged these findings during the tour, and the observations were reviewed with both the Administrator and the Maintenance Director at an exit conference later that day. The report notes that these examples are not exhaustive, suggesting that other unprotected penetrations may exist within the facility's fire/smoke barriers. It emphasizes the importance of conducting a thorough inspection of each barrier along its full length and height to ensure all penetrations are identified and properly sealed. The report underscores the necessity of maintaining the integrity of fire and smoke barriers to restrict the movement of fire and smoke, thereby ensuring the safety of the facility's occupants in the event of a fire emergency. It specifies that any breaches in fire-rated barriers must be repaired using a UL-listed approved system to restore the original fire or smoke-rated integrity of the walls, ceilings, or floors involved.
Plan Of Correction
NFPA 101 SUBDIVISION OF BUILDING SPACES SMOKE BARRIER 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Galilee wing, near room 233 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2) In the allegation of the Masada wing, near room 127 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will seal the alleged penetration in the smoke walls with Red Fire caulk. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K372 SUBDIVISION OF BUILDING SPACES-SMOKE BARRIER 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Galilee wing, near room 233 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2) In the allegation of the Masada wing, near room 127 having one penetration through both sides of the smoke wall. Maintenance will seal the penetration with Red Fire Caulk. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will seal the alleged penetration in the smoke walls with Red Fire caulk. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.
Improper Use of Power Strips and Lack of GFCI Protection
Penalty
Summary
The facility was found to have several deficiencies related to the improper use of power strips and the lack of ground-fault circuit-interrupter (GFCI) protection during a fire safety tour conducted on March 19, 2025. Observations revealed that power strips were improperly used in multiple areas, including the Reception desk and the Telecommunication Room, where power strips were plugged into other power strips instead of directly into wall receptacles. Additionally, in the Service Corridor, one of the vending machines lacked GFCI protection, which is a requirement for safety. Further deficiencies were noted in resident rooms, where televisions were plugged into power strips within six feet of the patient care area, which is against the regulations for patient care vicinities. These observations were made in Rooms 122, 123, 128, and 104. The Maintenance Director acknowledged these findings during the tour, and the issues were reviewed with both the Administrator and the Maintenance Director at the exit conference.
Plan Of Correction
K920 NFPA 99 ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENSION CORDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Reception Desk using power strip and not plugging directly into the wall receptacle. Maintenance staff will remove the power strip and plug items directly into the wall receptacle. 2) In the allegation of the Telecommunication Room using power strip and not plugging directly into the wall receptacle. Maintenance staff will remove the power strip and plug items directly into the wall receptacle. 3) In the allegation of the Service Corridor having a vending machine without GFCI protection, maintenance will add GFCI protection for that vending machine. 4) In the allegation of Room 122 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 5) In the allegation of Room 123 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 6) In the allegation of Room 128 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 7) In the allegation of Room 104 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance will ensure that power strips are not being used where they should not be used and items are plugged directly into the wall receptacle. - Maintenance will ensure that items that need GFCI protection have GFCI protection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K920 ELECTRICAL EQUIPMENT...POWER CORDS AND EXTENSION CORDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the Reception Desk using power strip and not plugging directly into the wall receptacle. Maintenance staff will remove the power strip and plug items directly into the wall receptacle. 2) In the allegation of the Telecommunication Room using power strip and not plugging directly into the wall receptacle. Maintenance staff will remove the power strip and plug items directly into the wall receptacle. 3) In the allegation of the Service Corridor having a vending machine without GFCI protection, maintenance will add GFCI protection for that vending machine. 4) In the allegation of Room 122 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 5) In the allegation of Room 123 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 6) In the allegation of Room 128 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 7) In the allegation of Room 104 using a power strip for the television. Maintenance staff will remove the power strip and plug the television directly into the wall receptacle. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance will ensure that power strips are not being used where they should not be used and items are plugged directly into the wall receptacle. - Maintenance will ensure that items that need GFCI protection have GFCI protection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25
Failure to Maintain Fire Sprinkler System Documentation
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system in accordance with NFPA 101 standards. During a record review conducted on March 19, 2025, between 10:00 AM and 2:00 PM, it was discovered that there was no documentation available for the 5-year hydrostatic test of the fire department connection (FDC) and the 5-year internal inspection of the fire-line backflow preventer. These deficiencies were identified during a review with the Maintenance Assistant, who acknowledged the findings. The issues were subsequently discussed with the Administrator and the Maintenance Director during the exit conference on the same day at 3:15 PM.
Plan Of Correction
K353 NFPA 101 SPRINKLER SYSTEM - MAINTENANCE AND TESTING 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of having no documentation for the FDC 5-year hydrostatic test. The Maintenance Director or designee will acquire the documentation of proof that the FDC 5-year hydrostatic test was completed. 2) In the allegation of having no documentation for the fire-line backflow preventer 5-year internal inspection. The Maintenance Director or designee will acquire the documentation of proof that the fire-line backflow preventer 5-year internal inspection was completed. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: - Maintenance Director or designee will ensure that there is proper documentation for the FDC 5-year hydrostatic test is up to date and available for inspection. - Maintenance Director or designee will ensure that there is proper documentation for the fire-line backflow preventer 5-year internal inspection documentation is up to date and available for inspection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25
Fire Extinguisher Obstructions and Installation Issues
Penalty
Summary
The facility failed to comply with NFPA 101 standards for portable fire extinguishers, as evidenced by observations made during a fire safety tour. Specifically, three out of twelve sampled portable fire extinguishers were not installed or maintained correctly. At 12:00 PM, a class ABC fire extinguisher in the Telecommunication Equipment Room was obstructed by equipment, and at 12:02 PM, the same room lacked a clean agent fire extinguisher. Additionally, at 12:55 PM and 1:22 PM, fire extinguishers near Rooms 203 and 209 were obstructed by carts, respectively. These deficiencies were confirmed through an interview with the Maintenance Director, who acknowledged the findings during the tour. The issues were further discussed with the Administrator and the Maintenance Director at an exit conference. Photographic evidence was obtained to support these observations, and the facility's non-compliance with NFPA 10 and NFPA 101 standards was documented.
Plan Of Correction
K355 NFPA 101 PORTABLE FIRE EXTINGUISHERS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of ABC fire extinguisher in the Telecommunication Equipment Room being obstructed by equipment. Maintenance has moved items around to ensure that the ABC fire extinguisher is unobstructed. 2) In the allegation of the Telecommunications room not having a clean agent fire extinguisher. Maintenance will place a clean agent fire extinguisher in the Telecommunication room. 3) In the allegation of the fire extinguisher near room 203 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 4) In the allegation of the fire extinguisher near room 209 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will ensure that in the Telecommunication room that the ABC fire extinguisher is not obstructed. Maintenance will put a clean agent fire extinguisher in the Telecommunication room. Maintenance will in-service staff not to place carts in front of fire extinguishers. Maintenance will ensure that carts are not placed in front of fire extinguishers during rounds. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K355 PORTABLE FIRE EXTINGUISHERS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of ABC fire extinguisher in the Telecommunication Equipment Room being obstructed by equipment. Maintenance has moved items around to ensure that the ABC fire extinguisher is unobstructed. 2) In the allegation of the Telecommunications room not having a clean agent fire extinguisher. Maintenance will place a clean agent fire extinguisher in the Telecommunication room. 3) In the allegation of the fire extinguisher near room 203 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 4) In the allegation of the fire extinguisher near room 209 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will ensure that in the Telecommunication room that the ABC fire extinguisher is not obstructed. Maintenance will put a clean agent fire extinguisher in the Telecommunication room. Maintenance will in-service staff not to place carts in front of fire extinguishers. Maintenance will ensure that carts are not placed in front of fire extinguishers during rounds. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.
Failure to Monitor and Document Pain Management
Penalty
Summary
The facility failed to monitor and record a resident's pain level as ordered and did not document the administration of pain medication for one of the sampled residents. The resident was admitted to the facility and had a comprehensive assessment indicating pain, with a care plan in place for pain management. Physician orders required the resident's pain level to be monitored and documented every shift. However, while the resident was monitored for pain, the pain level was not documented in the Medication Administration Record (MAR). Additionally, the Medication Monitoring/Control Record showed that Tramadol was removed for the resident on several occasions, but the MAR did not reflect that the medication was administered on those dates and times. These findings were confirmed during an interview with the Director of Nursing.
Failure to Administer IV Antibiotic as Ordered
Penalty
Summary
The facility failed to verify and administer an IV antibiotic, Vancomycin, for a resident upon admission. The hospital had sent a physician order for Vancomycin IV to be administered with each dialysis session until a specified date. However, this order was intended for Home Health Care and was not included in the discharge orders reconciled by the nurses upon the resident's admission to the facility. The Registered Nurse (RN) responsible for entering hospital orders into the facility's system did not include the Vancomycin IV order, as it was not part of the discharge orders. During a morning meeting involving the Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator, and Social Services, the Vancomycin order was not reviewed or clarified. The Social Services Coordinator noted that the order was intended for Home Health Care and not as a nursing order. Additionally, a Dialysis Center RN reported that the resident's spouse mentioned the need for Vancomycin IV during dialysis, but the on-duty nurse incorrectly stated that the resident was receiving oral Vancomycin. There was no evidence that the Vancomycin IV order was clarified with the physician or reviewed in the morning meeting, leading to a failure in administering the necessary medication.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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