Nspire Healthcare Tamarac
Inspection history, citations, penalties and survey trends for this long-term care facility in Tamarac, Florida.
- Location
- 5901 Nw 79th Avenue, Tamarac, Florida 33321
- CMS Provider Number
- 105609
- Inspections on file
- 25
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Nspire Healthcare Tamarac during CMS and state inspections, most recent first.
Surveyors identified that the facility did not maintain required documentation for 1.5-hour load bank testing, monthly generator load testing, weekly voltage checks, or monthly conductance testing for generator batteries. These omissions were confirmed during a record review and acknowledged by facility leadership.
Surveyors identified that the facility's Emergency Preparedness Program lacked required contact information for all staff and residents' physicians in its communication plan. The Administrator acknowledged these omissions during the review, and the findings were discussed with facility leadership.
Surveyors found that the facility's Emergency Preparedness Program listed satellite phones as an alternate means of communication, but the facility was unable to produce a satellite phone for inspection when requested. The Administrator confirmed that the alternate communication device was not available as required.
Surveyors found that two delayed egress exit doors lacked the required signage with a contrasting background, and one door in the Service Hallway automatically reset when tested, both in violation of NFPA 101 standards. These deficiencies were observed during a fire safety tour and acknowledged by facility leadership.
A resident with significant self-care limitations due to recent surgery and left-sided impairment reported long delays in call-light response and dissatisfaction with ADL care. Despite communicating these concerns to staff and family members reporting issues to the Administrator, no grievance documentation was found, and the facility failed to demonstrate a response to the resident's complaints as required by regulation.
A resident was found to have a vascular access device in place for eleven days without any physician orders for its care, maintenance, or removal. Nursing staff did not document or communicate the presence of the device, and no orders were obtained until prompted by surveyors. The device remained unused, and the resident was unaware of its purpose during their stay.
A resident had a line in place in the left upper arm for eleven days without a physician's order for its removal or care, and staff failed to notify the DON or physician or document the line in the care plan or progress notes. The line remained in place and unused, with visible discoloration at the site, and an order for removal was only obtained after surveyor inquiry.
Two residents did not receive meals consistent with their prescribed therapeutic diets due to the facility's failure to follow menu guidelines and ensure alignment between diet orders and meal preparation. One resident on a mechanical soft diet was served diced meats instead of ground, while another on a CHO-controlled, high-protein diet received incorrect portions and restricted items. Dietary staff and the dietitian confirmed confusion and lack of communication regarding menu breakdowns and diet order matching.
A resident with complex medical needs, including diabetes and a history of amputation, did not receive the physician-ordered CHO controlled, high-protein diet. Observations showed the resident was served meals inconsistent with the prescribed diet, and the CDM admitted to substituting menu items and not following the specific dietary order due to lack of guidance and communication with the dietitian. The resident was unaware of any special diet, and the facility's menu did not align with the required dietary restrictions.
Surveyors found that cooked chicken intended for resident meals was not maintained at the required hot-holding temperature on the steam table, with measured temperatures ranging from 107°F to 127°F instead of the required 165°F. The facility's food temperature log reflected only the post-oven temperature, not the holding temperature, and the Food Service Director acknowledged the discrepancy. This issue had the potential to affect all residents who received the alternate lunch meal containing chicken.
The facility did not complete required sensitivity testing for all smoke and duct detectors as mandated by NFPA 101 and NFPA 72. Record review revealed that 11 smoke detectors and two duct detectors were not tested, and inspection reports lacked documentation of sensitivity testing results. The Regional Maintenance Director acknowledged these findings during the survey.
Surveyors found that the Main Lobby had mixed sprinkler coverage, with two quick response and two standard sprinklers, which does not comply with NFPA requirements. The Regional Maintenance Director acknowledged the issue during the inspection, and the deficiency was documented with photographic evidence.
Surveyors found that a medication refrigerator was not connected to a distinctly marked receptacle powered by the critical branch of the EES, as required by NFPA 99. Additionally, the facility failed to provide documentation for required maintenance and testing of the EES, including generator inspections and load exercises. These deficiencies were confirmed through observation, staff interviews, and record review, affecting all residents receiving refrigerated medications and those dependent on emergency power systems.
A resident with significant self-care limitations following recent surgeries reported long delays in call-light response and dissatisfaction with ADL care. Despite voicing concerns to nursing staff and having her family report issues to the Administrator, no formal grievance documentation was submitted or addressed according to facility policy. Staff interviews confirmed the absence of grievance records for these complaints.
A resident had a vascular access device in place for eleven days without any physician orders for its care, maintenance, or removal, despite facility policy requiring such orders. The device was not in use, and staff failed to document or communicate its presence or need for removal, resulting in the device remaining in place until surveyor intervention.
Surveyors found that the facility did not provide prescribed therapeutic diets or follow the approved menu for two residents on specialized diets. One resident on a mechanical soft diet received chopped meats instead of ground, while another with diabetes and CKD received meals inconsistent with their diet order, including excess bread and bacon. Dietary staff confirmed discrepancies between diet orders and menu spreadsheets, leading to substitutions and mismatched diets.
A resident's complaints about delays in care and disturbances were communicated to staff but were not formally documented or submitted as grievances, despite facility policy requiring such action. The Social Worker and DON confirmed no grievance forms or documentation existed for these concerns, indicating a failure to follow the established grievance procedure.
The facility was found to have multiple deficiencies in maintaining a sanitary and comfortable environment for residents. Surveyors observed issues such as non-functional sinks, soiled floors, broken tiles, and privacy curtains that were too short, compromising resident privacy. Pervasive odors and damaged walls were also noted. The Corporate Maintenance Director acknowledged the problems and indicated that staff were not effectively using the computerized TELS system for reporting maintenance issues.
The facility failed to manage and dispose of controlled medications for two discharged residents, leaving them in storage instead of removing them for disposal. Emergency crash carts were found unsecured, containing expired supplies, and medication storage was poorly managed, with loose pills and expired medications found. Over-the-counter medications were left unattended, accessible to residents and staff, indicating lapses in following security protocols.
The facility failed to provide a nourishing diet due to broken refrigeration units, leading to the use of an emergency menu with non-perishable foods. Residents expressed dissatisfaction with the lack of fresh and hot meals, while staff consumed catered meals. The administration did not explore alternative refrigeration options or address residents' complaints effectively.
The facility failed to maintain the nutritional value of foods for 117 residents by preparing lunch items, including chicken and vegetables, too early and holding them hot for over two hours. Staff confirmed the early preparation, and the Dietary Director acknowledged concerns about the extended hot holding time. The facility's recipes did not address this issue.
The facility failed to adhere to food safety and hygiene standards, with issues such as improper food temperatures, inadequate sanitizer levels, and unsanitary food handling practices. Staff did not consistently perform hand hygiene, and there were storage and cleanliness issues in the kitchen and pantry areas.
The facility failed to implement Enhanced Barrier Precautions (EBP) for all sampled residents, with PPE not available at room entrances as required. A CNA did not follow proper infection control during Foley catheter care, leading to cross-contamination. In the dialysis suite, uncovered trash cans and improper storage of materials were observed, indicating broader infection control issues.
The facility failed to repair essential kitchen equipment, including a walk-in cooler and pellet warmer, leading to deficiencies in food service. The cooler had been out of order for over a week, and the warmer was incompatible with existing plates, resulting in resident complaints about cold food. Despite ongoing discussions since February, there was no evidence of a compatible warmer being ordered.
A resident with COPD, chronic bronchitis, depression, and a left BKA was not provided a wheelchair, hindering his mobility and participation in activities. Despite orders for activity participation and a care plan for wheelchair management, the facility failed to accommodate the resident's needs. Staff were unaware of the wheelchair's location, and documentation of care plan implementation was lacking.
A resident with multiple sclerosis and muscle weakness did not receive scheduled showers as per his preferences, due to miscommunication among staff at the LTC facility. Despite the facility's policy requiring assistance with bathing twice a week, the resident received only one shower over a two-week period. The care plan lacked specific ADL care instructions, leading to confusion between day and evening staff about who was responsible for the resident's showers. The issue was only addressed after surveyor intervention.
A resident with a Foley catheter did not receive appropriate care as observed during a survey. The CNA failed to follow proper procedures, such as wearing a gown, changing gloves, and performing hand hygiene. The CNA also left the resident's room door open, placed the catheter above the resident's chest, and did not use a catheter strap and anchor. Interviews confirmed the CNA's lack of preparation and failure to follow procedures.
A facility failed to ensure proper documentation and communication for a resident receiving dialysis care. Despite the resident's independence in ADLs and no cognitive impairment, the facility did not document critical information such as transfer times, medications, and shunt site observations. The dialysis center also failed to record pre and post dialysis weights, lab values, and finish times, indicating a systemic issue confirmed by the Corporate Nurse Consultant.
A facility's medication error rate was found to be 14.70%, exceeding the acceptable limit of 5%. An RN failed to administer all prescribed medications to two residents, one with COPD and diabetes, and another with multiple sclerosis and anemia. The RN omitted medications due to unfamiliarity with a new admission's regimen and nervousness during observation. The DON was informed of these errors.
The facility failed to address residents' food concerns and timely repair kitchen equipment, leading to the use of an emergency food menu due to a broken walk-in cooler. Residents expressed dissatisfaction with repetitive and non-substantial meals, while the administration was unaware of ongoing refrigeration issues. Additionally, meals were served cold due to the non-use of a pellet warmer, with no evidence of efforts to remedy the situation.
The facility failed to ensure call lights were within reach for three residents, impacting their ability to request assistance. One resident with cognitive impairment and multiple health issues had the call light out of reach, while another found it inside a nightstand and later on the floor. A third resident, dependent on assistance, had the call light stuck under the bed, compounded by visual impairment and a short overhead light string. Staff were either unaware or unable to promptly resolve these issues.
Failure to Maintain and Document Essential Electrical System Testing
Penalty
Summary
The facility failed to maintain the Essential Electrical System (EES) in accordance with NFPA 99 requirements, as evidenced by missing documentation and incomplete testing records. During a record review with the Regional Director of Plant Operations, surveyors found that there was no documentation for the required 1.5-hour load bank testing for 2024, nor was there evidence of monthly testing under a thirty percent load. This testing is necessary to ensure the generator can supply emergency power as required by regulation. Additionally, the facility did not provide documentation of weekly voltage checks for the two generator batteries. Regular monitoring of battery voltage is essential to confirm that the generator will function properly in the event of a power outage. The absence of these records indicates that the facility did not consistently monitor the generator batteries as required. Furthermore, there was no documentation of monthly conductance testing for the generator's two sealed batteries prior to 2025. Conductance testing is a standard procedure to assess the health and reliability of the batteries that support the emergency power system. The Regional Maintenance Director acknowledged these findings during the survey, and the deficiencies were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. An unannounced Fire & Life Safety Recertification survey was conducted on at Nspire Healthcare Tamarac, a nursing home in Tamarac, Florida. Nspire Healthcare Tamarac is not in compliance with 42 CFR 483 Subpart B, 42 CFR 488.307, and National Fire Protection Association (NFPA) 101 (2012 Edition), NFPA 99 (2012 Edition) requirements for nursing homes. Initial Plan Review. 1994 Existing NFPA 220 Construction Type: II (111) Number of beds: 151 Census: 122 The following is a description of the noncompliance. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. [Repeated sections with placeholders such as [R] and incomplete dates are included as in the original text.]
Incomplete Emergency Preparedness Communication Plan
Penalty
Summary
During a review of the facility's Emergency Preparedness Program (EP), surveyors found that the facility did not maintain a complete communication plan as required by federal regulations. Specifically, the communication plan was missing contact information for all staff members and for residents' physicians. This omission was identified during a record review conducted with the facility Administrator. The deficiency was confirmed through both documentation review and an interview with the Administrator, who acknowledged the absence of the required contact information in the EP. The findings were also discussed with the Regional Maintenance Director during the exit conference. No information was provided in the report regarding specific residents or their medical conditions at the time of the deficiency. The focus of the deficiency was solely on the incomplete communication plan within the facility's emergency preparedness documentation.
Plan Of Correction
Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030 Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030
Failure to Provide Alternate Communication Device Listed in Emergency Plan
Penalty
Summary
During a Fire & Life Safety re-licensure survey, surveyors reviewed the facility's Emergency Preparedness Program (EP) and found that the facility had listed satellite phones as an alternate means of communication in their emergency plan. However, when requested, the facility was unable to produce a satellite phone for inspection. This deficiency was identified through both record review and staff interview, where the absence of the listed communication device was confirmed. The Administrator acknowledged the findings during the interview and at the exit conference, confirming that the alternate communication method described in the EP was not available as required by federal regulations. The deficiency specifically relates to the facility's failure to ensure that the alternate means of communication, as outlined in their emergency preparedness plan, was present and accessible for inspection.
Plan Of Correction
Corrective Action for Affected Residents: The administrator added an updated list of primary and alternate means of communication. The facility does not use satellite phones. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: The administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure primary and alternate means of communication for the facility are listed. Monitoring/Quality Assurance: The Emergency Preparedness Manual will be reviewed annually, and findings will be submitted to QAPI.
Deficient Delayed Egress Door Signage and Function
Penalty
Summary
Surveyors observed that the facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 requirements. During a fire safety tour, it was found that two delayed egress exit doors—the first floor West Wing Rehabilitation Room door and the Service Hallway door—did not have the required signage with a contrasting background. This signage is necessary to comply with fire safety codes and to ensure that the doors are easily identifiable in an emergency. Additionally, the Service Hallway delayed egress exit door exhibited a malfunction during testing. Specifically, the door automatically reset when it was tested, which is not in accordance with the required operation for delayed egress doors. This issue could potentially interfere with the proper function of the delayed egress system, which is designed to allow safe evacuation during emergencies. The findings were confirmed through direct observation by surveyors and acknowledged by the Regional Maintenance Director during the inspection. The deficiency was reviewed with both the Administrator and the Regional Maintenance Director at the exit conference. Photographic evidence was obtained to document the observed issues. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.
Failure to Document and Respond to Resident Grievances Regarding Care Delays
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of documented grievances submitted by a resident regarding delays in call-light response and concerns related to activities of daily living (ADL) care. The resident, who was alert, oriented, and verbally responsive, had significant self-care limitations due to left-sided impairment and recent right-sided surgery. Her care plan required assistance with bathing, eating, hygiene, mobility, toileting, transfers, skin assessments, and the use of a call bell for help. Despite these needs, the resident reported waiting approximately four hours for assistance after activating her call light during nighttime hours and expressed dissatisfaction with the quality of care received upon admission. The resident stated that she communicated her concerns to nursing staff, but no improvements were observed. She also reported that certified nursing assistants (CNAs) told her they were responsible for 16 residents and did not have adequate time to provide timely care. The resident's family reported concerns to the Administrator but perceived the response as indifferent. Additionally, when the resident requested to receive ADL care before other residents due to her functional limitations, staff reportedly told her that permanent residents were prioritized over her. The administration did not address her complaints, and no documentation of her grievances was found. Interviews with staff revealed that while the resident's complaints were communicated to the Director of Nursing (DON) and documented in the facility's electronic system for other residents, no grievance documentation was submitted for this resident. The social worker confirmed that no grievance submissions were received from the resident and that there was no documentation indicating staff had submitted grievances on her behalf. The DON also stated that she had not received complaints from the resident or her family and described the facility's grievance procedure, which requires documentation and resolution within three days. However, no documentation existed for the resident's grievance, resulting in noncompliance with regulatory requirements.
Plan Of Correction
Resident #75 - grievances regarding ADL care and call light response were documented and addressed. A quality audit of current residents was conducted to ensure there are no undocumented grievances regarding delay in call light response and concerns related to activities of daily living (ADL) care. The Director of Nursing will educate the nursing staff on ensuring that grievances with residents' concerns are documented and addressed. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that staff is documenting grievances with residents' concerns. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly for 3 months or until substantial compliance has been met. per physician orders.
Failure to Obtain Physician Orders for Vascular Access Device Care and Removal
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician orders for the care, maintenance, or removal of a vascular access device in a resident. Upon re-admission, the resident had a vascular access device in the left upper arm, which was observed to remain in place for eleven days without any documented physician orders for its care or discontinuance. The facility's policy required nurses to obtain and verify physician orders for such devices, including their removal, care, and maintenance, but this was not followed. Multiple observations confirmed the device remained in place, with visible brownish discoloration and a small, darkened area at the site. The resident reported not receiving any medication through the device since admission and was unaware of the reason for its continued presence. Review of the resident's medical records, including physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR), revealed no orders for the device's care, maintenance, or removal during the resident's stay. Interviews with nursing staff indicated a lack of awareness regarding the device's presence and the absence of any action to obtain necessary physician orders. The nurse who changed the dressing admitted to not notifying the oncoming nurse, the DON, or the physician about the device, stating she had forgotten to do so. There was no documentation in the nursing progress notes, baseline care plan, or comprehensive care plan regarding the device, and the physician was not contacted for orders until prompted by the surveyor.
Plan Of Correction
A quality audit of current residents was conducted to ensure that no ([R]) were noted without a physician order in place. The Director of Nursing educated licensed nurses on ensuring that a physician order is obtained for residents with ([R]) lines. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that a physician order is obtained for ([R]) residents with [R] lines. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Obtain Physician's Order and Document Care for Unused Line
Penalty
Summary
A resident had a line in place in the left upper arm for eleven days without a current physician's order for its discontinuance or for its care and maintenance. Multiple observations confirmed the line remained in place and was not in use, with the site showing brownish discoloration and a small, darkened area noted in the tubing. The physician's orders for the resident only included two oral medications, with no order for the line during the facility stay. Staff who identified the line did not notify the oncoming nurse, the DON, or the resident's physician to obtain appropriate orders for removal or care, stating she had forgotten to do so. There was no documentation in the nursing admission progress notes, ongoing nursing progress, baseline care plan, or comprehensive care plan regarding the identification or existence of the line. The physician's order to remove the line was only obtained after surveyor inquiry.
Failure to Follow Prescribed Menus and Therapeutic Diet Orders
Penalty
Summary
The facility failed to follow prescribed menus and therapeutic diet orders for two residents, resulting in noncompliance with federal regulations regarding menu preparation, nutritional adequacy, and adherence to physician-ordered diets. For one resident on a mechanical soft diet, observations revealed that meals provided included diced or chopped meats rather than the ground meats specified in the facility's menu spreadsheet. The Certified Dietary Manager (CDM) and Speech Language Pathologist (SLP) confirmed that the menu breakdown called for ground meats, but the facility was serving bite-sized or chopped meats instead, citing their interpretation of the International Diet Standardization Initiative (IDDSI) guidelines. The CDM stated that the facility did not offer ground diets, despite the menu indicating otherwise. Another resident with a diet order for a carbohydrate-controlled, high-protein diet with regular texture and thin consistency was observed receiving meals that did not match the prescribed diet. The resident received two slices of bread and two strips of bacon for breakfast, and two rolls for lunch, which exceeded the menu's specified portions and included items not permitted on certain therapeutic diets, such as bacon for a CKD5 diet. The CDM admitted to substituting rolls for breadsticks and providing more bread than allowed, acknowledging these as mistakes. Additionally, the diet orders in the electronic health record (EHR) did not match the food service supplier's menu spreadsheets, leading to confusion and inconsistency in meal preparation. Interviews with dietary staff, including the CDM, Dietetic Technician (DTR), and the facility's Dietitian, revealed a lack of communication and review of the new menu spreadsheets. The CDM and DTR were not fully aware of the menu breakdowns or how to match them to resident diet orders, and the Dietitian confirmed that discrepancies between the EHR and menu spreadsheets had occurred previously. The facility's process for reviewing and updating menus, as well as ensuring that staff were trained on new menu guidelines, was insufficient, resulting in residents not consistently receiving meals that met their prescribed dietary needs.
Plan Of Correction
The Registered Dietician reviewed and updated the facility's menu to ensure a therapeutic diet is being provided for Resident #45 and Resident #1. A quality audit of current residents on a therapeutic diet was conducted to ensure the facility is following the menu for residents on a therapeutic diet. The Administrator educated the CDM (Certified Dietary Manager) on ensuring the menu is being followed for residents on a therapeutic diet. Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure the menu is being followed for residents on a therapeutic diet. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Follow Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when the facility failed to follow the prescribed therapeutic diet for a resident with multiple medical diagnoses, including Type 2 diabetes and a history of amputation. The resident had a physician's order for a carbohydrate (CHO) controlled, high-protein (Hi Pro) diet with regular texture and thin consistency. Despite this order, direct observation of the resident's meals revealed that the food provided did not match the prescribed diet. For breakfast, the resident received two slices of wheat bread and two strips of bacon, while the lunch meal included two rolls and no cauliflower, deviating from the intended dietary restrictions. Interviews with facility staff, including the Certified Dietary Manager (CDM), revealed a lack of understanding and implementation of the specific diet order. The CDM admitted to not having a CHO controlled diet on the spreadsheet and instead used a Hi-Pro diet as a substitute. The CDM also acknowledged that the number of bread servings provided was incorrect and that substitutions were made without proper guidance. Furthermore, the CDM stated that there was no review of the diets with him and only limited discussion with the facility's dietitian regarding discrepancies between the menu and the electronic health record (EHR) diet orders. The resident was unaware of being on a special diet and reported receiving the same meals as other residents. Review of the facility's menu and the "Nutritional Care Manual" indicated that certain foods, such as salty processed meats, should not have been included in the resident's diet, particularly for those with chronic kidney disease stage 5 (CKD5). The failure to provide the correct therapeutic diet as prescribed by the physician, and the lack of communication and oversight in dietary management, led to the cited deficiency.
Plan Of Correction
Resident #1 prescribed therapeutic diet order was reviewed and updated per physician order. A quality audit of current residents on a therapeutic diet was conducted to ensure the prescribed order is being followed. The Administrator educated the CDM (Certified Dietary Manager) on ensuring that prescribed therapeutic diet orders are being followed. Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that prescribed therapeutic diet orders are being followed. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Maintain Proper Hot-Holding Temperature for Cooked Chicken
Penalty
Summary
During a survey, it was observed that the facility failed to maintain cooked chicken at the required hot-holding temperature on the steam table prior to serving it to residents. Specifically, after two plates of chicken were prepared and placed on the food cart for distribution, the surveyor measured the temperature of the remaining chicken in the steam table pan. The pieces on the top registered at 107°F and those at the bottom at 127°F, both of which are below the required minimum hot-holding temperature of 165°F. Upon request, the chicken was reheated to the proper temperature before being served. A review of the facility's Prepared Food Temperature record revealed a discrepancy between the logged and observed temperatures. The log indicated a temperature of 162°F for the chicken, which the Food Service Director confirmed was the temperature when the meat was removed from the oven, not while it was being held on the steam table. The surveyor's direct measurement showed significantly lower temperatures at the point of service, indicating that the food was not maintained at safe temperatures during holding. The Food Service Director acknowledged that the temperature recorded in the log did not reflect the actual holding temperature and agreed that the temperature may have dropped while the chicken was on the steam table. This deficiency had the potential to affect all 12 sampled residents who received the alternate lunch meal containing chicken, with a total facility census of 121 at the time of the survey.
Plan Of Correction
Meat was reheated to the proper temperature. A quality audit of meat prepared and ready to be served was conducted to ensure it is maintained at the proper hot-holding temperature on the steam table. The Administrator educated the CDM (Certified Dietary Manager), and the Food Service Assistant on ensuring meat prepared and ready to serve is maintained at the proper hot-holding temperature on the steam table. The Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure meat prepared and ready to serve is maintained at the proper hot-holding temperature on the steam table. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Complete Required Fire Alarm System Sensitivity Testing
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 101 and NFPA 72 standards. During a record review with the Regional Maintenance Director, it was found that the biennial smoke detector sensitivity testing did not include 11 out of 73 smoke detectors. Additionally, the repairs inspection report did not indicate that the smoke detectors were sensitivity tested, nor did it provide the results of such testing. The annual fire alarm report listed 23 duct detectors in the inventory, but the duct detector differential pressure testing documented 24 duct detectors tested, and the smoke detector sensitivity testing only included 22 duct detectors, leaving two duct detectors untested for sensitivity. These discrepancies were identified through a combination of record review and staff interviews. The Regional Maintenance Director acknowledged the findings during the review. The records failed to demonstrate that all required smoke and duct detectors underwent the necessary sensitivity testing as mandated by the applicable codes and standards. The deficiency affects all residents and staff in the affected smoke compartments, as the fire alarm system is a critical component of the facility's safety infrastructure. The findings were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference, and photographic evidence was obtained to support the observations.
Plan Of Correction
Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically, the two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected. Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews.
Deficiency in Sprinkler System Compliance
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system (AFSS) in accordance with NFPA 101 and related standards for one of twelve sampled smoke compartments. During a fire safety tour, surveyors observed that the Main Lobby contained mixed sprinkler coverage, with two of the four sprinklers being quick response and the other two being standard sprinklers. This observation was made in the presence of the Regional Maintenance Director, who acknowledged the findings at the time. The deficiency was identified through a combination of direct observation, record review, and staff interviews. The surveyors specifically noted the inconsistency in the type of sprinkler heads installed within the same area, which does not comply with the requirements set forth by NFPA 13 and NFPA 25. The issue was discussed with both the Administrator and the Regional Maintenance Director during the exit conference, and photographic evidence was obtained to document the condition. No information was provided in the report regarding any residents' medical history or their condition at the time of the deficiency. The deficiency was limited to the fire protection system in the Main Lobby smoke compartment, and the report did not mention any immediate consequences or incidents resulting from the mixed sprinkler coverage. The focus of the findings was on the facility's failure to ensure uniform and compliant sprinkler system installation and maintenance as required by applicable fire safety codes.
Plan Of Correction
Continued from page 4 By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI.
Medication Refrigerator Not Connected to Critical Branch and EES Maintenance Documentation Lacking
Penalty
Summary
The facility failed to ensure that electrical receptacles serving medication preparation areas, specifically those used for medication refrigerators, were connected to the critical branch of the Essential Electrical System (EES) and were not distinctly marked as required by NFPA 99. During a fire safety tour, it was observed that a medication refrigerator was not plugged into a receptacle powered by the critical branch, and the required distinctive color or marking was absent. This deficiency was acknowledged by the Regional Maintenance Director during the observation and was reviewed with facility leadership at the exit conference. Photographic evidence was obtained to document the finding. Additionally, the facility did not maintain proper documentation for the maintenance and testing of the EES, including the generator and associated equipment. Required records for weekly inspections, monthly load exercises, and other scheduled maintenance activities were not provided during the record review with the Regional Director of Plant Operations. The lack of documentation means that the facility could not demonstrate compliance with NFPA 99, NFPA 110, and related standards for ensuring the reliability of emergency power systems. These deficiencies affect all residents who receive refrigerated medications from the affected medication room, as well as all residents and staff who rely on the facility's emergency electrical systems. The findings were based on direct observation, staff interviews, and record reviews conducted by surveyors during the inspection.
Plan Of Correction
Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: Weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in [date] and will be conducted annually, with the next test due [date], and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due [date], and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.
Failure to Document and Address Resident Grievances Regarding Call-Light Delays and ADL Care
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of documented grievances for a resident who reported significant delays in call-light response and concerns related to activities of daily living (ADL) care. The resident, who was alert, oriented, and verbally responsive, had been admitted with left-sided and recent right-sided surgery, resulting in significant self-care limitations. Her care plan required assistance with all ADLs, including bathing, eating, hygiene, mobility, toileting, transfers, and skin assessments, and she relied on the call bell for help. The resident reported waiting approximately four hours for assistance after activating her call light during nighttime hours and expressed dissatisfaction with the quality of care received. She stated that she communicated these concerns to nursing staff, but no improvements were observed. The resident also indicated that CNAs told her they were responsible for 16 residents and did not have adequate time to provide timely care. Additionally, her family reported concerns to the Administrator but perceived the response as indifferent. The resident further stated that when she requested to receive ADL care before other residents due to her functional limitations, staff responded that permanent residents were prioritized over her, and her complaints were not addressed by Administration. Interviews with staff revealed that while the resident's complaints were communicated to the Director of Nursing and documented in the facility's electronic system, no formal grievance documentation was submitted on her behalf. The Social Worker confirmed that no grievance forms had been received from the resident or staff, and the Director of Nursing stated that no complaints had been received from the resident or her family. The facility's grievance procedure requires documentation and resolution within three days, but no documentation existed for this resident's grievances.
Plan Of Correction
Resident #75- grievances regarding ADL care and call light response was documented and addressed. A quality review of current residents was conducted to ensure there is no undocumented grievances regarding delay in call light response and concerns related to activities of daily living (ADL) care. The Director of Nursing will educate the Nursing staff on ensuring that grievances with resident's concerns are documented and addressed. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that staff is documenting grievances with resident's concerns. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Obtain Physician Orders for Vascular Access Device Management
Penalty
Summary
The facility failed to obtain physician orders for the care, maintenance, or removal of a vascular access device for a resident. Upon review of the facility's policy and procedure, it was found that the policy requires nurses to obtain and/or verify physician orders for the type of solution or medication, dose, rate, length of treatment, and for the removal of such devices. However, for this particular resident, there were no physician orders documented for the discontinuance, care, or maintenance of the device, despite it being in place for an extended period without use. Observations revealed that the resident had a vascular access device in the left upper arm, which had not been used for medication administration since admission. The site was noted to have brownish discoloration and a small, darkened area in the tubing. The resident reported not knowing why the device was still in place, as she had not received any medication through it since admission. Record reviews, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), confirmed the absence of any orders related to the device's care or removal. Interviews with nursing staff indicated a lack of awareness regarding the presence and management of the device. One RN admitted she did not recall if the resident was admitted with the device in place and acknowledged that only oral medications had been administered. Another staff member who had changed the device dressing failed to notify the oncoming nurse, the DON, or the physician to obtain appropriate orders, stating she had forgotten to do so. There was no documentation in the nursing admission progress notes, ongoing nursing progress, baseline care plan, or comprehensive care plan regarding the existence or management of the device. The device remained in place and unused for eleven days, with no physician order for its removal until prompted by surveyor inquiry.
Plan Of Correction
Resident #111 was removed /2026 per physician orders. A quality audit of current residents was conducted to ensure that no [R] noted without a physician order place. The Director of Nursing educated licensed nurses on ensuring that a physician order is obtained for residents with [R] lines. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that a physician order is obtained for residents with [R] lines. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Provide Prescribed Therapeutic Diets and Follow Approved Menu
Penalty
Summary
Surveyors identified that the facility failed to provide prescribed therapeutic diets and did not follow the approved menu for residents requiring specialized diets. Specifically, one resident on a mechanical soft diet was observed receiving roast beef cut into pieces or chunks approximately 0.5 inches in size, rather than the ground meat specified in the facility's menu spreadsheet. Additionally, this resident was served diced or chopped chicken instead of ground meat, as required. The Certified Dietary Manager (CDM) and Speech Language Pathologist (SLP) both confirmed that the menu breakdown called for ground meats, but the facility did not offer ground diets, instead providing bite-sized or chopped meats for mechanical soft diets. Another resident with diagnoses including Type 2 diabetes and chronic kidney disease was prescribed a carbohydrate-controlled, high-protein diet with regular texture and thin consistency. Observations revealed that this resident received meals inconsistent with the prescribed diet, such as two slices of wheat bread and two strips of bacon for breakfast, and two rolls for lunch instead of the specified breadstick and cauliflower. The CDM acknowledged that the resident received too much bread and bacon, and that bacon is not permitted on the CKD5 diet. The CDM also stated that he substituted rolls for breadsticks due to unavailability and used a high-protein diet in place of the specific CKD5 diet, as the menu and electronic health record (EHR) did not match. Interviews with dietary staff, including the CDM, Dietetic Technician (DTR), and the facility's Dietitian, revealed a lack of alignment between the EHR diet orders and the food service supplier's menu spreadsheets. Staff admitted to not having reviewed the new menu breakdowns and to making substitutions or using alternative diets when the prescribed diet was not available or did not match the menu. The Dietitian confirmed that this mismatch had occurred previously and required customization, but there was no clear process to ensure residents consistently received the correct therapeutic diets as ordered by their physicians.
Plan Of Correction
Resident #1 prescribed therapeutic diet order was reviewed and updated per physician order. The Registered Dietician reviewed and updated the facility's menu to ensure a therapeutic diet is being provided for Resident #45 and Resident #1. A quality audit of current residents on a therapeutic diet was conducted to ensure the prescribed order is being followed, and to ensure the facility is following the menu for residents on a therapeutic diet. The Administrator educated the CDM (Certified Dietary Manager) on ensuring that prescribed therapeutic diet orders are being followed and ensuring the menu is being followed for residents on a therapeutic diet. The Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that prescribed therapeutic diet orders are being followed and that the menu is being followed for residents on a therapeutic diet. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Document and Address Resident Grievance
Penalty
Summary
A resident expressed frustration regarding delays in having her sanitary brief changed and reported these concerns to a staff member, who stated she communicated the issues to the Director of Nursing (DON) and documented them in the facility's electronic system. However, the staff member did not submit any formal grievance documentation for this resident, despite having done so for others. Another CNA, with long tenure at the facility, was aware of the resident's complaints about noise and other residents entering her room but did not report these issues to administration, as she did not consider them dangerous. The Social Worker confirmed that no grievance forms had been submitted by or on behalf of the resident, and the DON stated she had not received any complaints from the resident or her family. The facility's grievance procedure requires documentation and resolution within three days, but no documentation existed for this resident's concerns. This sequence of events demonstrates a failure to follow the facility's grievance policy, resulting in the resident's complaints not being formally documented or addressed as required.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for residents, as observed during a survey conducted by surveyors. The deficiencies were noted across multiple areas, including residential rooms, community shower rooms, activity rooms, and common areas on the First Floor West, Second Floor East, and Second Floor West. Specific issues included non-functional hand wash sinks, soiled and stained floors, broken wall tiles, and privacy curtains that were too short to ensure resident privacy. Additionally, there were reports of pervasive odors, damaged walls, and rust-laden portable commode seats. The surveyors observed that many rooms had privacy curtains that were too short, compromising resident privacy during personal care activities. Several rooms had soiled and stained floors, broken dresser drawers, and walls in disrepair. In some cases, there were pervasive odors, such as urine, which further contributed to the uncomfortable living conditions. The community shower rooms and nurse stations also exhibited significant cleanliness and maintenance issues, including dust accumulation, broken tiles, and non-functional faucets. The Corporate Maintenance Director acknowledged the issues and mentioned that the facility uses a computerized TELS system for reporting housekeeping and maintenance concerns. However, it was noted that staff were not utilizing this system effectively, leading to unresolved maintenance and housekeeping issues. The surveyor requested that all environmental concerns identified during the tours be reviewed with the Administrator, highlighting the need for improved reporting and maintenance practices within the facility.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to properly manage and dispose of controlled medications for two discharged residents. Resident #497, who had been prescribed Lacosamide for seizures, was discharged, yet the medication remained in the controlled substance drawer instead of being removed and given to the Director of Nursing (DON) for disposal. Similarly, Resident #496's controlled medication, Lorazepam Intensol, was found in a locked box in the refrigerator after the resident had been discharged. Staff interviews confirmed that these medications should have been removed and disposed of according to the facility's policy. The facility also failed to secure emergency crash carts and medications properly. During an observational tour, it was noted that the emergency crash cart on the first floor was unlocked and unattended, containing both sterile and non-sterile supplies, including syringes and normal saline with expired dates. Similar unsecured conditions were observed with the emergency crash carts at the 2-East and 2-West Nurse's stations. Staff interviews revealed uncertainty about whether the carts had been properly secured, indicating a lapse in following security protocols. Additionally, the facility did not manage medication storage effectively. Loose, unidentified pills were found in the medication cart drawers, and expired topical medications were stored in the wound treatment cart. Over-the-counter medications were left unattended and unsecured on a medication cart, accessible to residents, employees, and visitors. These observations highlight a failure to adhere to the facility's policies on medication storage and security, as acknowledged by the DON during interviews.
Failure to Provide Adequate Nutrition Due to Refrigeration Issues
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs. This deficiency was identified during a survey where it was found that the facility's walk-in and reach-in refrigerators had stopped working, leading to the implementation of an emergency menu consisting of non-perishable foods. The refrigeration issues began on 05/31/24 and 06/04/24, respectively, and despite attempts to repair the units, the facility was unable to store and prepare fresh foods, resulting in the use of canned and non-perishable items for meals. Residents expressed dissatisfaction with the meals, noting the lack of hot foods for breakfast and the poor taste of canned foods served for lunch and dinner. Interviews with residents revealed that they were aware of the refrigeration issues and felt that there had been ample time to address the problem and resume serving fresh meals. Additionally, residents observed staff eating catered meals, which exacerbated their dissatisfaction with the emergency menu. The facility administration acknowledged that they failed to explore alternative refrigeration options, such as utilizing existing refrigerators within the facility or arranging for a refrigerated truck from their grocery vendor. The administration was also unaware of the residents' complaints and the impact of the situation on their dining experience. The facility recognized that the refrigeration issues could have been managed more effectively to prevent the implementation of the emergency menu.
Deficiency in Food Preparation and Hot Holding
Penalty
Summary
The facility failed to prepare foods in a manner that maintains their nutritional value for potentially 117 residents. During an initial kitchen tour, it was observed that the hot holding unit was set up for the lunch meal, which included various dishes such as chicken, mechanically altered chicken, chicken and dumplings, mashed potatoes, rice, pureed chicken, pureed peas, mechanical soft peas, gravy, and carrots. Staff R confirmed that these items were prepared for lunch and stated that cooking began after breakfast was completed at about 8:30 AM. The carrots, which were canned, took approximately 20 minutes to prepare. However, there was no response from Staff R regarding the facility's policy for preparing foods prior to serving. The Dietary Director acknowledged concerns about the extended hot holding time, which exceeded two hours from cooking to serving. Additionally, the facility's recipe for canned carrots and peas did not address hot holding for extended periods.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to maintain food safety standards during food preparation, storage, and service. During a kitchen tour, it was observed that canned carrots were being held at an unsafe temperature of 93 degrees Fahrenheit. The sanitizer concentration was below the required level, and employee drinks were improperly stored in the walk-in freezer. Additionally, there was uncovered dough, dust accumulation on fan guards and vents, and food residue on a can opener blade. Serving utensils were found to be worn and unable to be properly sanitized. The facility's thawing process for meat was not followed correctly, as raw chicken was left in a bucket without running water, and staff failed to perform hand hygiene before donning gloves. Further observations revealed unsanitary practices during meal preparation and service. Staff members were seen reaching over food with loose clothing, changing gloves without hand hygiene, and improperly handling utensils. A waste receptacle in the processing area was nearly full and uncovered. In the unit pantry, there was mold in the ice dispenser chute and a lack of a working thermometer in a refrigerator. During meal service to residents, staff did not perform hand hygiene between serving trays until prompted by a nurse. The Activity Director acknowledged awareness of infection control practices but failed to implement them consistently during meal distribution.
Infection Control Deficiencies in PPE and Dialysis Suite
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) according to CDC guidelines and its own policies for all 24 sampled residents on EBP. Observations revealed that personal protective equipment (PPE) such as gowns and gloves were not available at the entrance of residents' rooms, as required. Interviews with staff indicated a lack of understanding and adherence to the facility's EBP policy, with some staff incorrectly stating that PPE was only needed for certain conditions or that PPE was available in limited quantities per wing. During a specific observation of Foley catheter care for a resident, a Certified Nursing Assistant (CNA) failed to don a gown and used the same pair of gloves throughout the procedure, leading to cross-contamination of multiple surfaces. The CNA also handled the resident's Foley catheter improperly and touched various surfaces without changing gloves or sanitizing hands. The Director of Nursing acknowledged that proper infection control techniques were not followed during this procedure. In the in-house dialysis suite, several infection control concerns were noted, including uncovered trash cans containing soiled gloves and gowns, broken covers on infectious waste cans, and improper storage of essential dialysis components. These observations indicate a broader issue with infection control practices within the facility, as evidenced by the improper handling and storage of potentially infectious materials.
Failure to Repair Kitchen Equipment Affects Food Temperature
Penalty
Summary
The facility failed to promptly repair and replace essential kitchen equipment, leading to deficiencies in food service. During an initial kitchen tour, it was observed that the walk-in cooler was out of order, and the facility had been using a disaster emergency menu since the cooler had been non-functional for over a week. The Dietary Manager confirmed that the cooler had been down since the end of May and was not expected to be repaired until mid-June. This delay in repair affected the facility's ability to store food at appropriate temperatures. Additionally, during a follow-up kitchen tour, it was noted that the kitchen staff were not using the pellet warmer while plating meals, resulting in complaints from residents about cold food. The facility had ordered a warmer that was incompatible with their existing plates, and despite ongoing discussions since February, there was no evidence of a compatible warmer being ordered. Documentation from an external agency highlighted repeated concerns about food temperature during visits from February to June. The facility's invoices indicated that the warmer had been non-functional since September of the previous year.
Failure to Provide Wheelchair for Resident's Mobility and Activity Participation
Penalty
Summary
The facility failed to provide a wheelchair to a resident, identified as Resident #13, which hindered his mobility and participation in activities. Resident #13 was admitted with diagnoses including COPD, chronic bronchitis, depression, and a left below-the-knee amputation. The resident had a moderate cognitive impairment and was dependent on assistance for various functional abilities, including transferring from bed to wheelchair. Despite physician's orders for the resident to participate in activities twice weekly and to modify the treatment plan as needed, the facility did not provide the necessary equipment to facilitate this. Observations and interviews revealed that Resident #13 had been without a wheelchair for months, preventing him from attending activities outside his room. The resident expressed his concerns to both morning and evening staff, but received no response regarding the whereabouts of his wheelchair. Multiple staff members, including a Licensed Practical Nurse, Certified Nursing Assistant, and the MDS coordinator, were unaware of the wheelchair's location. The Director of Activities claimed the resident refused to participate in activities, but there was no documentation to support this claim. The facility's records, including the Electronic Health Record and Occupational Therapy notes, lacked evidence of following through on the resident's care plan, particularly regarding wheelchair management training. Despite a speech therapist eventually locating the wheelchair, there was no explanation provided for its absence. The Physical Therapist Director was unable to provide documentation of interventions and outcomes for the resident during the months of April, May, and June, further highlighting the facility's failure to accommodate the resident's needs and preferences as required.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide appropriate personal assistive care and services for a resident, specifically in the area of bathing and showering. The facility's policy required assistance with showering and bathing at least twice a week, with the resident's preferences reviewed quarterly. However, the care plan for the resident did not include specific ADL care related to bathing, despite the resident's expressed preference for showers on specific days and times. The resident, who had intact cognition and a history of multiple sclerosis and muscle weakness, reported not receiving a shower for over a week, contrary to his preferences and the facility's schedule. Interviews with staff revealed a lack of clarity and communication regarding the resident's shower schedule. The resident's care plan focused on his limited physical mobility but did not address his personal ADL care needs. Staff members were unclear about who was responsible for providing the resident's showers, with both day and evening staff assuming the other was fulfilling this duty. This miscommunication resulted in the resident receiving only one shower over a two-week period, despite being scheduled for three showers. The facility's Director of Nursing acknowledged the oversight and the importance of honoring and clarifying residents' preferences for ADL care. The resident's dissatisfaction with the change in his shower schedule and the lack of follow-through on his requests for assistance highlighted the deficiency in the facility's adherence to its own policies and procedures. The resident's needs were not met until after surveyor intervention, indicating a failure in the facility's system to ensure consistent and personalized care for its residents.
Deficient Foley Catheter and Peri-care Observed
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Foley catheter, as observed during a survey. The resident, who had a neurogenic bladder and other medical conditions, was observed receiving peri-care and Foley catheter care from a CNA. The CNA did not follow proper procedures, such as wearing a gown, changing gloves, and performing hand hygiene. Additionally, the CNA left the resident's room door open, compromising privacy, and placed the Foley catheter above the resident's chest, which is against the care plan instructions. During the observation, the CNA used the same pair of gloves to clean the resident's perineal area and then touched various surfaces in the room, leading to cross-contamination. The CNA also left the resident unattended in a high bed position while she went to get additional supplies, further compromising the resident's safety. The CNA did not use a Foley catheter strap and anchor, which was not present in the resident's room, and there was no physician's order for it. Interviews with the resident and staff confirmed the deficiencies in care. The resident stated she had never used a Foley catheter strap and anchor. Both the RN and CNA acknowledged the CNA's lack of preparation and failure to follow appropriate procedures. The DON also recognized the CNA's failure to utilize proper infection control techniques during the procedure.
Inadequate Documentation and Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure proper communication and documentation for a resident receiving dialysis care. The resident, who was re-admitted with Chronic Kidney Disease and Altered Mental Status, was receiving in-house dialysis three times a week. Despite having no cognitive impairment and being independent in Activities of Daily Living, the facility did not maintain adequate records of the dialysis process. The Hemodialysis Communication Record lacked documentation of critical information such as the time of transfer to and from the dialysis center, medications administered prior to dialysis, and shunt site observations. The dialysis center also failed to document essential details, including pre and post dialysis weights, lab values, and dialysis finish times. This lack of documentation was consistent across multiple dates, indicating a systemic issue in maintaining proper records for dialysis care. The Corporate Nurse Consultant confirmed these findings, highlighting the facility's failure to ensure ongoing communication and collaboration with the dialysis center for the resident's care.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 14.70%. During a medication administration observation, a registered nurse (RN) prepared medications for a resident with multiple diagnoses, including COPD, diabetes, and end-stage renal disease. The RN initially prepared a medication labeled for a different resident but corrected this before administration. However, the RN omitted two medications, Cyanocobalamin and Pantoprazole Sodium, from the resident's morning regimen. The RN admitted to not contacting the pharmacy for the undelivered Pantoprazole and was unfamiliar with the new admission's medication regimen, leading to the omission of the Vitamin B12 tablet. In another instance, the same RN prepared and administered six out of eight prescribed medications to a resident with multiple sclerosis and anemia. The RN omitted Ferrous Sulfate and Magnesium Oxide, which were part of the resident's morning medications. The resident reported feeling tired and weak, symptoms associated with her condition. The RN acknowledged not recalling the administration of the omitted medications and attributed her oversight to nervousness due to the surveyor's presence. The Director of Nurses was informed of these observations and acknowledged the findings.
Deficiency in Addressing Food Concerns and Equipment Repairs
Penalty
Summary
The facility failed to develop and implement an effective Quality and Performance Improvement Plan (QAPI) to address residents' food concerns and timely repair of kitchen equipment. The walk-in cooler had been out of order since May 31, 2024, leading the facility to unnecessarily resort to serving the emergency food menu. Despite the availability of other refrigeration options within the facility, such as using refrigerators or renting a refrigerated truck, these alternatives were not utilized, resulting in the continued use of the emergency menu. Residents expressed dissatisfaction with the meals provided, noting a lack of variety and palatability. Interviews with residents revealed that they were served repetitive and non-substantial meals, such as peanut butter and jelly with cereal, instead of their preferred options like eggs and bacon. The facility administration was unaware of the residents' complaints and the ongoing refrigeration issues, which had been affecting meal quality and acceptance. Additionally, the facility failed to address the issue of cold meals being served to residents. The pellet warmer was not used during meal plating, and meals were delivered in carts without a heat source, resulting in food being served at ambient temperatures. Despite ongoing complaints and awareness of the issue since February, there was no evidence of efforts to remedy the situation, such as ordering compatible warmers or utilizing microwaves to reheat food upon request.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to maintain call lights within reach of residents, affecting three sampled residents. Resident #23, who has a moderate cognitive impairment and multiple health issues, was observed with the call light out of reach on multiple occasions. Despite the care plan indicating the need for the call light to be within reach due to the resident's high risk of falls, the call light was found clipped to the wall and on the floor, making it inaccessible. Staff were unaware of the issue, indicating a lack of attention to the resident's needs. Resident #481 also experienced issues with the call light being inaccessible. During a facility tour, the resident reported needing assistance but was unable to find the call light, which was discovered inside a nightstand and later on the floor. This indicates a failure to ensure the call light was consistently within reach, preventing the resident from calling for help when needed. Resident #13, who has moderate cognitive impairment and is dependent on assistance for daily activities, was found with the call light stuck under the bed, making it impossible to use. Despite the resident's repeated attempts to call for help, staff were either unaware or unable to resolve the issue promptly. The resident's inability to access the call light was compounded by visual impairment and a short overhead light string, further limiting their ability to communicate with staff. Maintenance was eventually called to address the issue, but the call light remained inaccessible for an extended period.
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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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