Frankfort Terrace

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a comfortable environment. This applies to 4 of 6 (R1, R2, R4, R6) residents reviewed for elevated environmental temperatures in a sample of 7. Based on observation, interview and record review the facility failed to maintain a comfortable environment. This applies to 4 of 6 (R1, R2, R4, R6) residents reviewed for elevated environmental temperatures in a sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This applies to 1 of 5 residents (R2) reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen and use proper sanitation while checking food temperatures. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on interview and record review the facility failed to implement and document measure that prevent the waterborne pathogen Legionella and provide an up-to-date infection control policy. \This applies to all 101 residents that resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a fully functioning call light system. This applies to all residents residing at the facility.

Inspectors wroteBased on observation, interview, & record review, the facility failed to provide ADL care (activities of daily living) to 4 0f 4 residents dependent of ADL care (R3, R42, R83 & R92) in a sample of 28.

Inspectors wroteBased on interview and record review the facility failed to invite residents to their interdisciplinary care plan meeting. This applies to 2 of 2 residents (R21 and R76) reviewed for care planning in a sample of 28 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician's order for 1 resident (R92) in a sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adaptive eating utensils to a resident with upper extremity impairments. This applies to 1 of 1 resident (R5) reviewed for adaptive utensils.

Inspectors wroteBased on observation, interview, and record review, the facility failed to contain respiratory equipment for 2 residents (R38 & R42) in a sample of 27. 1. On 06/04/24 at 11:00 AM R38's BIPAP (bilevel positive airway pressure) mask and O2 nasal cannula was observed not covered. R38 said I use my BIPAP ever night and the oxygen as needed. R38's electronic medical record showed that she has diagnoses including chronic obstructive pulmonary disease with acute exacerbation, asthma & sleep apnea. R38's 2/19/23 physician order showed, oxygen as needed for COPD (chronic obstructive pulmonary disease), & 12/19/23 Physician order showed, BIPAP at night at bedtime for COPD. 2. On 06/04/24 10:36 AM R42's CPAP mask (continuous positive airway pressure) and O2 nasal cannula was observed not covered. R42 stated, I use my CPAP every night at 10pm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store and label medications properly. This applies to 1 of 1 resident (R48) reviewed for medication storage in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to respect residents' right to make choices about their diet. This applies to 3 of 3 residents (R47, R57 and R101) in a sample of 28 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide mental health rehabilitation services to a resident identified with a serious mental health condition. This applies to 1 of 1 resident (R74) reviewed for mental health rehabilitative services in the sample of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to secure hazardous chemicals in a locked storage area in accordance with the facility policy. There were 96 ambulatory residents, all with psychiatric illness with access to the hallway where the chemicals were stored. This failure presented a serious health risk to all 96 residents residing in the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on June 14, 2023, when hazardous chemicals were observed in an unsecured hallway during the environmental tour. On June 14, 2023, at 12:48 PM with V16 (housekeeping supervisor) hazardous chemicals were observed in an unsecured hallway that leads to the kitchen and laundry room. The hallway has an unsecured door with direct access to the main dining room where ambulatory residents gather for meals and activities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods are stored and the dishes washed in a sanitary manner. This applies to all 105 residents who receive foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date medications after it was opened to determine expiration dates. This applies to 8 of 10 residents (R9, R15, R35, R40, R51, R71, R72, R103) reviewed for labeling and storage of medications.

Inspectors wroteBased on observations, interview and record review, the facility failed to serve portion sizes for regular and pureed diets as shown on the diet extension spreadsheet. This applies to 10 of 10 residents (R38, R50, R55, R72, R74, R85, R90, R96, R99, R103) reviewed for dining in the sample of 28.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the recipe to serve consistencies as shown for pureed and mechanical soft rice. This applies to 6 of 6 residents (R3, R5, R48, R50, R74, R97) observed for dining in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to offer residents the pneumococcal vaccine and administer the influenza vaccine to residents. This applies to 6 of 6 residents (R4, R41, R85, R91, R95, R103) reviewed for immunizations in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's signed POLST (Practitioner Order for Life-Sustaining Treatment) form and physician's order were consistent and reflected the resident's treatment wishes in an event of a medical emergency based on the facility's advance directives guideline. This applies to 1 of 2 residents (R5) reviewed for advance directives in the sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for hand hygiene during resident care. This applies to 1 of 28 residents (R3) reviewed for infection control in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for antibiotic stewardship. This has the potential to affect all 105 residents residing in the facility. The Resident Census and Conditions of Resident report dated June 12, 2023, shows the facility census as 105 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who smoke in the facility's ground/patio were supervised all throughout the smoking period. This applies to 6 of 19 residents (R5, R11, R27, R40, R70, R84) reviewed for smoking in the sample of 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date medications after they were opened to determine expiration dates. This applies to 10 of 10 residents (R18, R38, R41, R52, R53, R57, R60, R64, R72, R79) reviewed for labeling and storage of medications. The Findings Include: On [DATE] from 11:00 AM through 11:45 AM, the medication carts and refrigerator (used for medication storage) were inspected with V7 and V17 (Both Nurses). The medication carts and refrigerator were all stored inside the nurses' station. The following medications were observed as follows: 1. R64's Breo Ellipta opened and not dated. 2. R72's Basaglar Kwik Pen and Novolog Insulin were opened and not dated. In addition, R72's Basaglar Kwik pen was opened on [DATE] (expires 28 days after it was opened) and is mixed with the active medications. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility's policy and procedure on advance directives. This applies to 1 of 1 residents (R23) reviewed for advance directives in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to toilet and provide grooming assistance to residents that needed extensive assistance or the same. This applies to 3 of 3 residents (R10, R29, R63) reviewed for Activities of Daily Living care in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report high blood pressures of a resident to the Physician in a timely manner. This applies to 1 of 18 residents (R48) reviewed for Nursing Care in the sample of 19. The Findings Include: According to the EMR (Electronic Medical Record) R48 has congestive heart failure and hypertensive heart disease. The same record shows R48 was in the hospital from [DATE] to 6/28/22 and several blood pressure medications were discontinued at that time. On 7/11/22 at 2:30pm, R48 was in a wheelchair. R48 had swollen legs and ankles. R48 stated his ankle did swell every day. R48 stated he had been in the hospital a few weeks earlier and he's ok now. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pureed entrée portions as shown on the menu spreadsheet during the lunch meal. This applies to 1 of 1 resident (R29) reviewed for pureed diet in the sample of 19.

Inspectors wroteBased on interview and record review the facility failed to ensure all staff were fully vaccinated for COVID-19. This has the potential to affect all 88 residents in the facility.