Kirkwood by the River

Inspectors wroteBased on observation, interview, and review of the facility's Infection Prevention and Control Program, the facility failed to ensure Employee Identifier (EI) #3, laundry staff, changed gloves and sanitized her hands between residents during delivery of resident clothing, and did not place small baskets on the residents' dressers and return them to the clean laundry cart. This occurred on 10/6/21, one of three days of survey, and was observed while EI #3 was delivering clothing to four resident rooms. Findings Include: The facility's Infection Prevention and Control Program dated 9/12/17 documented . D. Hand Hygiene Protocol: 1. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, . J. Linens: 1. Laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. [...]

Inspectors wroteBased on observations, interviews, and a review of facility policies titled, FOOD Safety Requirements, Handwashing Guidelines Dietary Employees, Maintaining a Sanitary Tray Line, and Monitoring of Cooler/Freezer Temperatures, the facility failed to ensure: 1. food temperatures were taken prior to serving food from the tray line to residents on the skilled unit; 2. hands were washed by the kitchen worker serving tray line on the skilled unit while multi tasking; 3. refrigerator temperature was maintained to keep frozen food frozen solid; 4. employees hair was fully restrained and 5. green beans were not served to residents after a foreign object was removed from the green beans. These deficient practices had the potential to affect all 53 residents served meals from the kitchen. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview and review of a facility policy Maintaining a Sanitary Tray Line, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) did not touch a resident wheelchair with gloves then with the same gloves cut a resident's sandwich in quarters; and 2. a laundry aide did not deliver the resident clothing to the unit uncovered, did not take a small basket into multiple resident rooms then return it to the clean clothes cart and did not allow resident clothing to touch the floor as she carried them from the cart to the resident closet. This had the potential to affect one of one residents in the dining room and 41 residents whose laundry was done by the facility. Findings Include: 1. A review of a facility policy Maintaining a Sanitary Tray Line with effective date of 11/10/17 revealed Policy: [...]

Inspectors wroteBased on interview, medical record review and a review of the facility's policy titled, Personal Cell Phones Policy, the facility failed to ensure staff did not use a personal cell phone during resident care. This affected Resident Identifier (RI) #207, one of 15 residents who were observed during the provision of care. Findings Include: A review of a facility's policy titled, Personal Cell Phones dated 04/22/2016, documented: . Cell phones are to be kept in your handbag or vehicle while on duty. They may not be kept on your person or work area . while working. You may not use your cell phone in any residential area . even if you are on break or off duty . RI #207 was readmitted to the facility on [DATE] with a diagnosis of Fracture of Unspecified Part of Neck of Right Femur. On 03/21/2018 at 12:10 p.m., the surveyor entered RI #207's room. RI #207 stated around 10 a.m. [...]

Inspectors wroteBased on observation, interview, medical record review and a review of the facility's policy titled, Medications Administration and a review of [NAME] and Perry's Fundamentals of Nursing, the facility failed to ensure staff obtained Resident Identifier (RI) #12's heart rate before administering Metoprolol Tartrate. This affected one of 11 residents observed during medication administration observation. Findings Include: A review of the facility's policy titled, Medications Administration dated 11/19/12 revealed the following: Policy Medications are administered as prescribed, in accordance with good nursing principles and practices. Procedure: . 2. Medications are administered in accordance with written orders of the attending physician . [...]

Inspectors wroteBased on observation, interview and a record review, the facility failed to ensure staff followed Resident Identifier (RI) #12's care plan titled, . impaired cardiovascular status related to medical diagnosis of hypertension, by not obtaining RI #12's heart rate/vital signs as ordered. This affected one of 11 residents observed during medication administration observation and one of 15 residents whose care plans were reviewed. Findings Include: RI #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: Pneumonia and Unspecified Diastolic (Congestive) Heart Failure. A review of RI #12's Quarterly Minimum Data Set (MDS) dated [DATE], revealed RI #12's Brief Interview for Mental Status (BIMS) score 12, indicating moderate impairment in cognition. [...]

Inspectors wroteBased on observation, medical record review, interviews and a review of the facility's policies titled, Wound Care and Clean Dressing Change, the facility failed to ensure staff wiped Resident Identifier's (RI) #42's wound located on mid back from the inner to the outer aspect in one continuous wipe and cleaned the peri-wound area. This affected, RI #42, one of two residents observed during wound care. Findings Include: A review of the facility's policy titled, Wound Care dated 11/16/16 revealed the following: . Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure . 11. Wash tissue around the wound that is usually covered by the dressing, tape, gauze with wound cleanser or normal saline . A review of the facility's policy titled, Clean Dressing Change dated 10/16/16, revealed the following: . Policy: [...]

Inspectors wroteBased on observation, medical record review, interview and a review of the facility's policies titled, Skin Care and Gloves, the facility failed to ensure staff changed soiled gloves after cleaning Resident Identifier (RI) #42's wound and before applying a clean dressing. The facility further failed to ensure staff washed hands after removing soiled gloves and before applying clean gloves. This affected RI #42, one of two residents observed during wound care. Findings Include: A review of the facility's policy titled, Skin Care dated 11/16/12 revealed the following: . Procedure I. Dressing-Clean Technique: . 9. Remove dressing and discard . Remove gloves and wash hands. 10. Apply clean gloves. 11. Cleanse area . 12. Remove gloves, wash hands . A review of the facility's policy titled, Gloves dated 03/23/06, revealed the following: . handwashing is to be done after removal of gloves. [...]