Every finding on record at Deerfield Episcopal Retirement

Based on observations, record review, and staff interviews, the facility failed to provide safe oxygen tank storage for 1 of 5 residents reviewed for accident hazards (Resident #28). The findings included: Resident #28 was admitted on [DATE] with diagnoses including chronic kidney disease stage 4, Type 2 diabetes, anemia, and lumber stenosis. A physician's order for Resident #28 dated 11/14/25 indicated to provide oxygen via nasal cannula at 2 to 5 liters per minute to maintain comfort for shortness of breath. The quarterly Minimum Data Set (MDS) assessment on 5/22/26 for Resident #28 was coded for receiving oxygen therapy, and for wheelchair use. On 6/2/26 at 9:10 AM an observation of Resident #28's room revealed a portable oxygen tank (a metal cylinder 25 inches tall and 4.5 inches wide with a flow control regulator on top), on the floor leaned at an angle against a filing cabinet with the regulator touching the edge of a dresser directly next to it. The oxygen tank was in a spongy fabric holder which had straps for attachment to the resident's wheelchair. The oxygen tank's flow regulator was turned off, and the gauge indicator was in the space midway between one quarter full and empty. Resident #28 was asleep in bed, wearing an oxygen cannula connected to an oxygen concentrator. An empty rolling oxygen tank cart was seen in the room behind the entrance door. Observation was made of Resident #28's room on 6/2/26 at 10:20 AM and revealed the oxygen tank on the floor, leaned at an angle against the filing cabinet with the regulator touching the edge of the dresser directly next to it. The oxygen tank was in a spongy fabric holder which had straps for attachment to the resident's wheelchair. The oxygen tank's flow regulator was turned off, and the gauge indicator was in the space midway between one quarter full and empty. Resident #28 was asleep in bed and wearing an oxygen cannula connected to an oxygen concentrator. An empty rolling oxygen tank cart was seen in the room behind the entrance door. During a telephone interview on 6/3/26 at 9:01 AM, Nurse Aide (NA) #3 stated she had been Resident #28's NA the overnight shift 6/1/26 into 6/2/26. NA #3 explained sometime between 1:00 AM and 3:00 AM she went into Resident #28's room to get her wheelchair to weigh it which they did monthly for weight accuracy. She further explained Resident #28 was asleep in bed at the time and on oxygen connected to her oxygen concentrator. NA #3 revealed she removed the tank in its fabric holder from the wheelchair and set it on the floor next to the dresser then took the wheelchair out to weigh it. NA #3 stated when she brought the wheelchair back into Resident #28's room, as she was getting ready to reattach the oxygen tank to the wheelchair, another resident's call bell rang, and she left to answer it. NA #3 revealed she should have secured the oxygen tank in a rolling cart when removing the oxygen tank and she had known there was one in the room. She also stated she should have finished attaching the oxygen tank to the wheelchair before leaving to get the call bell and just didn't think about it and didn't notice the tank again when she went back in the room later in the shift. NA #3 stated she had been taught the importance of securing oxygen tanks for safety at orientation and the facility had plenty of rolling carts. An interview was conducted on 6/2/26 at 10:53 AM with Nurse Aide (NA) #2 who was Resident #28's day shift nurse aide. NA #2 revealed she had done walking rounds with the night shift aide, NA #3 at shift change about 6:50 AM. She explained it was dark in the room, but they looked around and laid eyes on the resident who had been sleeping. NA #2 stated she thought she saw the oxygen tank on the back of the wheelchair where it usually was. She explained she did not see an oxygen tank on the floor and if she had she had she would have put it back on the wheelchair holder or in the rolling cart. NA #2 stated she knew there was usually a rolling cart in Resident #28's room for when they weighed her or changed out oxygen tanks. In an interview on 6/2/26 at 10:31 AM with NA #1 who was assisting NA #2 this shift, she stated when Resident #28 left her room with oxygen they would connect oxygen to the tank in the fabric holder on the back of her wheelchair. NA #1 explained when Resident #28 was brought back to her room, sometimes she would get back in bed, and they would switch her cannula to the oxygen concentrator. NA #1 further explained if Resident #28 stayed in her wheelchair they might leave her on the tank attached to her chair. NA #1 explained portable oxygen tanks lasted a few hours, and staff knew how to use the rolling cart when moving oxygen tanks. In an interview on 6/2/26 at 10:38 AM with Nurse #1, she stated she was Resident #28's nurse and had been in her room earlier and spoken briefly with her about 9:15 AM and again about 10:30 AM. Nurse #1 stated she did not notice any oxygen tank in her line of sight either time she had been in the room. Nurse #1 further explained oxygen tanks should not be sitting on the floor but should be in a rolling cart or attached to the wheelchair which was where Resident #28's tank was usually kept when she left the room. An interview was conducted with the Director of Nursing (DON) on 6/2/26 at 10:25 AM in Resident #28's room. The DON observed the oxygen tank leaning against the filing cabinet and revealed that was not how oxygen tanks should be stored and it should have been in a rolling cart for safety. She confirmed the oxygen level to be between 1/4 full and empty and the presence of a rolling oxygen tank cart in the room. The DON explained they had not had problems with oxygen tank storage and didn't know how this happened. She further explained the night and day shift nurse aides did walking rounds together at shift change between 6:45 AM and 7:15 AM and should have caught the unsecured tank in there. During a follow up interview with the DON on 6/3/26 at 9:12 AM she explained oxygen tanks were to be secured in a rolling cart or a bag hooked to the resident's wheelchair and were in a secure rack in the oxygen storage room. The DON indicated proper oxygen storage was taught to new staff in orientation. The DON revealed oxygen tanks cannot be outside the rolling cart whether full or empty because it could be a safety hazard if they were not secured. In an interview with the Administrator on 6/3/26 at 9:30 AM he stated they had not had problems with oxygen tanks before, and this was a case of human error. He explained the oxygen tank was under pressure and if it had fallen or got bumped there could have been safety consequences. The Administrator further explained the expectation was that oxygen tanks were properly and safely secured.

Based on record review, observations and staff interviews, the facility failed to remove expired prepackaged produce stored for use in 1 of 3 kitchen refrigerators (reach-in refrigerator). The practice had the potential to affect food served to residents. Findings included On [DATE] at 9:05 AM an observation was made in the kitchen with the Dietary Manager (DM). The reach-in refrigerator was observed to contain an unopened bag of shredded cabbage with a use by date of [DATE] on the bag. The DM was interviewed on [DATE] at 12:30 PM and stated the shredded cabbage was brought to the kitchen from another kitchen on site to be used that night as an alternative food choice. The staff in the kitchen did not check the expiration date of the cabbage and it was placed into the reach-in cooler. The DM stated the procedure was to check all food delivered for expiration dates before storing it. The Administrator stated on [DATE] at 10:52 AM the kitchen should not have accepted the expired food brought into the kitchen. He said when food had expired it should be removed from storage and discarded.

Based on observations and staff interviews the facility failed to remove expired food stored for use from 2 of 3 kitchen refrigerators (#1 and #2). This practice had the potential to affect food served to residents. The findings included: On [DATE] at 10:20 AM an observation of the kitchen's reach-in refrigerator #1 with the Dietary Manager (DM) revealed expired food items. On the top shelf, a clear plastic bag of red peppers contained a pepper with black spotted and fuzzy areas. The DM removed and immediately disposed of the pepper. The bottom shelf of the refrigerator contained 2 box sheets of desserts that were opened and individually wrapped with the date [DATE] written on them. The DM stated during the observation that the desserts might have been frozen and thawed to use over the weekend. The DM disposed of the desserts. An observation of reach-in refrigerator #2 on [DATE] at 10:30 AM with the DM revealed 2 plastic storage bags that contained previously opened sandwich meat. The storage bags were dated ,d+[DATE] and the DM immediately disposed of the bags. The DM stated on [DATE] at 11:54 AM that the expired foods in the refrigerators were overlooked and should have been removed when the dietary staff checked the refrigerators earlier in the day. The Administrator stated on [DATE] at 10:03 AM in an interview that the DM completed regular in-servicing and kitchen inspections and has experienced staff. The Administrator said the expired and outdated food items were overlooked and should have been removed.

Based on observations and staff interviews the facility failed to discard outdated foods and ensure foods were dated and labeled in 2 of 2 refrigerators. The findings included: 1a. Initial tour of the skilled kitchen was conducted on 06/15/15 at 8:30 AM with the Director of Dining Services. Observation of reach in refrigerator #1 revealed one unopened package of sliced pastrami meat with use by date of 12/25/14, one unopened package of sliced corned beef top round with use by date 06/05/15, one open and wrapped container of prunes with discard date 06/05/15, and one bag of dark green leafy vegetable not labeled or dated. On 06/15/15 at 8:45 AM an interview was conducted with Director of Dining Services who stated refrigerators in the skilled kitchen were to be checked on a daily basis for outdated food and to assure food was labeled and dated. Director of Dining Services verified that in refrigerator #1 pastrami, corned beef, and prunes should have been discarded and dark green leafy vegetable should have been labeled and dated. On 06/15/15 at 2:40 PM an interview was conducted with Dietary Lead Server #1 who stated she checked for outdated food in refrigerator #1 last Friday (06/12/15). Dietary Lead Server #1 stated she overlooked checking the date on the prunes and did not check the dates on the pastrami and corned beef because they were delivered from the main kitchen and she assumed the dates were good. On 06/15/15 at 2:50 PM an interview was conducted with Sous Chef #1 who stated pastrami and corned beef stored in refrigerator #1 were outdated and stated the meat had been in refrigerator #1 for approximately 3 weeks. Sous Chef #1 stated the pastrami and corned beef should have been discarded. 1b. Initial tour of the skilled kitchen was conducted on 06/15/15 at 8:30 AM with the Director of Dining Services. Observation of reach in refrigerator #2 revealed one opened container of heavy ultra-pasteurized whipping cream with expiration date 04/27/15, sautéed vegetable base 16 ounce with discard date of 05/04/15, beef base 16 ounce with discard date 06/07/15, one bag of celery with discard date of 06/12/15, undated open container crab base 16 ounce, undated unopened container baking blend with cultured nonfat buttermilk 32 ounces, undated flat of unpasteurized eggs and undated unopened liquid pasteurized eggs. On 06/15/15 at 8:45 AM an interview was conducted with Director of Dining Services who stated refrigerators in the skilled kitchen were to be checked on a daily basis for outdated food and to assure food was labeled and dated. Director of Dining Services verified that in refrigerator #2 outdated heavy whipping cream, sautéed vegetable base, beef base, and bag of celery should have been discarded and crab base, baking blend with cultured nonfat buttermilk, flat of unpasteurized eggs and bag of liquid pasteurized eggs should have been dated. On 06/15/15 at 3:06 PM an interview was conducted with Sous Chef #2 who stated she was responsible to check for outdated food items and assure food items were labeled and dated in refrigerator #2. Sous Chef #2 stated she checked all of the creams for outdates in refrigerator #2 last Friday (06/12/15) and missed checking the date on pasteurized whipping cream and stated she should have discarded the pasteurized whipping cream. Sous Chef #2 stated she overlooked checking the date on the bag of celery and celery should have been discarded on Friday. Sous Chef #2 stated she overlooked checking the dates on the sautéed vegetable, and beef base and they were outdated and discarded today. Sous Chef #2 stated she should have checked for an open date on the crab base and had not checked for an expiration date on the baking blend with cultured nonfat milk and discarded the crab base and baking blend today. Sous Chef #2 stated she was unsure of when the liquid pasteurized eggs were delivered to the skilled kitchen because they were undated and should have been discarded. Sous Chef #2 stated she discarded the liquid pasteurized eggs today. Sous Chef #2 stated she was unsure when the flat of unpasteurized eggs were delivered to the skilled kitchen because they were not dated. On 6/16/15 at 9:34 AM an interview was conducted with the Director of Dining Services who stated her expectations were that dietary staff in skilled kitchen would have checked food items in refrigerator #1 and #2 for outdates and discarded outdated food items and checked that food items were labeled and dated. Director of Dining Services stated what had happened in the skilled kitchen with expired, undated, and unlabeled food was caused by human error. Director of Dining Services stated she had not realized in the facility central food storage area that pasteurized liquid eggs had been removed from their original containers and delivered to the skilled kitchen and were not dated when received in the skilled kitchen.