Every finding on record at Vicar's Landing Nursing Home

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect more than a limited number of residents who consumed foods from the facility, by failing to seal and date mark open food used for resident consumption in the dietary service area. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include: A follow-up tour of the kitchen was conducted on 07/30/2025 at 11:16 AM. During the tour, no date markings were observed on one open bottle of Simply Thick Easy Mix in the [NAME] Unit nourishment room, one open bottle of Simply Thick Easy Mix in the Assisted Dining Room, or on two open bottles of alcohol-removed wine in the Cambridge Unit refrigerator. (Photographic evidence obtained) During an interview on 07/30/2025 at 1:39 PM with Dining Server B, she explained that the facility's policy related to date marking food items was to add the open and expiration date to open foods. During an interview on 07/30/2025 at 1:46 PM with Dining Server C, she stated food items that were opened, used, and placed back in the refrigerator or freezer were to be sealed, labeled and dated. During an interview on 07/30/2025 at 2:07 PM with Dietary Supervisor D, he explained that the facility's policy related to date marking food items was to add the open and use-by date. During an interview on 07/30/2025 at 2:15 PM, the Certified Dietary Manager (CDM) confirmed that the kitchen staff used labels on open food items to add the date opened, used-by date, and initial. A review of the facility's policy and procedure titled Food Labeling Policy (dated 10/17/2022), revealed: It is the policy of this facility to ensure that all food items stored, prepared, or served within the Health Center comply with Federal, state, and local food safety regulations. All opened food items in the facility, including those in dietary service areas and at nursing unit refrigerators must be properly labeled to ensure food safety.

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care received oxygen therapy as ordered for one (Resident #4) of 23 residents receiving oxygen therapy in a total survey sample of 26 residents. The findings include: On 7/28/2025, at 12:47 PM, Resident #4 was observed in her room in a chair beside her bed in a hospital gown. She was receiving oxygen via nasal cannula. She reported she received oxygen at a flow rate of two liters per minute (2 L/min). The oxygen concentrator was in her bathroom, not within arm's reach of the resident, and was set at 3 L/min. (Photographic evidence obtained) On 7/29/2025, at 12:13 PM, Resident #4 was observed in her room in a chair beside her bed in a hospital gown. She was receiving oxygen via nasal cannula. The oxygen concentrator was in her bathroom and was set at 3 L/min. (Photographic evidence obtained) A review of Resident #4's medical record revealed active physician's orders for oxygen therapy: Continuous oxygen via nasal cannula at 2L/min every shift for hypoxia (dated 3/7/2025). Oxygen bubbler and tubing need to be changed every week, write date and initials when changed, remove old bubbler and tubing (dated 3/9/2025), and oxygen in use card to be place by residents and door and checked - verified by nurse every shift for oxygen safety (dated 3/7/2025). Other orders included albuterol sulfate inhalation nebulization solution (2.5 mg/3ml - milligrams per milliliter) 0.083% (dated 3/7/2025) and morphine sulfate (concentrate) oral solution 20 mg/ml (morphine sulfate), give 0.25 ml by mouth every four hours as needed for shortness of breath/non-acute, moderate to severe pain SL (dated 7/9/2025). (Copy obtained) Further review of the medical record revealed that Resident #4 was readmitted to the facility on [DATE] with an initial admission date on 9/16/2023. Her primary diagnoses included: Acute respiratory failure with hypoxia, shortness of breath, chronic obstructive pulmonary disease (COPD), unspecified; and obstructive sleep apnea. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/25/2025, revealed the resident was receiving hospice care, required oxygen therapy, and had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 possible points, indicating moderate cognitive impairment. Resident #4 was independent with eating and required supervisory or touching assistance for toilet transfers. A review of the care plan, focus and goals related to oxygen therapy included altered respiratory status/difficulty breathing related to congestive heart failure (CHF), sleep apnea, and COPD. Interventions included oxygen settings: oxygen via nasal prongs (cannula) at 2L/min, administer medication/puffers as ordered, monitor for effectiveness and side effects, and set-up or clean-up assistance. A review of the resident's oxygen saturations from 7/1/2025 - 7/29/2025 revealed a range of 93-98% (oxygen via nasal canula), on 7/15/2025: 94% (room air), and on 7/22/2025: 98% (room air). The resident's Medication Administration Record (MAR) for July 2025 was initialed for continuous oxygen via nasal cannula at 2 L/min every shift for hypoxia and oxygen bubbler and tubing need to be changed every week, write date and initials when changed, remove old bubbler and tubing, as ordered by physician. (Copy obtained) On 7/29/2025 at 3:46 PM, Licensed Practical Nurse (LPN) A confirmed that Resident #4's oxygen setting was set at 3L/min and stated the oxygen order was for 2 L/min. The LPN also confirmed there was no bubbler/humidifier on the oxygen concentrator. Nurses provide ongoing monitoring of the resident's oxygen therapy. Nursing is responsible for assuring that the resident is receiving the correct oxygen flow rate as ordered. Correct oxygen settings are identified through reports and by checking the order. Nurse staff on the night shift are responsible for changing the resident's oxygen tubing every Sunday. Correct settings are communicated from one staff person to another through shift reports. The LPN stated in the past Resident #4 would turn the concentrator on and off when leaving her room, but she had not turned off the machine in a while. Sometimes Resident #4 took off the nasal cannula; she was reminded to put it back on with no problem. On 7/30/2025 at 10:27 AM, the Director of Nursing (DON) confirmed that correct oxygen flow rate settings were identified by checking the orders and the Medication Administration Record and Treatment Administration Record. Residents who sometimes moved the dial were educated on the importance of maintaining oxygen at the correct setting. A review of the facility's policy and procedure titled Oxygen Administration (revised on 1/2025), revealed: Oxygen is administered to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the residents' goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 2. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentration, or evidence of complications associated with the use of oxygen. (Copy obtained)

Based on observations and interview, the facility failed to post the total number and the actual hours worked by licensed and unlicensed nursing staff (registered nurses, licensed practical nurses and certified nursing assistants) directly responsible for resident care per shift as required. The findings include: Observations during each day of the survey, throughout the survey, by all members of the survey team, revealed that no staffing information with the total number and the actual hours worked was posted or available in the front lobby or any other prominent area in the facility. During an interview with the Administrator and the Assistant Director of Nursing (ADON) on 09/13/18 at 11:55 am, they confirmed that there were no staffing hours meeting the regulation criteria posted in a prominent place for viewing. They stated that they were not aware that this was a regulatory requirement.

Based on observations, staff interviews, and facility document review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment and to help prevent development and transmission of communicable disease and infection as evidenced by non-use of personal protective equipment (PPE) when sorting soiled laundry. The findings include: Employee B, Laundry Staff, on 10/24/2017 at 3:20 pm, was observed sorting soiled linens in the laundry room. He did not have on personal protective equipment (PPE) gown/apron. He had donned latex gloves. He tore open plastic bags with soiled linens in them and put the linens in a large rolling laundry bin. During an interview with Employee A, Laundry Supervisor, on 10/24/2017 at 3:25 p.m., she stated that she was aware that the laundry staff was to have on PPE (gowns/aprons). She asked Employee B where the PPE gowns were, and he pointed to a shelf in the room. On the shelf were several folded yellow PPE gowns. He continued to sort the soiled linens, and did not go and put one on after being asked. Employee C, laundry staff, was observed on 10/25/2017 at 8:20 a.m. working in the soiled laundry room. She had donned latex gloves and was pulling soiled sheets and lift pads out of a large rolling laundry cart and putting them into another one. She opened plastic bags and removed the soiled linens inside by placing them in the laundry cart with the sheets and pads. She was not wearing PPE (yellow gown) to cover her clothing. During an interview with Employee C on 10/25/2017 at 8:30 a.m., she stated that she usually wore PPE (gown/apron) when sorting laundry. She was trained to do so. She stated she was responsible for distributing the clean linens to the various locations in the Continuing Care Retirement Community. She was observed to then go into the washing room and load the soiled linens into two washing machines. She took an empty rolling cart and unloaded a washer. She rolled the clean wet laundry into the clean linen room and parked the cart in front of a dryer. She then opened a dryer, took out a shirt, and looked for the name on it. She put the shirt back into the dryer, shut the door, and let it run. She returned to the wash room and then to the soiled laundry room. She did not put on PPE (gown/apron) after confirming that she was trained to wear one. During an interview with Employee D, Laundry Supervisor, on 10/25/2017 at 8:40 a.m., he stated that he did the training for the laundry staff, and they were trained to wear PPE (gown/apron) when sorting soiled linens. He stated that the sheets and pads could be soiled, and the laundry staff would contaminate their own clothing if they did not wear PPE. He confirmed that the same staff that sorted the soiled linens was responsible for distributing the clean linens throughout the community later in the day. He agreed that it was important to wear the PPE so as not to contaminate the clean linens. During an interview with the Director of Nursing (DON) on 10/25/2017 at 2:12 p.m., he indicated that he was unaware that the laundry staff was not donning PPE (gowns/aprons) when sorting soiled linens, and was then handling the clean linens with contaminated clothing on. He stated that the laundry staff should be wearing a gown and gloves when handling soiled linen. Even though there were no residents in isolation beds, sheets and pads had germs on them that could be spread to clean linens and the clothing of the laundry staff, who then distributed the clean linens throughout the community. As the infection control nurse, he would address this finding with the Director of Housekeeping and Laundry to ensure that the staff was in-serviced. During an interview with the Administrator, the Regional Nurse Consultant, and the Regional Director at 4:22 p.m., the Administrator stated that he had been made aware of the laundry staff not using PPE while sorting soiled linens. He indicated that they should have had the PPE (gowns/aprons) on while sorting the soiled linens. He stated the Director of the Housekeeping and Laundry services was out that day and was therefore unaware of the findings. He would inform her, and she would in-service the staff. Review of the training curriculum for the laundry staff revealed a form entitled 'Laundry Checklist'. The form read: Laundry Personnel: Strict clothing and linen handling procedures are followed to avoid contamination of one's own clothing. Rubber gloves and aprons are worn when handling and loading soiled linen into washers. Personnel are oriented to Infection Control policies and procedures upon hiring and orientation is documented. Review of the Laundry Department's in-service training sign-in sheets, dated 12/15/2016 and 03/30/2017, revealed Employees B and C were present for both trainings and had signed the sheet. The form dated 12/15/2016 read, Always used protective gear when handling chemical/soiled linens or disposing of trash. The form dated 03/30/2017 read, Always use protective gear such as gloves/mask/apron/goggles when sorting linens, and always sanitize all equipment after using it.

Based on observations and staff interviews, the facility failed to prepare and serve foods under sanitary conditions. The findings include: During the initial observation of the main kitchen in the facility on 10/23/2017 at 10:51:35 AM, the following was observed: 1) Grease pans of the two stove tops, the top grill, and the two deep fat fryers were observed impacted with burnt food debris. The two deep fat fryers were observed with food debris in the oil, as well as dirt/oil stains on the equipment. At 11:00 AM, the chef stated he would have staff clean them immediately. During the observation/interview with the chef on 10/23/17 at 11:05AM, he stated that the facility used the fryers the day before and not on the morning of 10/23/17. The staff will clean the fryers at the end of the day. 2) In the dairy walk-in refrigerator, three cartons of Silk Protein milk that expired on 10/18/17 were observed. 3) On 10/23/17 at 2:03 PM, the nourishment refrigerator at the Cambridge unit was observed with five expired nectar-thickened orange juices (dated 10/17/17), and one strawberry shake supplement (dated 10/22/17). A box of Dove ice cream and cheddar prerogies, which were unlabeled and undated, were observed. .

Based on staff interview and record review, the facility failed to ensure that a resident's drug regimen was adequately monitored for 1 resident (Resident #12), out of 5 residents reviewed for unnecessary medications. The findings include: Record review of Resident #12's September, 2014 Medication Administration Record [REDACTED]. There were no pulses recorded on the resident's MAR. Record review of Resident #12's August, 2014 MAR indicated [REDACTED]. There were no pulses recorded on the resident's MAR. Record review of Resident #12's September, 2014 physician's orders [REDACTED]. Record review for Resident #12 revealed that vital signs, including pulse, were recorded x 6 in August, 2014 and x 3 to date in September, 2014. None of the vital signs recorded were taken at the time of the [MEDICATION NAME] administration. On 9/9/2014 at 3:05 PM, during an interview with Employee A (Registered Nurse), she stated that staff weren't monitoring the resident's pulse as ordered prior to administering the [MEDICATION NAME]. She said the resident's pulse was only recorded a few days this month. She confirmed the medication was given twice daily. She confirmed the pulse was not recorded before each dose on the MAR, or anywhere else in the record. She stated she would correct that now. .

Based on observations and staff interviews, the facility failed to maintain safe food handling practices during 2 out of 2 private dining room observations. The findings include: A random observation of the Private Dining Room on 9/8/14 at 12:32 p.m. during lunch revealed Employee C, Certified Nursing Assistant (CNA), was observed picking up a grilled cheese sandwich with her ungloved hands, and handing it to a resident. A random observation of the Private Dining Room on 9/9/14 at 12:19 p.m. revealed Employee C was observed picking up a cucumber sandwich with ungloved hands, and handing it to a resident. An interview with Employee C on 9/9/4 at 12:59 p.m. revealed that she had been told it was permitted to hand residents their food off of their plates with her bare hands, as long as she uses the hand sanitizer gel. Employee C stated that yesterday (9/8/14) was her first time working the private dining room. In an interview on 9/10/14 at 11:37 am with Employee D, Acting Director of Nurses, she stated that the facility uses fine dining techniques, therefore gloves are discouraged during dining, but it is not recommended to touch the food. She said the CNA should have used a different technique to hand residents their food off of the plates. "It is not acceptable to pick food up with bare hands." A review of the Food Code, US Public Health Service, Food and Drug Administration 2013, page 65 revealed methods to Prevent Contamination of Food by Employees. Preventing Contamination from Hands: (A) FOOD EMPLOYEES shall wash their hands as specified under ? 2-301.12. (B) Except when washing fruits and vegetables as specified under ?3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. The 2013 Food Code contained the following definitions on pages 16 and 17: Ready-to-Eat Food: (1) "Ready-to-eat food" means FOOD that: (a) Is in a form that is edible without additional preparation to achieve FOOD safety. An example (of a ready to eat food) is a bakery item such as bread, cakes, pies, fillings, or icing for which further cooking is not required for FOOD safety.

Based on observation and staff interview, the facility failed to ensure food safety when they did not follow the manufacturer's recommendations for the disposal of expired health shakes, when they did not monitor the temperature of leftover cold holding foods, when they did not clean and sanitize pots and pans effectively, and when they did not remove a dented can from the dry storage area. The findings include: 1. An observation of the small food preparation area that was separated from the main kitchen, on 5/25/11 at 11:30 AM revealed the reach-in refrigerated unit housed approximately 50 individual health shakes. The shakes were defrosted, sitting in water, and staff had written a date on the side of each shake that read 6/10/11 or 6/11/11. Interview with staff on 5/25/11 at 11:35 AM confirmed they had placed the shakes in the refrigerated unit on 5/24/11 and the date written on each shake reflected when staff was to discard the shakes. A review of the manufacturer's recommendations, printed on each health shake, revealed they were to be discarded 14 days after defrost. For food safety, staff should have discarded the defrosted milk shakes on 6/7/11 and not on 6/10/11 or 6/11/11. An observation of the nourishment room on the Cambridge Hall on 5/25/11 at 12:45 PM revealed eight defrosted milk shakes that had a date of 6/10/11 or 6/11/11. No documentation could be located that reflected when the milk shakes had been defrosted. If staff had defrosted the shakes on 5/24/11, they would expire after 6/7/11. 2. An observation of the kitchen and the reach-in refrigerated unit on 5/25/11 at 7:20 AM revealed four 5-gallon buckets of leftover ham and bean soup that were dated 5/24/11. The labels did not contain a time and each of the buckets were at least ? to ? full. An interview with the chef on 5/25/11 at 7:25 AM confirmed the labels did not contain a time and no documentation could be located that reflected the soup had reached a safe internal temperature of 71 degrees F within 2 hours of refrigeration or 41 degrees F within an additional 4 hours to ensure food safety. 3. Observation of the kitchen and the third compartment sink on 5/25/11 at 11:30 AM revealed clean pots and pans were hanging directly above and within inches of the dirty wash sink. Observation of the "clean" hanging pots and pans revealed they contained food debris and had a greasy appearance. An interview with the dishwashing employee on 5/25/11 at 11:30 AM confirmed the clean pots and pans should not be hanging directly above the dirty wash water sink. 4. An observation of the dry storage area on 5/25/11 at 11:35 AM revealed a dented #10 can of sliced apples was placed on the "ready to use" shelving unit. The chef stated, at that time, that staff should have removed the can from the shelving unit to ensure food safety. .

Based on observation, facility policy and staff interview, the facility failed to ensure that the treatment cart did not contain any expired medications and/or expired supplies in the medication room and one (1) of the five (5) drawers on the treatment cart (5th drawer). The findings include: On 05/26/11 at 11:45 AM, the following expired items were in the facility's treatment cart, which was stored in the medication room at the nurse's station: In the fifth drawer of the treatment cart, three (3) packs of 3 inch x 18 inch, Vaseline Petroleum Gauze, had an expiration date of 08/2009; it was stored in-between the non-expired packs; a urethral female catheter kit with the expiration date of 08/2010 was in the fifth drawer of the treatment cart; two (2) pairs of medium Synsation gloves had an expiration date of 01/2005; one Medi-vac Tubing Connector with expiration date of 12/2010 was found in the fifth drawer of the treatment cart. One large box of sterile dressing with 18 Tagaderm pads, 9 x 20 cm was sitting in a box on top of the medication refrigerator; both the box and each of the eighteen Tegaderm dressings had the expiration date of 11/2010. The medication nurse for the unit stated, "These all need to be thrown away since they all have expired." She gave them to the treatment nurse who stated she would throw them away. The facility policy entitled, "Medication Storage In the Facility" reads, "Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists." .