Renaissance At The Terraces

Based on observation and interview, the facility failed to properly store raw meat to prevent cross contamination of ready to eat food in the walk-in refrigerator of the facility.The findings included:On 2/2/26 at 10:30 a.m., during a tour of the kitchen, Life Safety Code observation of the walk-in refrigerator revealed a pan containing raw beef tenderloin stored over cooked meat and raw mushrooms. The Director of dining verified that the raw meat was stored over ready to eat food.On 2/2/26 at 10:54 a.m., in an interview the Director of dining said the walk-in cooler went out a few nights prior. They moved all the food to the walk-in refrigerator. He said it had been challenging to get everything in the refrigerator and they missed the raw meat stored over the cooked meat and mushrooms. He said normally they kept meat on one side and dairy on the other. The Director of dining verified that raw meat should not be stored over ready to eat food, including vegetables. He said they were working on getting a quote on getting the walk-in cooler fixed. He said the Executive Chef was in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure and staff interviews, the facility failed to prepare, and store food in a sanitary manner by failing to cover and date food in 1 walk-in dairy refrigerator and 1 refrigerator and failed to clean surfaces on food preparation equipment including ovens and ice machine to prevent potential contamination. Additionally, the facility did not ensure staff wear hair restraints during preparation of food. The lack of sanitation in the kitchen had the potential to affect all residents consuming an oral diet. The findings included: 1. On 7/1/24 at 9:09 a.m., during an initial observation of the kitchen in the presence of the Director of Food and Beverages, the following was observed: The outside of the ice machine had a layer of dust with debris on the top of the machine. There was a brown colored substance on the outside top of the machine. Observation of the ice machine lid was dusty and grimy with brown substance and debris. The inside of the ice machine where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review, and review of facility policy and procedure, the facility failed to ensure 2 (Residents #22 and #30) of 19 residents with bed rails were assessed for alternative interventions prior to the use of the bed rails. The findings included: The facility policy Proper Use of Bed Rails, effective 10/20/22 documented, It is the policy of the Renaissance two utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. Alternatives include but are not limited to: Roll guards, foam bumpers, lowering the bed, and concave mattresses. Alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions, symptoms or behavioral patterns for which a bed rail was considered. If no appropriate alternatives are identified the medical record should include evidence of the following purpose for which the bed rail was intended…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to show effective coordination to ensure 1 resident (#94) of 2 residents reviewed received podiatry services to maintain good foot health for identified foot concerns. The findings included: Review of the facility policy on Foot Care effective 10/17/22: It is the policy (of the facility) to ensure residents receive care and treatment to maintain good foot health. 1b. If necessary, the facility will assist the resident in making appointments with a qualified person, arranging for transportation to and from such appointments. 2b. A comprehensive assessment process is used for identifying conditions that increase the risk for impaired skin integrity of the foot. 2c. The comprehensive assessment will include an assessment of the feet for disorders which may require treatment including but not limited to corns, neuromas, calluses, bunions, hammertoes, heel spurs, and nail disorders. 3aiii. Referrals to podiatrists will be made when appropriate. Review of the clinical record for Resident #94 revealed an admission date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure proper cleaning of the CPAP (Continuous Positive Airway Pressure) machine to prevent respiratory infections for 1 (Resident #93) of 1 resident requiring the use of the CPAP machine. The findings included: The facility's policy for CPAP machine with an effective date of 5/18/23 noted, It is the policy of the facility to clean CPAP equipment in accordance with current Centers for Disease Control guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection . Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections . Empty the (water) chamber completely after each use and wipe dry . Clean mask and tubing daily after use, dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. Review of the clinical record for Resident #93 revealed an admission date of 5/10/23. Diagnoses included unspecified sleep apnea (sleep disorder in which breathing repeatedly stops and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policies and procedures, resident and staff interviews, the facility failed to provide the necessary care and services to maintain grooming and hygiene for 2 (Resident #3 and Resident #180) of 3 dependent residents reviewed for assistance with activities of daily living. This has the potential to cause psychological harm to the resident. The findings included: A review of the facility policy Activities of Daily Living (ADLs), Supporting (revised 11/28/16), specified, Residents who are unable to carry out ADLs independently, will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming and oral care). 1. A review of Resident #3' s clinical record revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of policies and procedures, resident and staff interview, the facility failed to provide reasonable interventions and adequate monitoring to meet the needs of 1 (Resident #180) of 1 sampled resident requiring continuous use of oxygen. The findings included: The facility policy Oxygen Administration (revised 10/2010) documented, The purpose of this procedure is to provide guidelines for safe oxygen administration . Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (blue tone to the skin and mucous membranes). 2. Signs or symptoms of hypoxia (rapid breathing, rapid pulse, restlessness, confusion). 3. Signs or symptoms of oxygen toxicity (difficulty breathing, slow or shallow rate of breathing). Review of the clinical record showed Resident #180 was admitted on [DATE] with diagnoses including, chronic obstructive pulmonary disease and dependence on supplemental oxygen. The admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to ensure all medications were locked and secured when not in sight and failed to date opened medications to prevent expired medications from being administered to residents in 1 (3rd floor medication cart) of 2 medication carts. This had the potential for unsecured and expired medications to create hazardous health consequences for residents in the facility. The findings included: The facility policy Storage of Medications (revised 4/2007) specified, The facility shall store all drugs biologicals in a safe, secure and orderly manner . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . Compartments (including carts, drawers, and boxes) containing drugs and biologicals shall be locked when not in use. 1. On 9/20/21 at 9:35 a.m., during observation the 3rd floor medication cart with Registered Nurse (RN) Staff H the following was found: A Budes/Formot AER 80-4.5 inhaler (medication inhaled to treat respiratory symptoms) for Resident #180 with directions to discard the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and interview, the facility failed to store, label, food products in walk in refrigerator and freezer in a safe and sanitary manner to prevent potential cross contamination. The facility failed to discard expired food items in the walk-in refrigerator. The findings included: The Santa Fe Senior living Food Storage and Handling Policies and Procedures created March 2020 read, Policy It is the policy of the Dining services team (managers and associates) to cover, label, date, and store all foods in a safe storage area: refrigerator, freezer, or dry storage. Purpose The purpose is to prevent food borne illness(es). Procedures All cooked, pre-packaged open container, protein-based salads, desserts, and canned fruits are labeled, dated, and accurately covered. Dating System for Opened Foods Always securely cover the food item(s). Using a label, complete the following information using the referenced guide. Clearly write the item mane/contents, made on date, use by date, and initials of the person who prepared the label. On 9/20/21 at 9:20 a.m., during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.