Extendicare Health and Rehab

Inspectors wroteBased on observations, interviews, and review of a facility policy titled, Policy and Procedures Food Storage and Labeling, the facility failed to ensure frozen food items were labeled and dated properly in one of one kitchen and failed to ensure two of three fans in the kitchen area were maintained in clean condition. This had the potential to affect 122 residents who received an oral diet.

Inspectors wroteBased on observations, interviews, record review, and review of facility policies titled, Pharmacy Consultant Review and Psychotropic Drugs, the facility failed to ensure the medication regimen was free of unnecessary psychotropic medications for one (Resident Identifier [RI] #58) of four sampled residents reviewed for unnecessary psychotropic medications. Specifically, the facility: - failed to ensure attempts were made to gradually reduce the dose of antipsychotic and antianxiety medication prescribed for a resident with dementia in the absence of physician's documentation of specific reasons why a dose reduction would be contraindicated for RI #58. - failed to ensure behavioral monitoring was consistently conducted and documented to determine the effectiveness and continued necessity of the antipsychotic and antianxiety medications for RI #58.

Inspectors wroteBased on observations, interviews, record review, and review of a facility policy titled, Bed Rail Policy,'' the facility failed to ensure an assessment was conducted and documented for the type of bed rails that were in use and failed to ensure a physician's order for bed rails was obtained for one (Resident Identifier [RI] #73) of six sampled residents reviewed for bed rails.

Inspectors wroteBased on observation, record review, interview, and review of facility policies titled, Medication Administration and Policy and Procedure for the Silent Knight Tablet Crushing System, the facility failed to maintain a medication error rate of less than 5% for one (Resident Identifier [RI] #4) of five residents observed during medication administration. Medication errors were made by one of five facility nurses observed administering medications. The medication error rate was 13.79% based on observation of 29 medications administered and a total of four medication errors detected.

Inspectors wroteBased on interviews, review of a facility incident report to the State Agency, review of a policy titled, Facility Petty Cash and a facility document titled, Protection of Funds Plan of Action, the facility failed to ensure resident funds were not stolen. This affected the funds of 23 residents of 47 residents whose funds were managed by the facility. Residents affected were as follows: Resident Identifier (RI) #s 199, 94, 149, 76, 107, 63, 81, 91, 54, 106, 74, 87, 5, 37, 104, 79, 121, 137, 33, 136, 109, 134, and 152. Findings Include: A review of a State Agency incident report, submitted by the facility on 4/19/19, revealed misappropriation of resident property. The facility provided the names of the residents who's funds were affected. The facility reported the local police department was also notified. [...]

Inspectors wroteBased on observations, interviews and a review of facility policies titled, Ice Cream Storing/Serving Policy and, MACHINE WAREWASHING, the facility failed to ensure: 1. ice cream in the ice cream chest was not soft; 2. spoons, forks and knives were not wet in silverware holders at the tray line and; 3. plates and bowls on the tray line were free of food like substances. This had the potential to affect 157 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Ice Cream Storing/Serving Policy, with no date, revealed: Purpose: To ensure . safe serving condition. 5. If staff should find that cups are no longer firm, these should be discarded and supervisor notified. On 7/15/19 at 3:39 at p.m., the surveyor observed in cooler number one, six ice creams in a zip loc bag and two were not frozen. [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy titled, . Clean Dressing Change Policy, the facility failed to ensure the treatment nurse did not clean the wound on Resident Identifier (RI)#6's left buttock then wipe over the wound again with the same soiled 4 x 4. Furthermore, the treatment nurse failed to clean the sacral wound before placing the ordered treatment. This was observed during wound care observation and affected one of two residents observed for wound care. Findings Include: A review of a facility policy titled . Clean Dressing Change Policy with an implemented date of 8/6/18 revealed . Policy Explanation and Compliance Guidelines: . 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound ( i.e clean outward from the center of the wound) . [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy titled, Controlled Drugs: Count Verification, the facility failed to ensure the metal box containing controlled medication Lorazepam (Ativan) was permanently affixed in the medication refrigerator in the Hall 1 medication room. This affected one of four medication rooms observed. Hall 1 medication room was designated for refrigerated control medications.

Inspectors wroteBased on observation, interview and review of a facility policy titled, Handwashing Guidelines-Dietary Employees, the facility failed to ensure that a worker did not pick up a stove knob from the floor and place it back on the stove and change her gloves or wash her hands before going back to handling pans of cooked food items. This had the potential to affect all 150 residents receiving meals from the kitchen.

Inspectors wroteBased on observations, record review, interviews and review of facility policy titled Oxygen Concentrator with an implementation date of 01//15/2018, the facility failed to ensure that Resident Identifier (RI) #40's oxygen tubing was replaced as scheduled. This affected one of nine residents sampled using oxygen. Findings Include: A review of facility policy titled Oxygen Concentrator dated 01/15/2018 revealed Policy: To administer oxygen for the treatment of certain diseases or conditions. 2. Care of concentrator - Document in the resident's clinical record. b. Change tubing weekly RI #40 was admitted to the facility on [DATE] with diagnoses of Dyspnea and Chronic Obstructive Pulmonary Disease. On 07/30/2018 at 4:15 PM an observation was made of RI #40's oxygen tubing on the oxygen concentrator with a date of 7/18/2018. [...]

Inspectors wroteBased on record review, interview and review of facility policy Medications: Non-Controlled Drug Disposition and Medications: Controlled Drug Disposition, the facility failed to ensure one of 12 months of non controlled medication destruction sheets contained the required two signatures for destruction and one of 12 months of controlled medication destruction sheets contained three of the required signatures. This was reviewed on 8/1/18 and affected one month of twelve reviewed for each non-controlled and controlled medication destruction. Findings Include: A review of facility policy Medications: Non-Controlled Drug Disposition with a revised date of 1/16/07 revealed .Procedure: . The pharmacist shall verify that the list of drugs to be destroyed is accurate; [...]

Inspectors wroteBased on observation, interview, and review of a facility policy Infection Prevention and Control Program, the facility failed to ensure licensed staff did not removed Resident Identifier (RI)# 146's sock then return to the treatment cart without washing her hands. This was observed on 07/31/18 and affected one of three observations of wound care. Finding Include: A review of a facility policy Infection Prevention and Control Program with an effective date of 1/8/18 revealed . 4. Hand Hygiene Protocol: a. All staff shall wash their hands .,after handling contaminated objects, . RI#146 was admitted to the facility on [DATE] with orders for preventive measures to the heels. On 7/25/18, the physician provided an order for treatment to RI #146's left heel for a Stage 1. On 7/31/18 at 10:17 AM, Employee Identifier (EI) #1, Registered Nurse, was observed providing wound care for RI #146. [...]