Olney Rehabilitation and Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. The wooden cabinet doors beneath the handwashing sink did not close completely. 2. The high-temperature dish machine did not work properly and was not being used. 3. The dietary staff were manually washing the resident use eating utensils, beverage glasses, coffee cups, the pots, pans, mixing bowls, cooking utensils and serving utensils in a two-compartment sink.4. The dietary staff did not document water temperatures and bleach sanitizer levels for the two-compartment sink.5. Floor tiles were missing beneath the high temperature dish machine.6. Wooden shelf units and cabinet had scraped surfaces and peeling paint with the porous wooden surfaces exposed and not sealed.7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the maintenance of mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen, in that:The low temperature dish machine was not operating and was not being used to wash and sanitize the resident use eating utensils, beverage glasses, coffee cups, and the food preparation pots, pans, mixing bowls, cooking utensils, and serving utensils. This failure placed the residents at risk for foodborne illness and a decline in health status from being served food that had been prepared with pans and utensils that had not been properly sanitized.

Inspectors wroteBased on interviews and record review, the facility failed to ensure 1 Quarterly MDS (Minimum data set) Assessment and 1 Significant Change MDS Assessment was encoded, accurate, complete, and electronically transmitted to the CMS (Center for Medicare & Medicaid Services) system for 2 of 6 residents (Resident #1 and Resident #12) whose MDS records were reviewed. The facility did not ensure the Quarterly MDS assessment was completed and electronically transmitted as required for Resident #1. The facility did not ensure the Significant Change MDS assessment was completed and electronically transmitted as required for Resident #12. These deficient practices placed residents at risk for not being assessed for current functional status and changes in condition to develop or revise a plan of care to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the health status for 2 of 14 residents (Residents #13 and #27) whose MDS assessments were reviewed, in that:1. Resident #13 had a physician order for insulin to be administered one time weekly on Monday per a sliding scale. Her MDS documented she received insulin injections daily.2. Resident #27 had a physician order for an antiplatelet medication. Her MDS assessments documented she received an anticoagulant medication. This failure placed residents at risk for not receiving care and services to meet their physical needs.

Inspectors wroteBased on observation interviews and record review the facility failed to ensure that residents were free of a med error of 5% or greater (7.69%) 2 of 6 residents who reviewed for medication errors . 1. The facility failed to ensure LVN A primed (removing air bubble to ensure that the needle is open and working) insulin pen for Resident #35 before administering Fiasp (insulin aspart) 2. The facility failed to ensure LVN B primed the insulin pen for Resident #37 before administering Fiasp (insulin aspart). 3. The facility had a 7.69% medication error rate based on 2 errors out of 26 opportunities, which involved 2 of 6 reviewed for pharmacy services. This failure placed resident at risk of increased doses of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 2 (West Hall Medication Cart and Treatment Cart) of 3 carts observed for medication storage. The facility did not ensure [NAME] Hall Medication Cart and Treatment Cart were locked and secure. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: A. floors were swept and free from dirt and food crumbs. B. bottom shelves were clean. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #4) resident reviewed for infection control practices, in that: LVN C failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #4. This failure could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 residents reviewed for quality of care (Resident #1). The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #1. This failure could result in residents with wounds of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: 1. The range was soiled with a built up, sticky grease like substance. 2. There were soiled wet towels and food crumbs on the floor. 3. There were dead crickets in standing water in the drain underneath the dishwasher an in the clean handwashing sink. 4. The commercial refrigerator contained one half of a watermelon covered in saran wrap and not dated, an opened block of butter was open to the refrigerator air and not dated or covered by an airtight container, an open plastic container of brown gravy dated 7/20, ½ water melon not dated and covered with saran wrap and an undated zip lock baggie of cut onions. 5. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 3 of 7 residents (Residents #11, #26 and #27) whose records were reviewed for assessments after significant change. The facility failed to complete a comprehensive MDS assessment after Resident #11 and Resident #27 had a significant weight loss. The facility failed to complete a comprehensive MDS assessment after Resident #26 returned from the hospital and had a significant decline. These failures placed residents at risk of having assessment that do not reflect significant changes in their conditions and need for additional care/treatment.

Inspectors wroteBased on interview, and record review the facility failed to complete an assessment that accurately reflected the resident's status for 6 of 17 residents (Residents #'s 11, 16, 27, 29, 35, and 36) whose records were reviewed for MDS accuracy, in that: The facility failed to ensure Resident #11's most recent Annual MDS Assessment reflected a significant weight loss. The facility failed to ensure Resident #16's reflected the usage of a wheelchair harness under restraints. The facility failed to ensure Resident #27's Quarterly MDS accurately reflected her significant weight loss. The facility failed to ensure Resident #29's MDS documented the last attempt for a GDR. The facility failed to ensure Resident #35's MDS accurately reflected her weight loss. The facility failed to ensure Resident #36's admission MDS accurately reflected his mood status. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of the resident's admission for 6 of 15 residents (Resident #s 7, 16, 26, 27, 35 and 36) whose records were reviewed for baseline careplans, in that: 1. Resident #7 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 2. Resident #16 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 3. Resident #26 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive care plan within 7 days after completion of the comprehensive assessment for 9 of 15 residents (Resident #7, Resident #11, Resident #16, Resident 18, Resident #22, Resident #26, Resident #27, Resident #35, and Resident #36) whose records were reviewed for assessments and care plans timing., as well as having an IDT team present at the care conference. The facility failed to ensure that Resident #7, Resident #11, Resident #16, Resident #18, Resident #19, Resident #22, Resident #26, Resident #35, and Resident #36 had care plan developed and updated within 7 days following the completion of the MDS as well as having an Intradisciplinary Team present at the care conference. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #22) of two residents reviewed for infection control techniques in that: 1. CNA B did not wash her hands or conduct any hand hygiene practices after passing our trays, touching her hair and assisting other residents before feeding Resident #22. This deficient practice could affect residents and could result in cross contamination and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate the assessment of one Resident, (Resident #7) of three residents with the pre-admission screening and resident review (PASRR) program, of resident assessments reviewed for PASRR evaluations. The facility did not identify Resident #7 as having mental illness with a primary diagnosis of dementia that would require a PASRR 1012 form or a new PL1 form. This failure could affect residents with psychiatric diagnoses who may not be evaluated for PASRR services and place them at risk of not receiving services for care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 2 of 4 residents (Resident #11 and Resident #17) reviewed for respiratory orders in that: Resident #11 did not have her oxygen flow rate set at 2 liters per continuously as ordered by her physician. Resident #17 had her nebulizer mask that was not bagged and left lying on her nightstand uncovered. This these deficient practices could affect the residents who used oxygen and nebulizer treatments and could result in residents receiving incorrect or inadequate respiratory support and could result in a decline in health.

Inspectors wroteBased on observation, interview, and record review facility failed to maintain an accurate record of the disposition of all controlled drugs and failed to destroy medications for destruction in that: DON failed to count and sign off on the medication sheets before they were put in storage for destruction. The facility failed to do a final count for the following controlled medications- Hydrocodone-Acetaminophen 10-325 (QTY 23), Clonazepam 0.5 MG (QTY 8), Hydrocodone-Acetaminophen 5-325MG (QTY 40) These failures could place the residents at risk of losing their medications in a drug diversion which could result in delayed healing. Findings Include: [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure drugs and biological used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory cautionary instructions, and the expiration date when applicable for 1 of 1 medication rooms. The Medication Room had expired and discontinued medication and biologicals. This failure could the residents who resided in the facility at risk of receiving expired medications

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to conduct the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses.