St. Andrew Post-Acute Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare and follow professional standards for food service safety in two (main and satellite) of two kitchens, as evidenced by: 1. two trash cans were not sanitarily maintained; 2. food was not maintained for safe consumption to include improper food handling practices; 3. kitchen shelving used for storage of food was observed rusted/oxidized, 4. temperature logs for the refrigerator and freezer were not documented accurately, and 5. one staff member (Q) not donning a hairnet upon entry to the kitchen during two (9/3/24 and 9/5/24) of three days of the survey.

Inspectors wrote4. On 9/3/2024 at 10:00 a.m. Resident #15 was heard yelling out and moaning aloud from behind her closed room door. During an interview at this time, the resident stopped yelling aloud and revealed she wanted staff to come and take her to the shower. Review of Resident #15's admission Record revealed she was admitted to the facility on [DATE]. Review of the admission Record revealed Resident #15's diagnoses to include altered mental status, cognitive communication deficit, dementia, major depression, mood disorder, and schizoaffective disorder. In addition, the medical chart contained a Level 1 PASRR. Further review of the Level I PASRR revealed the MI, Suspected MI Section I (a) showed Resident #15 was checked for diagnoses to include bipolar and schizophrenia. However, major depression was not checked. On 9/5/24 at 10:00 a.m. [...]

Inspectors wrote3. On 9/3/2024 at 11:08 a.m. an observation of Resident #28 revealed he was laying down in bed, with the bedsheets pulled to slightly over his waist, and his hands were over the bedsheets. An observation of his hands revealed long fingernails. Observations of his right hand revealed his ring fingernail was splitting horizontally, in the middle of his nail bed. The ring fingernail on his right hand was lifted up from splitting. An observation of Resident #28's left hand revealed his thumb nail was jagged and splitting horizontally from about half of the nail. On 9/4/2024 at 1:24 p.m. Resident #28 was observed sitting in a wheelchair with the bedside table in front of him. Resident #28's family member was observed sitting on the bed beside him. An observation of his hands revealed long fingernails. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of infection related to staff not offering hand hygiene to residents prior to a meal and two staff members (R, and G) not performing hand hygiene with the potential to affect a census of 41 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide administration of intravenous medication in accordance with professional standards of practices for one resident (#11) of four residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to monitor the oxygen saturation level for one resident (#9) of one resident sampled for respiratory care.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed and nine errors were identified for two (#27 and #7) of three residents observed. These errors constituted a 25% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of practice for three (#19, 28, 146) out of four residents sampled. Findings Included: 1. On 09/06/22 at 12:33 p.m. Resident #19 was observed sitting in her wheelchair in her bedroom, and smiled when approached. Resident #19 stated I can't leave my room as she pointed to her nose that contained oxygen tubing. The tubing was attached to concentrator, which was turned on and registered at 2 liters. The tubing reflected the date 08/24/2022. Additionally on the bedside table a small volume nebulizer machine was observed with the tubing and mask dated 08/24/2020. The nebulizer aerosol mask was lying on top of a gait belt and not stored in a clean manner (photographic evidence obtained). On 09/07/22 at 11: 00 a.m. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed, and seven errors were identified for five (#8, 6, 24, 30 and 9) of six residents observed. These errors constituted a 22.58% medication error rate Findings Included: 1. On 09/08/2022 at 9:15 a.m. medication observed task was conducted alongside Staff Member D, Licensed Practical Nurse (LPN) as she prepared medications for Resident #8. She confirmed the medications that were prepared was all that was due at that time except the Medrol dose pack. She said it was not available to be given. She stated when the order was put in the medication administration record it was not transcribed accurately. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the Physician was informed of medication refusal over a period of 12 days (08/22/22, 08/23/22, 08/29/22, 08/30/22, 08/31/22, 09/01/22, 09/02/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, 09/07/22) days for one (#346) of five sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a report was filed as a formal grievance and acted upon, for one (#37) of 19 sampled residents related to missing clothing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate comprehensive assessment for one (#13) of one residents reviewed. Findings Included: Medical record review of Resident #13 minimum data sheet (MDS) dated [DATE] reflected a restraint was used. The restraint was coded as used daily and used in chair or out of bed and coded: Other. On 09/06/2022 at 12:20 p.m. Resident #13 was observed sitting in a high back wheelchair in the dining room eating his lunch. His legs were elevated and resting on foot pedals. No restraints were identified at the time. On 09/07/2022 at 03:37 p.m. an interview was conducted with the Minimum Data Sheet Coordinator (MDSC), who stated the restraint was an abdominal binder for his peg tube. She said the binder was to prevent him from pulling the tube out. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a Baseline admission Care Plan was completed with the input of Resident#37, and that a summary was provided to the resident for one (#37) of 18 sampled residents.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure 1.) skin condition was accurately assessed and documented for one resident (#27) of three residents reviewed; and 2.) wound care was provided as per Physician's orders for one resident (#10) of three residents reviewed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure communication and coordination with an external service were conducted on days of treatment for one (#32) out of three residents who receive hemodialysis. Findings Included: On 09/06/22 at 10:05 a.m. Resident #32 call light was on she stated, I going to dialysis pretty soon and I'm waiting for the nurse to apply cream to my site. The resident said she was at the facility for short term therapy services and was hoping to return home some. Medical record review for Resident #32 revealed admission to the facility a month prior. Diagnosis information read dependence on renal dialysis, acquired absence of kidney, and end stage renal disease. On 09/07/22 at 11:30 a.m. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a paid caregiver for one (Resident#30) of 18 sampled residents had specific competencies and skill sets necessary to care for the Resident#30 care needs.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain drugs and biologicals in a safe and secure manner in one (A) out of two medication carts. Findings Included: On 09/06/22 at 09:03 a.m. upon entrance to the facility lobby multiple residents were observed sitting in their wheelchairs. Staff and family members were also observed walking through the area to enter adjoining units. An unlocked medication cart was observed positioned next to one of the residents. Upon closer observation a soufflé cup sat on top of the cart that contained multiple different colored capsules and tablets. The cart top also contained a blister card facing the lobby entrance revealing a resident name. There were no licensed staff members in the immediate vicinity (photographic evidence obtained). [...]

Inspectors wroteBased on record review and interview, the facility failed to make attempts to ensure hospice services were appropriately coordinated related to effective communication and consistent delivery of services was maintained for one (#27) of two residents sampled for hospice services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one Resident #31 received indwelling catheter care to reduce the potential for infection by storing and reusing used catheter bags observed with urine in a plastic bag hanging from the safety rail in the bathroom for 2 of 4 days of 5 residents with urinary catheters. Findings Included: During an interview with Resident #31 on 5/24/21 at 11:40 a.m. she stated she was new to using an indwelling catheter and gets a leg bag that is removed and placed in the bathroom until the next day whey the same bag is put back on while she is out of bed. The resident was observed wearing a drain bag laying in bed and said she was waiting for a shower to go to therapy. Resident #31 was observed on 5/24/21 at 11:48 a.m. going to the shower room with a leg bag on for her shower. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision measures were in place to prevent falls for two (Resident #28 and Resident #188) out of five sampled residents. Findings Included: 1. During the entrance conference conducted on 05/24/21 with the facility Administrator (NHA) and the facility Director of Nursing (DON), it was reported that Resident #188 was under transmission-based isolation precautions because she was a new admission to the facility. During the initial tour of the facility on 05/24/21, the resident's door was observed closed, and it was observed to be always closed throughout the survey period (05/24/21-05/27/21). Record review revealed that Resident #188 had been admitted to the facility on [DATE] following a hip fracture with surgical repair. Other diagnoses included Parkinson's disease and dementia. [...]