St. George Rehabilitation

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to store, prepare, and serve food in a sanitary manner for 1 of 2 nourishment refrigerators and 1 of 1 kitchen. Specifically, the staff failed to date foods brought in from visitors to be stored in the nourishment refrigerators and discard opened food items that were undated and had been in the nourishment refrigerators for an indeterminate amount of time. Additionally, the staff failed to change gloves and wash their hands after touching high-contact surfaces and before touching food items. This had the potential to affect 96 of 96 residents who received food from the dietary department.

Inspectors wroteBased on interview, record review, document review, and policy review, the facility failed to protect residents' rights to be free from verbal abuse and physical abuse by staff and by a resident for 2 (Resident #33 and Resident #47) of 13 sampled residents reviewed for abuse. On 08/21/2023, Licensed Practical Nurse (LPN) #29 was heard by staff to verbally abuse Resident #47. In addition, Resident #145 physically abused Resident #33 on two occasions, on 04/17/2024 resulting in knuckle marks to the resident's forehead and on 04/28/2024 resulting in scratches to the resident's face.

Inspectors wroteBased on interview, record review, document review, and policy review, the facility failed to ensure an allegation of verbal abuse was reported immediately to the Administrator for 1 (Resident #47) of 13 sampled residents reviewed for abuse. Specifically, on 08/21/2023 at approximately 7:00 PM/8:00 PM, Certified Nursing Assistant (CNA) 27 and CNA #28 heard Licensed Practical Nurse (LPN) #29 verbally abuse the resident; however, the staff did not report the allegation of abuse to the Administrator until 10:15 PM.

Inspectors wroteBased on interview, record review, document review, and policy review, the facility failed to implement their abuse policy for 2 (Resident #47 and Resident #395) of 13 sampled residents reviewed for abuse. Specifically, the facility failed to remove the accused staff member rom care of any resident after staff reported to the Administrator they heard Licensed Practical Nurse (LPN) #29 verbally abuse Resident #47 on 08/21/2023. The facility also failed to interview the alleged perpetrator and other residents when it was alleged that Resident #396 poked Resident #395 in the breast in the hallway on 04/09/2023.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop a care plan to address the supplemental oxygen usage for 2 (Resident #37 and Resident #76) of 2 sampled residents reviewed for respiratory care.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to revise the care plan to include added new interventions after a fall for 1 (Resident #86) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow a physician's order to hold a nicotine patch when the resident was smoking for 1 (Resident #86) of 4 sampled residents reviewed accidents.

Inspectors wroteBased on observation, interview, and review of manufacturer's information, the facility failed to ensure they maintained a medication error rate of less than 5 percent (%). The facility had 2 errors out of 34 opportunities, resulting in a medication error rate of 5.88 %, affecting 1 (Resident #14) of 3 residents observed during medication administration.

Inspectors wroteBased on observation and interview, it was determined, for 4 of 24 sampled residents, that the facility did not provide each resident with a safe, clean homelike environment. Specifically, a resident had plastic in the corner of her room where the roof had leaked, there were gashes in the drywall behind a resident's bed, wheelchair was soiled, and rooms had trash and debris on the floor. Resident identifiers: 8, 28, 73 and 128.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 24 sample residents, that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. Specifically, a Speech Language Pathologist (SLP) wrote a physician's order to provide a resident with maximum assistance with eating and the resident was observed to be eating in her room without assistance. Resident identifier: 127.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure proper treatment and assistive devices to maintain vision abilities. Specifically, a resident with dementia's glasses were missing and staff were not aware. Resident identifier: 127.

Inspectors wroteBased on interview and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed in the clinical record. Specifically, a resident was prescribed an anti-psychotic medication without a supporting clinical diagnosis and no gradual dose reduction. Resident identifier 11.

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was dust in a vent above the food preparation area, food splatter on the ceiling, uncooked bacon stored above ready to eat food, an open beverages was not dated, and another beverage was served after the use by date.

Inspectors wroteBased on observation and interview it was determined, for 1 of 24 sample residents, that the facility did not ensure that each shared room bed had ceiling suspended curtains, which extend around the bed to provide full visual privacy in combination with adjacent walls and curtains. Resident identifier 127.

Inspectors wroteBased on observations, interviews and record reviews it was determined, for 4 of the 34 residents, that the facility did not provide therapeutic diets prescribed by the attending physician or licensed dietitian. Specifically, 4 residents had orders in their electronic medical record for consistent carbohydrate diet (CCHO) and were provided a regular diet per their meal tray tickets. Resident identifiers: 22, 32, 51, 257.

Inspectors wroteBased on observation and interview it was determined the facility did not store, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility's resident refrigerator had items stored without being labeled with names and/or dates, the facility's kitchen had items not dated and labeled or left open to air in the refrigerators with an observation of a used rag found within the refrigerator next to an opened package or deli meat, and beverages and salad dressings on residents trays were observed being transported from the meal cart to resident rooms without being covered. Findings Include: 1. The resident refrigerators were inspected on 5/19/21 and 5/20/21. The following observations and interviews were conducted regarding the resident refrigerator: a. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 34 sampled residents, that the facility did not ensure that the receiving health care institution had the resident's medical record information including; the contact information of the practitioner responsible for the care of the resident, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plan, and any other documentation to ensure a safe and effective transition of care. Specifically, the resident was transferred to the local area hospital emergency department (ED) without any accompanying medical records. Resident identifier 4.

Inspectors wroteBased on interview and record review it was determined, for 1 of 34 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which would indicate the dose should be reduced or discontinued; or any combinations of these reasons. Specifically, a resident was administered Diltiazem when it should have been held per facility wide physician parameters. Resident identifier 42.

Inspectors wroteBased on interview and record review it was determined, for 1 of 34 sampled residents, that the facility did not ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed in the clinical record. Specifically, a resident was prescribed an anti-psychotic medication without a supporting clinical diagnosis. Resident identifier 55.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of the 34 sampled residents, the facility did not provide each resident with drinks, including water and other liquids consistent with the residents' needs and preferences and sufficient to maintain resident hydration. Specifically, a resident with a physician orders for thickened liquids was observed with regular water and juice at the bedside, and care staff were observed to be unaware of the resident's liquid consistency or the procedure for mixing thickened liquids at meal times. Resident identifier 22.

Inspectors wroteBased on observations, interviews and record review it was determined, for 1 of the 34 sampled residents, the facility did not maintain medical records on each resident that were complete and readily accessible. Specifically, the facility did not keep a complete, readily-accessible record of a resident's hemodialysis treatment and dialysis communication records. Resident identifier 31.

Inspectors wroteBased on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance for the same deficiencies identified in the last annual recertification survey.

Inspectors wroteBased on observation and interview it was determined, for 1 of 34 sampled residents, that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, hand hygiene was not performed prior to entering and exiting a resident room, and gloves were not donned prior to performing direct patient care. Resident identifier 48.

Inspectors wroteBased on interview and record review it was determined, for 2 of 34 sampled residents, that the facility did not ensure that each resident was offered an Influenza and Pneumococcal immunization and that the medical records included documentation that the resident either received the immunization or did not due to contraindications or refusal. Specifically, one resident did not have Influenza immunization documentation in the medical record. Additionally, a second resident did not receive a Pneumococcal immunization until after the survey had started and the facility was asked about it. Resident identifiers: 42 and 47.