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Based on interview with staff member and review of elevator permit, the facility failed to ensure essential equipment has a current permit to operate.

Findings include:

On 01/17/20 at 09:00 AM an interview was conducted with Building Maintenance Worker (BMW) and Environmental Services Worker (ESW). A review of the preventive maintenance was done with the staff members. The BMW reported the facility contracts a private provider for the preventive maintenance of the elevator. The facility provided a copy of the preventive maintenance report, supplementary maintenance was done on 12/04/19. However, the facility's "Permit to Operate" and elevator expired on 11/05/16.

Based on record review and interview with staff member, the facility failed to ensure physician's order was specific to manage 1 (Patient 2) of 6 patient's bowel regimen.

Findings include:

Patient (P)2 was admitted to the facility on 11/25/19 for IV antibiotic (osteomyelitis). P2 has a history of medication non-compliance; insulin dependent DM II; and multiple amputations in both hands for gangrene.

On 01/15/20 at 02:30 PM a record review found physician's order for Colace, 100 mg twice a day as needed for constipation (hold for loose stools); milk of magnesia (MOM) suspension, 30 ml twice a day as needed for constipation; and Dulcolax suppository, 10 mg every 72 hours as needed. The physician ordered two prn medications for constipation; however, the order does not include which medication to use and time parameters for administration (how many days without bowel movement before medication is indicated).

On 01/16/20 at 10:25 PM concurrent record review and interview with the Nurse Manager (NM)1 was done. The NM confirmed the prn orders for constipation in the electronic health record. Inquired when would these medications be administered, NM1 responded if the patient does not have a bowel movement for two days. The NM also reported Colace is usually a scheduled medication and the MOM is administered when the patient doesn't have a bowel movement for two days. NM1 stated the physician will be notified for clarification of the order.

Based on resident and staff interviews, record reviews, and a review of the facility's policy and procedures, the facility failed to develop and implement a comprehensive person-centered care plan which included non-pharmacological interventions addressing Patient (P)5's pain within 14 days of admission.

Findings include:

P5 was admitted to the facility on 12/18/19, with a diagnoses of: L3-L5 discitis/osteomyelitis; atrial fibrillation; congestive heart failure; urinary tract infection; dementia; chronic kidney disease stage 3; unilateral osteoarthritis right knee; and hypertension.

On 01/15/19 at 12:19 PM, conducted an interview with P5. P5 stated his/her pain (back and knee pain) was not managed and is "...learning to live with the pain. One medication doesn't help and I don't like the way the other medication makes me feel. I don't want to spend the rest of my life out of it, on pain medications, sleeping all the time." P5 stated medication was the only pain management strategy implemented by the facility. P5 receives Acetaminophen 650 mg by mouth twice a day for pain; and Ultram (Tramadol Hcl) 50 mg by mouth every 6 hours as needed for pain. A review of P5's medication administration record confirmed P5 did not regularly receive Ultram 50 mg for pain.

On 12/18/19 at 06:05 PM, the facility conducted an admission assessment, which documents P5 is oriented to person, place, age and name and was cognitively able to understand concepts. P5 was asked whether he/she has pain now or in the recent past, P5 answered affirmatively. Although pain was identified during the assessment, the care plan did not address pain as a problem. The care plan implemented on 12/18/19 at 08:11 PM identified the following problems: infection; high risk for impaired skin integrity; high-risk for falls/injury; high risk for bleeding; and discharge planning.

On 01/17/20 at approximately 09:45 AM, concurrent review of the electronic health record was done with the assistance of the Long Term Care Director of Nursing (LTC DON). LTC DON confirmed P5 did not have a care plan for pain which should have been included. Furthermore, LTC DON confirmed the facility failed to develop and implement a care plan that included and addressed non-pharmacological interventions.

The policy and procedure for Pain Management was provided by the facility. The policy includes, provision of an in-depth pain assessment when pain is identified during the initial assessment. A review of the section regarding interventions, the following was noted: staff are encouraged to use non-pharmaceutical interventions to assist in pain management and a plan of care for pain management will be developed based on the individual patient's assessment, pain severity with interdisciplinary evaluation and input.