Resident 57, who had been diagnosed with dementia and was cognitively impaired, was discovered lying in bed with an oblong yellow pill sitting in a medication cup on his bedside table. A small plastic cup of water sat next to it. The resident couldn't say what the medication was or when it had been left there.
Medication Aide 1, who was assigned to the resident, told inspectors she had administered his morning medications that day and stayed with him while he took them. But she admitted she hadn't checked the medication cup after he finished to make sure he had taken everything.
"Resident 57 should not take medication by himself and I should have checked the medication cup before leaving his room," the aide told inspectors.
The facility's Director of Nursing said medications should never be left at the bedside. Nurse 2, who worked the same shift, was more direct: "It was not the right thing to do, it was the wrong thing to do."
The medication violation was one of several safety failures inspectors documented at the 91 Victoria Road facility during their August 7 complaint investigation.
Staff also failed to follow doctor's orders for oxygen therapy. Resident 3, who had chronic respiratory failure and congestive heart failure, was observed receiving oxygen through a nasal cannula set at 2 liters per minute during four separate observations over two days. But inspectors found no physician's order for oxygen anywhere in his medical record.
The Unit Manager suspected the oxygen order had "fallen off" the resident's order panel after a recent hospital visit. The facility's Nurse Practitioner confirmed that Resident 3 had a long history of respiratory failure and had used oxygen since his original admission, but said all residents receiving oxygen required an active physician's order.
Another resident received the wrong oxygen dose for months. Resident 70, who was diagnosed with congestive heart failure and asthma in February 2024, had a doctor's order for oxygen at 2 liters per minute. But during three separate observations, inspectors found her oxygen concentrator set at only 1 liter per minute.
Medication Aide 2, who was assigned to Resident 70, said she usually checked oxygen flow rates during her morning medication pass but hadn't checked this resident's setting. When the Unit Manager reviewed the physician's orders during the inspection, she immediately corrected the oxygen flow rate from 1 to 2 liters per minute.
Inspectors also discovered expired medications scattered across medication carts. On the 200 hall cart, they found a bottle of Ferrous Gluconate that expired in May 2024, containing 91 pills, and an opened insulin pen that had been opened June 25 but was only good for 28 days.
The 100 hall cart contained a bottle of Bisacodyl laxative that expired in February 2024 with 188 pills still inside, and Nitroglycerin heart medication that also expired in February with 21 tablets remaining.
Nurse 4, who was working with both carts, acknowledged that expired medications should be removed and discarded but said she hadn't been using the outdated drugs.
The facility's infection control failures were equally troubling. A treatment nurse aide performing wound care on Resident 31 wore the same pair of gloves while treating two foot wounds, providing incontinence care, and applying cream to the resident's buttocks. She never changed gloves or performed hand hygiene between the different procedures.
The same aide failed to wear a protective gown while treating Resident 31, even though facility policy required Enhanced Barrier Precautions for residents with wounds. No signage indicating the special precautions was posted on the resident's door, and no protective gowns were available outside his room.
During another wound care session, the treatment aide wore contaminated gloves while touching the resident, multiple surfaces in the room, and supplies from her treatment cart. She reached into her pockets with soiled gloves to retrieve keys and wound care supplies.
"I was overwhelmed and nervous about being watched during wound care and had just forgotten a lot during the wound treatments," the aide told inspectors.
The facility also failed to maintain accurate medical records when the treatment aide used another nurse's login credentials to document treatments in the electronic medical record. The aide had been unable to access the computer system for three to four weeks but never reported the problem to supervisors.
Instead, she used Nurse 3's login information to sign off on 28 treatments in July and 3 in June. Nurse 3, who worked the night shift, denied giving her login information to anyone and said she wasn't comfortable with treatments being documented under her name.
The Administrator acknowledged that all protocols should be followed and said staff members should not share login credentials for medical record documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elevate Health and Rehabilitation from 2024-08-07 including all violations, facility responses, and corrective action plans.
Additional Resources
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