Rehabilitation Center at Sandalwood, the

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on two out of three units. Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers cleaned high touch areas; -Ensure hand hygiene was completed during room cleaning; and,-Ensure dwell times were followed per manufacture recommendations.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a resident choices regarding their personal funds for one #11) of two residents reviewed for personal funds out of 35 sample residents. Specifically, the facility failed to provide resident choices for storage of funds.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care were delivered by individuals who have the skills, experience and knowledge to do a particular task or activity for one (#80) of five residents reviewed for quality of care out of 35 sample residents. Specifically, the facility failed to ensure Resident #80 was assessed by a registered nurse (RN) following a fall on 12/13/25.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) to ensure the highest practicable quality of life and care, for two (#12 and #70) of three residents reviewed for ADLs out of 35 sample residents. Specifically, the facility failed to:-Ensure denture care was provided for Resident #12; and,-Ensure Resident #70 received meal assistance.

Inspectors wroteB. Resident #15 1. Resident Status Resident #15, age [AGE], was admitted on [DATE]. According to the April 2024 CPO, diagnoses included dementia with behavioral disturbances, bipolar disorder (mental illness causing shifts in mood, energy, activity levels, and concentration), personality disorder (thoughts, feelings, and behaviors different from an established societal norm), anxiety, arthritis, history of falls, contractures (permanent tightening of the muscles and tendons causing joints to shorten and stiffen) of right foot ankle and hand and chronic kidney disease. The 3/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance from one staff member for dressing, toileting, and setup with personal hygiene. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide timely and effective interventions to prevent weight loss for one (#41) of four residents reviewed for weight loss out of 35 sample residents. Resident #41 was admitted to the facility for long term care on 1/14/23 and readmitted on [DATE] with diagnoses of hyper-[NAME] syndrome (a rare immunodeficiency syndrome), anemia (low blood count) and dementia. Resident #41 had multiple food allergies, including soy protein, brussels sprouts, mushrooms, nuts, pine nuts, shellfish, wheat products and protein hydrolysate. On 10/1/23, Resident #41 weighed 139 pounds (lbs). On 10/15/23, Resident #41 weighed 119.2 lbs, which indicated the resident had lost 19.8 lbs. The registered dietitian (RD) requested the resident to be reweighed on 10/16/23, 10/19/23, 10/24/23 and 10/26/23. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to medication regimen review (MRR) by not providing physicians with the pharmacist recommendations so the physicians could respond to the recommendations timely which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one (#63) of one resident reviewed for activities of daily living out of 35 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to: -Provide Resident #63, who had difficulty with communication, with an appropriate communication tool to ensure the resident was able to effectively communicate his needs to staff; and, -Create a person-centered care plan for Resident #63 which addressed his communication deficits.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#17) of one resident out of 35 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents'choices. Specifically, the facility failed to ensure Resident #17 received a new CPAP (continuous positive airway pressure) mask timely.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#15 and #10) of two residents reviewed for limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent a further decrease in their ROM out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #15 was monitored for the use of splints (devices that stabilize a part of your body and hold it in place); and, -Ensure Resident #10 was properly positioned in her wheelchair to ensure her head was in a comfortable position.

Inspectors wroteBased on interviews and record review, the facility failed to provide an environment free from accident hazards and risks as possible for three (#60, #52 and #43) of seven residents reviewed for accidents/hazards out of 35 sample residents. Specifically, the facility failed to -Ensure neurological checks were completed per standards of practice after Resident #60 sustained unwitnessed falls; and, -Ensure staff were properly trained to assist Resident #52 and Resident #43 with slide board transfers after the residents sustained falls during transfers.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#191) of two residents out of 35 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to ensure consistent communication and documentation with the dialysis center occurred regarding care and services provided for Resident #191.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#5) of one resident reviewed for ancillary services, such as dental services, out of 35 sample residents received routine and 24-hour emergency dental care. Specifically, the facility failed to provide Resident #5 with timely dental care when she sustained a broken tooth.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#1 and #2) of three residents reviewed for pressure injuries/ulcers out of five sample residents. Specifically, the facility failed to: -Ensure Resident #2's was provided and encourage proper repositioning to prevent the development of new pressure injuries; and; -Ensure Resident #1's pressure injury treatment was consistently changed per physician orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure four (#17, #18, #58 and #62) of six residents received adequate supervision to prevent accidents out of 33 sample residents. Specifically, the facility failed to: -Develop and implement a person-centered care plan that identified Resident #17 fall risk and put effective interventions into place to reduce falls and prevent injury for Resident #17; -Ensure registered nurse (RN) assessments were completed following falls for Resident #18; -Ensure Resident #58 plan of care identified that the resident was a wander risk and had eloped from the facility on one occasion with person-centered interventions to prevent further elopement episodes, ensure a physician's order was in place with consent obtained for the use of the wanderguard system and monitored the placement and function of the wanderguard; [...]

Inspectors wroteBased interviews and record review the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that were significant to the resident for two (#13 and #133) of six residents reviewed out of 33 sample residents. Specifically, the facility failed to: -Respect the wishes of Resident #13 to receive showers and not bed baths; and -Provide showers according to Resident #133's plan of care/preference.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents were free from resident-to-resident abuse for two (#36 and #58) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to prevent: -Resident #36 from physical abuse by Resident #83. Resident #83 had documented aggressive behaviors prior to the physical abuse incident on 8/22/22; and, -Resident #58 from physical abuse by Resident #17. Resident #17 had prior behaviors which the facility documented that she did not get along with prior roommates.

Inspectors wroteBased on record review and interviews, the facility failed to develop and update a comprehensive care plan for three (#53, #58 and #7) out of 33 sample residents for services that were to be furnished to attain or maintain the practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #53's comprehensive care plan addressed the resident's use of antidepressant medication; -Ensure Resident #58's use of anticoagulant medication was addressed in the comprehensive care plan with person-centered interventions; and, -Ensure Resident #7's behaviors were identified in the comprehensive care plan with person-centered interventions in place.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#67) of seven out of 33 sample residents. Specifically, the facility failed to ensure that Resident #67, who was high risk and had skin breakdown, was offered and repositioned in a timely manner.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#58) out of 33 sample residents. Specifically, the facility failed to ensure Resident #58 was monitored for use of an anticoagulant medication.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure effective interventions were in place to address weight loss timely in one (#42) of two sample residents out of 33 sample residents. Specifically, the facility, after identifying weight loss in a resident at high risk for nutritional and hydration deficits, failed to provide effective person centered interventions to assist in preventing additional weight loss and further deterioration of nutrition and hydration status.

Inspectors wroteBased on interviews and record review, the facility failed to establish parameters for pain medication for two (#50 and #5) of two residents in a manner consistent with professional standards of practice out of 33 sample residents. Specifically, the facility failed to: -Pain parameters were implemented on pain medications ordered and the location of pain was identified on the physician order for Resident #50; and, -Pain parameters ordered for pain medications were followed for Resident #5.

Inspectors wroteBased on observations, record review and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one out of three units. Specifically, the facility failed to: -Ensure contaminated gloves were removed and hand hygiene was performed after providing incontinence care and before touching the barrier cream tube; -Ensure soiled gloves from incontinence care were removed and hand hygiene performed before touching outside packaging of incontinence wipes; and, -Ensure soiled packaging of incontinence wipes and barrier cream were disposed of prior to placing it on the nightstand.