Sandgate Gardens Rehab and Nursing Center

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide adequate supervision and assistive equipment to prevent 1 of 3 sampled residents, Resident #1, from having a fall with injury.

Inspectors wroteBased on observation, menu review, and interview, the facility failed to follow the menu for 1 of 2 observed meals (lunch on 04/16/25) affecting 96 of 99 resident who consume food orally.

Inspectors wroteBased on observation and interview, the facility failed to ensure the form of food met the needs of residents who consume pureed and mechanical soft foods for 1 of 2 meals observed (lunch on 04/16/25), affecting sampled Residents #69, #31, #82, and #30 who consume pureed foods, and affecting sampled Residents #59, #2, #73, #12, and #58 who consume mechanical soft foods. This practice had the potential to affect 12 of 99 residents who consume pureed foods, and 20 of 99 residents who consume mechanical soft foods (20).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident choices of television channels were respected for 1 of 5 sampled residents reviewed, Resident #34.

Inspectors wroteBased on record review and interview, the facility failed to complete comprehensive assessments within 14 days of admission, or annually in a timely manner, for 4 of 21 sampled residents, Residents #14, #61, #84, and #151.

Inspectors wroteBased on record review and interview, the facility failed to complete quarterly assessments no less than every 3 months for 3 of 21 sampled residents, Residents #14, #21, and #61.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 4 of 21 sampled residents, as evidenced by inaccurate dialysis coding for Resident #86, inaccurate medication coding for Residents #70 and #31, and inaccurate hospice coding for Resident #69.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure communication with a resident who was unable to speak English for 1 of 2 sampled residents, Resident #60.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for 3 of 3 sampled residents reviewed for Activities of Daily Livings (ADLs), Residents #59, #13, and #4.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate care and services for 2 of 6 sampled residents, as evidenced by the lack of offloading (relieve pressure) of a surgical wound for Resident #75, and failure to follow physician ordered parameters for antihypertensive (blood pressure) medications for Resident #82.

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate and timely administration of antibiotics for 1 of 1 sampled resident, Resident #86, who had a Urinary Tract Infection (UTI). The resident was subsequently admitted to the hospital and returned to the facility with the diagnosis of sepsis secondary to the UTI, with additional orders for intravenous (IV) antibiotics.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and treat pain appropriately for 4 of 4 sampled residents, as evidenced by failure to identify and treat pain for Resident #60; failure to ensure pain medication availability for Resident #84; failure to ensure appropriate indication of use of medication for Resident #86; and failure to ensure pre and post assessment for PRN (as needed) pain medication for Resident #151.

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate drug regimen reviews for 2 of 5 sampled residents as evidenced by the failure to follow pharmacy recommendations for Resident #151, and failure to provide rationale for physician disagreement in a pharmacy recommendation for Resident #70.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure indication of use, rationale, or behavior for antipsychotic use for 1 of 5 sampled residents, Resident #70, related to anti-psychotic medication.

Inspectors wroteBased on observation and interview, the facility failed to secure medications in 1 of 5 medication carts B unit, and ensure medication was not found at the bedside for Resident#11.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices for 1 of 5 sampled residents on Enhance Barrier Precaution (EBP) and 3 of 3 sampled residents with Contact Precautions as evidenced by failure to implement Personal Protective Equipment (PPE) and EBP orders for Resident #21 who had a wound; failure to have orders and implement Contact precautions for Residents #2, #86, and #84.

Inspectors wroteBased on record review and interview, the facility failed to administer intravenous (IV) antibiotics timely for 1 of 1 sampled resident, Resident #151.

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal immunization for a resident with signed consent for 1 of 5 sampled residents, Resident #24.

Inspectors wroteBased on clinical and administrative record review and staff interview, the facility failed to ensure that 3 of 3 sampled residents, Residents #1, #2 and #3, reviewed for pressure ulcers, received the necessary treatment and services in a timely manner, consistent with professional standards of practice to promote healing, as evidenced by the staff failed to ensure that a resident who is admitted with a Stage III pressure ulcer received the necessary care and services for 10 days; failed to provide evidence that weekly skin assessments were completed; and failed to provide evidence that the prescribed treatments were performed as prescribed and documented accordingly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to smoke during designated times for 1 of 1 sampled resident who voiced concerns, Resident #152, and affecting 16 current residents who smoke, including an additional 5 of 6 sampled residents, Residents #32, #34, #63, #151, and #325.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide housekeeping and maintenance services to provide a clean, comfortable and homelike environment on 2 of 2 units, the outside smoking patio and the common areas of the facility.

Inspectors wroteBased on observation interview and record review, the facility failed to maintain an effective pest control program, as evidenced by pest sightings in the room of Resident #25, the main dining room / activities room, the 100 and 200 units' Clean Utility rooms, and documentation of pests in room [ROOM NUMBER].

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement care plans for the use of bed rails for 2 of 2 sampled residents reviewed for bed rails, Resident #20 and Resident #151.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure clean and trimmed fingernails for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADLs), Resident #13.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a safe and secure bedrail which resulted in an injury for 1 of 2 sampled residents reviewed for siderails, Resident #151, which included failure to: a. Identify the hazard and risk; b. Evaluate and analyze the hazard(s) and risk(s) after an incident occurred; and c. Implement interventions after the incident occurred.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide tube feedings in accordance with physician's orders, and failed to ensure weights were monitored as ordered for 1 of 2 sampled residents reviewed for tube feeding, Resident #89.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to timely manage pain for 1 of 3 sampled residents reviewed for pain, as evidence by Nursing staff failed to properly assess for the effectiveness of as needed pain medication, failed to notify the physician of the ineffective pain medication, and failed to timely update the change in frequency of pain medication once received from the physician for Resident #152.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure competent nurse staffing related to medication administration for 2 of 6 sampled residents observed, as evidenced by: Staff C, Registered Nurse (RN)/B Wing Unit Manager, failed to ensure the proper dose of insulin for Resident #57; and Staff B, RN, failed to properly administer medications via enteral (tube) for Resident #80.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate documentation between the medication administration records (MARs) and the medication monitoring control record for 2 of 4 sampled residents, Resident #152 and #23.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that nursing staff administered insulin as per routine physician's orders and as per physician orders with set parameters for 1 of 5 sampled residents, Resident #45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications during for 1 of 6 sampled residents observed during the medication pass observation, Resident #57; and failed to properly store the extra supply of OTC (over the counter) medications in the Central Supply storage room. The facility had independently ambulatory residents in the facility at the time of the survey.

Inspectors wroteBased on record review and interview, the facility failed to ensure laboratory services for 1 of 7 sampled residents, Resident #37.

Inspectors wroteBased on observation and interview, the facility failed to ensure the inspection of bed mattresses and bedrails to identify potential hazards, for 2 of 2 sampled residents reviewed for bedrails, Residents #20 and #151.

Inspectors wroteBased on record review and interview, the facility failed to ensure required interdisciplinary team (IDT) members participation in care planning process for 12 of 22 sampled residents reviewed for care plan, Residents #73, #94, #47, #41, #36, #5, #27, #78, #54, #35, #45, and #3.

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow standards of practice for infection control practices related to PPE (Personal Protective Equipment) use and glucometer disinfecting. This has the potential to affect all residents in the facility. The census at the time of the survey was 99 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure COVID-19 testing was completed as per manufacturer's instructions for 6 of 6 observed staff tests (Staff N, Staff O, Staff P, Staff Q, Staff R, and Staff S); and for 4 of 4 observed sampled residents (Residents #210, #48, #78, and #102). Upon entrance to the facility on [DATE], there were eleven (11) COVID-19 positive residents. After completion of resident testing on 08/22/22, there were eighteen (18) COVID-19 positive residents. After resident testing on 08/24/22, there were an additional six positive residents (25 positive residents). The nursing staff were not following manufacturer's instructions for COVID-19 testing, thus the actual number of COVID-19 positive residents and or staff may have been more.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide enablers per resident request for 1 of 3 sampled resident's reviewed for choices, Resident #78.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a safe, clean comfortable homelike environment for the residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 2 of 22 sampled residents, as evidenced by Resident #94 was inaccurately coded as having wandering behaviors and an indwelling urinary catheter; and Resident #207 was admitted to the facility and continued to utilize oxygen, while the MDS lacked any documentation of the oxygen use.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure care and services for Foley catheter for 1 of 2 residents, Resident #206, reviewed for indwelling catheters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely nutritional assessment for 2 of 4 sampled residents, Resident #27 who had a facility acquired pressure ulcer of Stage 4, and failed to ensure timely nutritional assessment for a resident who had a significant weight loss and to ensure weights were obtained, Resident #41.

Inspectors wroteBased on observation, record review and interview, the facility failed to obtain a physician's order for oxygen and ensure proper maintenance was done for 1 of 1 sampled resident reviewed, Resident #207.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure appropriate coordination of care for 1 of 1 sampled resident, Resident #73, reviewed for dialysis care, as evidenced by the resident was scheduled for a procedure to the dialysis fistula (access) and the facility staff did not ensure NPO (nothing by mouth) status; and failed to ensure pre and post dialysis assessments were completed for Resident #73.

Inspectors wroteBased on record review and interview, the facility failed to ensure ordered labs were completed for 2 of 6 sampled residents reviewed, Residents #35 and #3.