Sandstone Estates Rehab Centre

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy, the facility failed to make prompt efforts to resolve a grievance and issue a written decision/ response, per regulation and per policy for one resident, #33. The deficient practice could compromise a resident's basic safety, psychosocial well-being and serve as a breach of trust between the resident and the facility.

Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure 1 (#81) of 3 sampled residents received proper treatment and care to maintain mobility and good foot health by ensuring regular podiatry appointments were maintained. The deficient practice could lead to developing foot problems, infections, wounds or amputations.

Inspectors wroteThe facility failed to ensure RN coverage was provided 8 hours a day, 7 days a week. Number of residents sampled:Number of residents cited:Based on staff interviews, review of facility documentation, policy, and procedure, the facility failed to ensure there was a registered nurse (RN) on duty for 8 consecutive hours for 7 days a week. The deficient practice could have a substantial impact on the quality of care and outcomes for residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure that food was stored in accordance with professional standards for food safety. The deficient practice has the potential to place residents at risk for consumption of expired or unsafe food. The census was 51.

Inspectors wroteBased on review of the facility documentation, staff interviews, and review of facility policy and procedures, the facility failed to ensure that the Level I PASRR (Pre-admission Screening and Resident Review) screening was accurately completed and updated for two residents (#13 and #63). The deficient practice could result in failure to identify residents with mental illness and/or intellectual disabilities, leading to unmet care needs. The census was 51. Findings Include:-Regarding Resident #13Resident #13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Schizoaffective Disorder, and Anxiety Disorder. The Level I PASRR (Pre-admission Screening and Resident Review) dated May 6, 2024, indicated that a referral for a level II PASRR was not necessary. [...]

Inspectors wroteBased on a review of facility documentation, staff interviews and facility policies and procedures, the facility failed to ensure the provision and implementation of necessary behavioral health services for one resident (#5) with identified mental health needs. The deficient practice has the potential to worsen the residents symptoms and reduce quality of life. The sample was 1. The universe was 19 and the census was 51.

Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#25) was provided specialized rehab services to meet the needs of the resident and in order to reach the resident's highest practicable level of function. The deficient practice could result in a resident not attaining their highest practicable level of function, or result in a functional decline.-

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#3) was provided with adequate supervision.

Inspectors wroteBased on observation, interviews, review of documentation, and review of facility policies, the facility failed to implement written policies and procedures that prohibit and prevent abuse for two of two sampled residents (#11 and #13). The deficient practice could lead to a failure of the facility to investigate and report allegations of abuse, and could lead to harm to a resident. -Regarding Resident #11: Resident #11 was admitted to the facility on [DATE], with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interviews, review of documentation, and review of facility policies, the facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two of two sampled residents (#11 and #13). The deficient practice could lead to a failure of the facility to report allegations of abuse timely, and could lead to continued abuse for a resident. -Regarding Resident #11: Resident #11 was admitted to the facility on [DATE], with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. [...]

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure a thorough investigation for allegations of abuse were completed for two of two sampled residents (#11 and #13) and that the residents were protected from further abuse during an investigation. The deficient practice could result in residents not protected from further abuse and appropriate corrective action not taken. -Regarding Resident #11: Resident #11 was admitted to the facility on [DATE], with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive. [...]

Inspectors wroteBased on clinical review, staff interviews, and facility policy, the facility failed to ensure that physician orders were followed according to professional standards for two out of five residents (#24 and #29). The deficient practice could result in residents not receiving care that meets professional standards.

Inspectors wroteBased on observations, staff interviews, review of records, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two residents (#43 and #21). The medication error rate was 7.41%. The deficient practice could result in further medication errors.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident (#420) was free from misappropriation of resident medications. The deficient practice could result in further incidents of misappropriation. -Findings Include: Resident #420 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, major depressive disorder, post-traumatic stress disorder, and heart failure. A physician order dated January 26, 2023, for Oxycodone HCl Oral Tablet 20 mg to give 1 tablet by mouth every 3 hours as needed for pain. The order was placed by a licensed practical nurse (LPN/Staff #220) and discontinued the same day by the same LPN. An additional order dated February 02, 2023 revealed Morphine Sulfate Oral Tablet 15 MG to give 1 tablet by mouth every 3 hours as needed by pain. [...]

Inspectors wroteBased on observation, clinical record review, staff and resident interviews, and policy review, the facility failed to ensure one resident (#12) was provided shower and dressing in timely manner. This deficient practice could result in residents not being provided hygiene care and services.

Inspectors wroteBased on observations, staff interviews, facility documentation, policies and procedure, the facility failed to ensure expired medications were appropriately disposed of and not available for resident use. The deficient practice could result in residents receiving expired medications.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident (#24) of five sampled residents was not administered an unnecessary medication. The deficient practice could result in further incidents of residents receiving unnecessary medications.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure that one resident (#43) was free from significant medication errors. The deficient practice could result in residents receiving unnecessary medications.

Inspectors wroteBased on resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was provided that was palatable and at a temperature that is safe for consumption. The deficient practice has the potential for residents to acquire food-born illness. Review of the lunch menu for October 22, 2024 revealed the following: -Chili Cheese Dog -Sweet Potato Fries -Herb [NAME] Beans -Banana Pudding An observation was conducted on October 22, 2024 at 12:50 PM of a test tray. The test tray temperatures were taken by staff as follows: -Chili Cheese Dog-123 F -Sweet Potato Fries-121 F -Banana Pudding 63 F The test tray sampled by surveyors who reported that the chili cheese dog cooked but served cold. Two of the seven surveyors noted that the sweet potato fries were cold but crunchy. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure proper hand hygiene was conducted during medication administration. The deficient practice could result in contaminated medications being administered to residents.

Inspectors wroteBased on clinical record review, staff interviews, the RAI (Resident Assessment Instrument) Manual and policy review, the facility failed to ensure a significant change MDS (Minimum Data Set) assessment was completed for one resident (#4) within the required timeframe. The sample size was 23. The deficient practice could result in the resident not receiving continuity of care.

Inspectors wroteBased on clinical record review, staff interview, facility documentation and review of policies and procedures, the facility failed to ensure that a care plan for treatment and care of pressure ulcer was developed for one resident (#77).

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#20) received treatment and services in accordance with professional standards of practice. The deficient practice could result in residents not receiving the treatment and care based on their assessed needs.

Inspectors wroteBased on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to prevent a pressure ulcer from developing in accordance with professional standards by failing to provide consistent preventative treatment for one resident (#77).

Inspectors wroteBased on observations, resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#238) environment was free from accidents/hazards, and that one resident (#74) received adequate supervision to prevent medication accidents. The sample size was 23. The deficient practice could lead to residents sustaining accident-related injuries.

Inspectors wroteBased on the clinical record review, staff interviews and policy reviews, the facility failed to ensure one resident ' s (#4) weight was obtained as ordered and/or that he maintained acceptable parameters of nutritional status. The sample size was 23. The deficient practice could result in residents with unplanned weight loss.

Inspectors wroteBased on review of facility documentation, staff interviews, review of the Payroll Based Journal (PBJ) and policy, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 82. The deficient practice has the potential to affect resident care.

Inspectors wroteBased on observations, staff interviews, review of the policy and procedures, the facility failed to discard expired medications and failed to ensure expired medications were not available for administration.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to ensure that one resident (#4) had care plan revisions to meet their needs. The sample size was 23. The deficient practice could result in a lack of care provided to meet the resident's needs.

Inspectors wroteBased on closed clinical record review, staff interviews, and review of facility policies, the facility failed to ensure that one resident's (#4) clinical record was accurately documented in accordance with accepted professional standards of practices. The deficient practice could result in the resident's clinical record not being accurate and complete.