Sandtown Health and Rehabilitation

Inspectors wroteBased on observation, staff interview, and review of the facility's policies titled Date and Label, and Employee Hygiene, the facility failed to ensure expired food items were discarded by the expiration date, and opened items were labeled and dated after opening. In addition, the facility failed to ensure dietary staff were wearing beard guards while working in the kitchen area. The deficient practice increased the risk for 81 residents who were on an oral diet from a census of 83 residents to consume expired food items. Findings Include:Review of facility's policy titled Date and Label, dated 03/2025, documented in the Policy Statement: It is the policy of the facility to handle food in a safe and sanitary manner. The government has mandated with the following statement: [...]

Inspectors wroteBased on observation, staff interviews, and review of the facility policy titled Enhanced Barrier Precautions, the facility failed to follow Enhanced Barrier Precautions (EBP) for one resident (R) (R5) from a sample of 19 residents. The deficient practice increased the risk of cross contamination and the spread of infection between staff and residents.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide dental services for one of 38 sampled residents (R) (R25). This failure had the potential to negatively impact R25's quality of life.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, and policy review, the facility failed to maintain an environment free from verbal and physical abuse for eight residents (R#156, R#16, R#11, R#23, R#25, R#39, R#101 and R#27) of 47 sampled residents. Specifically: 1. R#68 engaged in ongoing verbal and physical abuse of residents including R#156, R#16, R#11, R#23, R#25, R#39, and R#101. 2. R#27 was physically held down by a staff member while being dressed. On 11/10/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and the Regional Consultant were informed of the Immediate Jeopardy for F600 on 11/11/22 at 4:30 p.m. [...]

Inspectors wroteBased on observations, electronic and paper medical record reviews, facility policy reviews, and staff interviews, the facility failed to ensure care plan interventions for emergency tracheostomy (trach) care were developed for four residents (R) (R#6, R#91, R#96, and R#256) reviewed for tracheostomy care. Additionally, the facility failed to ensure a care plan was developed to include special treatments (hemodialysis) for one resident (R#85) reviewed for dialysis. The sample size was 47 residents. On 11/10/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, the Regional Consultant, and the Director of Nursing were informed of the Immediate Jeopardy for F656 on 11/10/22 at 11:10 a.m. [...]

Inspectors wroteBased on observations, record reviews, staff interviews, and policy review, the facility failed to ensure staff were trained for emergency care of tracheostomies (trachs) and provide emergency tracheostomy kits for four of four residents (R) (R#96, R#91, R#6, and R#256) reviewed for tracheostomy care. The facility's failure to train staff and provide emergency tracheostomy kits in the event that the resident's airway was compromised, placed all residents with tracheostomies at increased likelihood of serious harm or death. On 11/10/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable level of well-being four of four residents (R) (R#96, R#91, R#6, and R#256) reviewed for tracheostomy care and for seven residents reviewed for abuse (R#156, R#16, R#11, R#23, R#25, R#39, R#101 and R#27). Specifically: 1. The facility administration failed to ensure competent clinical staff and provide supplies to care for residents with tracheostomies to include emergency care for accidental trach dislodgement for four of four residents (R) (R#96, R#91, R#6, and R#256). Cross Refer to F695. 2. The facility administration failed to ensure the environment was maintained free from abuse from R#68. Cross refer to F600. [...]

Inspectors wroteBased on observations, record reviews, staff interviews, and policy review, the facility failed to ensure competent clinical staff were trained to care for residents with tracheostomies and for emergency care for accidental trach dislodgement for four of four residents (R) (R#96, R#91, R#6, and R#256) reviewed for tracheostomy care. The facility's failure to properly train staff for complex care of tracheostomies and emergency airway maintenance placed all residents with tracheostomies at increased likelihood of serious harm or death. On 11/10/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on observations, record review, policy review, and staff interviews, the facility failed to ensure that three residents of 47 sampled residents (R) (R#18, R#34, and R#19) had a clean, comfortable, and homelike environment.

Inspectors wroteBased on interviews, observations, and record review, the facility (1) failed to ensure that staff conducted weekly skin assessments to monitor a rash for one of 47 sampled residents (R) (R#34); (2) failed to followed physician's orders for wound care for one of 47 sampled residents (R#39); and (3) failed to obtain a physician's order for fingerstick glucose levels for two of 47 sampled residents (R#29 and R#3).

Inspectors wroteBased on observations, staff interviews, record review, and policy review, the facility failed to ensure six of 47 sampled residents (R) (R#68, R#18, R#27, R#53, R#84, and R#34) were monitored for specific behaviors.

Inspectors wroteBased on an interview, record reviews, and facility policy review, the facility failed to evaluate its resident population and identify the resources needed to provide the necessary care and services to meet the needs of four of four residents (R) (R#6, R#256, R#91, and R#96) requiring tracheostomy (surgical procedure to open a direct airway through an incision in the trachea [windpipe]) care and suctioning (removal of thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing) on the facility assessment.