Sanfield Rehab & Living Center

Inspectors wroteBased on interview and record reviews, the facility failed to complete a significant change in status Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days of a resident's admission to hospice services, for 2 of 3 sampled residents (Resident #10 [R10] and R9). 1. Review of the RAI (Resident Assessment instrument) manual directs that a significant change MDS ARD (assessment reference date) date is no later than 14th calendar day after determination that significant change occurred. Completion is the 14th calendar day after determination. On 7/22/25 at 12:16 p.m., a review of R10's clinical record was completed. R10 was admitted to Hospice on 6/27/25 and a Significant Change MDS was initiated with an Assessment Reference Date (ARD) of 7/3/25 but was not completed. The completion date should have been 7/11/25 and as of 7/22/25 the MDS was not completed. [...]

Inspectors wroteBased on record reviews, Minimum Data Set 3.0 (MDS) reviews and interviews, the facility failed to electronically submit discharge MDS data to the State MDS database within 14 days after completion for 4 of 12 residents MDS's reviewed (Resident #2 [R2], R3, R19, R21).1. On 7/21/25, a review of R2's clinical record indicated that R2 was discharged on 6/5/25. A review of R2's discharge MDS with an ARD date of 6/5/25 indicated that assessment was due to be completed by 6/19/25 and was required to be electronically submitted to the State MDS database within 14 days after completion (7/3/25) but had not been submitted at time of review. 2, On 7/21/25, a review of R3's clinical record indicated that R3 was discharged on 6/6/25. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of Hospice care for 2 of 3 residents reviewed for Hospice (Resident #10 [R10] and R9). 1. Review of R10's clinical record stated he/she was admitted into Hospice on 6/27/25. The clinical record lacked evidence that a comprehensive care plan had been developed in the area of Hospice care that included goals and interventions. On 7/22/25 at 12:30 p.m., during an interview with the Director of Nursing the surveyor confirmed the above finding. 2. On 7/22/25, R9's clinical record was reviewed indicated R9 was admitted on Hospice on 6/22/25. The clinical record lacked evidence that a comprehensive care plan had been developed in the area of Hospice care that included goals and interventions. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete an annual Comprehensive Minimum Data Set (MDS) 3.0 with Care Area Assessments timely for 1 of 1 resident reviewed for Accident Hazards (Resident #17 [R17]). The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.19.1, dated October 2024, on page 2-16, Section 2.6 Required OBRA Assessments for the MDS provided a table RAI OBRA-required Assessment Summary required assessments that directs when assessments are due to be completed. Annual MDS are due to be completed 14 days from the ARD date. On 7/22/25, a review of R17's clinical record was completed. R17's annual MDS with an Assessment Reference Date (ARD) of 4/2/25 was due to be completed by 4/16/25, 14 days from the ARD date. The CAA completion date was 4/28/25, 12 days late. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) 3.0 in a timely manner for 2 of 12 sampled residents (Resident #11 [R11] and R7). The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.19.1, dated October 2024, on page 2-16, Section 2.6 Required OBRA Assessments for the MDS provided a table RAI OBRA-required Assessment Summary required assessments that directs when assessments are due to be completed. Quarterly MDS are due to be completed 14 days from the ARD date. 1. On 7/21/25, R11's clinical record was reviewed. R11's Quarterly MDS had an Assessment Reference Date (ARD) of 7/3/25 and was due to be completed by 7/17/25, which is the ARD plus 14 calendar days. The assessment was not completed at time of review. [...]

Inspectors wroteBased on performance evaluation review and interview, the facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1]). 1. CNA1 was hired on 8/3/2004. The facility was unable to provide evidence of a completed annual performance evaluations for 2024. On 7/23/25 at 12:45 p.m., in an interview with a surveyor, the Administrator confirmed that CNA1 had not received an annual performance evaluations in 2024.

Inspectors wroteBased on observations, record review and interview, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to wear gloves during a subcutaneous injection for 1 of 1 resident observed during medication administration. (Resident# 12 [R12])On 7/22/25 at 7:50 a.m., the Charge Nurse was observed in the nurse's station preparing R12's Lantus insulin dose 25 units with no infection control concerns. The Charge Nurse then entered R12's room and asked him/her where they wanted their injection. The charge nurse then cleaned the abdominal area with an alcohol prep pad and then administered the 25 units of Lantus subcutaneously without wearing gloves. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure that a bed gap filler (bumper pad) was in place between the mattress and foot of bed frame to eliminate the potential risk of entrapment of body parts for 1 of 22 resident beds observed (Resident #17 [R17]). On 7/21/2025 at 12:42 p.m., two surveyors observed a gap stuffed with blankets between the foot board of bed frame and mattress of R17's bed. The gap between the end of the mattress and foot board was 5 inches. On 7/21/25 at 2:15 p.m., during an observation of R17's bed, the Administrator stated that there should have been a bumper pad in place and not stuffed with blankets, thinking maybe it was soiled and sent for cleaning. The bumper pad was immediately put in place by the facility.

Inspectors wroteBased on interviews and record review the facility failed to assist residents to organize and hold monthly Resident Council meetings for 3 of 20 residents reviewed for Resident Council. This has the potential to affect all residents in the facility.

Inspectors wroteBased on review of resident council meeting minutes and interview, the facility failed to inform residents of his or her rights on an ongoing basis after admission for 3 of 20 Residents reviewed for Resident Rights. (#19, #18, #12)

Inspectors wroteBased on care plan reviews, observations and interviews, the facility failed to provide residents with a continuous resident centered activities program for 5 of 9 residents reviewed for activity participation. (Resident's #2, #4, #12, #14, and #19).

Inspectors wroteBased on record review and interviews the facility failed to develop/implement goals and interventions for a pacemaker for 1 of 12 residents reviewed for care plans. (Resident #4)

Inspectors wroteBased on record review and interview the facility failed to obtain provider orders for the maintenance and monitoring of a pacemaker. In addition, the facility failed to initiate goals and interventions necessary for the presence of a pacemaker for 1 of 12 residents reviewed for care plans (Resident #4). Resident #4 was admitted to facility on 9/13/21 with diagnoses to include vascular dementia, major depressive disorder, and anxiety. Further review of Resident #4's clinical record revealed that he/she had a pacemaker implanted in 2012. Review of quarterly Minimal Data Set (MDS) dated [DATE], indicates a Brief interview for Mental Status (BIMS) of 1 of 15. Review of section I: Active Diagnoses indicate Resident #4 has Atrial Fibrillation or Other Dysrhythmias. Review of Resident #4's clinical record reveled Referral to clinic/physician dated 4/25/22 for pacer check [pacemaker]. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure that a resident who requires dialysis services was monitored for weight loss/gain for 1 of 1 resident reviewed for dialysis. (Resdient #12).

Inspectors wroteBased on observations, interview, and the facility's food storage policy, the facility failed to date and label foods in 2 of 4 reach-in freezers and 1 of 2 refrigerators( a walk-in refrigerator and a reach-in refrigerator). The facility also failed to cover/seal food in 1 of 1 dry storage area for 1 of 3 days of survey (8/22/22).

Inspectors wroteBased on Certified Nursing Assistant (CNA) education and training report reviews and interviews, the facility failed to ensure that 2 of 5 CNA's completed education/training for Abuse, Neglect, Exploitation, and Misappropriation of Property annually. (CNA2, and CNA3)