Sloan's Lake Rehabilitation Center

Inspectors wroteBased on observations and interviews the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease on 2 out of 2 units. Specifically, the facility failed to ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing care to residents who were on enhanced barrier precautions.

Inspectors wroteIII. Resident #96 A. Resident status Resident #96, age greater than 65, was admitted on [DATE] and discharged on 2/24/23. According to the February 2023 CPO, diagnoses included major depressive disorder, anxiety disorder, fracture of the upper and lower end of right fibula, muscle weakness, moderate obesity and presence of an artificial knee joint. The 1/8/23 MDS assessment revealed the resident was cognitively intact with a BIM) score of 15 out of 15. The resident required supervision with oral hygiene, dependent with bed mobility, toileting, and maximal assistance with personal hygiene which included showers. He had no behaviors or refusals of care. B. [...]

Inspectors wroteBased on resident observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#12) of four residents reviewed for supplemental oxygen use out of 30 sample residents. Specifically, the facility failed to: -Ensure a physician's order was in place for Resident #12's continuous oxygen use.

Inspectors wroteBased on observations, interviews and record review, the facility failed to establish parameters for pain medication for one (#105) of five residents in a manner consistent with professional standards of practice out of 30 sample residents. Specifically, the facility failed to: -Ensure pain parameters were established and implemented for physician ordered as needed (PRN) pain medications; and, -Ensure non pharmacological interventions were implemented before administration of an opioid pain medication.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#191) of two residents out of 30 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 regarding care and services was completed for Resident #191.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#196) of five residents reviewed for medication errors of 30 sample residents. Specifically, the facility failed to ensure that Resident #196 was administered an anticoagulant medication correctly by removing the medication from a capsule before administration to the resident.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs that accommodated resident allergies, intolerances and preferences for two (#106 and #191) of six residents out of 30 sample residents. Specifically, the facility failed to: -Ensure Resident #106 was provided appropriate vegetarian meal items per the menu spreadsheets after the meat was eliminated; -Ensure Resident #191 was provided or offered a substitute meal when the resident did not like the lunch item provided; -Ensure Resident #191 was provided with dinner after a late dialysis appointment; and, -Follow the therapeutic dialysis diet for Resident #191.

Inspectors wroteBased on observations, interviews and record review, 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 two floors. Specifically, the facility failed to: -Ensure a resident's room was cleaned in a sanitary manner; -Ensure that the proper cleaning agent was used to clean a resident's room who was on transmission based precautions; and -Ensure appropriate personal protective equipment (PPE) was worn to clean a resident's room who was on transmission based precautions for Clostridium difficile.

Inspectors wroteBased on record review and interviews the facility failed to ensure residents had the right to formulate advance directives for four (#140, #137, #141, and #188) out of seven residents reviewed for advance directives out of 21 sample residents. Specifically, the facility failed to ensure: -Medical orders for scope and treatment (MOST) forms, used to summarize and consolidate important information about an individual's preferences for life-sustaining treatments including: cardiopulmonary recussications (CPR), artificial nutrition, and hydration, were completed accurately and thoroughly, for Residents #140, #137, #141, and #188; -That when an individual other than the resident signed and completed the resident's MOST form that resident representative had the legal authority to do so, for Residents #140, #137, #141 and #188; [...]

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. Specifically, the facility failed to: -Clean glucometers between residents; and, -Properly don and doff personal protective equipment (PPE) for isolation rooms.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (#191) resident reviewed of five sample residents received treatment and care in accordance with professional standards of practice out of 21 sample residents. Specifically, the facility failed to have a wound care order in place prior to treatment being provided for Resident #191.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one of five residents (#197) reviewed for respiratory services out of 21 sample residents, received respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the facility failed to have an order for oxygen in place for Resident #197.