Sloan's Lake Rehabilitation Center

Based 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. Findings include: I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 4/2/24, retrieved on 3/9/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high-contact resident care activities. Expand the use of PPE and refer to the use of gown and gloves during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY III. 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. Record review Resident #96's comprehensive care plan, initiated on 1/2/2023, identified the resident had an ADL self-care performance deficit related to toe-touch weight bearing (TTWB), open reduction and internal fixation (ORIF) of the left ankle. Interventions included one to two staff assistance with personal hygiene including showers. -The [NAME] did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: I. Facility policy The Oxygen Administration Policy, revised March 2019, was provided by the nursing home administrator (NHA) on 1/23/24 at 10:47 a.m. It read in pertinent part, The purpose of the oxygen policy is to provide sufficient oxygen to the bloodstream and tissues. The oxygen administration procedure included obtaining the appropriate physician's order. II. Resident #12 A. Resident status Resident #12, over age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included atrial fibrillation, hyperlipidemia, cardiac arrhythmia, hypoxia (low blood oxygen) and traumatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: I. Facility policy and procedure The Pain Management policy, revised November 2019, was provided by the nursing home administrator (NHA) on 1/22/24 at 10:52 a.m. It read in pertinent part, Residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. The facility assists each resident with pain to maintain or achieve the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: I. Facility policy and procedure The Renal Dialysis, Care of Resident and Hemodialysis policy, revised December 2020, was provided by the nursing home administrator (NHA) on 1/22/24 at 10:00 a.m. It read in pertinent part, Facility licensed nurses will complete the baseline information, pre and post dialysis section of the nurses dialysis communication record. Dialysis center licensed nurses will complete the dialysis center section of the nurses dialysis communication record. II. Resident #191 A. Resident status Resident #191, age less than 65, was admitted on [DATE]. According to the January 2024 computerized physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: I. Professional reference Boehringer Ingelheim Pharmaceutical. (November 2023). Package insert. Pradaxa. U. S. Food and Drug Administration (FDA). https://content.boehringer-ingelheim.com/DAM/c669f898-0c4e-45a2-ba55-af1e011fdf63/pradaxa%20capsules-us-pi.pdf, retrieved on 1/24/24 at 10:07 a.m. Pradaxa capsules should be swallowed whole. Pradaxa capsules should be taken with a full glass of water. Breaking, chewing, or emptying the contents of the capsule can result in increased exposure (more of the drug in a shorter amount of time). Amaraneni, A., Chippa, V., and [NAME], A.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: I. Facility policy and procedure The Resident Food Preferences and Meal Alternates policy, revised July 2021, was provided by the nursing home administrator (NHA) on 1/23/24 at 2:32 p.m. It read in pertinent part, Specific food preferences,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: I. Housekeeping A. Professional reference 1. The Centers for Disease Control (CDC) Frequently Asked Questions for Clinicians about Clostridium Difficile (10/25/22), https://www.cdc.gov/cdiff/clinicians/faq.html, retrieved on 1/25/24 at 10:26 a.m., read in pertinent part, Wear gowns and gloves when entering Clostridium difficile infection (CDI)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; and, -The facility obtained documentation proof that the resident representative signing the resident's MOST form had the legal authority to make medical decisions on behalf of the resident,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: I. Facility policy and procedure The Fingerstick Blood Sugar/Hypoglycemia/Hyperglycemia policy, dated July 2022, received from the director of nursing (DON) on 10/13/22 at 3:50 p.m. read in pertinent part, procedure 1. gather equipment; glucose monitor, test strips, lancet, gloves, and germicidal disposable wipes. 2. Wipe down blood glucose monitor with approved germicidal wipes 3.explain procedure to resident 4. Provide privacy 5. wash hands 6. apply gloves 7. Wipe residents' fingers with alcohol wipe, allow air dry, do not blow on area 8. obtain finger stick blood sugar level 9. Discard lancet in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: I. Facility policy and procedure The Pressure Ulcer Skin Monitoring and Management policy, dated October 2021, received from the director of nursing (DON) on 10/13/22 at 3:50 p.m. In pertinent part read, a resident having a pressure ulcer receives necessary treatment and services to promote healing, prevent infection and prevent new avoidable sores from developing. The nurse is responsible for assessing and evaluating the residents wounds on admission, readmission, weekly and discharge. Prevent existing pressure ulcers from worsening, nursing staff to implement the following approaches as appropriate and consistent with care plan; referral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: I. Facility policy and procedure The Oxygen Administration policy, dated July 2022, received from the director of nursing (DON) on 10/13/22 at 3:50 p.m., documented in pertinent part, oxygen therapy is administered, as ordered by the physician. Procedure includes obtaining a physician's order. II. Resident status Resident #197, age [AGE], was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnoses included cervical laminectomy (surgical procedure to relieve pressure on the spinal cord and nerves), subdural hemorrhage (bleeding between the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.