Rehabilitation Center at Sandalwood, The

In the surveyor’s words

From the most serious findings on record at Rehabilitation Center at Sandalwood, The, in the surveyor’s own words.

• Immediate jeopardy, widespreadF756Apr 26, 2024

  Based on interviews and record review, the facility failed to implement policies and procedures that ensured potential irregularities identified by the consulting pharmacist (CP) and documented in monthly drug regimen reviews (MRRs) as recommendations, would be timely reviewed and acted upon by the medical provider, medical director, and the director of nursing (DON). This failure affected four of four residents (#51, #60, #15, #64) whose records were reviewed. In an interview, the CP responsible for the facility's MRRs stated she emailed the residents' MRRs to the DON monthly. There had been no response to the MRR recommendations for four months, beginning in January 2024. […]

• Actual harm, isolatedF692Apr 26, 2024

  Based on interviews and record review, the facility failed to provide timely and effective interventions to prevent weight loss for one (#41) of four residents reviewed for weight loss out of 35 sample residents. Resident #41 was admitted to the facility for long term care on 1/14/23 and readmitted on [DATE] with diagnoses of hyper-[NAME] syndrome (a rare immunodeficiency syndrome), anemia (low blood count) and dementia. Resident #41 had multiple food allergies, including soy protein, brussels sprouts, mushrooms, nuts, pine nuts, shellfish, wheat products and protein hydrolysate. On 10/1/23, Resident #41 weighed 139 pounds (lbs). On 10/15/23, Resident #41 weighed 119.2 lbs, which indicated the resident had lost 19.8 lbs. […]

• Actual harm, isolatedF686Sep 21, 2021

  Based on observations, record review, and staff interviews, the facility failed to ensure two (#86 and #15) of four out of 31 sample residents received the care and services necessary to prevent the development of pressure ulcers and to promote healing of pressure ulcers. For Resident #86, the facility failed to prevent the development of pressure injuries for this high risk resident who was admitted post [CONDITION(S)]. Resident #86 was admitted to the facility on [DATE] with intact skin. On [DATE], nine days after admission, the resident developed an open area to her coccyx that progressed to unstageable full thickness necrosis by [DATE], then to stage four full thickness with infection and deterioration by [DATE]. […]

• No harm, potential for more than minimal, widespreadF867Apr 26, 2024

  Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to medication regimen review (MRR) by not providing physicians with the pharmacist recommendations so the physicians could respond to the recommendations timely which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include: I. […]

• No harm, potential for more than minimal, patternF880Feb 11, 2026

  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 possible development and transmission of infectious diseases on two out of three units.Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers cleaned high touch areas; -Ensure hand hygiene was completed during room cleaning; and,-Ensure dwell times were followed per manufacture recommendations. Findings include:I. […]