Sachem Center for Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Sachem Center for Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 4, 2025

  Based on observation, interview, and record review the facility failed to ensure a resident at high risk for developing pressure ulcers received the necessary care, treatment, and services consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#10) out of 18 sampled residents. Specifically, the facility failed to complete wound care as ordered, complete skin check/assessment as ordered, complete Norton Assessments as ordered, and to offload his/her heels, resulting in the worsening of a Stage 3 Pressure Ulcer (full thickness skin loss, exposing subcutaneous tissue, not bone, muscle, or tendon) to the coccyx (tailbone) and the development of a new Unstageable Deep Tissue Injury (DTI: depth of the tissue damage is… […]

• Actual harm, isolatedF600Feb 6, 2024

  Based on observation, interview, and record review, the facility failed to protect one Resident's (#33) right to be free from neglect. Specifically, for Resident #33, the facility failed to respond to requests for pain medications for at least 75 minutes for a Resident with a Stage 4 pressure injury (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone) of the sacral region. Findings include: Review of the facility's policy titled Abuse, dated March 2023, indicated but was not limited to the following: -Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]

• Actual harm, isolatedF697Feb 6, 2024

  Based on record review, interviews, and observations, the facility failed to manage and effectively treat two Residents (#33 and #69), out of a total sample of 21 residents for pain. Specifically, the facility failed: 1. For Resident #33, to ensure staff provided requested as needed pain medication timely when the Resident had a 9 out of 10 pain level (based on a pain scale of 1-10 with 10 being the worst pain); and 2. For Resident #69, to implement Benzocaine spray (a topical anesthetic) when recommended to assist with pain during wound dressing changes of a Stage 4 pressure injury (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) to the coccyx and a Deep Tissue Injury (DTI- pressure related injury to subcutaneous… […]

• Actual harm, isolatedF684Apr 20, 2022

  Based on interview and medical record review, the facility failed to arrange transportation to outside specialist medical consultants, therefore delaying essential medical care for two Residents (#45 and #82), out of a total sample of 19 residents. Specifically, the facility 1. Failed to arrange transportation to a neurologist appointment for evaluation and treatment of neck pain with radiating pain into the left arm and hand for Resident #45 which resulted in ongoing pain requiring narcotic medication, and a 5-week delay and potential change in treatment; and 2. […]

• No harm, potential for more than minimal, widespreadF946Feb 6, 2024

  Based on document review and interview, the facility failed to provide their staff training on facility ethic standards, policies, and procedures. Findings include: Review of the Facility Assessment, dated May 2023, indicated but was not limited to the following: Staff training/education and competencies: - Throughout the year employees receive training and education on topics related to patient care and services. - Some trainings provided during general orientation is repeated at least annually. - Other topics are provided during the year based on Quality assurance performance improvement initiatives, ensuring regulatory compliance, best practices, clinical competencies and program development. […]