Sanctuary Pointe Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sanctuary Pointe Nursing & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 25, 2024

  Based on observations, staff interviews and policy review, the facility failed to store, prepare, distribute, and serve foods in a sanitary manner and in accordance with the facility policies. This had the potential to affect all 114 residents who received food from the kitchen. Facility census was 114. Findings include: 1. Observations of the facility kitchen on 04/22/24 8:20 A.M., revealed the following areas of concern: a. There was no temperature log of the dishwasher temperatures for the month of April 2024 through the past six months. b. The ice machine, which provided ice to the entire facility, had a pink wet substance on the inside of the ice storage bin which was touching the ice. c. […]

• No harm, potential for more than minimal, patternF761Apr 25, 2024

  Based on medical record review, observations, staff interviews and review of facility policy, the facility failed to ensure medications were discarded after their expiration date. This affected one (#59) of three residents observed for medication administration and also affected four (#1, #38, #72, and #368) of 30 residents who received medication from the 200 hall medication cart. The facility census was 114. Findings include: 1. Review of the medical record for Resident #59 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus (DM II), Alzheimer's disease, and atrial fibrillation. […]

• No harm, potential for more than minimal, isolatedF770Apr 25, 2024

  Based on medical record review, staff interviews and policy review, the facility failed to ensure blood work was completed as ordered. This affected two (#23 and #88) out of five residents reviewed for laboratory services. Facility census was 114. Findings include: 1. Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included dementia, peripheral vascular disease (PVD), psychosis, atrial fibrillation, anxiety disorder, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. […]

• No harm, potential for more than minimal, isolatedF580Dec 12, 2023

  Based on medical record review, staff and physician interviews, and review of facility policy, the facility failed to notify a physician of a resident's change in condition. This affected one (#110) of three residents reviewed for death. The census was 108. Findings include: Review of Resident #110's closed medical record revealed an admitted [DATE]. Diagnoses included diverticulosis, hypertension, atrial fibrillation, carotid stenosis, congestive heart failure, and chronic obstructive pulmonary disease. Resident #110 passed away in the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had severe cognitive impairment and was receiving Hospice services. Review of progress notes dated [DATE] at 10:41 A.M. […]

• No harm, potential for more than minimal, isolatedF849Dec 12, 2023

  Based on medical record review, staff and physician interviews and policy review, the facility failed to coordinate hospice care to ensure hospice recommendations were timely implemented. This affected one (#110) of three residents reviewed for death. The census was 108. Findings include: Review of Resident #110's closed medical record revealed an admitted [DATE]. Diagnoses included diverticulosis, hypertension, atrial fibrillation, carotid stenosis, congestive heart failure, and chronic obstructive pulmonary disease. Resident #110 passed away in the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had severe cognitive impairment and was receiving Hospice services. Review of progress notes dated [DATE] at 10:41 A.M. […]