Sandy Health and Rehab

In the surveyor’s words

From the most serious findings on record at Sandy Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Aug 16, 2023

  Based on observation, interview, and record review it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were 2 freezers in the kitchen that did not maintain appropriate temperatures to keep food items frozen. These findings resulted in immediate jeopardy. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator (Admin 2), Administrator (Admin 1), and a the Director of Leadership Development (DLD) on 7/30/23 at 12:56 PM. […]

• Actual harm, patternF600Aug 16, 2023

  Based on interview and record review it was determined, for 5 of 68 sampled residents, that the facility did not ensure each resident was free from verbal, mental, sexual, or physical abuse. Specifically, a resident was forced to do Activities of Daily Living (ADL's), a male resident did not have the mental capacity to consent prior to moving in with a female resident, a resident was transferred inappropriately resulting in a femur fracture, and a Certified Nursing Assistant (CNA) was allowed to work with a specific resident after the CNA caused the resident to fall. This resulted in a finding of HARM for 3 residents. Resident identifiers: 16, 20, 22, 44 and 78. Findings include: HARM 1. […]

• Actual harm, patternF689Aug 16, 2023

  Based on interview, observation and record review, the facility did not ensure that 10 of 68 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically, residents eloped from the facility, water temperatures were at a level that could cause burns, interventions were not put into place after falls to prevent additional falls, a door was not working correctly, and staff transfers resulted in resident injury. Three of the findings were determined to have occurred at a harm level. Resident identifiers: 18, 22, 35, 39, 40, 49, 50, 51, 54, and 156. Findings include: HARM 1. Resident 156 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, Alzheimer's disease, dementia, and major depressive disorder. […]

• Actual harm, patternF865Aug 16, 2023

  Based on interview, record review, and observation, multiple system failures were identified during the survey, and the facility was found to be in non-compliance at a harm level with F600, F644, F679, F686, F689, F692, F726, F742; and F812 at an Immediately Jeopardy level, indicating substandard quality of care. Resident identifiers: 16, 18, 20, 22, 35, 39, 40, 44, 49, 50, 51, 54, 62, 65, 78, 88, 156, and 158. Findings include: 1. Based on interview and record review it was determined, for 5 of 68 sampled residents, that the facility did not ensure each resident was free from verbal, mental, sexual, or physical abuse. […]

• Actual harm, patternF867Aug 16, 2023

  Based on observation, interview, and record review the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI (Quality Assurance and Performance Improvement) program, and act on available data to make improvements. Specifically, deficient practices identified during the survey included repeat deficiencies in the areas of prevention of accident hazards, develop and or implement comprehensive care plans, provide activities of daily living (ADLs) care for dependent residents, maintenance of nutrition, label and store drugs and biologicals, maintaining identifiable information in the resident records, infection prevention, and Food storage. […]