Sanford Health & Rehabilitation Co

In the surveyor’s words

From the most serious findings on record at Sanford Health & Rehabilitation Co, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 1, 2022

  Based on record review, observation and staff interview, the facility failed to provide supervision to prevent a severely cognitively impaired resident from exiting the facility unsupervised, failed to ensure the resident was safe in the parking lot, and failed to report that a cognitively impaired resident was in the parking lot for 1 of 5 sampled residents reviewed for accidents (Resident #59). Resident #59, who was in his wheelchair, was found by Nurse Aide (NA) #1 in the parking lot unsupervised, didn't intervene and then, the resident was found to have gone out to the road. The resident was discovered by the Housekeeper on a 2-lane road where the speed limit was 55 miles per hour (MPH) west bound and was a quarter mile away from the facility's front door. […]

• Immediate jeopardy, isolatedF760Feb 8, 2021

  Based on record review, Physician, Physician Assistant (PA), Nurse Practitioner (NP), Pharmacist and staff interviews, the facility failed to prevent significant medication errors by not administering a medication as ordered, not entering verbal order, not verifying medication orders and not transcribing physician's prescribed medications to the Medication Administration Record (MAR) which resulted in prescribed medications not administered as ordered for 3 of 3 sampled residents reviewed for medication administration (Residents #5, #11 & #12). Resident #5 was prescribed intravenous (IV) [MEDICATION NAME] (an antibiotic drug) for bacteremia (presence of bacteria in the bloodstream) on 1/8/21. [MEDICATION NAME] was not verified and transcribed to the MAR until 1/11/21 and he missed 5 doses. […]

• Actual harm, isolatedF760Jun 13, 2024

  Based on record review, Medical Director, Nurse Practitioner, staff and resident interviews the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for medication administration when two blood pressure (BP) medications, Isosorbide mononitrate and hydralazine were not administered per orders for Resident #1. This resulted in Resident #1 ' s BP to drop to 82/50 causing a near syncope event that required a visit to the emergency room for further evaluation. […]

• Actual harm, isolatedF550Dec 1, 2022

  Based on record review, observation and resident and staff interview, the facility failed to promote dignity by failing to address resident's repeated request for incontinence care (Resident #60) and by ignoring resident's request and allowing a resident to lay in a wet pad (Resident #51) for 2 of 3 sampled residents reviewed for dignity (Residents #60 & #51). The facility's failure to promote dignity made Resident #60 angry and made Resident #51 feel deserted. The findings included: 1. Resident #60 was admitted to the facility 9/5/2022 with diagnoses that included cerebral infarct (stroke). Resident #60's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, had clear speech, understood others and could be understood by others. […]

• Actual harm, isolatedF689May 6, 2021

  Based on record review, observation and staff interview, the facility failed to determine root causes of each fall and to revise the care plan intervention after each fall (Residents #34 & #70) and also failed to put effective interventions in place following each fall to prevent repeated falls (Resident #70). This was evident for 2 of 5 sampled residents reviewed for accidents (Residents # 34 & # 70). Resident #34 ' s falls resulted in abrasions, lump, bruises, pain and emergency room (ER) evaluation. Findings included: 1. Resident #34 was admitted to the facility on [DATE] with multiple diagnoses including dementia with behavioral disturbances and [CONDITION(S)]/[CONDITION(S)] following cerebro vascular disease. […]