Sanford Health Sylvan Court

In the surveyor’s words

From the most serious findings on record at Sanford Health Sylvan Court, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 13, 2025

  Based on observation and interview, the facility failed to ensure frozen food items were safely stored off the floor in 2 of 2 walk in freezers located in the kitchen. This had the potential to affect all 43 residents. Findings include: Observation on 2/10/25 at 10:48 a.m., during the initial kitchen tour with the dietary manager (DM) present identified they had 2 walk-in freezers. Upon entering the 1st walk-in, there were multiple boxes of frozen food including sweet potato fries, corn bread, Swedish meatballs, cheese tortellini, potato cubes, breaded chicken, and chili observed on the floor under the bottom shelf. […]

• No harm, potential for more than minimal, patternF880Aug 5, 2021

  Based on observation, interview and document review the facility failed to ensure 1 of 1 staff (housekeeper (H)-A followed transmission-based precautions (TBP) for appropriate use of personal protective equipment (PPE). This had the potential to affect 17 of 43 residents who resided on that unit. The facility also failed to ensure policies were reviewed and/or revised annually. Findings include: Observation beginning on 8/2/21 at 12:45 p.m., upon entrance to the facility, identified R143's room had a blue PPE holder on the door. A bright orange sign indicating Contact Precautions were required was tucked into a center pocket with only the top 2 inches visible. PPE required for any persons entering the room included a gown, gloves, mask, and eye protection. […]

• No harm, potential for more than minimal, isolatedF755Mar 25, 2026

  Based on observation, interview and document review, the facility failed to ensure 1 of 1 medication, Docusate Sodium, (Colace-stool softener), was not outdated prior to administration for 1 of 25 medication administration observations. Findings include: Observation and interview on [DATE] at 8:45 a.m., with trained medication aide (TMA)-A as she prepared to administer R42's morning medications including Docusate Sodium (Colace) 100 milligram (mg) soft gels from the stock bottle in the medication cart. TMA-A retrieved the bottle of Docusate Sodium removed 2 soft gel capsules and placed them into the medication cup with the other medications. TMA-A then delivered the medications to R42 who took the medication. […]

• No harm, potential for more than minimal, isolatedF641Feb 13, 2025

  Based on record review and interview, the facility failed to ensure medications were coded accurately on their Minimum Data Set (MDS) assessment for 1 of 5 residents (R43) reviewed for medications. Findings include: R43's 1/22/25, admission MDS admission assessment identified he had a diagnosis of diabetes. R43 was noted to have received one injection of insulin during the look back period. R43's current, physician orders identified no insulin was ordered. The physician orders did include a once weekly dose of Ozempic 0.5 milligrams (mg) injection (a non-insulin medication used to improve blood sugar control). […]

• No harm, potential for more than minimal, isolatedF758May 1, 2024

  Based on interview and record review the facility failed to complete a gradual dose reduction (GDR) attempt annually or document a rationale for no gradual dose reduction (GDR) for 2 of 5 residents (R2 and R11) reviewed for unnecessary medications. Findings include: R2's 1/18/24, annual Minimum Data Set (MDS) identified R2 had adequate hearing, his speech was unclear, and he had some difficulty communicating some words or finishing thoughts, but he was able to make his needs understood. R2 was able to understand others. R2's cognition was moderately impaired. R2 was identified during the assessment period to feel down and depressed. R2 displayed no behaviors. R2 was dependent on staff for assistance with grooming and transfers. […]