Sanford Hillsboro Care Center

In the surveyor’s words

From the most serious findings on record at Sanford Hillsboro Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jun 5, 2024

  1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure an environment free of accident hazards for 1 of 1 sampled resident (Resident #27) who experienced a burn related to hot coffee. Failure to ensure appropriate coffee/water temperatures resulted in Resident #27 sustaining a burn and placed all residents at risk for serious burns/injuries. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 05/28/24 at 6:20 p.m. The IJ resulted from temperature readings obtained from the coffee/hot water machine, a lack of temperature monitoring by staff, and an injury to a resident. […]

• Actual harm, isolatedF689Nov 2, 2023

  Based on record review, review of facility policy, and staff and resident interview, the facility failed to provide necessary supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) with a burn. Failure to ensure placement of a barrier between the resident's skin and the heating pack and monitor the resident resulted in a burn to Resident #1's shoulder. Findings include: Review of the facility policy titled Heat Applications occurred on 11/02/23. This policy, dated 11/29/22, stated, . Procedure: Microwave Heating Packs . Place pack in microwave and follow manufacturer's recommendations for setting and length of heating time. Cover pack with towel and place on treatment area of resident . Check area in one minute for any redness of skin . […]

• No harm, potential for more than minimal, patternF880Feb 17, 2022

  Based on observation, facility policy review, and staff interview, the facility failed to follow standard infection control practices for 2 of 2 sampled residents (Resident #3 and #281) on isolation. Failure to follow infection control practices related to proper procedure for personal protective equipment (PPE) usage and isolation signage may result in the spread of infection to residents, staff, and/or visitors. Findings include: Review of the facility policy titled Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID) occurred on 02/17/22. This policy, revised 02/08/22, stated, . Upon identification of any resident with suspected or positive COVID-19, a COVID-19 precautions sign indicating precaution type and PPE will be posted on the outside of the resident's room. […]

• No harm, potential for more than minimal, patternF886Feb 17, 2022

  Based on record review and staff interview, the facility failed to document required COVID-19 test documentation for 3 of 3 sampled residents (Resident #3, #5, and #281). Failure to document COVID-19 testing results in each resident's medical record may lead to a lack of further required interventions and/or an incomplete medical record. Findings include: Review of resident medical records occurred on 02/15/22 and showed Resident #3, #5, and #281's records failed to contain documentation of negative COVID-19 test results. During an interview on 02/15/22 at 10:42 a.m., an administrative nurse (#1) confirmed the facility failed to ensure all resident medical records contained documentation of negative COVID-19 test results.

• No harm, potential for more than minimal, patternF641Jan 27, 2021

  Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 5 of 12 sampled residents (Resident #13, #14, #18, #26, and #27). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs, and has the potential to affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION H: BLADDER AND BOWEL The Long-Term Care Facility RAI Manual, revised October 2018, pages H-3-6 , . Steps for Assessment: H0200A, Trail of a Toileting Program . […]