Sansbury Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jul 2, 2025

  Based on observation, interview, review of the Food and Drug Administration's document, and review of the facility's documents and policy, the facility failed to prepare and serve food in accordance with professional standards for food service safety with incomplete documentation of hot and cold food temperatures, use of a cleaning cloth not sanitized after each use, and preparation of sanitizer at the wrong strength. This deficient practice had the potential to affect 44 current residents. The findings include: Review of the facility's policy titled, Sanitizing Solution-Quaternary, dated 2013, revealed containers used for sanitizing work areas, and the cleaning cloth, were changed every shift or as needed. […]

• No harm, potential for more than minimal, patternF887Jul 30, 2026

  Based on interview, record review, and review of the facility's policies, the facility failed to ensure the resident's medical record included declination documentation indicating the resident or resident representative was provided education regarding the benefits and potential risks of the COVID-19 vaccine, or documentation the resident received the vaccine, for 3 of 5 residents sampled for immunizations, Resident (R) 2, R5, and R7.1. Review of R2's medical record revealed no documentation of COVID-19 vaccine consent or declination, and no documentation of education provided on the benefits and potential risks of the vaccination.2. […]

• No harm, potential for more than minimal, patternF761Aug 8, 2024

  Based on observation, interview, record review, review of a medication package insert, and review of the facility's policy, the facility failed to remove expired medications from 2 of the 2 medication carts and 1 of the 2 medication refrigerators. The findings include: Review of the facility's policy titled, Medication Storage, revised November 2020, revealed discontinued, outdated, or deteriorated drugs or biologicals were returned to the dispensing pharmacy or destroyed. 1. Observation on 08/07/2024 at 11:17 AM of the medication refrigerator in the second-floor medication room revealed a box of Fluzone High Dose influenza vaccine that had an expiration date of 06/2024. The box had contained 10 single-dose prefilled syringes, 0.7 milliliters each. […]

• No harm, potential for more than minimal, isolatedF657Jul 30, 2026

  Based on interview, record review, and review of the facility's policy, the facility failed to reassess the effectiveness of the interventions and review and revise the resident's care plan to meet the resident's needs for 1 of 25 sampled residents, Resident (R) 7.The facility failed to revise R7's care plan with interventions to improve or stabilize the skin integrity/tissue breakdown and to provide treatments after a skin assessment revealed the resident had skin breakdown on her buttocks delaying appropriate treatment for two weeks.The findings include:Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 2022, revealed an individualized, comprehensive, person-centered care plan is required for each resident that addresses identified physical,… […]

• No harm, potential for more than minimal, isolatedF684Jul 30, 2026

  Based on interview, record review, and review of the facility's policies, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 25 sampled residents, Resident (R) 7.R7's weekly skin assessments, dated 07/02/2026 and 07/09/2026, documented skin breakdown over the coccyx; however, Registered Nurse (RN) 1 failed to follow facility procedure by not completing an incident report or notifying the appropriate clinical personnel of the resident's skin breakdown. […]