Sayre Health Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Mar 7, 2025

  Based on observation and staff interview, it was determined that the facility failed to store, prepare, and serve food in a manner to prevent the potential spread of foodborne illness in the main kitchen and the facility's pantry for one of two nursing units (Unit 1 Nursing Unit). Findings include: According to HACCP (Hazard Analysis and Critical Control Points) to avoid the potential for food borne illness, food must be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours, and from 70 degrees Fahrenheit to 41 degrees Fahrenheit or lower in the next four hours. […]

• No harm, potential for more than minimal, widespreadF812May 23, 2023

  Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a safe and sanitary condition in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen on May 20, 2023, between 10:42 AM and 11:15 AM with Employee 1, Dietary Supervisor, revealed the following: A significant accumulation of dust and debris on top of the coffee machine. Multiple open wire rack storage shelves with food and food serving items were observed in the dry goods storage area. […]

• No harm, potential for more than minimal, widespreadF812May 6, 2022

  Based on observation and staff interview, it was determined that the facility failed to store, prepare, and distribute food in a manner to prevent the potential for food borne illness in the main kitchen and for two of two nutrition centers (Unit 1 and Unit 2). Findings include: Observation of the facility's main kitchen on May 3, 2022, at 10:22 AM was conducted with Employee 7, dietary manager. Observation of the walk-in cooler revealed cartons of prune juice that were not dated with an expiration date or use by date. Employee 1 indicated that the prune juice was previously frozen. There were eight bottles of open juice not marked with the date they were opened. A case of thawed Mighty Shakes was marked with the date of April 29 but did not specify what this date meant. […]

• No harm, potential for more than minimal, patternF700Apr 3, 2026

  Based on a review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to assess potential entrapment risks from the use of side rails for four of four residents reviewed for accident hazards (Residents 5, 42, 6, and 70). Findings include: The FDA (The United States Food and Drug Administration) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, is guidance that identifies key parts of the body at risk for entrapment, describes potential entrapment areas or zones, and recommends maximum and minimum dimensional limits of gaps or openings in hospital bed systems. […]

• No harm, potential for more than minimal, patternF759Apr 3, 2026

  Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Residents 10 and 59).Findings include:The facility's medication error rate was 7.41 percent based on 27 medication opportunities with two medication errors.Observation of a medication administration pass on April 1, 2026, at 8:09 AM revealed Employee 4 (licensed practical nurse) administer Sucralfate (anti-ulcer medication, adheres to the stomach lining to protect it from acids and enzymes) 1 gm (gram) to Resident 59. The packaging of the Sucralfate medication included instructions to administer the medication on an empty stomach. […]