Sibley Mem Hosp Renaissance

In the surveyor’s words

From the most serious findings on record at Sibley Mem Hosp Renaissance, in the surveyor’s own words.

• Immediate jeopardy, isolatedF740Feb 6, 2024

  Based on record review and staff interviews, for one (1) of five (5) sampled residents, facility staff failed to provide the necessary social and health care services to attain, maintain, or support the behavioral health (emotional and mental well-being) needs of Resident #1. Due to these failures, an Immediate Jeopardy (IJ-J) was identified on February 5, 2024 at 12:07 PM. During this survey, Immediate Jeopardy was identified at 42 CFR S483.40, Behavioral Health (F740), on February 5, 2024 at 12:07 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on February 5, 2024 at 7:52 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on February 6, 2024 at 2:15 PM. […]

• Actual harm, isolatedF686Apr 23, 2021

  Based on observation, record review, and resident and staff interview, facility staff failed to ensure that Resident #20, who was admitted to the facility with a bruise to the left heel received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent a deep tissue injury from developing for approximately 14 days, for one (1) of 17 sampled residents. The findings included . Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration - Intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature changes often preceded skin color changes. […]

• No harm, potential for more than minimal, patternF695Jan 9, 2023

  Based on observation of nine (9) nasal cannulas (delivers oxygen via the nose), facility staff failed to maintain respiratory/oxygen care equipment in accordance with the professional standards of practice. The findings included: During an observation of the Respiratory Equipment Cart on [DATE] at 12:14 PM, nine (9) of nine (9) Vyaire (manufacturer) nasal cannula tubing with expiration dates of [DATE] ([DATE]) were stored for resident use, approximately three (3) months after the expiration date. During a face-to-face interview conducted on [DATE] at 12:59 PM, Employee #12 (Respiratory Therapy Manager) stated, There's no daily or weekly inventory check of the respiratory equipment cart. If supplies are needed, they [the nurses] call us and we bring the supplies. […]

• No harm, potential for more than minimal, patternF812Apr 23, 2021

  Based on observations and staff interview, facility staff failed to prepare and distribute foods under sanitary conditions as evidenced by one (1) of two (2) soiled convection oven in the bake shop area, two (2) of two (2) soiled convection ovens in the patient hotline area, and 32 of 33 food service trays that were cracked at both handles. The findings included . During a walkthrough of dietary services on 04/19/2021, at approximately 11:15 AM, the following were observed: 1. One (1) of two (2) convection ovens in the bake shop area was soiled with burnt food residue. 2. Two (2) of two (2) convection ovens in the patient hotline area were soiled with burnt food residue. 3. […]

• No harm, potential for more than minimal, patternF908Apr 23, 2021

  Based on observation and staff interview, facility staff failed to maintain essential equipment in good working condition as evidenced by two (2) of six (6) convection ovens with a loose door handle, and one (1) of two (2) steam kettles that intermittently blew out steam from its connection valve in the patient hotline area. The findings included . During a walkthrough of dietary services on 04/19/2021, at approximately 11:15 AM, essential pieces of equipment were not functioning as intended: 1. One (1) of two (2) convection ovens in the bake shop area had a loose door handle. 2. One (1) of four (4) convection ovens at station #6 had a loose door handle. 3. […]