Sleepy Eye Rehabilitati Center

In the surveyor’s words

From the most serious findings on record at Sleepy Eye Rehabilitati Center, in the surveyor’s own words.

• Actual harm, isolatedF745May 15, 2024

  Based on observation, interview and document review the facility failed to provide a method to communicate effectively with a non-English speaking resident and educate staff on identified communication needs for 1 of 1 resident (R12) reviewed for communication. This resulted in harm for R12 who suffered loneliness, depression, isolation when describing how staff failed to allow him an opportunity to communicate in a meaningful manner and did not assure that critical information could be conveyed, such as explanation of routine care, and the ability to refuse care and services. Further, the facility failed to provide sufficient guidance for staff, including temporary staff, on how to communicate and deliver care for the R12. […]

• No harm, potential for more than minimal, widespreadF812May 15, 2024

  Based on interview and document review, the facility failed to follow manufacturer's instructions for cleaning and sanitizing 1 of 1 ice machines used for resident consumption. This had the potential to affect all 53 residents who resided in the facility. Findings include: During an interview on 5/14/24 at 9:08 a.m., maintenance director (MD)-A, stated the facility had one ice machine used for resident consumption and identified its location near the dining room. MD-A stated he cleaned the ice machine once a year using distilled water. The manufacturer's user's manual was requested. During an observation on 5/14/24 at 9:12 a.m., the ice machine was observed to be in a small room off the main dining room. It was a Scotsman brand, counter-top style ice machine. […]

• No harm, potential for more than minimal, widespreadF880May 15, 2024

  Based on observation and interview staff failed to ensure a mechanical transfer lift was cleaned after resident used for 1 of 1 residents (R23) observed for infection control practices. In addition, the facility failed to ensure proper glove use and hand hygiene was preformed between resident use and proper infection prevention practices was observed when sorting soiled laundry. Findings Include: Mechanical lift R23's face sheet printed 5/15/24 included diagnoses of right humerus (upper arm), diabetes mellitus and heart failure. R23's plan of care indicated assist with transfer using 2 assist and patient lift. During observation on 5/15/24 at 7:35 a.m., nursing assistant (NA)-D and NA-C with the assist of a mechanical lift, transferred R23 from her bed to her chair. […]

• No harm, potential for more than minimal, widespreadF755May 13, 2021

  Based on observation, interview and document review, the facility failed to ensure a system for routine reconciliation of controlled substances medication for 1 of 1 emergency kit (E-kit) to prevent potential loss/diversion. In addition, failure to reconcile discontinued controlled substances stored in the director of nursing (DON's) office. Findings include: On [DATE], at 6:00 p.m., a tour of the medication storage room and clean utility room, was conducted with registered nurse (RN)-A. Located within the medication storage room was a affixed locked storage cabinet that contained the facility E-Kit controlled substances. […]

• No harm, potential for more than minimal, widespreadF761May 13, 2021

  Based on observation, interview and document review, the facility failed to ensure controlled substance medications were stored in a secure affixed double lock system in 2 of 3 storage rooms. In addition, the facility failed to have a system to dispose of controlled substances timely, to prevent and minimize the risk of diversion. Findings include: On [DATE], at 6:00 p.m., a tour of the medication storage room and clean utility room, was conducted with registered nurse (RN)-A. The E-Kit located in the utility room refrigerator, contained 2 vials of injectable lorazepam (an anti-anxiety medication/controlled substance) There was a lock on the portable (moveable) refrigerator door as well as a locked tackle box inside the refrigerator. The tackle box contained 2 vials of lorazepam. […]