Sloan's Lake Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sloan's Lake Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jul 15, 2021

  Based on record review and interviews, the facility failed to ensure residents are free of any significant medication errors for one (#87) of five out of 25 sample residents related to anticoagulant management. Specifically, the facility failed to ensure anticoagulant medication was administered in a timely manner for Resident #87. Resident #87 was admitted to the facility following a surgical procedure. Upon admission, the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not receive the anticoagulant medication between 3/3/21 (admitted ) and 3/9/21, representing 12 missed doses. Although the medication was not received from the pharmacy until 3/9/21, it was recorded on the medication administration record (MAR) as given on several occasions. […]

• Actual harm, isolatedF760Aug 2, 2022

  Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of three sample residents. Specifically, the facility failed to ensure a licensed practical nurse (LPN #1) correctly transcribed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN administered the 2.5 mg of [MEDICATION(S)] to Resident #1 on 6/23/22, and registered nurse (RN) #1 administered the 2.5 mg of [MEDICATION(S)] as well as the 30 mg/ml [MEDICATION(S)] on the morning of 6/24/22. On 6/25/22 the resident had altered mental status (according to the nursing progress notes) and was transported to a local hospital. […]

• Actual harm, isolatedF686Jan 20, 2021

  Based on record review, observation and interviews, the facility failed to ensure two (#1 and #2) residents received care to prevent pressure ulcers and did not develop avoidable pressure ulcers; and residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure both Resident #1 and Resident #2 did not sustain avoidable facility acquired pressure ulcers. The facility failed to ensure the accuracy of the pressure ulcer risk assessment, increase monitoring of Resident #1's skin, implement timely interventions to avoid skin breakdown. The interventions that were implemented, the facility failed to ensure were provided to the resident. […]

• No harm, potential for more than minimal, patternF578Oct 13, 2022

  Based on record review and interviews the facility failed to ensure residents had the right to formulate advance directives for four (#140, #137, #141, and #188) out of seven residents reviewed for advance directives out of 21 sample residents. Specifically, the facility failed to ensure: -Medical orders for scope and treatment (MOST) forms, used to summarize and consolidate important information about an individual's preferences for life-sustaining treatments including: cardiopulmonary recussications (CPR), artificial nutrition, and hydration, were completed accurately and thoroughly, for Residents #140, #137, #141, and #188; -That when an individual other than the resident signed and completed the resident's MOST form that resident representative had the legal authority to do so, for… […]

• No harm, potential for more than minimal, patternF880Oct 13, 2022

  Based on observations, record review, and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to: -Clean glucometers between residents; and, -Properly don and doff personal protective equipment (PPE) for isolation rooms. Findings include: I. Facility policy and procedure The Fingerstick Blood Sugar/[CONDITION(S)]/[CONDITION(S)] policy, dated July 2022, received from the director of nursing (DON) on 10/13/22 at 3:50 p.m. read in pertinent part, procedure 1. gather equipment; glucose monitor, test strips, lancet, gloves, and germicidal disposable wipes. 2. […]