Spjst Rest Home 1

In the surveyor’s words

From the most serious findings on record at Spjst Rest Home 1, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 27, 2024

  Based on observation, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for three (Resident #1, and Resident #2) of five residents reviewed for accidents and hazards. Hospitality Aide A and CNA C observed the sling prior to entering Resident #1 room and determined at this time the sling was not safe to use. Hospitality Aide A and CNA C did not report this to anyone and used the unsafe sling on the Mechanical lift during transfer of Resident #1. Hospitality Aide A and CNA C observed the loops on the sling to be frayed. There were four green loops on the sling and three of the four green loops broke during the transfer. […]

• Immediate jeopardy, isolatedF726Jul 27, 2024

  Based on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1 and Resident #2 .reviewed for Mechanical lift transfers. The facility failed to ensure Resident #1 was transferred with qualified staff. Hospitality Aide A knew the sling was not safe to use by observing the bottom loops were broken and three of the four top purple loops was frayed and beginning to tear. Hospitality Aide A did not report the unsafe sling to nurse prior to using the sling. Hospitality Aides were allowed to assist with resident transfers outside of the scope of their job description. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:27 PM. […]

• Immediate jeopardy, isolatedF908Jul 27, 2024

  Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 6 residents (Resident #1) reviewed for safe requirements. The facility failed to provide a safe sling to be used for Resident #1 on [DATE]. On [DATE], Resident #1 was being transferred by Mechanical lift and the sling broke while Resident #1 was in the air, and she fell and hit her face on the legs of the Mechanical lift. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury, serious impairment, or death. […]

• Immediate jeopardy, isolatedF600Jun 6, 2024

  Based on interview and record review, the facility failed to ensure staff did not use physical abuse or corporal punishment on a resident for one of three residents (Resident #1) reviewed for abuse. CNA C pulled Resident #1's hands and refused to stop when Resident #1 repeatedly stated to stop and there was a bruise on Resident #1's right hand after CNA C pulled on her hand. Resident #1 stated CNA C was hurting her while attempted to transfer her from lying position in bed to sitting position on the side of bed. Resident #1 was afraid of CNA C and isolated self in room after the incident. An Immediate Jeopardy (IJ) situation was identified on 06/03/2024 at 8:19 PM. […]

• Immediate jeopardy, isolatedF607Jun 6, 2024

  Based on interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse of residents for one (Resident #1) of three residents reviewed for abuse. The facility did not implement the Abuse and Neglect Policy when CNA C abused Resident #1 and CNA C was not immediately relieved of duty. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. An Immediate Jeopardy (IJ) situation was identified on 06/03/2024 at 8:19 PM. […]