Surrey Place St Lukes Hospital Skilled Nursing

In the surveyor’s words

From the most serious findings on record at Surrey Place St Lukes Hospital Skilled Nursing, in the surveyor’s own words.

• Actual harm, isolatedF760Aug 1, 2024

  Based on interview and record review, the facility failed to ensure residents were free from significant medication error after one resident with an allergy to penicillin (a class of antibiotics that are commonly used to treat bacterial infections) was ordered and administered Zosyn (a penicillin antibiotic used to treat infections) intravenously (IV, into the vein) to treat a urinary tract infection (UTI) (Resident #503). The facility failed to get a detailed account of the resident's reaction to penicillin after it was reported and the resident's reactions were not documented in the medical record. The resident's family reported to facility staff the resident's reaction to penicillin was blood clots, he/she was highly allergic, and it could kill him/her. […]

• No harm, potential for more than minimal, widespreadF726Aug 1, 2024

  Based upon document review and interview, the facility failed to ensure staff were trained in required infection control practices such as enhanced barrier protection (EBP) and/or other isolation precautions. The facility failed to have staff's competencies in relation to the infection control training. This failure placed all 80 residents at risk of infection. The lack of adequate training and evaluation of staff's competencies had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility. Findings include: Review of the course printouts for available education on the computer-based system provided by the facility revealed the Annual Mandatory Courses list indicated Bloodborne Pathogens as the only infection control related education. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2024

  Based on observation, interview, review job description, and facility policy review, the facility failed to ensure one of one dietary freezer, and three of three nourishment room (Alpine Park, Canyon Creek, and Dakota) refrigerators had all food labeled, dated and was free of dirt and sticky shelves. This failure has the potential to create the environment for food-borne illnesses to occur throughout the population of 80 residents. Findings include: Observation and interview on [DATE] at 9:34 AM, on the shelves in the dietary department walk-in freezer revealed an unsealed bag in a box of frozen fish, an unsealed bag of hashbrowns, and an unsealed bag of potato wedges. […]

• No harm, potential for more than minimal, widespreadF838Aug 1, 2024

  Based on record review, interview and policy review, the facility failed to conduct and document a comprehensive Facility-wide Assessment to determine what resources were necessary to care for its residents competently during day-to-day operations. The facility failed to ensure the Facility Assessment included infection control services, such as surveillance and antibiotic use, as well as the facility employing an Infection Preventionist (IP) who would was responsible for overseeing the infection control program. The lack of an adequate facility assessment had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility to competently care for all 80 residents who resided at the facility. […]

• No harm, potential for more than minimal, widespreadF868Aug 1, 2024

  Based on interview, document review, and policy review, the facility failed to ensure the Infection Preventionist (IP) attended the quarterly Quality Assurance and Performance Improvement (QAPI) meeting. This failure had the potential to affect all 80 residents who reside in the facility and an application of infection control prevention measures to be evaluated. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) dated 01/19 indicated, .These are the steps that Surrey Place is implementing to be compliant with the CMS QAPI regulations .QAPI will be held quarterly, and the following individuals or designee will be invited to attend.Executive Director.Medical Director.DON (Director of Nursing).ADON (Assistant Director of… […]