Waters of Sweetwater a Rehabilitation & Nursing

In the surveyor’s words

From the most serious findings on record at Waters of Sweetwater a Rehabilitation & Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Oct 8, 2022

  Based on facility policy review, review of national guidelines for Basic Life Support, medical record review, interview, and review of personnel records, the facility failed to honor resident wishes to receive Basic Life Support services (BLS, medical care requiring knowledge and skills in cardiopulmonary resuscitation [CPR] and use of an Automated External Defibrillator [AED], a portable lifesaving device designed to treat people experiencing sudden [CONDITION(S)]) for 1 resident (Resident #65) of 8 residents reviewed for death. […]

• Immediate jeopardy, isolatedF867Oct 8, 2022

  Based on facility policy review, review of national guidelines for Basic Life Support, medical record review, review of personnel files, and interview, the facility failed to follow the Quality Assurance Performance Improvement (QAPI) policy to develop corrective actions for an adverse event when Resident #65, who was a full code (a resident who is to receive basic life support [BLS] if found unresponsive or in [CONDITION(S)]), was found unresponsive. The staff initiated cardiopulmonary resuscitation (CPR), then discontinued CPR without an order from a physician prior to EMS (Emergency Medical Services) arrival. […]

• No harm, potential for more than minimal, widespreadF732May 15, 2024

  Based on facility policy review, record review, observation, and interview the facility failed to post accurate staffing information to reflect daily staffing levels and failed to document Registered Nurse (RN) hours. The findings include: Review of the facility policy titled, Guidelines for BIPA (Benefits Improvement and Protection Act) Staffing Posting Requirement, revised 7/24/2023, revealed .SNF's [Skilled Nursing Facilities] must post daily, at the beginning of each shift, the specific shift schedule for the 24-hour period, the number and category of nursing staff employed or contracted by the facility for each 24-hour period, as well as the total number of hours worked by licensed nursing staff . […]

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

  Based on facility policy review, observation, and interview the facility failed to ensure food items were sealed properly, which had the potential to affect 69 of 70 residents. The findings include: Review of the facility's policy titled, Food Storage Areas, dated 6/04/2021, revealed .Spice jars should be closed when not in use .opened food should be transferred to an airtight container or zip lock bag . Observation of the food preparation room on 5/13/2024 at 10:30 AM, with the Dietary Manager (DM), revealed the following items were not sealed and open to air: One 16-ounce (oz) bottle of garlic powder One 19-oz bottle of onion powder One 42-oz box quick oats 3/4 full During an interview on 5/13/2024 at 10:40 AM, the DM stated dry cereal and dried seasoning are to be fully sealed… […]

• No harm, potential for more than minimal, widespreadF812Sep 7, 2023

  Based on facility policy review, observation, and interview the facility failed to properly store food items in 1 of 1 nourishment refrigerator which had the potential to affect 78 of 80 residents. The findings include: Review of the facility's policy titled, Nourishment Storage Areas, dated 3/25/2012, showed .facility will ensure the areas where nourishments and snacks are stored for the residents outside of the Food and Nutrition Services Department are maintained according to local/state/federal regulations and facility guidelines .Food is covered, labeled and dated appropriately .Only items intended for residents will be stored in nourishment areas . […]