Rehabilitation Center at Sandalwood, the

Construction Deficiencies

Use approved construction type or materials.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

A Comparative Federal Monitoring Survey was conducted on 6/25/24, following a State Agency Annual Survey on 5/14/24, in accordance with 42 Code of Federal Regulations, Part 483: Requirements for Long Term Care Facilities. During this Comparative Federal Monitoring Survey, the facility was found to be in compliance with the Requirements for Participation in Medicare and Medicaid. A Comparative Federal Monitoring Survey was conducted on 6/25/24, following a State Agency Annual Survey on 5/14/24, in accordance with 42 Code of Federal Regulations, Part 483: Requirements for Long Term Care Facilities. During this Comparative Federal Monitoring Survey, the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid.The findings that follow demonstrate noncompliance with Title 42, Code of Federal Regulations, 483.90 (a) et seq. (Life Safety from Fire). Based on observation, record review and interview, the facility failed to maintain fire dampers. The deficient practice affected 2 of 6 smoke compartments. The facility had a capacity for 103 beds with a census of 78 on the day of the survey.The findings include:Observation during the building inspection tour,on 6/25/24 revealed facility had spring loaded fire dampers in oxygen transfer rooms. Record review on 6/25/24 revealed no evidence on maintenance of the fire dampers in oxygen transfer rooms. It was noted that other 60 fire dampers were maintained as required. An interview on 6/25/24 with the Maintenance Director revealed that he was not aware of this problem.The census of 78 was verified by the Administrator on 6/25/24. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview on 6/25/24. The facility was found to be in compliance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness).

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:Fire caulking is missing in an area on the ceiling in an electrical room (Evergreen electrical room).NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this electrical room smoke compartment. Deficient items were discussed with the Administrator and Maintenance Director at the exit conference. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1.This was evidenced by the following:An escutcheon plate on fire suppression piping has dropped down in the kitchen.8.5.6.4 Where sprinklers penetrate a single membrane of a fire resistance–rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 1/2 in. (13 mm), measured between the edge of the membrane and the sprinkler.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the kitchen smoke compartment. Deficient items were discussed with the Administrator and Maintenance Director at the exit conference. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on May 14, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."Building A1 is a one (1) story, Type V (000) wood frame construction. The facility has a partial basement that is used for staff support functions and has no resident access. The facility was constructed in 1957 and is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry-pipe fire sprinkler system. Buildings A1 and A2 are separated by 2-hour rated construction.Building A2 is a one (1) story, Type V (111) wood frame construction. The facility was constructed in 2009 and known as Rehabilitation. The building is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic anti-freeze fire sprinkler system. The facility is licensed for 103 beds and the census on the date of the survey was 87. The results of this survey were discussed with the Facility Administrator and the Maintenance Director during the exit conference conducted on May 14, 2024.