Sloan's Lake Rehabilitation Center

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

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

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

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

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

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 safe and appropriate respiratory care for a resident when needed.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

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 101One painted sprinkler head in the women' s restroom, 6th floor. NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than an hour apart, not at varied times. February and March: are 15 minutes apart. January and July: twenty minutes apart. Need to be an hour apart.NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on February 13, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is an eight (8) story, Type I (332) (1-A) construction with a full basement. This facility is equipped with piped medical gas that is being utilized by residents. The facility was constructed in 1962 and 1967. This facility is licensed for 42 beds. The census on the date of the survey was 42. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The facility utilizes a fire pump located in the basement. This facility is classified as fully-sprinklered.

A recertification survey with complaint #CO34407 and #CO34552 was completed on 1/17/24 to 1/23/24. Seven deficiencies were cited. An Emergency Preparedness survey was conducted from 1/17/24 to 1/23/24. No deficiencies were cited. Based on observation, record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#196) of five residents reviewed for medication errors of 30 sample residents.Specifically, the facility failed to ensure that Resident #196 was administered an anticoagulant medication correctly by removing the medication from a capsule before administration to the resident.Findings include:I. Professional referenceBoehri.. Based on observations, interviews and record review, the facility failed to establish parameters for pain medication for one (#105) of five residents in a manner consistent with professional standards of practice out of 30 sample residents.Specifically, the facility failed to:-Ensure pain parameters were established and implemented for physician ordered as needed (PRN) pain medications; and,-Ensure non pharmacological interventions were implemented before.. Based on observations, interviews and record review, 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 and infection on one out of two floors.Specifically, the facility failed to:-Ensure a resident' s room was cleaned in a sanitary manner;-Ensure that the proper cleaning agent was used to clean a resident' s room who was on .. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services and assistance for bathing for two (#108 and #96) of four sample residents reviewed out of 30 sample residents. Specifically, the facility failed to provide bathing for Resident #108 and #96 to maintain personal hygiene.Findings include:I. Facility policy and procedureThe Activity of D.. Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs that accommodated resident allergies, intolerances and preferences for two (#106 and #191) of six residents out of 30 sample residents.Specifically, the facility failed to:-Ensure Resident #106 was provided appropriate vegetarian meal items per the menu spreadshe.. Based on record review and interviews, the facility failed to ensure one (#191) of two residents out of 30 sample residents received dialysis services consistent with professional standards of practice.Specifically, the facility failed to ensure consistent communication and documentation with the dialysis center regarding care and services was completed for Resident #191.Findings include:I. Facility policy and procedureThe Renal Dialysis, Care of Resident an.. Based on resident observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#12) of four residents reviewed for supplemental oxygen use out of 30 sample residents. Specifically, the facility failed to:-Ensure a physician' s order was in place for Resident #12' s continuous oxygen use. Findings include: I. Facility policy The Oxygen Administration Policy, revis..