Inspection Reports for
The Rehabilitation Center at Sandalwood
3835 HARLAN ST, WHEAT RIDGE, CO, 80033-5311
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 9
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, medication management, safety, and quality assurance.
Findings
The facility had multiple deficiencies including failure to provide appropriate communication tools and care plans for residents, failure to provide timely treatment and care such as CPAP mask replacement and dental care, inadequate monitoring and positioning of residents, failure to complete neurological checks after falls, failure to ensure staff training on transfers, failure to prevent severe weight loss, failure to ensure consistent dialysis communication, failure to timely review and respond to pharmacist medication regimen review recommendations, and failure to maintain an effective quality assurance program.
Deficiencies (9)
F 0676: The facility failed to provide Resident #63 with an appropriate communication tool and a person-centered care plan addressing communication deficits.
F 0684: The facility failed to ensure Resident #17 received a new CPAP mask timely and failed to have physician orders for wound care related to skin breakdown from the CPAP mask.
F 0688: The facility failed to ensure Resident #15 was monitored for splint use and Resident #10 was properly positioned in her wheelchair to prevent discomfort and pain.
F 0689: The facility failed to complete neurological checks after unwitnessed falls for Resident #60 and failed to ensure staff were trained on slide board transfers for Residents #52 and #43 after falls.
F 0692: The facility failed to provide timely and effective interventions to prevent severe weight loss for Resident #41, including failure to obtain timely reweighs and implement nutritional interventions.
F 0698: The facility failed to ensure consistent communication and documentation with the dialysis center for Resident #191.
F 0756: The facility failed to ensure timely review and response to pharmacist medication regimen review recommendations by medical providers, medical director, and director of nursing, creating immediate jeopardy.
F 0791: The facility failed to provide Resident #5 with timely dental care for a broken tooth and failed to ensure emergency dental services were provided during a state survey.
F 0867: The facility failed to implement an effective quality assurance program to identify and address medication regimen review concerns, contributing to immediate jeopardy.
Report Facts
Weight loss percentage: 27.7
Weight loss percentage: 16.2
Weight loss percentage: 6.6
Weight loss percentage: 11.9
Number of MRR recommendations not responded: 138
Number of MRR recommendations not responded: 131
Number of MRR recommendations not responded: 143
Number of MRR recommendations not responded: 163
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Provided Kardex and interviewed about Resident #10 positioning. |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #17 CPAP mask and neurological checks. |
| DOR | Director of Rehabilitation | Interviewed about therapy and communication care plans for Resident #63 and splint use for Resident #15. |
| DON | Director of Nursing | Interviewed about Resident #63 communication care plan, neurological checks, dialysis communication, and medication regimen review process. |
| CNA #1 | Certified Nurse Aide | Interviewed about splint use for Resident #15. |
| CNA #2 | Certified Nurse Aide | Reported Resident #52 fall during slide board transfer. |
| CNA #3 | Certified Nurse Aide | Reported Resident #43 fall during slide board transfer and interviewed about meal assistance. |
| CP | Consultant Pharmacist | Interviewed about medication regimen review process and lack of responses. |
| MP #1 | Medical Provider | Interviewed about medication regimen review process. |
| NHA | Nursing Home Administrator | Interviewed about QAPI program and medication regimen review process. |
| SSC | Social Services Coordinator | Interviewed about dental services scheduling for Resident #5. |
| VPO | Vice President of Operations (Dental Team) | Interviewed about dental services scheduling and Resident #5's emergency dental care. |
| RN #2 | Registered Nurse | Documented dental care coordination for Resident #5. |
| DRN | Dialysis Registered Nurse | Interviewed about dialysis communication forms for Resident #191. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to pressure ulcer prevention and treatment at the Rehabilitation Center at Sandalwood.
Findings
The facility failed to ensure residents received appropriate pressure ulcer care, including proper repositioning and consistent dressing changes per physician orders, resulting in new pressure ulcers for Resident #2 and inconsistent wound care for Resident #1.
Deficiencies (1)
F 0686: The facility failed to provide and encourage proper repositioning for Resident #2 to prevent new pressure injuries and failed to consistently change Resident #1's pressure injury dressing per physician orders.
Report Facts
Pressure ulcer measurements: 1
BIMS score: 1
BIMS score: 14
Dressing change dates: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed regarding Resident #2's pressure ulcers and dressing changes for Resident #1. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about dressing changes for Resident #1 and wound care procedures. | |
| Licensed Practical Nurse (LPN) #2 | Observed administering medication to Resident #2 without offering repositioning. | |
| Certified Nurse Aide (CNA) #1 | Interviewed about care provided to Resident #2 including turning and assistance. | |
| Clinical Nursing Consultant (CNC) | Interviewed regarding education of nursing staff on dressing changes. | |
| Wound Physician | Interviewed about Resident #2's pressure ulcers and care recommendations. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jan 11, 2023
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident care, abuse prevention, care planning, supervision, and infection control at the Rehabilitation Center at Sandalwood.
Complaint Details
The investigation was complaint-driven, focusing on allegations of failure to respect resident bathing preferences, resident-to-resident abuse, inadequate care planning, insufficient supervision to prevent falls and elopement, poor nutritional and hydration support, improper pain management, and infection control breaches.
Findings
The facility failed to respect resident preferences for bathing, prevent resident-to-resident abuse, develop comprehensive care plans, provide adequate assistance with activities of daily living, monitor anticoagulant medication use, prevent falls and elopement, provide adequate nutrition and hydration, manage pain appropriately, and maintain infection control practices.
Deficiencies (9)
F 0561: The facility failed to honor residents' rights to self-determination by not providing showers according to Resident #13 and #133's preferences and plans of care.
F 0600: The facility failed to protect residents #36 and #58 from resident-to-resident physical abuse and did not report or prevent repeated incidents.
F 0656: The facility failed to develop and update comprehensive care plans for Residents #53, #58, and #7 to address antidepressant use, anticoagulant medication monitoring, and behavioral interventions.
F 0677: The facility failed to provide timely repositioning and care for Resident #67, who was high risk with skin breakdown.
F 0684: The facility failed to monitor Resident #58 for side effects of anticoagulant medication and did not have a care plan or physician orders for monitoring.
F 0689: The facility failed to provide adequate supervision to prevent accidents for Residents #17, #18, #58, and #62, including fall prevention, RN assessments after falls, elopement prevention, and aspiration monitoring.
F 0692: The facility failed to provide effective interventions to address weight loss and nutritional deficits for Resident #42, including assistance with eating and hydration.
F 0697: The facility failed to provide safe and appropriate pain management for Residents #5 and #50 by not following pain medication parameters and lacking person-centered pain care plans.
F 0880: The facility failed to maintain infection control practices by not removing contaminated gloves and performing hand hygiene during incontinence care, and improperly handling barrier cream and incontinence wipe packaging.
Report Facts
Resident weight: 93.5
Resident weight loss percentage: 4.59
Resident weight loss: 4.5
Resident weight loss percentage: 3.71
Resident weight loss: 3.6
Resident weight loss percentage: 2.6
Resident weight loss: 2.5
Resident weight: 369
Resident falls: 9
Medication administrations: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Witnessed resident-to-resident abuse incident involving Resident #36 |
| DON | Director of Nursing | Interviewed regarding multiple findings including bathing preferences, abuse incidents, care planning, falls, and infection control |
| RN #2 | Registered Nurse | Observed and interviewed regarding infection control and anticoagulant medication monitoring |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding fall incident and call light issues for Resident #17 |
| CNA #5 | Certified Nurse Aide | Interviewed regarding fall incident and call light issues for Resident #17 |
| SSA | Social Services Assistant | Interviewed regarding care planning and wanderguard device use |
| RN #1 | Registered Nurse | Interviewed regarding anticoagulant medication monitoring and pain management |
| CNA #3 | Certified Nurse Assistant | Interviewed regarding infection control practices |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding pain medication administration |
| Registered Dietitian | Registered Dietitian | Interviewed regarding nutritional care for Resident #42 and Resident #62 |
Inspection Report
Routine
Census: 86
Deficiencies: 5
Date: Sep 21, 2021
Visit Reason
Routine inspection of the Rehabilitation Center at Sandalwood to assess compliance with healthcare regulations including pressure ulcer care, restorative services, medication administration, medication storage, and infection control.
Findings
The facility failed to prevent pressure ulcers in two residents, failed to provide consistent restorative services to maintain range of motion for three residents, failed to administer a prescribed medication due to stock issues, failed to properly label and remove expired medications, and failed to ensure housekeeping staff cleaned high-touch surfaces during routine daily room cleaning.
Deficiencies (5)
F 0686: The facility failed to prevent pressure ulcers for Residents #86 and #15 due to inadequate care planning, inconsistent skin assessments, and failure to implement physician-ordered treatments.
F 0688: The facility failed to provide consistent restorative nursing services to maintain or prevent decline in range of motion for Residents #25, #54, and #73 due to staffing shortages and incomplete therapy sessions.
F 0755: The facility failed to ensure Resident #75 was administered Glatiramer Acetate as ordered due to medication being out of stock and lack of communication with physician and pharmacy.
F 0761: The facility failed to properly label medications with resident names and remove expired medications from medication carts, risking administration of expired or unlabeled medications.
F 0880: The facility failed to ensure housekeeping staff cleaned and disinfected high-touch surfaces during routine daily room cleaning on one unit, increasing risk of infection transmission.
Report Facts
Facility census: 86
Residents affected by pressure ulcer deficiency: 2
Residents affected by restorative services deficiency: 3
Residents affected by medication administration deficiency: 1
Residents affected by medication storage deficiency: 3
Residents affected by infection control deficiency: 1
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