Sandrock Ridge Care and Rehab hit with multiple Infection Prevention & Control citations |

Sandrock Ridge Care and Rehab hit with multiple Infection Prevention & Control citations

Federal Infection Control Focused Survey shows assisted living facility failed to comply with a number of infection control procedures inside the building

Sandrock Ridge Care and Rehab was cited for a number of Infection Prevention & Control citations during a Nov. 18, 2020 Federal Infection Control Focused Survey inside the facility, according to a recent report from the Colorado Department of Public Health and Environment (CDPHE).

The citation report states that Sandrock Ridge Care and Rehab “failed to properly maintain an infection control program designed to prevent the spread of the novel Coronavirus (COVID-19) in three of the four hallways.” Sandrock was also cited for failing to ensure staff and residents were using proper hand hygiene, wearing proper face coverings at all times; failing to properly educate newly-hired staff regarding COVID-19 infection control, and failing to ensure cross-contamination practices in shared spaces.

A Dec. 9 follow-up investigation showed that Sandrock was not cited for deficient practice. However, in the time between Nov. 18’s citations and the Dec. 9 follow-up investigation from CDPHE, 10 Sandrock Ridge Care and Rehab residents died either due to COVID-19, or with COVID-19. In total, 13 residents at Sandrock have died since a coronavirus outbreak in the assisted living facility was first reported on Oct. 23.

Neither Sandrock Ridge Care and Rehab Nursing Home Administrator Chandler Larsen, nor the Senex Foundation of Denver, Inc. – which oversees Sandrock Ridge – responded to requests for comments.

“Nursing homes, which house our most vulnerable in society, have nationally been ground zero for countless coronavirus outbreaks across the United States making it even more imperative for facilities to demonstrate consistently exemplary infection control practices,” said Kari Ladrow, Moffat County’s Public Health Director. “Lives of vulnerable people are depending on that happening every day, all the time and there isn’t any margin for error.”

“I am extremely disappointed and disheartened to see the survey results [from Sandrock Ridge] and that so many people have lost their life in such a short amount of time,” said Olivia Scheele, Moffat County’s Public Health Nurse said.

In the citation report dated Nov. 18 that has a scope and severity level of F, staff were observed failing to adhere to guidelines throughout the day on Nov. 17 and Nov. 18 despite a number of COVID-19 protocols and procedures posted throughout the building.

On Nov. 17, an investigator observed two staff members passing out meal trays to residents without offering or assisting proper hand hygiene to residents when delivering and setting up their meal. Staff also did not perform proper hand-hygiene as they entered and exited the rooms, according to the citation report.

The investigator also observed a staff member of the facility pass out breakfast trays on the morning of Nov. 17 without following proper hand hygiene when entering or exiting rooms.

On Nov. 18, the citation reports an observation of a resident walking through the dining room area of the residence without a mask on, and was later seen talking to a staff member, who failed to offer the male a mask.

That same day, the facility’s registered dietitian was observed coming out of the kitchen with a meal cart. He was not wearing a face shield and was observed removing meal trays from the cart while heading down the east and west hallways around lunchtime.

A cook was also observed removing a plastic bag out of her left pocket of her scrub shirt pocket and used it to cover a Styrofoam glass of milk that was later served to a resident for breakfast. The use of the plastic bag from the pocket of her scrub led to the milk being contaminated.

In addition to the failures of improper hand hygiene and not wearing face shields, the citation also cites the facility’s failures to properly train new staff on COVID-19 infection control practices.

When interviewing one staff member, the investigator was told by the staff member that they were mostly working nights in the facility and that no one had mentioned anything to her about offering hand sanitizer or alcohol wipes to residents before and after eating meals.

Additionally, the investigator observed that one staff member who had recently been rehired by the facility between Nov. 9 and 13 had no completed the required training prior to working on the floor with residents.

Sandrock Ridge Care and Rehab currently remains in outbreak status at this time.


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