Sandgate Gardens Rehab and Nursing Center

In the surveyor’s words

From the most serious findings on record at Sandgate Gardens Rehab and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686May 13, 2021

  Based on clinical and administrative record review and staff interview, the facility failed to ensure that 1 of 3 sampled residents (Resident #2), reviewed for pressure ulcers, received care consistent with professionals standards of practice to accurately assess, provide services to promote healing, prevent infection and prevent the development of new ulcers. This failure is evidenced by the facility failing to provide wound care evaluation and treatment by a qualified professional in a timely manner; and failed to perform the prescribed medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: The facility's policy for Prevention and Management of Wounds, created July 1, 2017, was reviewed. The Policy did not have an identified last revision date. […]

• No harm, potential for more than minimal, patternF692Aug 6, 2026

  Based on policy review, observation, record review and interviews, the facility failed to provide care and services for 5 of 11 sampled residents as evidenced by the failure to prevent significant weight loss and follow Physician and Registered Dietitian orders for weights for Resident #37 and #72 and failed to follow Physician and Registered Dietitian orders for weights for Residents #41, #59, and #5. The resident census at the time of survey was 102.The findings included: Review of the policy titled, Weight Assessment issued on 09/2022 and revised on 12/2024 revealed, in part, 1. With the resident's permission, the nursing staff will measure the resident weight within 72 hours of admission and monthly thereafter or as determined by the physician or per the resident's preference. #4. […]

• No harm, potential for more than minimal, patternF803Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to follow the portion sizes listed on the menu for regular and puree diets that were signed by the Registered Dietitian. This had the ability to affect 8 residents who were on the pureed diet and 66 on a regular diet. The census at the time of survey was 102. The findings included: Observations were made on 08/04/26 at 11:50 AM in the kitchen of the lunch tray line. A review of the menu for week 5 Tuesday lunch menu revealed the puree menu included 6-ounce (oz) puree chicken parmesan, 4 oz puree pasta, 4 oz puree Italian Vegetables, 2-oz puree roll with garlic butter and 4-oz puree apple cobbler. […]

• No harm, potential for more than minimal, patternF803Apr 18, 2025

  Based on observation, menu review, and interview, the facility failed to follow the menu for 1 of 2 observed meals (lunch on 04/16/25) affecting 96 of 99 resident who consume food orally. The findings included: Review of the menu for the lunch meal on 04/16/25 documented the following menu items. The following observations were made on the tray line in the kitchen on 04/16/25 beginning at 11:30 AM: a) The menu for the regular Philly Beef sandwich was documented to include a cheese sauce made with a cheese sauce mix and hot water. The observed sandwiches, prepared by the cook for the regular and mechanical soft diets, was topped with shredded cheese. b) The menu for the regular lunch meal was to contain a parsley sprig for garnish. […]

• No harm, potential for more than minimal, patternF805Apr 18, 2025

  Based on observation and interview, the facility failed to ensure the form of food met the needs of residents who consume pureed and mechanical soft foods for 1 of 2 meals observed (lunch on 04/16/25), affecting sampled Residents #69, #31, #82, and #30 who consume pureed foods, and affecting sampled Residents #59, #2, #73, #12, and #58 who consume mechanical soft foods. This practice had the potential to affect 12 of 99 residents who consume pureed foods, and 20 of 99 residents who consume mechanical soft foods (20). The findings included: An observation of the lunch meal on 04/16/25 revealed the main entree was a Phili Beef Sandwich. […]