Sandridge Post Acute

In the surveyor’s words

From the most serious findings on record at Sandridge Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684Feb 17, 2021

  Based on clinical record review, review of facility records, observations, resident and staff interviews, and review of policies and procedures, the facility failed to ensure that a mode of transport used to transport one resident (#65) through a courtyard was used safely, which resulted in bilateral fractured femurs. The deficient practice could result in additional resident injuries. Findings include: Resident #65 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Date Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) of 14, which indicated that the resident was cognitively intact. […]

• No harm, potential for more than minimal, patternF607Dec 2, 2025

  Based on a review of clinical records, staff interviews, facility documentation, policies and procedures, and the State Agency (SA) database, the facility failed to implement its policy requiring a thorough investigation of abuse and neglect allegations for four residents (#29, #33, #37 and #38). This deficient practice could place residents at risk for ongoing abuse and neglect.Findings include: Regarding Resident #38 Resident #38 was admitted on [DATE], with diagnoses that included senile degeneration of the brain, hypertension, and a personal history of COVID-19. Resident #38 expired at the facility on [DATE]. Review of the SA database revealed that the facility submitted a self-report on [DATE]. […]

• No harm, potential for more than minimal, patternF610Dec 2, 2025

  Based on record review, staff interviews, review of facility policies and review of SA database, the facility failed to ensure a through investigation was conducted for abuse and misappropriation of property for two residents (#29 and #33). The deficient practice could result in ongoing abuse of residents.Findings include: -Regarding resident #29Resident #29 was admitted [DATE], and discharged [DATE], with diagnoses that include chronic obstructive pulmonary disease; schizophrenia; bipolar disorder, unspecified; anxiety disorder, unspecified; major depressive disorder, recurrent, unspecified; and personal history of transient ischemic attack, and cerebral infarction, without residual deficits. […]

• No harm, potential for more than minimal, patternF761Dec 2, 2025

  Based on observations, interviews, and a review of facility policy and procedure, the facility failed to ensure that three medication carts were secured in accordance with professional standards and facility policy when left unattended. The deficient practice could result in residents, visitors, and/or staff members having unrestricted access to medications and medical supplies.Findings include:An observation conducted on December 16, 2025, at 11:13 a.m., revealed that a medication cart on the Beta 2 unit was unattended and unlocked while outside of the direct line of sight of staff. […]

• No harm, potential for more than minimal, patternF600Apr 18, 2025

  Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure six of six sampled residents (#2, #3, #4, #5, #6 and #8) were free from sexual or physical abuse from one resident #1. The deficient practice could lead to sexual, physical and psychosocial harm to the residents. Findings include: -Regarding residents #1 and #2: -Resident #1 was admitted to the facility December 21, 2021 with dysphagia following cerebral infarction, unspecified dementia, mild, with agitation, schizophrenia, unspecified. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. […]