Sandy Lake Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Sandy Lake Rehabilitation and Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF604May 3, 2021

  Based on observation, interview and record review, the facility failed to ensure that the resident is free from physical restraints imposed for convenience and that are not required to treat the resident's medical symptoms, and the facility failed to use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. The Facility: 1. failed to assess for entrapment risks and attempt less restrictive measures prior to installing bed rails for 88 of 88 residents; 2. failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. failed to care plan for bed rails for 47 of 88 residents; and 4. […]

• Immediate jeopardy, widespreadF700May 3, 2021

  Based on observation, interview and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for all 88 residents in the facility. The Facility: 1. failed to assess for entrapment risks and attempt less restrictive measures prior to installing bed rails for 88 of 88 residents; 2. failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. failed to care plan for bed rails for 47 of 88 residents; and 4. […]

• Immediate jeopardy, isolatedF689Apr 17, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of four residents reviewed for supervision. The facility failed to provide adequate supervision to prevent Resident #1, who had severe cognitive impairment from eloping from the facility on 03/21/25. The resident was found at an intersection, across the street from the facility. The resident did not sustain any injuries and was found by a pedestrian. The noncompliance was identified as PNC IJ. The noncompliance began on 03/21/25 and ended on 03/21/25. […]

• Immediate jeopardy, isolatedF580Jul 25, 2024

  Based on interviews and record reviews the facility failed to notify the physician of an accident that resulted in an injury and required the physician intervention for 1 (Residents #25) of 1 resident reviewed for notification of changes. The Director of Therapy failed to notify Resident #25's physician when the resident injured her left leg on 04/02/24 while being transported in her wheelchair without footrests. Resident #25 sustained a fracture which was not discovered until 04/06/24 when the NP was notified and ordered an x-ray. This failure placed the resident at risk of not receiving immediate medical attention and at risk of further damage to her leg. The noncompliance was identified as past noncompliance (PNC) The IJ began on 04/02/24 and ended on 04/08/24. […]

• Immediate jeopardy, isolatedF689Jul 25, 2024

  Based on interviews and record reviews the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents for 1 (Residents #25) of 1 resident reviewed for accidents and hazards. On 04/02/24, Director of Therapy failed to utilize Resident #25's footrest when transporting her which resulted in a fracture to her left leg. This failure placed the resident at risk of further injury due to improper use of equipment. The noncompliance was identified as past noncompliance (PNC) The IJ began on 04/02/24 and ended on 04/08/24. The facility had corrected the noncompliance before the state's investigation began. Findings included: Record review of Resident #25's face sheet, dated 07/23/2024, revealed she was a [AGE] year-old female admitted on [DATE]. […]