Sandy Ridge Center for Rehabilitation and Healing

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678May 3, 2023

  Based on staff interviews, record review, policy review, and review of the facility corrective action plan, the facility failed to initiate basic life support including Cardio-Pulmonary Resuscitation (CPR) for 1 of 3 residents sampled for Advanced Directives (#1). The facility failed to commence CPR after finding resident #1 in bed without respirations and heartbeat. The facility failure to initiate CPR led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Director of Nursing (DON) and the Nursing Home Administrator were informed of the Immediate Jeopardy on [DATE] at 2:45 PM. The Immediate Jeopardy began on [DATE] at approximately 5:30 AM and was corrected on [DATE] after verification of compliance achievement. […]

• No harm, potential for more than minimal, isolatedF656Feb 25, 2026

  Based on observations, interviews, and record reviews, the facility failed to implement and maintain accident prevention interventions for 1 resident (Resident #1) who previously sustained a fall with major injury, resulting in the resident experiencing a second preventable injury. The facility did not follow the resident's updated care plan requiring two person assistance for bed baths only and allowed the resident to be taken to the shower despite this restriction. This failure resulted in the resident sustaining a humerus fracture and placed the resident at continued risk for further avoidable harm. This deficient practice is cross referenced to F0689 due to the facility's failure to provide adequate supervision and accident prevention interventions. […]

• No harm, potential for more than minimal, isolatedF689Feb 25, 2026

  Based on observations, interviews, and record reviews, the facility failed to implement and maintain accident prevention interventions for one resident (Resident #1) with a known history of fall related injury. The facility did not follow the resident's updated care plan requiring two person assistance for bed baths only, and allowed the resident to be taken to the shower despite this restriction. This failure resulted in the resident sustaining a left humerus fracture and placed her at continued risk for avoidable injury.The findings include:A record review of Resident #1's chart on 02/25/2026 revealed that she had a right closed hip fracture and displaced hip following a fall from the bed on 09/29/2025. […]

• No harm, potential for more than minimal, isolatedF656Apr 3, 2024

  Base on staff interview and record reviews, the facility failed to develop care plans for 2 of 5 residents sampled for unnecessary medications, Resident #7 and 41. The findings include: Resident # 41 Electronic Medical record review reveals resident #41 was readmitted to the facility on [DATE] with a previous admission in October 2023. Medical diagnosis and history include Cerebral infarction (stroke), type 2 diabetes and chronic Atrial Fibrillation (AFIB-an irregular heartbeat). Admission orders revealed resident receiving Insulin Glargine and Insulin Lispro (injectable medications used to lower blood glucose levels) for type 2 diabetes. Resident is also receiving Eliquis (a blood thinner used to prevent blood clots). […]

• No harm, potential for more than minimal, isolatedF686Apr 3, 2024

  Based on observation, resident interview, staff interview, and clinical record review, the facility failed to develop and implement a process regarding turning and repositioning to prevent the development of pressure ulcers for 1 of 3 residents sampled for facility acquired pressure ulcers, resident #49. The findings include: On 4/1/2024 at 2:02 PM an interview was conducted with resident #49. Resident #49 indicated he had a bed sore on his bottom for which he was receiving wound care every day. The resident indicated he was dependent upon staff for mobility, and was unable to turn or reposition himself when he arrived at the facility back in February. […]