Sandy Lake Rehabilitation and Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident participated in the development and implementation of his or her person-centered plan of care, including the planning process, the right to identify individuals or roles to be included in the planning process, the right to request meetings, and the right to request revisions to the person-centered plan of care for 1 of 8 residents (Resident #5) reviewed for Care Plan development and assessments. The facility failed to ensure Resident #5 participated in the development of her Quarterly Care Plan assessment. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment, receiving housekeeping services, and supports for daily living safely for 15 of 20 resident rooms on the 300 and 400 halls (Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) reviewed for a clean and homelike environment. The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15, were thoroughly cleaned and sanitized. This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for 1 (Resident #28) of twelve residents reviewed for accident hazard. The facility failed to ensure that a container of germicidal (substance that destroys germs and microorganism) wipes was not left inside Residents #28's room on 08/17/2025. This failure could prevent the residents from having an environment that was free from toxic chemicals.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Residents #2, #28, and #71) of twelve residents reviewed for respiratory care. 1. The facility failed to ensure an Oxygen in Use sign was placed outside Resident #2's room on 08/17/2025. 2. The facility failed to ensure Resident #28's CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) mask was properly stored when not in use on 08/17/2025. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one of eight residents (Resident #3) reviewed for pharmaceutical services The facility failed to dispose of Resident #3's expired Duloxetine dated 11/17/2024. This failure could place residents at risk of not receiving the medication's full therapeutic benefits and the possible side effects of taking expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident #70) of eight residents reviewed for medication administration. The facility failed to ensure RN C would not crush or dissolve Resident #70's Venlafaxine extended-release medication on 08/18/2025. These failures placed residents at risk of not receiving the full benefit of the medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medications for eight (Residents #2, #3, #5, #7, #49, #60, #68, and #77) of twenty-one residents were stored properly in locked compartments or provided a safe and secured storage with limited access. 1. The facility failed to ensure Resident 2's zinc oxide (cream used to treat skin irritations, diaper rash, and other skin conditions) was not left on top of the resident's side table on 08/17/2025. 2. The facility failed to ensure Resident 3's zinc oxide was not left on top of the resident's side table on 08/17/2025. 3. The facility failed to ensure Resident 5's zinc oxide was not left on top of the resident's side table on 08/17/2025. 4. The facility failed to ensure Resident 7's Theraworx (medication used for muscle cramps) was not left on top of the resident's side table on 08/17/2025. 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure foods in the freezer was concealed from air borne contaminants. 2. The facility failed to ensure food in the walk-in cooler and freezer were labeled and dated when stored. 3. The facility failed to discard molded food in the walk-in cooler. 4. The facility failed to ensure storage bins in the dry storage area were thoroughly cleaned. These failures could place residents at risk for cross contamination and air-borne illnesses.

Inspectors wroteBased observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #23, #28, #48, #70, and #71) of twelve residents reviewed for infection control. 1. The facility failed to ensure CNA J wore a gown while fixing Resident #23's beddings, who had a catheter (flexible tube inserted into the bladder to remove the urine), on 08/17/2025. 2. The facility failed to ensure RN D placed a cap ( green disinfecting caps) Resident 28's PICC line (long, flexible tube inserted into the vein used for administering intravenous medications) on 08/17/2025. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #50) reviewed for dignity. CNA S failed to assist feed Resident #50 at eye level when assisting the resident with her lunch. This failure placed residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident is assessed using the standardized Quarterly Review assessment tool no less than once every 3 months between comprehensive assessments for one of six residents (Resident #54) reviewed for Resident Assessments. The facility failed to ensure Resident #54 completed a Quarterly Review assessment within 3 months of the previous completed on 04/18/25. This failure could place residents at risk of their needs not being met and addressing any potential change in condition.

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs were identified in the comprehensive assessment for a resident for 2 of 8 residents (Residents #1 and #50) reviewed for Care Plans. The facility failed to ensure Resident #1's usage of a BiPAP device was care planned. The facility failed to ensure Resident #50 was care planned for requiring feeding assistance. These failures could place the residents at risk of not receiving the necessary care and services required.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #70) of two residents reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure RN C would not use too much water to flush Resident #70's medication via g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach). This failure could place residents with g-tubes at risk for aspiration, discomfort, and overhydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurses were able to demonstrate competency in assessment related to fall risk for 1 of 23 residents reviewed for fall risk assessments (Resident # 1). The facility failed to ensure LVN B was competent to accurately assess fall risks on 04/03/2025 and 06/03/2025. This failure could place the residents at risk for insufficient assessments and insufficient interventions for fall risk.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, Resident #2, and Resident #3) of eight residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #1, Resident #2, and Resident #3's rooms were in a position that was accessible to the residents on 05/13/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased 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. The facility corrected the noncompliance before the investigation began. This failure could place residents at risk for injury and/or death.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 3 (Resident #1) residents reviewed for Care Plans. The facility failed to ensure Resident #1's bed was in the lowest position and ensure his bedside table was in a safe location to assist in fall prevention. These failures could place residents at risk of injury.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' bed was free from any physical or chemical restraints imposed for purposes of discipline or convenience for 2 (Resident #1 and Resident #2) of 5 residents reviewed for physical restraints, The facility failed to obtain physician orders or a physician assessment as of 01/08/25 for Residents #1 and Resident #2 for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free from any physical or chemical restraints.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for Respiratory Care. The facility failed to ensure Resident #1's nasal cannula was properly stored when not in use. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection for 1 (Resident #22) of 2 residents reviewed for infection control. The facility failed to ensure Resident #22's foley catheter bag (collects urine drained from the bladder) was not touching the floor on 12/19/24. This failure could place the residents at risk for the development and transmission of infections. Review of Resident #22's Face Sheet, dated 12/19/24, reflected Resident #22 was a [AGE] year-old male admitted to the facility on [DATE] with neuromuscular dysfunction of the bladder (nerves controlling bladder function are damaged). [...]

Inspectors wroteBased 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. The facility had corrected the noncompliance before the state's investigation began.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 12 (room [ROOM NUMBER], #106, #107, #108, #109, #110, #112, #113, #115, #116, #117, and #120) of 12 resident rooms and the facility common areas observed for cleanliness and sanitization. The facility failed to ensure that Resident Room ##105, #106, #107, #108, #109, #110, #112, #113, #115, #116, #117, and #120 were thoroughly cleaned, and sanitized. The facility failed to ensure the handrails on the hallways of the facility, were thoroughly cleaned, and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for seven (Resident #100, Resident #20, Resident #18, Resident #10, Resident #30, Resident # 36, and Resident #53) of eighteen residents observed for Infection Control. 1. The facility failed to ensure that CNA C changed her gloves and performed hand hygiene while providing incontinent care to Resident #100. 2. The facility failed to ensure that RN G would not bring the whole container of test strips for checking blood sugar inside Resident #100's room. 3. The facility failed to ensure that MA D completed hand hygiene during medication administration. 4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #53) of 5 residents reviewed for dignity. The facility failed to treat Resident #53 with dignity and promote enhancement of his quality of life when the resident was not provided a privacy bag for his catheter bag. This failure placed residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Residents #20 and Resident #45) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #20's breathing mask was properly stored. 2. The facility failed to ensure Resident #45's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat or drink independently for 1 (Resident #1) of 3 residents reviewed for nutrition services. The facility failed to provide Resident #1 with an adaptive drinking aid (specialized cup) to assist with mobility issues and prevent accidental spills. On 02/03/24, CNA B served Resident #1 hot coffee in a 12-ounce insulated handle-free tumbler. Resident #1 did not have a grasp on the handle-free tumbler; coffee spilled and scalded the skin to [Resident #1's] right upper chest. This failure could place residents at risk for loss of self-worth and empowerment for independent drinking, which could lead to unplanned dehydration or more than minimal harm.

Inspectors wroteBased on Observations, interviews and record reviews the facility failed to provide a safe clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for three of eight rooms (Room # 208, #211, and #215) reviewed for cleanliness. The facility failed to ensure that resident rooms were cleaned and sanitized daily, and in accordance with the facility's Housekeeping Workers' Checklist. This failure could place residents at risk of negatively impact the facility's ability in preventing the spread of disease-causing organisms in residents' living areas and on resident care equipment.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to effectively clean and sanitize kitchen storage containers in the dry storage area. The facility failed to ensure foods in the facility's refrigerator and freezer were stored and dated according to guidelines. The facility failed to ensure outside food source was properly labeled, dated, and sealed. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct initially and periodically a comprehensive, accurate, and standardized reproducible assessment of each resident's functional capacity for 1 of 5 (Resident #49) reviewed for accuracy of assessments. The facility to ensure Resident #49's Minimum Data Set (MDS) was accurate to reflect her dialysis care. This failure could place residents at risk of not receiving proper care and not having their needs met. Findings Included: Review of Resident #49's Face Sheet, dated 06/07/23, revealed she was a [AGE] year-old female re-admitted on [DATE] from an acute care hospital. Relevant diagnoses included acute respiratory failure, end stage renal disease, dependence on renal dialysis, seizures, schizophrenia, cardiac pacemaker. Review of Resident #49's active physician orders revealed: Cinacalet tablet 30 mg . 1 tablet . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained as free of accident hazards as is possible and ensure that each of these residents received adequate supervision and assistance devices to prevent accidents for one of the six residents (Resident #39) reviewed for accidents hazards and devices. The facility failed to ensure Resident #39's bed was in the lowest position as an accident intervention. These failures could place residents at risk of falling and sustaining injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure that a resident who required dialysis care was provided with care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #49) reviewed for dialysis care. 1. The facility failed to ensure MA A provided safe care consistent with professional standards of practice when she obtained Resident #49's vital signs upon observation on 06/07/23 at 9:36 AM. 2. The facility failed to ensure Resident #49's Atriovenous (AV) shunt, essential for her dialysis treatments, received care consistent professional standards of practice. 3. The facility failed to ensure Resident #49 had physician orders reflecting care consistent with professional standards of practice. [...]

Inspectors wroteBased observation, interview, and record review the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #16, Resident #36, and Resident #49) of five residents observed reviewed for infection control. The facility failed to ensure MA A sanitized the blood pressure device and cuff between use with Resident #16, Resident #36, and Resident #49. These failures could place residents at risk of cross contamination and the spread of infection. Findings Included: Review of Resident #16's Face Sheet, dated 06/08/23, revealed he was an [AGE] year-old male re-admitted on [DATE] from home. Relevant diagnoses included dementia, difficulty swallowing, major depressive disorder, and stroke. [...]