Sand Springs Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure assessments were accurate for 1 (#28) of 17 sampled residents reviewed for falls.The administrator identified 59 residents resided in the facility. Findings: A quarterly assessment for Resident #28, dated 11/25/25, showed a BIMS of 03 which indicated the resident was severely impaired for daily decision making. The assessment showed diagnoses which included hypertension, non-Alzheimer's disease, anxiety disorder, depression and psychotic disorder. Section J of the assessment showed Resident #28 had no falls since admission/entry, reentry, or prior assessment. On 12/17/25 at 3:36 p.m., the MDS coordinator stated they ensured the accuracy of the MDS by looking at the provided documentation and doing the assessment themself. They stated when a resident had a fall, they added the falls to the assessment and the care plan. The MDS coordinator reviewed the quarterly assessment dated [DATE] for Resident #28 and stated they had not accurately coded the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to: a. assess the resident for the use of side rails, b. ensure to mattress fit correctly for the bed frame and use of side rails, c. monitor for safety and maintenance for the use of side rails, d. obtain an informed consent prior to the use of side rails, for one (#27) of one sampled residents reviewed for side rails. The DON identified eight residents who used side rails. Findings: The policy for Bed Safety and Bed Rails documented use of bed rails were prohibited unless the criteria for use had been met. The policy documented bed frames, mattress and bed rails were checked for compatibility and size prior to use. The policy documented regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. The policy documented the maintenance staff was to routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. Resident #27 had diagnoses which included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide enough staff to ensure assistance with ADL's and a clean environment was provided for one (#33) of three residents reviewed for ADL's The administrator reported the census was 52. Findings: An undated facility policy titled Staffing, Sufficient and Competent Nursing, read in part, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment Res #33 had diagnoses including paraplegia and diabetes mellitus. An admission assessment, dated 05/14/24, indicated the Res #33 was independent with daily decision making and was dependent on staff for transfers. A physician order, dated 06/17/24, documented Per resident request: up to chair daily as tolerated to facilitate wound healing On 06/17/24 at 11:00 a.m., Res #33 stated that he wanted to get out of bed more often, but staff didn't always help him. Res #33 also stated they had not been out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure nurse staffing information was posted on a daily basis. The administrator identified 52 residents resided in the facility. Findings: On 06/17/24 at 10:35 a.m., the nurse staffing board was not observed as posted in any high visibility area. On 06/19/24 at 12:44 p.m., a staffing board was observed posted at the nurses station near the front door. The staffing data on the posting was dated 06/18/24. On 06/20/24 at 9:36 a.m., a staffing board was observed posted at the nurses station near the front door. The staffing data on the posting was dated 06/18/24. On 06/21/24 at 8:22 a.m., a staffing board was observed posted at the nurses station near the front door. The staffing data on the posting was dated 06/18/24. On 06/21/24 at 8:26 a.m., the DON stated the staffing data was posted right up front. They pointed to the staffing data observed at the nurses station near the front door. The DON stated the staffing data was supposed to be update daily but was not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview , the facility failed to administer medication as ordered by the physician for one (#51) of five sampled residents who were reviewed for unnecessary medication. The administrator identified 52 residents resided in the facility. Findings: Resident #51 had diagnoses which included acute embolism and thrombosis of unspecified deep veins of the lower extremity, cardiomyopathy, chronic systolic heart failure, hemiplegia to left nondominant side, and anemia. A five day assessment, dated 05/24/24, documented the resident was cognitively intact and was receiving an anticoagulant medication. A hospital discharge order, dated 06/12/24, documented the resident was to receive Eliquis (a anticoagulant medication) 10mg by mouth twice a day for six days then decrease to 5mg by mouth twice a day. The Resident #51's MAR for June 2024 did not document the resident received Eliquis as ordered by the physician. On 06/19/24 at 2:15 p.m., LPN #2 stated they admitted the resident to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facililty failed to maintain an infection control program for enhanced barrier precautions for three (#29, 46, and #51) of three reviewed for infection control. The DON identified eight residents who currently had EBP. Findings: A policy titled Enhanced Barrier Precautions documented in parts .EBPs employ targeted gown and glove use during high contact resident care activitites when contact precautions do not otherwise apply .Examples of high-contact resident care activitites requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing) . 1. Res #29 had diagnoses which included obstructive and reflux uropathy, diabetes mellitus, atrial fibrillation, polyneuropathy, and depressive disorder. On 06/17/24 at 10:20 a.m., signage was noted at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to maintain a clean comfortable environment for one (#33) of three residents sampled for environment. The administrator reported the census was 52. Findings: An undated facility policy titled Cleaning and Disinfecting Residents' Rooms, read in part, Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled Res #33 had diagnoses including paraplegia and diabetes mellitus. An admission assessment, dated 05/14/24, documented the resident was independent with daily decision making and was dependent on staff for transfers. On 06/17/24 at 11:00 a.m., Res #33's room was observed. The trash can was observed to be full and soiled linens were piled in two separate areas of the floor. The floor was discolored in areas and sticky to the touch. Two pairs of soiled gloves were observed near the wall by the bathroom. Food debris was observed near the resident's bed. On 06/17/24 at 11:05 a.m., Res #33 stated housekeeping came in every day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure assistance with ADL's was provided for one (#33) of three residents reviewed for assistance with ADL's. The administrator reported the census was 52. Findings: Res #33 had diagnoses including paraplegia and diabetes mellitus. An admission assessment, dated 05/14/24, indicated the resident was independent with daily decision making and was dependent on staff for transfers. A physician order, dated 06/17/24, documented Per resident request: up to chair daily as tolerated to facilitate wound healing. On 06/17/24 at 11:00 a.m., Res #33 stated that they wanted to get out of bed more often, but staff didn't always help them. Res #33 also stated they had not been out of bed since the end of last week. On 06/18/24 at 10:00 a.m., Res #33 stated they still had not been out of bed. On 06/19/24 at 10:10 a.m., Res #33 stated they had an order from the doctor to get up, and they still had not been out of bed. On 06/20/24 at 9:28 a.m., CNA #3 stated they try to get Res #33 up, but they are pulled away a lot of times…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to complete weekly skin assessments as ordered to identify impaired skin integrity for one (#27) of three residents reviewed for pressure ulcers. The DON identified two residents with pressure ulcers. Findings: Res #27 had diagnoses which included diabetes mellitus, morbid obesity, and hypertension. A care plan, dated 07/19/20, documented the resident had potential for impaired skin integrity related to fragile skin, incontinence, and/or impaired mobility. A physician order, dated 08/21/23, documented the facility was supposed to do weekly skin assessments. The staff was to examine the resident's skin from head to toe and document any new abnormalities and notify the physician for treatment every evening shift on Mondays. A weekly skin assessment, dated 05/13/24, documented the resident had redness and moisture to the groin area. A weekly skin assessment, dated 05/27/24, documented the resident had moisture associated redness to the left iliac crest and a treatment was in place. On 06/17/24 at 2:51 p.m., the Res…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a PRN order for an antianxiety had a 14 day stop date and an antipsychotic had an appropriate diagnosis for one (#53) of five sampled residents reviewed for unnecessary medications. The administrator identified 52 residents resided in the facility. Findings: Res #53 had diagnoses which included dementia. A physician order, dated 04/04/24, documented to administer Seroquel (an antipsychotic) 200 mg at bedtime for dementia. A MAR for April 2024 documented Seroquel was received by the resident 25 times. A physician order, dated 05/05/24, documented to administer Ativan (an anti-anxiety) 0.5 mg every six hours as needed for agitation. A MAR for May 2024 documented Seroquel was received by the resident 31 times, and Ativan was received by the resident 16 times. A MAR through 06/19/24, documented Seroquel was received by the resident 18 times, and Ativan was received by the resident 9 times. On 06/19/24 at 2:41 p.m., the DON stated it was the responsibility of the DON to ensure the end date for the PRN and the diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure resident records were accurate for one (#49) of four sampled residents reviewed for accidents. The administrator identified 52 residents resided in the facility. Findings: Res #49 had diagnoses which included dementia. A progress note dated 04/30/24 at 10:08 a.m., documented the resident's hand was deep purple, swollen, and painful. The note documented the physician was notified. On 06/20/24 at 1:51 p.m., the medical director stated the report they received did not include pain or discoloration. An observation of a text message documented the staff reported to the doctor the hand was swollen and not painful. The message to the doctor included a photograph. The photograph did not show the resident's hand was discolored.

Based on observation, record review, and interview, the facility failed to inspect the bed frame, mattress, and bed rails as part of a regular maintenance program for one (#27) of one sampled residents reviewed for side rails. The DON identified eight residents who used side rails. Findings: The policy for Bed Safety and Bed Rails documented use of bed rails were prohibited unless the criteria for use had been met. The policy documented bed frames, mattress and bed rails were checked for compatibility and size prior to use. The policy documented regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. The policy documented the maintenance staff was to routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. Res #27 had diagnoses which included diabetes mellitus, morbid obesity, and hypertension. The care plan, dated 06/13/19, documented the resident had an ADL self care deficit. The care plan documented the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than five percent for three (#34, 27, and #31) of 16 residents observed during medication passes. A total of 25 opportunities were observed with three errors and a total error rate of 12%. Findings: 1. Resident #34 had diagnoses which included diabetes. A physician's order, dated 03/13/23, documented the resident was to receive Novolog insulin per sliding scale readings at 150 mg/dL or greater. The resident was to receive six units for a finger stick blood sugar reading between 251 mg/dL and 300 mg/dL. On 05/10/23 at 4:43 p.m., LPN #1 stated the resident's finger stick blood sugar reading was 267 mg/dL. LPN #1 stated the resident was to receive four units of Novolog insulin for every 50 mg/dL above 150 mg/dL. On 05/10/23 at 4:43 p.m., LPN #1 was observed to administer eight units of Novolog insulin for a finger stick blood sugar reading of 267 mg/dL. This is two units more than the Novolog sliding scale insulin (6 units) for a finger stick blood sugar of 267 mg/dL. 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to store foods according to professional standards for food service safety. The facility failed to discard left-over refrigerated foods within the timeframe allotted for food service safety and failed to label/date left-over foods stored in the refrigerator according to professional standards for food service safety. The director of nursing identified 56 residents who ate meals prepared in the kitchen. Findings: On 05/11/23 at 7:10 a.m., the following items were observed stored in the walk in refrigerator: - a resealable bag, dated 05/03, of cooked hamburger patties, - an undated container of hand diced tomatoes - a container, dated 05/06, of vanilla pudding, - a covered plate of hashbrowns, dated 05/06, - a pan of mechanically soft sweet and sour chicken, dated 05/08, and - an undated pan of spanish rice. On 05/11/23 at 5:00 p.m., the assistant dietary manager was asked what the facility policy was regarding the storage of left-overs. The ADM stated deserts were stored in the refrigerator for up to 24 hours and everything else…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.