Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sand Springs Nursing And Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident, independent in dressing, transfers, and toileting, reported that a CNA entered the room after a late-night shower, remained there for an extended period, and engaged in oral sex and attempted intercourse, which the resident described as not forced but initiated by the CNA. The resident consistently repeated this account to the DON, administrator, and APS, including details of the CNA touching the resident’s chest, placing the resident’s hand on his genital area, exposing himself, and then receiving oral sex followed by an attempted sexual act. Staff statements supported that the CNA was in the resident’s room for an unusually long time, was unaccounted for elsewhere on the unit, and was providing care on a hall to which he was not assigned. The facility substantiated the allegation of sexual abuse, demonstrating a failure to protect the resident from sexual abuse by staff.
Inaccurate MDS Fall Assessment: A resident with severe cognitive impairment and multiple diagnoses had a quarterly MDS that incorrectly indicated no falls since admission or the prior assessment. The MDS coordinator stated they review documentation to complete the MDS and acknowledged the falls were not accurately coded on the assessment.
A cognitively intact resident with multiple medical conditions was subjected to sexual abuse by a CNA who was unaccounted for during their shift and provided care in an unassigned area. The facility failed to prevent unauthorized staff access and did not adequately supervise staff, resulting in a substantiated incident of sexual abuse.
A facility failed to assess and monitor the use of bed rails for a resident with multiple diagnoses, including diabetes and obesity. The resident's bed had an ill-fitting mattress and quarter rails, with no informed consent or proper safety assessments conducted. The DON was unaware of the rail use and unsure of the responsibility for bed safety assessments.
A resident with paraplegia and diabetes mellitus was not assisted out of bed for several days due to inadequate staffing at the facility. Despite having a physician's order to be up in a chair daily, the resident remained in bed, and their room was observed to be unclean. Staff interviews confirmed that staffing shortages prevented CNAs and LPNs from completing required tasks, and housekeeping staff reported insufficient personnel to maintain cleanliness.
The facility did not post updated nurse staffing information daily in a high visibility area. Observations on multiple days revealed that the staffing board, located at the nurses' station near the front door, displayed outdated data. The DON confirmed that the staffing information was not updated daily as required.
A facility failed to administer Eliquis as ordered for a resident with multiple diagnoses, including acute embolism and thrombosis. Despite hospital discharge orders specifying the dosage, the resident's MAR did not document the administration of Eliquis. An LPN admitted the resident and entered the orders into the system, but the medication was not given. The DON confirmed the oversight after reviewing the orders.
The facility failed to implement enhanced barrier precautions for three residents requiring such measures. A resident with multiple diagnoses had signage for gown and glove use, but an LPN was unaware of the precautions. Another resident with ESBL in the urine had PPE available, yet a CNA did not use it during care. Additionally, a resident with a stage four pressure ulcer did not receive proper gown use from an LPN and ADON during wound care.
A resident's room was consistently found to be unclean, with full trash cans, soiled linens on the floor, and food debris present. The resident, who has paraplegia and diabetes, reported inadequate housekeeping services. Staff interviews revealed that insufficient housekeeping staff led to rooms not being cleaned properly.
A resident with paraplegia and diabetes, dependent on staff for transfers, was not assisted out of bed despite a physician's order to be up daily. The resident reported not being out of bed for several days, and staff confirmed this, citing understaffing as a reason for the lack of assistance.
A facility failed to perform weekly skin assessments for a resident with conditions like diabetes and obesity, as required by their care plan. The assessments were not completed in June, leading to the resident experiencing discomfort and developing pressure areas on both hips. These areas were discolored and at risk of opening if untreated, as confirmed by an LPN and the DON.
A facility failed to comply with regulations for administering psychotropic medications to a resident with dementia. Seroquel was prescribed without an appropriate diagnosis, and Ativan was ordered PRN without a 14-day stop date. The MAR showed frequent administration of both medications. The DON acknowledged responsibility for ensuring compliance with these requirements.
A resident with dementia had a progress note indicating their hand was deep purple, swollen, and painful, and the physician was notified. However, the medical director later stated that the report they received did not mention pain or discoloration. A text message to the doctor reported the hand as swollen and not painful, with a photograph that did not show discoloration.
A facility failed to inspect bed frames, mattresses, and bed rails regularly, leading to a deficiency in the care of a resident using side rails. The resident's mattress did not fit the bed frame, exposing the metal frame and requiring rolled blankets for adjustment. The DON was unaware of the resident's use of quarter rails and admitted to a lack of routine safety assessments, despite the facility's policy requiring such checks.
Failure to Protect a Resident From Sexual Abuse by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by staff. A cognitively intact resident with a BIMS score of 15, and diagnoses including heart failure, DVT, HTN, depression, and bipolar disorder, was care planned as independent with dressing, transfers, and toileting, requiring no staff assistance for these tasks. There was no documentation indicating any prior history of the resident seeking sexual encounters with caregivers. Despite this, a CNA entered the resident’s room around the time of or after a late-night shower and remained there for an extended period, during which the resident later reported engaging in oral sex and attempted intercourse with the CNA. The resident provided a handwritten statement describing that after taking a shower between approximately 12:30 a.m. and 1:00 a.m., the CNA came into the room, offered help with dressing, and then initiated oral sex followed by an attempt at intercourse. The resident stated they were not forced and characterized the encounter as consensual or out of curiosity. The DON and administrator both documented interviews in which the resident consistently reported having performed oral sex on the CNA in the shower and again in the room, and that they attempted intercourse. Other staff statements corroborated the CNA’s unexplained presence with the resident at that time, including one CNA who noted that the CNA was in the resident’s room for an unusually long period and could not be located elsewhere on the unit. Additional staff and APS documentation further detailed the resident’s account that the CNA rubbed the resident’s chest area, placed the resident’s hand on the CNA’s genital area, exposed himself, and that the resident then performed oral sex, followed by an attempt at sexual intercourse while the CNA commented that the resident was “tight.” The administrator acknowledged awareness of the sexual abuse allegation and that the CNA had been providing care to the resident on a hall to which the CNA was not assigned and was unaccounted for approximately 45 minutes during the shift. The facility ultimately substantiated the allegation of sexual abuse based on the consistency of the resident’s description and the alignment of staff interviews with the reported timeline, establishing that the resident was not protected from sexual abuse by a staff member.
Inaccurate MDS Fall Assessment
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to accurately complete a quarterly assessment for Resident #28 related to falls. The assessment dated 11/25/25 listed a BIMS score of 03, indicating severe impairment in daily decision making, and included diagnoses of hypertension, non-Alzheimer's disease, anxiety disorder, depression, and psychotic disorder. However, Section J of the assessment indicated the resident had no falls since admission, reentry, or the prior assessment. During interview on 12/17/25 at 3:36 p.m., the MDS coordinator stated they ensured MDS accuracy by reviewing documentation and completing the assessment themselves, and that falls were to be added to the assessment and care plan when a resident had a fall. After reviewing the quarterly assessment for Resident #28, the MDS coordinator stated the falls were not accurately coded.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from sexual abuse by staff. The incident involved a cognitively intact resident with diagnoses including heart failure, DVT, hypertension, depression, and bipolar disorder. The facility's records indicated that a certified nursing assistant (CNA) was found to be missing from their assigned area for 45 minutes during a shift and was discovered to have been providing care to the resident on a hall where they were not assigned. An investigation substantiated that an oral sex interaction occurred between the CNA and the resident. The failure to ensure the resident's safety and prevent unauthorized staff access led to the substantiated incident of sexual abuse. The facility's lack of adequate supervision and monitoring of staff assignments contributed to the occurrence of the abuse, as the CNA was able to interact with the resident without detection for a significant period of time.
Failure to Assess and Monitor Bed Rail Use
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for a resident, leading to a deficiency. The resident, who had diagnoses including diabetes mellitus, morbid obesity, and hypertension, was observed using a halo rail/Ubar on their bed to assist with turning and repositioning. However, the facility did not conduct a proper assessment for the use of side rails, nor did they ensure the mattress fit correctly on the bed frame. Additionally, there was no informed consent obtained prior to the use of side rails, and the facility did not monitor the safety and maintenance of the side rails. The Director of Nursing (DON) was unaware of the resident's use of quarter rails and acknowledged that the mattress did not fit the bed frame. The DON was also unsure about who was responsible for assessing and monitoring the beds for safety and the use of rails. It was noted that the bed frame and rails should be assessed at least monthly, but there was no evidence of such assessments or monitoring being conducted. The DON provided a side rail consent form and a restraints assessment for the resident, but these documents were completed without a date, indicating they were likely filled out after the surveyor's inquiry.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of a resident with paraplegia and diabetes mellitus, identified as Resident #33. The resident was dependent on staff for transfers and had a physician's order to be up in a chair daily to facilitate wound healing. However, the resident reported not being assisted out of bed since the previous week, despite expressing a desire to do so. Observations confirmed the resident's room was not maintained in a clean condition, with full trash cans, soiled linens on the floor, and food debris present. Staff interviews revealed that the resident had not been assisted out of bed due to staffing shortages, with CNAs and LPNs acknowledging that required tasks were not always completed. Housekeeping staff also reported insufficient staffing levels, which impacted their ability to maintain cleanliness in the resident's room. The housekeeping supervisor and a housekeeper both confirmed that rooms were not being deep cleaned appropriately due to a lack of staff. The CNA responsible for the resident's care stated they were often the only aide on the hall and were frequently pulled away, preventing them from assisting the resident as needed. This deficiency highlights the facility's failure to provide sufficient nursing and housekeeping staff to meet the needs of its residents, as outlined in their policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily in a high visibility area, as required. On June 17, 2024, at 10:35 a.m., the nurse staffing board was not observed in any high visibility area. Subsequently, on June 19, 2024, at 12:44 p.m., a staffing board was found posted at the nurses' station near the front door, but the data was dated June 18, 2024. This outdated information was still posted on June 20 and June 21, 2024, indicating that the staffing data had not been updated daily as required. The Director of Nursing (DON) confirmed that the staffing data was supposed to be updated daily but acknowledged that it was not.
Failure to Administer Anticoagulant Medication as Ordered
Penalty
Summary
The facility failed to administer medication as ordered by the physician for a resident who was reviewed for unnecessary medication. The resident had diagnoses including acute embolism and thrombosis of unspecified deep veins of the lower extremity, cardiomyopathy, chronic systolic heart failure, hemiplegia to the left nondominant side, and anemia. A five-day assessment documented that the resident was cognitively intact and was receiving an anticoagulant medication. A hospital discharge order specified that the resident was to receive Eliquis 10mg by mouth twice a day for six days, then decrease to 5mg by mouth twice a day. However, the resident's Medication Administration Record (MAR) for June 2024 did not document that the resident received Eliquis as ordered. An LPN admitted the resident from the hospital and stated that physician orders were entered into the computer and faxed to the pharmacy, but was unsure why the medication was not on the MAR or why Eliquis had not been given. The Director of Nursing reviewed the hospital physician orders and confirmed that the resident had not received Eliquis as ordered.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program for enhanced barrier precautions (EBP) for three residents. Resident #29, who had multiple diagnoses including obstructive and reflux uropathy and diabetes mellitus, had signage indicating the need for gown and gloves, but an LPN was unaware of the precautions required. Despite the Director of Nursing (DON) stating that staff had been in-serviced on EBP, the lack of awareness by the LPN indicated a failure in implementing the program effectively. Resident #51, diagnosed with neuromuscular dysfunction of the bladder and other conditions, required EBP due to ESBL in the urine. Although signage and personal protective equipment (PPE) were available, a CNA failed to wear the necessary gown and gloves during catheter care and dressing assistance. The CNA acknowledged the oversight, and the DON confirmed the requirement for PPE. Similarly, Resident #46, with a stage four pressure ulcer, required EBP, but an LPN and the Assistant Director of Nursing (ADON) did not wear gowns during wound care, acknowledging the lapse afterward.
Failure to Maintain Clean Environment Due to Staffing Issues
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for a resident diagnosed with paraplegia and diabetes mellitus, who was dependent on staff for transfers. Observations of the resident's room over several days revealed consistent issues with cleanliness. The trash can was full, soiled linens were piled on the floor, and the floor was discolored and sticky. Additionally, soiled gloves and food debris were repeatedly found in the room, indicating a lack of proper cleaning. Interviews with the resident and staff highlighted systemic issues contributing to the deficiency. The resident expressed dissatisfaction with the housekeeping services, stating that they did not perform adequately. The housekeeping supervisor and a housekeeper both acknowledged that the rooms were not being cleaned properly due to insufficient staffing. The supervisor noted that CNAs were responsible for ensuring dirty linens were not left on the floor, but ultimately, housekeeping was responsible for maintaining cleanliness, which was not being achieved due to staffing shortages.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident diagnosed with paraplegia and diabetes mellitus. The resident was dependent on staff for transfers and had a physician's order to be up in a chair daily to aid wound healing. Despite this, the resident reported not being assisted out of bed since the previous week. Observations and interviews with staff confirmed that the resident had not been out of bed for several days. A CNA mentioned being unable to assist the resident due to being frequently pulled away and being the only aide on the hall. An LPN also confirmed not seeing the resident out of bed since late the previous week.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to complete weekly skin assessments as ordered for a resident with a potential for impaired skin integrity due to conditions such as diabetes mellitus, morbid obesity, and hypertension. The care plan indicated the need for weekly skin assessments to identify any new skin abnormalities, with documentation and physician notification required every Monday evening shift. However, the assessments were not conducted in June 2024, as confirmed by the Director of Nursing. Observations revealed that the resident experienced discomfort and had pressure areas on both hips, which were discolored and at risk of opening if left untreated.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications for a resident diagnosed with dementia. A physician's order dated April 4, 2024, prescribed Seroquel, an antipsychotic, to be administered at bedtime for dementia, which lacks an appropriate diagnosis for such medication. The Medication Administration Record (MAR) for April 2024 showed that Seroquel was administered 25 times. Additionally, a physician's order dated May 5, 2024, prescribed Ativan, an anti-anxiety medication, to be given every six hours as needed for agitation, without a 14-day stop date for the PRN order. The MAR for May 2024 documented that Seroquel was administered 31 times and Ativan 16 times. By June 19, 2024, Seroquel had been administered 18 times and Ativan 9 times. The Director of Nursing (DON) acknowledged the responsibility to ensure the PRN order had an end date and that the psychotropic medication had an appropriate diagnosis.
Inaccurate Resident Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy of resident records for a resident diagnosed with dementia. A progress note dated April 30, 2024, documented that the resident's hand was deep purple, swollen, and painful, and that the physician was notified. However, on June 20, 2024, the medical director stated that the report they received did not include information about pain or discoloration. An observation of a text message revealed that the staff reported to the doctor that the hand was swollen and not painful, and included a photograph that did not show discoloration of the resident's hand.
Failure to Inspect Bed Safety Equipment
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to a deficiency in the care of a resident who used side rails. The facility's policy prohibited the use of bed rails unless specific criteria were met and required that bed frames, mattresses, and bed rails be checked for compatibility to prevent entrapment risks. However, the facility did not adhere to this policy, as evidenced by the lack of routine inspections by maintenance staff to identify potential risks and problems. The deficiency was identified during an observation where a resident was found lying in bed with a mattress that did not fit the bed frame, leaving the metal frame exposed from midway down. Rolled blankets were used between the mattress and the quarter rails, indicating an improper fit. The DON was unaware of the resident's use of quarter rails and admitted that the mattress did not fit the bed frame. Furthermore, the DON was unsure who was responsible for assessing and monitoring the safety of beds and rails, although they acknowledged that such assessments should occur at least monthly. The resident had been using the current bed since 2019, highlighting a prolonged period without proper inspection.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sand Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sherwood Manor Nursing Home | 5.2 mi | ★★★★★ | 0 | 0 |
| Saint Simeons Episcopal Home | 6.4 mi | ★★★★★ | 0 | 0 |
| Covenant Living At Inverness | 7.4 mi | ★★★★★ | 0 | 0 |
| Colonial Manor Nursing Home | 8.6 mi | ★★★★★ | 2 | 0 |
| Ambassador Manor Nursing Center | 9.1 mi | ★★★★★ | 4 | 0 |
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