Sandy Ridge Center For Rehabilitation And Healing
SANDY RIDGE CENTER FOR REHABILITATION AND HEALING in MILTON, FL — inspection on February 25, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the resident when bathing.A review of Resident #1's bath documentation showed inconsistent
reflected 4 bed baths, 2 showers, and 2 refusals. In December 2025, the resident received 6 bed baths
documentation of a shower provided on 01/02/2026-prior to the resident reporting to her daughter that she had been taken to the shower and that her arm had been pulled.
During an interview with the MDS Coordinator on 02/25/2026 at 2:18 PM, she stated she was unsure why the care plan had been updated to include baths/showers following the reported shoulder fracture.
She also stated there was no clinical reason that would prevent the resident from using the shower, even with a history of a hip fracture and despite the family's expressed preference for bed baths.
During an interview with the Administrator and Director of Nursing on 02/25/2026 3:25 PM, they stated that Resident #1's injury investigation was closed based on the Nurse Practitioner's (NP) assessment that the fracture was pathological.
They explained that the NP reached this conclusion because no tissue damage or inflammation was observed.
While the plan of correction following the October fall mandated a two-person assist for bed baths, the facility could not explain why the care plan was edited to allow showers after the January incident.
The Administrator verbalized that the family preferred bed baths.
During an interview with the Nurse Practitioner on 02/25/2026 at 3:56 PM, he explained that he determined the fracture to be pathological rather than traumatic based on the resident's history of diffuse osteopenia and the absence of visible swelling or bruising.
When asked whether he was aware that the family had requested bed baths only and that this was reflected in the care plan, he stated he was not. He also stated he was unsure whether Resident #1 had been taken to the shower. He was informed that documentation showed the resident received a shower on 01/02/2026, that nursing staff had been notified of the resident's arm pain, and that he was contacted after Resident #1's daughter reported pain and noted swelling.
When asked if this injury could have been caused by pulling the resident's arm, he stated yes.
When asked if he discussed his findings with the radiologist who concluded Resident #1 had an acute fracture, he said no.
105552 02/25/2026
Sandy Ridge Center for Rehabilitation and Healing 5360 Glover Lane Milton, FL 32570
prevent accidents.
accidentˆprevention interventions for one resident (Resident #1) with a known history of fallˆrelated
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.
The facility reported the following corrective actions after the incident: All bed baths for Resident #1 are now conducted with two person assist.An interview and observation of Employee B, Certfied Nursing Assistant, on 02/25/2026 at 11:19 AM revealed that the facility uses a sticker system outside each resident's door to indicate the required level of assistance, with 1P meaning oneˆperson assist and 2P meaning twoˆperson assist. An observation of the sticker outside Resident #1's room indicated she requires a twoˆperson assist.A sign above Resident #1's bed stating 2ˆperson assist, bed bath only was observed on 02/25/2026 at 11:30 AM. Resident #1's daughter, who was present during the observation, reported that this sign had been in place since the resident's first injury in September 2025.
The daughters also stated Resident #1 informed them she sustained an injury while being showered in January. Resident #1 alleged staff pulled on her arm and hurt her.A review of Resident #1's radiology report from 01/05/2026 revealed: Acute left humeral neck fracture.During an interview with Employee D, Licensed Practical Nurse (LPN), on 02/25/2026 at 1:20 PM, she stated that bath preferences should be listed on each resident's care plan.A review of Resident #1's care plan and chart showed that it was updated on 10/02/2025, following the September 2025 injury, to require a twoˆperson assist for bed baths.
The care plan was later revised again on 01/07/2026, after the resident sustained a second injury, to indicate a twoˆperson assist for baths/showers.
Documentation also showed that the resident had been taken to the shower on 01/02/2026, along with six additional showers documented since September 2025.
During an interview on 02/25/2026 at 2:18 PM, the Minimum Data Set (MDS) Coordinator stated she was unsure why the care plan had been modified to include baths/showers after the January fracture.
She acknowledged that Resident #1's family preferred twoˆperson assist bed baths but maintained that there was no clinical contraindication that would prevent the resident from receiving a shower.An interview with Employee F, CNA, on 02/25/2026 at 3:13 PM revealed that she recalled assisting another CNA in bringing Resident #1 to the shower in January, prior to the resident's left arm injury.An interview with the Director of Nursing and the Administrator on 02/25/2026 at 3:25 PM confirmed they were aware that Resident #1's family preferred bed baths only with two staff assisting.
They were unable to explain the subsequent care plan changes that allowed for baths/showers.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.