Cura of Sandstone

Inspectors wroteBased on interview and document review, the facility failed to ensure the facility staff administered medications without significant medication errors for 4 of 21 residents whose medication error reports reviewed. R4's Order Summary dated 3/01/26, indicated R1 had seizure disorder and diffuse traumatic brain injury with loss of conscious of unspecified duration. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had severe cognitive impairment, received anticonvulsant medications and had seizure disorder.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate infection control while providing laundry services, as well as failing to maintain an effective Infection Prevention and Control Program specific to infection surveillance. The facility's system did not track culture results, organisms identified, or transmission-based precautions (TBP) initiated to ensure residents received appropriate treatment and infection control measures were maintained. This had the ability to affect all 36 residents. In addition, the facility failed to ensure proper glove use and hand hygiene during care for 1 of 1 resident (R8) during completion of ADL cares.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow care planned interventions necessary to prevent an avoidable accident from occurring for 2 of 5 (R30, R14) residents reviewed for falls and accidents. In addition, the facility failed to ensure the safety of a resident with suicidal ideations and not following provider orders for safety precautions for 1 of 5 residents (R2) reviewed for accident hazards. Finally, the facility failed to evaluate a resident with an increased risk of aspiration for 1 of 1 residents (R8) reviewed for accident hazards.

Inspectors wroteBased on interview and document review the facility failed to notify family/guardian when a resident had a change of condition. This affected 1 of 1 (R8) resident reviewed for change of condition. Findings Include: R8's annual Minimum Data Set (MDS) dated [DATE] indicated R8 had moderate cognitive impairment. Diagnoses included dementia and epilepsy. The MDS indicated R8 was on a mechanically altered diet. R8's care plan undated, identified a potential for altered nutritional status due to hospice. Interventions included a mechanically altered textured diet and to observe, document, and report and signs or symptoms of dysphagia like pocketing, choking, coughing and holding food in mouth. R8's provider orders dated 3/19/25, identified a mechanical soft textured solid food diet with thin liquids. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure residents with constipation received assessment, effective intervention and notification of the provider for 2 of 5 residents (R2, R3) reviewed for unnecessary medications. This deficient practice had the potential for resident discomfort and medical complications related to constipation.

Inspectors wroteBased on interview and document review, the facility failed to perform a passive range of motion (PROM) program for 1 of 2 (R13) residents reviewed for restorative care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to attempt to elevate the head of bed (HOB) to prevent aspiration for a resident laying flat with tube feeding (TF) running. This effected 1 of 1 (R28) residents reviewed for TFFindings Include: R28's annual Minimum Data Set (MDS) dated [DATE] indicated R28 had moderate cognitive impairment. Diagnoses included abdominal distention and hemiplegia (complete to total muscle loss to one side of the body). R28 received TF with 51% or greater intake received through TF. R28's care plan undated, indicated a nutritional problem related to a diagnosis of hemiplegia. Interventions included to provide TF and water flushes as ordered. R28's care plan also indicated a risk for aspiration related to TF and inconsistent maintenance of HOB greater than 30 degrees secondary to resident preference/refusal. [...]

Inspectors wroteNumber of residents sampled: 1Number of residents cited: 1Based on interview and document review, the facility failed to ensure the facility antibiotic stewardship program was followed for antibiotic use for 1 of 1 resident (R13) reviewed for antibiotic use.

Inspectors wroteBased on observation, interview and document review the facility failed to develop care plans to include enhanced barrier precautions (EBPs) for 2 of 3 residents when nursing assistant (NA)-A was observed lacking required personal protective equipment (PPE) while performing high contact care for R2 who required EBPs.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow established infection control practices for 3 of 3 residents (R1, R2, R3) on enhanced barrier precautions (EBPs) while performing high-contact care.

Inspectors wroteBased on interview and document review, the facility failed to ensure safe transfer with a EZ Way smart lift, according to manufacturer's recommendations for 1 of 3 (R1) residents. This resulted in immediate jeopardy (IJ) when R1 fell out of the sling and sustained a contusion to the scalp, closed wedge compression fracture (front part of the vertebrae collapses) of T4 vertebra, and was sent to the Emergency Department (ED). The IJ began on 11/29/25 at 6:00 p.m., when staff, under the age of eighteen, used a full body mechanical lift to transfer R1 from her wheelchair to her bed, did not follow facility policy or manufacturer's instructions, and R1 fell out of the sling. The administrator, director of nursing, corporate nurse, and regional director of operations were notified of the IJ at 11:45 a.m. on 12/4/25. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure the right to weekend mail delivery occurred for 5 of 5 residents (R2, R3, R19, R28, R36) who were reviewed for weekend mail delivery. This deficient practice had the potential to impact all 41 residents who resided at the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure alcohol based hand sanitizer was in use in the hand hygiene dispensers throughout the facility. In addition, the facility failed to ensure oxygen tubing was changed timely for 1 of 1 resident (R11) reviewed for oxygen therapy.

Inspectors wroteBased on interview and document review, the facility failed to maintain a surety bond (a written agreement to guarantee payment of another company's obligation under a separate contract) to protect the account balance of the resident trust fund. This had the potential to affect 23 of 41 residents at the facility who had a trust account managed by the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure that temperature-controlled medications were properly stored for 6 of 6 residents (R10, R14, R17, R1, R19, R6) and any resident needing medications from the pharmacy-provided emergency kit, stock vaccine, and tuberculin testing medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provider orders for medication parameters were followed for 1 of 5 residents (R18) reviewed for unnecessary medications. In addition, the facility failed to ensure provider orders for a fluid restriction and daily weights were followed for 1 of 2 (R142) residents reviewed for hydration.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure aspiration precautions were followed for 1 of 2 residents (R24) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure oxygen was administered as ordered for 1 of 1 residents (R11) reviewed for oxygen therapy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure use of an as-needed (i.e., PRN) psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medication for 1 of 5 residents (R11) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure resident call lights were within reach from the bathroom floor in multi-resident bathrooms for 3 of 3 residents (R24, R11, R30) reviewed for call light accessibility.

Inspectors wroteBased interview and record review the facility failed to report misappropriation of resident's property to the state agency immediately, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 3 of 3 residents (R1, R2, and R3) when narcotic medications were missing and not accounted for out of resident's medications cards.

Inspectors wroteBased on observation, interview and document review the facility failed to provide privacy during personal cares for 1 of 5 residents (R143) observed during personal cares.

Inspectors wroteBased on observation, interview and document review, the facility failed to develop a comprehensive care plan to identify and direct staff to care for 1 of 1 resident (R11) reviewed for diabetic care.

Inspectors wroteBased observation, interview and document review the facility failed to provide timely assistance with toileting for 1 of 1 resident (R13) reviewed for activities of daily living and were dependent on staff assistance.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents were repositioned timely who were at risk for pressure ulcers for 2 of 2 residents (R13, R35) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure routine dental services were provided for 1 of 1 resident (R1) reviewed for dental services.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper hand hygiene was utilized during wound care for 2 of 6 residents (R143, R10) observed during wound care. In addition, the facility failed to ensure proper hand hygiene was completed during cares for 1 of 1 resident (R13) observed for cares.