Sandstone Heights

Inspectors wroteThe facility reported a census of 22 residents, with 11 residents sampled, including six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were implemented to prevent falls for three residents. Resident (R)14 had multiple falls with no fall prevention interventions placed and fell on [DATE] at approximately 07:20 AM, which resulted in a fractured (broken bone) right hip that required hospitalization and surgical repair. The facility also failed to investigate, develop, and implement fall prevention interventions to prevent multiple falls for R9 and R10.

Inspectors wroteThe facility reported a census of 22 residents. Based on interview and record review, the facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all nursing personnel.

Inspectors wroteThe facility had a census of 22 residents. The sample included 11 residents with three reviewed for discharge. Based on observation, record review, and interviews, the facility failed to provide a written bed hold policy notice to Residents (R) 3, R14, and R 9, or the resident's representatives, when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R3, R14, and R19.

Inspectors wroteThe facility reported a census of 22 residents and included 11 residents sampled and reviewed for care plan revision. Based on observations, interviews, and record reviews, the facility failed to ensure the care plans were reviewed and revised to develop and implement appropriate interventions to prevent multiple falls for three residents, Resident (R) 9, R10 and R14. These deficient practices resulted in ongoing increased risk of falls and had the potential to lead to uncommunicated needs that would negatively affect the physical and psychosocial well-being of the residents.

Inspectors wroteThe facility reported a census of 22 residents. Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions for the residents of the facility. Finings included: - On 03/11/25 at 01:34 PM, kitchen tour with Dietary Aide (DA) K, revealed the following areas of concern: 1. Thirteen cookie sheets/pans with brown, dried, caked on substance on the exterior and the interior corners and cooking surfaces of each pan. Pans were in a upside down position, one on top of other, which resulted in the outside of one pan in direct contact with the cooking surface of the next pan. The surfaces were unsanitizable. 2. [...]

Inspectors wroteThe facility reported a census of 27 residents. The sample included 15 residents with facility held personal fund accounts, reviewed for misappropriation and exploitation. Based on observation, interview, and record review the facility failed to ensure a system in place for the accurate accounting and reconciliation of resident fund accounts to prevent staff misappropriation and exploitation. The facility kept 14 manilla envelopes, each labeled with a resident's name, for the personal funds of Resident (R) 1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14. Observation of the 14 envelopes revealed no paper cash in any of the 14 envelopes. R15 elected the facility as the payee and responsible party for her finances. The facility kept R15's money in a bank account with a debit card available. [...]

Inspectors wroteThe facility reported a census of 26 residents. Based on observation, interview and record review, the facility failed to have Registered Nurse (RN) coverage for at least eight continuous hours on 07/31/22 as required. This placed the residents in the facility at risk for unsupervised nursing care and services.

Inspectors wroteThe facility reported a census of 26 residents. Based on observation, interview and record review the facility failed to maintain an effective infection control program with the failure of staff to provide appropriate perineal (the area of the body between the anus and genitals) care and urinary catheter (a hollow flexible tube that collects urine and leads to a collection bag) care for Resident (R)3, failure of the staff to sanitize equipment between resident use, failure to contain soiled laundry in appropriate containers and failure to maintain cleanable surfaces in the laundry area. This deficient practice with potential to negatively affect infection control for all residents in the facility.

Inspectors wroteThe facility reported a census of 26 residents. Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for residents and staff in the facility laundry.

Inspectors wroteThe facility reported a census of 26 residents and identified seven that received stock medication of magnesium oxide and multivitamins. Based on observation, interview, and record review the facility failed to monitor and ensure administration of nonexpired medication to these seven residents who received expired stock medication of magnesium multivitamin 400 milligrams. The seven affected residents included (R)1, R3, R5, R18, R22, R26, and R27.

Inspectors wroteThe facility reported a census of 26 residents with 12 selected for review. Based on interview, observation, and record review, the facility failed to protect the dignity of R3 when the environment around the resident and in her room contained the foul urine odors.

Inspectors wroteThe facility reported a census of 26 residents with 12 selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the MDS for Resident (R)15 and R3, with administration of oxygen. This placed the resident at risk for uncommunicated care needs.

Inspectors wroteResident #29 Discharge Dx: pain, bph, htn, CAD, presence of right artificial shoulder joint, aftercare following joint replacement surgery MDS: 3/15/23 admission MDS: BIMS: 15, TSS: 0, no behaviors, required limited assistance of one staff for all cares, was receiving PT/OT, indicates discharge plan was for resident to return to the community. CAAs: ADL:Resident is here in facility post R shoulder surgery due to osteoarthritis. Resident has an amputated L arm at the shoulder. He is here for a short stay for skilled services thru PT and OT. Resident currently has a sling with cushion and he is not to be doing own cares to promote healing. He requires toileting assistance due to inability to adjust clothing or to provide peri-care, but he remains continent of bowel/bladder. [...]

Inspectors wroteThe facility had a census of 26 residents, with 12 sampled residents with two closed records reviewed. Based on record review, and interviews, the facility failed to provide a recapitulation of stay (summary of stay) upon discharge from the facility for Resident (R)29. This deficient practice placed R29 at risk for an interruption in the continuity of care.

Inspectors wroteThe facility reported a census of 26 residents, with 12 sampled, including one resident sampled for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide adequate assistance with personal hygiene care for the one sampled Resident (R) 3 related to incontinence care, cleaning of body folds and care of the perineum (area of the body between the genitals and the anus), to maintain adequate personal hygiene.

Inspectors wroteThe facility census totaled 23 residents residing on two halls. Based on interview and record review the facility failed to designate one or more individuals as the infection preventionist, who completed specialized training in infection prevention and control, and would be responsible for the facility's infection control program. This had the potential to affect all residents in the facility.

Inspectors wroteThe facility census totaled 23 residents residing on 2 units. Based on interview and record review the facility failed to culture infections to ensure the appropriate use of antibiotics for three residents with urinary tract infections (UTI) and one resident with a wound infection for Resident (R) 12, R20, R5, and R14.

Inspectors wroteThe facility reported a census of 23 residents. Based on observation, interview, and record review the facility failed to keep the resident environment free of accident hazards by the failure to keep hazardous chemicals locked away for resident safety. Findings Include: - During initial tour on 11/02/21 at 07:25 AM observation revealed of a 14-ounce aerosol spray can of Asepticare Virucide (Disinfectant Germicidal Deodorizer) with a warning label to keep out of reach of children, located in an unlocked cabinet on a resident hallway. On 11/02/21 at 07:40 AM Administrative Nurse B stated she expected all hazardous chemicals in the cabinet to be locked up. On 11/02/21 at 07:40 AM revealed Administrative Nurse B had removed the Asepticare Virucide spray and placed it in a safe, locked location. [...]

Inspectors wroteThe facility reported a census of 23 residents. The facility had one medication room where medications were stored. Based on observation, interview, and record review the facility failed to date two opened vials of injectable Aplisol (tuberculin PPD, diluted, is a sterile aqueous solution of a purified protein fraction for intradermal administration as an aid in the diagnosis of tuberculosis). The facility further failed to ensure staff disposed of Aplisol in the recommended time frame with multiple doses remaining in the four vials and accessible for use, as stored in the medication refrigerator.

Inspectors wroteThe facility census totaled 23 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure a sanitary environment when staff did not change gloves when going from dirty to clean areas while changing the brief of Resident (R) 3.