Cura of Sandstone

In the surveyor’s words

From the most serious findings on record at Cura of Sandstone, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 4, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Apr 8, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF576Feb 13, 2025

  Based 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. Findings include: R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 was cognitively intact. R3's quarterly MDS assessment dated [DATE], indicated R3 was moderately cognitively impaired. R19's quarterly MDS assessment dated [DATE], indicated R3 was moderately cognitively impaired. R28's quarterly MDS assessment dated [DATE], indicated R28 was moderately cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF880Feb 13, 2025

  Based 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. Findings include: On 2/10/25 at approximately 2:15 p.m., during resident screenings the hand sanitizer dispensed from the hallway wall dispenser and the dispensers in resident rooms felt watery and was odorless. On 2/11/25 at 2:03 p.m., housekeeper (H)-A stated housekeeping was in charge of refilling the hand hygiene dispensers. […]

• No harm, potential for more than minimal, patternF760Jul 16, 2026

  Based 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. Findings include: R4 R4's Order Summary dated 3/01/26, indicated R4 had seizure disorder and diffuse traumatic brain injury with loss of conscious of unspecified duration. […]