Sandstone Heights

In the surveyor’s words

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

• Immediate jeopardy, patternF602Jan 16, 2024

  The 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. […]

• Actual harm, isolatedF689Mar 13, 2025

  The 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. […]

• No harm, potential for more than minimal, widespreadF851Mar 13, 2025

  The 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. Findings included: - Review of the PBJ Staffing Data Report for Fiscal Year (FY) for Quarter 1 - 2024 (October 1 - December 31), revealed the facility failed to have Licensed Nursing Coverage 24 hours/Day on the following dates: 10/14/24 Saturday (SA), 10/20/24 Friday (FR), 10/21/24 Saturday (SA), 10/22/24 Sunday (SU), 10/28/24 Saturday (SA), 11/19/24 Sunday (SU). […]

• No harm, potential for more than minimal, widespreadF727Jun 15, 2023

  The 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. Findings included: - The facility provided Daily Census Report, dated 06/12/23 documented 26 residents resided in the facility. On 06/12/23 at 10:30 AM, observation revealed 26 residents resided in the facility. Review of the nursing schedules for 07/01/22 through 08/31/22 documented one day without the required consecutive eight hours of RN coverage (07/31/22). Review of RN payroll documents for 07/01/22 through 08/31/22 revealed a lack of RN coverage on 07/31/22. […]

• No harm, potential for more than minimal, widespreadF880Jun 15, 2023

  The 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. […]