Inspection Reports for
Sandstone Estates

Onsite investigation of intakes May 8-9, 2025. One deficiency cited related to facility premises and equipment maintenance.

The facility failed to provide adequate supervision to resident #3, who was identified as an elopement risk and exhibited wandering and agitation behaviors. Despite multiple staff interviews and documented behavioral notes indicating the resident's risk and attempts to leave, the resident eloped from the facility and was found at a bus stop. The facility did not move the resident to a secured unit until after the elopement incident.

Recertification survey for Medicare under Life Safety Code 2012 conducted October 29, 2024. Two deficiencies cited related to smoke barrier construction and gas equipment storage.

The complaint investigation was substantiated regarding narcotic diversion by an LPN (Staff #220) who was terminated. Multiple allegations of abuse and neglect were investigated for residents #11, #13, and #33, with findings of failure to report and protect residents. The facility failed to report allegations timely to the state and other authorities. The investigation revealed multiple failures in abuse prevention, reporting, and investigation.

The facility failed to prevent narcotic diversion by an LPN, failed to implement and report allegations of abuse timely for multiple residents, failed to protect residents from further abuse during investigations, failed to follow physician orders properly, failed to ensure medication error rates were below 5%, failed to provide timely hygiene care, failed to ensure expired medications were discarded, failed to prevent unnecessary medications, failed to ensure medication administration infection control, and failed to provide palatable and safe food temperatures.

Recertification survey conducted October 21-24, 2024 with investigation of complaints. Twelve deficiencies cited related to abuse reporting, medication errors, care planning, infection control, and food safety.

The complaint investigation was substantiated. The facility identified over 34 orders started and discontinued in the same shift by the LPN, with falsified prescriptions. No harm occurred to patients. The LPN was terminated and authorities were notified.

The facility failed to prevent misappropriation of resident medications by an LPN who falsified prescriptions and diverted narcotics. The investigation substantiated the complaint, resulting in the termination of the LPN and implementation of corrective measures to prevent recurrence.

Onsite complaint survey conducted April 27 and May 5, 2023 for investigation of intakes. Four deficiencies cited related to abuse, neglect, quality of care, and care planning.

The complaint investigation found substantiated neglect related to delayed notification of low blood pressure and delayed treatment for resident #55, who developed severe sepsis and expired. The facility failed to monitor and communicate significant changes in condition timely.

The facility failed to timely notify the physician of the resident's low blood pressure and delayed interventions, resulting in the resident developing severe sepsis and ultimately expiring. Documentation gaps and delayed communication were noted, along with failure to monitor and treat the resident's condition promptly.

Recertification survey conducted February 1, 2023 for Medicare under Life Safety Code 2012. Eleven deficiencies cited related to emergency preparedness, fire safety, electrical systems, and gas equipment storage.

The facility was found deficient in multiple areas including failure to complete significant change assessments, incomplete care plans for pressure ulcers, inadequate treatment and monitoring of wounds, failure to prevent pressure ulcers, unsafe environment hazards, medication management issues including expired medications and unsecured medications, failure to maintain adequate RN staffing, and inaccurate clinical documentation.

The facility was found deficient in multiple areas including failure to obtain psychotropic medication consents timely, incomplete advance directives documentation, untimely resident assessments, incomplete care plans for dialysis, unsafe discharge medication practices, inadequate assistance with activities of daily living, inconsistent fall interventions, insufficient dialysis monitoring, medication availability issues, failure to hold medications per parameters, improper medication monitoring, unlabeled medications and glucose solutions, food safety violations, and inadequate infection control practices including PPE use.