Inspection Reports for
Sandstone Estates

The complaint investigation found that resident #3, who had severely impaired cognition and was an elopement risk, eloped from the facility on April 24, 2025. The resident was found at a bus stop unharmed. Staff interviews revealed inadequate supervision and failure to move the resident to a secured unit despite known risks. The resident's family later approved placement on a secured unit.

The facility failed to ensure adequate supervision of resident #3, who was identified as an elopement risk and exhibited wandering and agitation behaviors. The resident eloped from the facility, was found at a bus stop, and the facility did not initially place her in a secured unit despite known risks. Interviews with staff confirmed lapses in supervision and delayed response to the resident's elopement risk.

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.

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.

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.

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 skin conditions, failure to maintain accurate and timely weight monitoring, medication management issues including expired medications and unsecured medications at bedside, failure to ensure RN coverage for 8 consecutive hours daily, and incomplete clinical documentation.

The facility was found deficient in multiple areas including failure to obtain psychotropic medication consents timely, incomplete advance directive documentation, failure to provide timely Medicaid/Medicare notices, incomplete resident assessments, inadequate care planning for dialysis, unsafe discharge medication practices, inadequate assistance with activities of daily living, inconsistent fall prevention interventions, dialysis care deficiencies, medication availability issues, improper medication administration outside ordered parameters, improper storage and labeling of medications and glucose solutions, food safety violations, and lapses in infection control practices including PPE use.