Inspection Reports for
Sandstone Heights Nursing Home
440 STATE STREET, LITTLE RIVER, KS, 67457
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
10.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
61% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 22
Deficiencies: 5
Date: Mar 13, 2025
Visit Reason
Routine inspection of Sandstone Heights nursing home to assess compliance with regulatory standards including bed hold notifications, care plan revisions, fall prevention, food safety, and staffing submissions.
Findings
The facility failed to provide written bed hold notifications to residents transferred to hospitals, failed to review and revise care plans to prevent falls for multiple residents, failed to implement fall prevention interventions after multiple falls, failed to maintain sanitary food storage and preparation conditions, and failed to submit accurate staffing data to the federal agency.
Deficiencies (5)
F 0625: The facility failed to provide written bed hold policy notifications to residents or their representatives at the time of hospital transfer for residents R3, R14, and R9.
F 0657: The facility failed to review and revise care plans to develop and implement appropriate interventions to prevent multiple falls for residents R9, R10, and R14, resulting in ongoing fall risks.
F 0689: The facility failed to ensure adequate supervision and fall prevention interventions, resulting in multiple falls with injuries for residents R9, R10, and R14, including a fractured right hip for R14.
F 0812: The facility failed to store and prepare food under sanitary conditions, including unclean pans, rusty racks, uncovered and unlabeled food containers, and wet towels in the refrigerator.
F 0851: The facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ), inaccurately reporting licensed nursing coverage.
Report Facts
Residents census: 22
Residents sampled: 11
Residents reviewed for discharge: 3
Residents reviewed for care plan revision: 11
Residents reviewed for accidents: 6
Cookie sheets/pans: 13
Frying pans/skillets: 7
Dates with missing licensed nursing coverage in PBJ: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed 24-hour nursing coverage despite PBJ inaccuracies and described fall definitions and reporting |
| Administrative Nurse C | Administrative Nurse | Confirmed fall definitions, lack of care plan interventions, and fall investigation processes |
| Dietary Manager E | Dietary Manager | Confirmed food sanitation deficiencies and improper food storage practices |
| Certified Nurse Aide J | Certified Nurse Aide | Described fall reporting procedures and resident assessments after falls |
| Certified Medication Aide H | Certified Medication Aide | Described fall definitions and nurse notification procedures |
| Licensed Nurse G | Licensed Nurse | Described fall assessment and reporting procedures |
| Dietary Aide K | Dietary Aide | Reported on unsanitary kitchen conditions and food storage issues |
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 4
Date: Mar 13, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements including resident care, safety, food handling, and staffing.
Findings
The facility failed to review and revise care plans to prevent multiple falls for three residents, resulting in ongoing risk and actual harm including a fractured hip. Food storage and preparation were unsanitary, and the facility failed to submit accurate staffing data to the federal agency.
Deficiencies (4)
F 0657: The facility failed to review and revise care plans to develop and implement appropriate interventions to prevent multiple falls for Residents 9, 10, and 14, resulting in ongoing increased risk and actual harm including a fractured hip requiring surgery.
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent falls, resulting in actual harm to residents due to repeated falls without appropriate interventions or investigations.
F 0812: The facility failed to store and prepare food under sanitary conditions, including dirty pans, rusty racks, uncovered and unlabeled food containers, and wet towels in the refrigerator, risking foodborne illness.
F 0851: The facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ), inaccurately reporting licensed nursing coverage on multiple dates.
Report Facts
Residents sampled: 11
Residents census: 22
Falls documented for Resident 14: 6
Dates with missing licensed nursing coverage in PBJ: 6
Cookie sheets/pans with brown caked substance: 13
Frying pans/skillets with brown caked substance: 7
Unlabeled uncovered glasses of juice: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed 24-hour nursing coverage despite PBJ inaccuracies and discussed fall investigation process |
| Administrative Nurse C | Administrative Nurse | Confirmed fall definitions, lack of care plan interventions, and fall investigation procedures |
| Dietary Aide K | Dietary Aide | Reported unsanitizable pans and food storage issues in kitchen |
| Dietary Manager E | Dietary Manager | Confirmed food sanitation deficiencies and improper food storage |
| Certified Nurse Aide J | Certified Nurse Aide | Described fall reporting procedures and resident assessments |
| Certified Medication Aide H | Certified Medication Aide | Explained fall definitions and reporting |
| Licensed Nurse G | Licensed Nurse | Explained fall definitions and reporting |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: Jan 16, 2024
Visit Reason
The inspection was conducted due to concerns about misappropriation and exploitation of residents' personal funds, specifically involving an employee who was the payee for a resident and responsible for managing multiple resident fund accounts.
Complaint Details
The investigation was complaint-driven due to allegations of financial exploitation by a facility employee who was the payee for Resident 15. The complaint was substantiated with evidence of unauthorized cash withdrawals and purchases totaling thousands of dollars. The employee was terminated and law enforcement notified.
Findings
The facility failed to ensure accurate accounting and reconciliation of resident fund accounts, resulting in unauthorized withdrawals and purchases from a resident's bank account by a facility employee. The facility lacked oversight and a system to track resident funds, placing 15 residents at immediate jeopardy of financial exploitation.
Deficiencies (1)
F 0602: The facility failed to protect residents from misappropriation and exploitation of their personal funds. An employee used a resident's bank card for unauthorized withdrawals and purchases without consent. The facility lacked proper accounting and reconciliation systems for resident funds.
Report Facts
Residents with personal fund accounts: 15
Facility census: 27
Unauthorized cash withdrawals and purchases: 3000
Employment duration of responsible employee: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Staff D | Social Services Staff | Employee responsible for resident funds who misappropriated money and was terminated. |
| Administrative Staff A | Administrator | Reported findings of misappropriation, took over payee duties for Resident 15, and implemented corrective actions. |
| Administrative Nurse B | Administrative Nurse | Assisted in reconciling resident fund envelopes and oversight. |
Inspection Report
Annual Inspection
Census: 26
Deficiencies: 8
Date: Jun 15, 2023
Visit Reason
Annual inspection of Sandstone Heights nursing home to assess compliance with regulatory requirements including resident dignity, assessment accuracy, discharge planning, personal hygiene care, nursing coverage, medication management, infection control, and facility environment.
Findings
The facility failed to protect resident dignity due to foul urine odors, inaccurately completed MDS assessments for oxygen use, lacked discharge planning documentation, failed to provide adequate personal hygiene care, lacked required RN coverage for 8 continuous hours on one day, administered expired stock medications, failed infection control practices including inadequate perineal and catheter care, unsanitized equipment, and unsanitary laundry conditions, and failed to maintain a safe and sanitary laundry environment.
Deficiencies (8)
F 0557: The facility failed to protect the dignity of Resident 3 when the environment around the resident and in her room contained foul urine odors.
F 0641: The facility failed to accurately complete the MDS for Residents 3 and 15 regarding oxygen use, placing residents at risk for uncommunicated care needs.
F 0660: The facility failed to plan Resident 29's discharge to meet goals and needs, lacking discharge planning, recapitulation of stay, and interdisciplinary team documentation.
F 0661: The facility failed to provide adequate assistance with personal hygiene care for Resident 3, including inadequate incontinence care, cleaning of body folds, and perineal care.
F 0727: The facility failed to have Registered Nurse coverage for at least eight continuous hours on 07/31/22 as required, placing residents at risk for unsupervised nursing care.
F 0761: The facility failed to monitor and ensure administration of nonexpired stock medications, administering expired magnesium oxide and multivitamins to seven residents.
F 0880: The facility failed to maintain an effective infection control program, including failure to provide appropriate perineal and catheter care, failure to sanitize equipment between resident use, failure to contain soiled laundry properly, and failure to maintain cleanable surfaces in the laundry area.
F 0921: The facility failed to ensure a safe and sanitary environment in the laundry, including uncovered trash can with used PPE, unsanitizable cabinet surfaces, and broken/missing floor tiles.
Report Facts
Residents present: 26
Residents selected for review: 12
Expired medication days - Magnesium Oxide: 45
Expired medication days - Multivitamins: 58
Broken/missing floor tiles: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse J | Licensed Nurse | Prepared medications, confirmed expired medications, and provided statements on perineal care and equipment sanitization |
| Administrative Nurse B | Administrative Nurse | Confirmed findings related to dignity buckets, MDS documentation, RN coverage, medication expiration, infection control, and equipment sanitization |
| Certified Nurse Aide I | Certified Nurse Aide | Assisted Resident 3 with incontinence care and provided statements on dignity bucket use and perineal care |
| Laundry/Housekeeping Supervisor D | Laundry/Housekeeping Supervisor | Confirmed laundry area infection control and environmental concerns |
| Administrative Staff A | Administrative Staff | Confirmed laundry environmental concerns and discharge planning expectations |
| Social Services F | Social Services | Revealed lack of discharge planning and recapitulation of stay documentation |
Inspection Report
Annual Inspection
Census: 23
Deficiencies: 5
Date: Nov 4, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations and resident safety.
Findings
The facility was found deficient in maintaining a safe environment by failing to secure hazardous chemicals, properly date and dispose of medications, ensure sanitary infection control practices, monitor antibiotic use appropriately, and designate a qualified infection preventionist.
Deficiencies (5)
F 0689: The facility failed to keep hazardous chemicals locked away, posing accident hazards to residents.
F 0761: The facility failed to date and dispose of opened vials of injectable Aplisol, leaving outdated medications accessible.
F 0880: Staff failed to change gloves and perform hand hygiene when moving from dirty to clean areas during resident care.
F 0881: The facility failed to culture infections to ensure appropriate antibiotic use for residents with urinary tract and wound infections.
F 0882: The facility failed to designate a qualified infection preventionist with specialized training responsible for infection control.
Report Facts
Residents present: 23
Open vials of Aplisol: 4
Residents in infection sample: 12
Residents with UTI or wound infection: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Reported expectations for chemical storage, medication management, hand hygiene, and infection control oversight | |
| Administrative Nurse C | Participated in medication room observation and infection control oversight | |
| Certified Nursing Assistant D | Observed failing to change gloves and perform hand hygiene during resident care |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 27, 2018
Visit Reason
The inspection was conducted as a health survey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations, indicating full compliance with the regulatory requirements for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 27, 2018
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 10, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection related to resident falls and related care procedures.
Findings
The facility identified deficiencies related to resident fall assessments, triage policies, transportation after injury, and communication regarding falls. The Plan of Correction outlines staff education, updated procedures, and ongoing monitoring to prevent and manage falls.
Deficiencies (1)
F684-D Licensed nursing staff were educated on thorough resident assessments after falls, triage policy, and transportation expectations. The facility updated fall notification procedures, educated staff on accident prevention, and implemented regular meetings to monitor fall risks and interventions.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 29, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the facility's plan of correction.
Findings
All previously reported deficiencies were reviewed and marked as corrected with completion dates of 06/02/2017. No uncorrected deficiencies were noted at the time of this revisit.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 24, 2017
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Sandstone Heights Assisted Living dated 05/24/2017.
Findings
No deficiencies were cited during the referenced inspection.
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 6
Date: May 24, 2017
Visit Reason
The visit was a health resurvey to assess compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to update and revise care plans for pressure ulcer prevention and treatment, failure to obtain valid medical justification for indwelling catheter use, unsafe grab bar installation posing entrapment risk, unsecured hazardous chemicals accessible to residents, improper storage and labeling of food items, and expired medications in stock.
Deficiencies (6)
F280: The facility failed to update and revise the care plan for a resident with an unstageable pressure ulcer, lacking timely and effective interventions to prevent further skin breakdown.
F314: The facility failed to provide care consistent with professional standards to prevent and treat pressure ulcers, resulting in a facility-acquired unstageable pressure ulcer for a cognitively impaired resident.
F315: The facility failed to obtain a valid medical justification for the use of an indwelling urinary catheter for a resident, lacking appropriate diagnosis documentation.
F323: The facility failed to ensure the resident environment was free from accident hazards, including an unsafe grab bar with a large gap that posed entrapment risk, and unsecured hazardous chemicals accessible to cognitively impaired residents.
F371: The facility failed to store, prepare, distribute, and serve food under sanitary conditions, including unlabeled and undated opened food and beverage items in the nourishment refrigerator.
F431: The facility failed to ensure stock medications and vaccine vials were not expired in medication carts and medication room, placing residents at risk of receiving ineffective medications.
Report Facts
Resident census: 27
Pressure ulcer size: 6
Pressure ulcer size: 4
Medication expiration: 1
Medication expiration: 1
Medication expiration: 1
Grab bar gap width: 10.25
Grab bar gap distance from mattress: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Verified pressure ulcer development, medication expiration, unsecured chemicals, and catheter use findings | |
| Nurse Aide H | Reported resident did not have pressure relieving boots until after pressure ulcer developed | |
| Nurse J | Reported resident's pressure ulcer started as a blister and worsened | |
| Dr. K | Physician who verified resident's pressure ulcer and ordered pressure relieving boots | |
| Dietary Staff C | Reported responsibility for checking nourishment refrigerator | |
| Dietary Staff D | Verified opened food items should not be in nourishment refrigerator | |
| Nurse G | Reported resident's use of grab bar | |
| Nurse Aide F | Reported resident's use of grab bar |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 24, 2017
Visit Reason
The visit was a resurvey of the Assisted Living/Residential Healthcare facility to verify compliance following a previous inspection.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 1
Date: May 24, 2017
Visit Reason
The visit was a Health survey conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, specifically noncompliance with F314 related to Pressure Ulcers. Due to these deficiencies, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Deficiencies (1)
F314 Pressure Ulcers: The facility was noncompliant in preventing avoidable pressure ulcers and ensuring appropriate care to prevent worsening of existing pressure ulcers.
Report Facts
Denial of payment effective date: Jun 14, 2017
Noncompliance correction deadline: Nov 24, 2017
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Named as contact for questions regarding the enforcement action and informal dispute resolution |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 24, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report dated May 24, 2017.
Findings
The facility developed and implemented corrective actions to address deficiencies related to care plans, wound care, catheter diagnosis, assistive device use, nourishment refrigerator management, and medication management. The facility aimed to achieve substantial compliance by early June 2017.
Deficiencies (7)
F0000: The facility will develop and implement a facility-wide system to assure compliance with regulations.
F280-D: The care plan was updated with interventions for wound care including pressure relieving boots, dietary supplements, and wound treatments.
F314-G: Nursing staff were educated to inspect skin daily and care plans for high-risk residents were updated with wound prevention procedures.
F315-D: An appropriate diagnosis for catheter use was obtained and placed in EMAR and care plans; nursing staff were educated on CMS catheter diagnosis.
F323-E: A grab bar brought in by a family member was removed; staff were educated on assistive device policy and monitoring was implemented.
F371-F: Improperly labeled food items in the nourishment refrigerator/freezer were removed; dietary and nursing staff received in-service training on proper labeling and storage.
F431-E: Outdated medications were removed and disposed of; staff were educated on inventorying med carts and monitoring medication expiration dates.
Report Facts
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 17, 2017
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Report Facts
Effective date for denial of payments: Jun 17, 2017
Provider agreement termination date: Sep 17, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement actions. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 14, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies related to regulations 483.25 and 483.25(h) were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Sep 28, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Sandstone Heights.
Complaint Details
This Plan of Correction is related to deficiencies cited during a complaint investigation at Sandstone Heights on September 28, 2016.
Findings
The facility plans to develop and implement a facility-wide system to assure compliance with regulations. Nurses have been re-oriented on Change in Condition and Incident/Accident Occurrence policies, with monitoring by the Director of Nursing and Assistant Director of Nursing to ensure continued compliance.
Deficiencies (3)
F0000: The facility will develop and implement a facility-wide system to assure compliance with regulations and provide this form 2567 to the Quality Assurance and Assessment Committee for review and approval. The facility aims for substantial compliance by October 14, 2016.
F309-D: All nurses have been re-oriented on the Sandstone Heights Change in Condition Policy. Nurses understand change in condition statuses and notification procedures. The DON and ADON will monitor compliance.
F323-D: All nurses have been re-oriented on the Incident/Accident Occurrence Policy. Nurses understand procedures to follow in the event of a fall and notification requirements. The DON and ADON will monitor compliance.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Sep 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint Investigation #101597 and #105410 regarding care and supervision concerns.
Complaint Details
The findings represent the results of Complaint Investigation #101597 and #105410.
Findings
The facility failed to provide necessary care and services, including thorough assessment and pain management after a fall with injury for one resident. The facility also failed to ensure adequate supervision to prevent accidents, resulting in a resident fall and wrist fracture.
Deficiencies (2)
F 309: The facility failed to provide necessary care and services, including thorough assessment and pain management after a fall with injury for Resident #1.
F 323: The facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in Resident #1 falling and sustaining a wrist fracture.
Report Facts
Resident census: 31
Sample residents reviewed: 4
Pain medication dosage: 325
Fall time to assessment delay: 5
Visual check interval: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide A | Reported finding resident on floor and pain in left wrist. | |
| Nurse B | Stated staff should assess resident and check vital signs on condition change. | |
| Administrative Nurse C | Verified staff failed to complete thorough assessment and pain management after resident fall. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 28, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level, indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 10, 2016
Visit Reason
The document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The facility plans to develop and implement a system to assure compliance with regulations and update Assisted Living Negotiated Service Agreements as needed. The facility aims to be in substantial compliance by February 10, 2016.
Deficiencies (2)
The facility will develop and implement a facility-wide system to assure compliance with regulations. A complete copy of the Plan of Correction will be reviewed by the Quality Assurance and Assessment Committee.
The Director of Nursing reviewed and updated all Assisted Living Negotiated Service Agreements on January 26, 2016. Agreements will be reviewed annually or when resident status changes.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 10, 2016
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously cited deficiencies identified by regulation numbers 483.25(d), 483.25(l), 483.60(c), 483.65, and 483.75(o)(1) were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Feb 10, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The facility outlines corrective actions for deficiencies related to urinary catheter care, vital sign monitoring, medication regimen review, perineal care, and Medical Director attendance at Quality Assurance meetings. The facility aims to achieve substantial compliance by February 10, 2016.
Deficiencies (6)
F0000: The facility will develop and implement a facility-wide system to assure compliance with regulations and provide the Plan of Correction to the Quality Assurance and Assessment Committee for review and approval.
F315-D: All CNA's/CMA's have been retrained in urinary catheter care including sanitary procedures, glove use, perineal care, repositioning residents, and contamination prevention. Monitoring will be conducted by charge nurses and the DON.
F329-D: Charge nurses have been re-oriented on vital sign monitoring frequency and facility policy. Nurses have been re-trained on electronic medical records to ensure accurate charting. Monitoring will be done by the DON and ADON.
F428-D: The medication regimen review finding was reviewed with the Pharmacy Consultant and facility policy. The DON and ADON will monitor compliance and present findings to the Quality Assurance committee.
F441-F: CNA's/CMA's have been re-trained in perineal care and urinary catheter care including sanitary procedures, washing techniques, contamination avoidance, and disposal of materials. Monitoring will be conducted by charge nurses and the DON.
F520-F: The Medical Director has been invited to all Quality Assurance meetings and attendance will be scheduled during monthly visits. The Administrator will ensure continued compliance by verifying attendance.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 10, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency related to regulation 26-41-202(d) was corrected as of 2016-02-10. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 26-41-202(d) deficiency was corrected as of 2016-02-10.
Inspection Report
Re-Inspection
Census: 6
Deficiencies: 1
Date: Feb 1, 2016
Visit Reason
The inspection was a licensure resurvey of an Assisted Living/Residential Healthcare facility to assess compliance with negotiated service agreement review requirements.
Findings
The facility failed to ensure the review and, if necessary, revision of the negotiated service agreements at least once every 365 days for three sampled residents. The agreements for Residents #1, #2, and #3 had not been reviewed or revised since their admission dates in 2014.
Deficiencies (1)
26-41-202 (d) Negotiated Service Agreement Revisions: The facility failed to review and revise negotiated service agreements at least once every 365 days for Residents #1, #2, and #3 as required.
Report Facts
Census: 6
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Stated staff had not completed annual review of negotiated service agreements |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 1, 2016
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The survey identified 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 5
Date: Feb 1, 2016
Visit Reason
The inspection was a health resurvey to assess compliance with previously identified deficiencies related to catheter care, medication monitoring, infection control, and quality assurance.
Findings
The facility failed to provide proper catheter and perineal care to prevent urinary tract infections, failed to obtain scheduled blood pressure monitoring for multiple residents, failed to ensure pharmacist oversight of medication monitoring, failed to maintain proper infection control practices during catheter and incontinent care, and failed to ensure required attendance at Quality Assessment and Assurance committee meetings.
Deficiencies (5)
F 315: The facility failed to ensure proper treatment and services to prevent urinary tract infections when staff did not provide thorough personal hygiene care for 2 residents with urinary incontinence and catheter care.
F 329: The facility failed to obtain scheduled blood pressure checks as ordered by the physician for 3 residents and failed to ensure pharmacist oversight of medication monitoring.
F 428: The pharmacist failed to identify and report lack of blood pressure monitoring to the director of nursing for 3 residents, compromising medication regimen review.
F 441: The facility failed to ensure proper infection control practices during catheter and incontinent care, including improper handling of urinary drainage and contaminated washcloth use.
F 520: The facility failed to ensure required Quality Assessment and Assurance committee members attended meetings, limiting the committee's ability to identify and correct quality deficiencies.
Report Facts
Resident census: 27
Sample size: 14
Residents reviewed for medications: 5
Blood pressure checks missed: 128
Blood pressure checks documented: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 19, 2015
Visit Reason
This document is a Plan of Correction report completed by a state surveyor to show deficiencies previously reported on the CMS-2567 and the dates such corrective actions were accomplished.
Findings
The report lists previously identified deficiencies and confirms their correction status with dates. No new deficiencies or findings are detailed in this document.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected with completion date 12/14/2015.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 19, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Sandstone Heights.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation at Sandstone Heights.
Findings
The facility was cited for deficiencies related to resident safety involving lift chair assessments and care plan compliance. The plan outlines corrective actions including assessments, staff training, and monitoring to ensure compliance.
Deficiencies (2)
F0000: The facility will develop and implement a facility-wide system to assure compliance with regulations and provide this plan to the Quality Assurance and Assessment committee for review and approval by December 14, 2015.
F323-G: A lift chair assessment was done on Resident 1 after a fall on 10/23/2015 and the lift chair was disabled to prevent accidental operation. All nurses will complete a matrixcare e-learning module and ongoing assessments will be conducted for residents using lift chairs.
Report Facts
Date of fall: Oct 23, 2015
Plan of Correction completion date: Dec 14, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Date: Nov 19, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#93178) regarding the facility's failure to provide adequate supervision and accident prevention for a resident with a history of falls.
Complaint Details
The complaint investigation #93178 found the facility failed to supervise Resident #1 adequately, who had multiple falls from an electric recliner, culminating in a cervical fracture. The care plan lacked timely updates and interventions after falls, and staff did not evaluate the resident's safe use of the recliner until after the third fall.
Findings
The facility failed to provide adequate supervision and timely interventions to prevent accidents for Resident #1, who had severe cognitive impairment and a history of falls, resulting in a third fall from an electric lift recliner causing a cervical fracture.
Deficiencies (1)
483.25(h) The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision or timely interventions to prevent falls for Resident #1. The resident sustained a cervical fracture after sliding out of an electric lift recliner three times without appropriate care plan updates or safety evaluations.
Report Facts
Resident census: 28
Fall risk score: 20
Number of falls: 3
Days delay: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide A | Nurse Aide | Reported resident's confusion and interaction with recliner controls |
| Nurse Aide B | Nurse Aide | Reported lack of instruction to watch resident's use of recliner controls |
| Nurse C | Nurse | Reported increased confusion of resident and use of recliner controls |
| Administrative Nurse E | Administrative Nurse | Verified three falls from recliner and lack of prior safety evaluation |
| Nurse D | Nurse | Reviewed care plan after fall but did not make changes; unaware of safety evaluation |
| Physician F | Physician | Stated expectation for facility to evaluate resident's safe use of electric recliner after recurrent falls |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 19, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be a 'G' level. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions will be imposed until compliance is achieved.
Deficiencies (1)
The most serious deficiency found in the facility was a 'G' level deficiency as per Title 42, Code of Federal Regulations.
Report Facts
Denial of payment effective date: Feb 19, 2016
Denial of payment effective date: Feb 19, 2015
Termination recommendation date: May 19, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named in relation to instructions about informal dispute resolution and enforcement actions. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Oct 1, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously identified deficiencies related to regulations 483.25, 483.25(d), and 483.25(h) were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.25 deficiency was corrected by 10/01/2015.
Regulation 483.25(d) deficiency was corrected by 10/01/2015.
Regulation 483.25(h) deficiency was corrected by 10/01/2015.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 24, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions and related to the survey findings. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 3
Date: Sep 24, 2015
Visit Reason
The inspection was conducted as a complaint investigation for allegations related to care and services at Sandstone Heights nursing facility.
Complaint Details
The inspection was triggered by complaint investigations #90779 and #91096. The findings substantiated failures in resident care, assessment, infection prevention, and safe transfer practices.
Findings
The facility failed to provide thorough, timely, and accurate assessments for residents, failed to prevent urinary tract infections related to catheter care, and failed to provide safe transfers using mechanical lifts, resulting in resident harm and safety concerns.
Deficiencies (3)
F 309: The facility failed to provide a thorough, timely, and accurate assessment for Resident #3 during an episode of low blood sugar after insulin administration and after weight gain and swelling.
F 315: The facility failed to provide appropriate treatment and services to prevent urinary tract infections for Residents #2 and #3 with indwelling urinary catheters, including improper catheter care and infection control practices.
F 323: The facility failed to provide a safe transfer with a mechanical lift for Resident #2, resulting in falls due to improper use of the sit to stand lift and lack of investigation into incidents.
Report Facts
Resident census: 29
Sample size: 7
Weight gain: 11
Weight gain: 12
Blood sugar: 227
Blood sugar: 173
Blood sugar: 58
Blood sugar: 52
Insulin dosage: 38
Insulin dosage: 12
Insulin dosage: 17
Catheter size: 20
Catheter balloon size: 10
Antibiotic dosage: 500
Antibiotic dosage: 100
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 19, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report documents that the previously identified deficiency under regulation 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h): The previously cited deficiency was corrected by the revisit date of 05/19/2015.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 14, 2015
Visit Reason
This document is a plan of correction submitted in response to deficiencies cited during a complaint investigation at the facility.
Complaint Details
This plan of correction is related to deficiencies cited during a complaint investigation at Sandstone Heights.
Findings
The facility was found noncompliant with regulations related to supervision of residents who are elopement risks in the patio and outside areas. The plan includes staff inservice and monitoring to ensure compliance.
Deficiencies (2)
F0000: The facility will develop and implement a facility-wide system to assure compliance with regulations. A copy of this plan will be provided to the Quality Assurance and Assessment Committee quarterly.
F323-D: Staff were reminded of policies requiring supervision of residents who are elopement risks when in the patio and outside areas. The Director of Nursing and Administrator will monitor compliance and report quarterly.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 14, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a "D" level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The most serious deficiency was a "D" level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: May 14, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#86207) regarding the facility's supervision and accident hazard prevention.
Complaint Details
The complaint investigation (#86207) substantiated that the facility failed to adequately supervise Resident #1, who eloped from the facility's unsecured courtyard.
Findings
The facility failed to adequately supervise a resident identified as an elopement risk, who eloped from the unsecured courtyard for approximately 15 minutes and was found four blocks away. The courtyard gate was secured only with a chain and clasp hook, lacking a locking device.
Deficiencies (1)
F 323: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent elopement of a resident from the unsecured courtyard.
Report Facts
Resident census: 31
Elopement duration: 15
Distance eloped: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Provided observations and statements regarding the elopement and courtyard security. | |
| Nurse B | Provided statements about the resident's elopement risk and behavior. | |
| Administrative Staff C | Provided information about the resident's prior living situation and facility entry/exit behavior. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 13, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of 04/13/2015. No other deficiencies or issues were noted in this report.
Deficiencies (1)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected by 04/13/2015.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 13, 2015
Visit Reason
This document is a plan of correction submitted in response to deficiencies cited during a complaint investigation at the facility.
Complaint Details
This plan of correction addresses deficiencies cited during a complaint investigation.
Findings
The facility was cited for deficiencies related to unwitnessed falls with injury and all other falls with significant injury not being reported to appropriate agencies within 5 working days. The facility plans to develop and implement a system to assure correction and continued compliance with regulations.
Deficiencies (2)
F0000: The facility will develop and implement a facility-wide system to assure correction and continued compliance with regulations. A complete copy of the plan will be provided to the Quality Assurance and Assessment Committee quarterly.
F225-D: Unwitnessed falls with injury and all other falls with significant injury will be reported to appropriate agencies within 5 working days. Investigation will be started by the Director of Nursing or designee as soon as aware and monitored by DON and Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Named as submitter of the plan of correction. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 9, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The most serious deficiency was a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Signed letter as Complaint Coordinator related to survey findings. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Date: Apr 9, 2015
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of failure to report resident falls and injuries to the state agency within required timeframes.
Complaint Details
Complaint #84803. The facility failed to report Resident #1's fall with injury and fall resulting in rib fractures to the state agency within the required timeframe.
Findings
The facility failed to report two falls involving Resident #1 to the state agency within 5 working days, including one fall resulting in lacerations and another resulting in rib fractures. The resident had severe cognitive impairment and was at high risk for falls.
Deficiencies (1)
F225 - The facility failed to report a fall with injury and another fall resulting in rib fractures for Resident #1 to the state agency within 5 working days as required by state law.
Report Facts
Census: 32
Residents reviewed: 3
Days late reporting fall: 9
Rib fractures: 2
Lacerations sutured: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Verified the late reporting of Resident #1's falls to the state agency |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 21, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 30, 2014
Visit Reason
The licensure resurvey was conducted to assess compliance for continued program participation.
Findings
The licensure resurvey of the facility resulted in no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 30, 2014
Visit Reason
The inspection was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a widespread 'F' level deficiency indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective November 21, 2014.
Deficiencies (1)
The facility was cited with a widespread 'F' level deficiency indicating no actual harm but potential for more than minimal harm without immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 11
Date: Oct 30, 2014
Visit Reason
Health Resurvey and Complaint Investigation #80063 conducted to investigate allegations of misappropriation of resident property and other care concerns.
Complaint Details
Complaint investigation #80063 focused on allegations of misappropriation of resident property and other care concerns. The facility failed to thoroughly investigate and report the allegations and had multiple deficiencies in care and safety.
Findings
The facility failed to thoroughly investigate and report allegations of misappropriation of resident property, provide dignity during insulin administration, provide medically-related social services including dental care, accurately assess dental issues, ensure qualified care for feeding tube residents, educate residents on edema and footwear safety, prevent urinary catheter contamination, maintain a safe environment free of hazards, provide routine and emergency dental services, administer medications as ordered, and maintain infection control practices.
Deficiencies (11)
F225: Facility failed to thoroughly investigate and report allegations of possible misappropriation of resident property for Resident #22.
F241: Facility failed to provide privacy during insulin administration for Residents #7 and #10 and dignity during blood sugar testing in common areas.
F250: Facility failed to provide medically-related social services for dental care and clothing/shoes for Residents #22 and #28.
F272: Facility failed to accurately assess dental issues for Resident #22, incorrectly coding the MDS.
F282: Facility failed to ensure qualified staff provided feeding tube care and failed to immediately report displaced feeding tube for Resident #32.
F309: Facility failed to educate Resident #34 on consequences of bilateral lower extremity edema and unsafe loose fitting footwear.
F315: Facility failed to prevent urinary catheter bag and tubing from contacting the floor for Residents #5 and #10, increasing infection risk.
F323: Facility failed to keep residents' closets accessible, failed to assess and provide safe side rails without unsafe gaps for Resident #10, and failed to secure a hot towel warmer from cognitively impaired residents.
F412: Facility failed to provide or obtain routine and emergency dental services for Residents #22 and #28 who had dental needs and lacked dentures.
F425: Facility failed to administer enteric coated aspirin as ordered to Resident #35.
F441: Facility failed to use appropriate hand hygiene during medication administration and failed to provide a sanitary environment to prevent infection transmission.
Report Facts
Resident census: 24
Sample size: 15
Deficiencies cited: 11
Fall risk score: 10
BIMS score: 15
BIMS score: 9
BIMS score: 11
BIMS score: 5
Aspirin dosage: 81
Towel warmer temperature: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide G | Administered incorrect aspirin type to Resident #35 | |
| Administrative Nurse A | Verified multiple findings including feeding tube incident and medication error | |
| Housekeeping Staff P | Used non-disinfectant cleaner for resident sinks | |
| Nurse Aide C | Failed to check feeding tube placement for Resident #32 | |
| Nurse Aide B | Found feeding tube on floor and failed to report immediately | |
| Social Service Staff I | Verified lack of dental service provision for residents | |
| Nurse D | Reported resident dental condition and footwear issues | |
| Therapy Staff F | Reported concerns about resident footwear and edema |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 21, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency classified as an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was found to have an 'F' level deficiency that was widespread with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Nov 21, 2014
Provider agreement termination date: Feb 21, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 16, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously cited deficiency under regulation 483.60(b), (d), (e) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.60(b), (d), (e) deficiency was corrected by 09/16/2013.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 29, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The facility identified deficiencies related to narcotic count accuracy and signature requirements. Corrective actions include nurse inservice training and ongoing monitoring of narcotic audits by the Director of Nurses and pharmacy consultant.
Deficiencies (2)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations. A copy of the deficiency will be provided to the Quality Assurance and Assessment committee by September 16, 2013.
F431: An inservice for all nurses was held emphasizing the importance of narcotic count and signature accuracy. The Director of Nurses will monitor narcotic audit sheets weekly and the pharmacy consultant will monitor audits monthly.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 28, 2013
Visit Reason
The licensure survey was conducted to assess compliance for facility licensing.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 1
Date: Aug 28, 2013
Visit Reason
The inspection was a health resurvey to assess compliance with medication storage and narcotic drug audit procedures.
Findings
The facility failed to ensure that the oncoming and offgoing nurses signed the narcotic count sheets to verify the accuracy of narcotic counts on two medication carts. Multiple missing signatures were documented across various shifts and dates.
Deficiencies (1)
F 431: The facility failed to have the oncoming and offgoing nurses sign the narcotic count sheets ensuring the narcotic count was correct on 2 medication carts. Missing signatures were found on multiple shifts between July and August 2013.
Report Facts
Resident census: 28
Sample size: 13
Missing signature days: 14
Missing signature shifts: 18
Missing signature days: 9
Missing signature shifts: 11
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 11, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies identified by regulation numbers and prefix codes were corrected by 08/16/2012 as documented in the report.
Report Facts
Deficiencies corrected: 10
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Aug 16, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The facility identified multiple deficiencies related to incident notification, dental services, housekeeping and maintenance, care plan compliance, accident prevention, food sanitation, and infection control. The Plan of Correction outlines specific actions to achieve substantial compliance by August 16, 2012.
Deficiencies (9)
F157-D: The facility will notify the physician when a resident has an accident resulting in injury using a new incident notification form. Nurses will be trained on the form and compliance monitored quarterly by the DON.
F250-D: The facility will provide medically-related social services including scheduling dental appointments and transportation for residents in need. The MDS coordinator will review dental needs quarterly.
F253-E: The facility will maintain a sanitary and orderly environment by repairing scratched bathroom doors, loose toilet caulking, replacing soiled utility room door, and fixing protruding door coverings. Maintenance will monitor doors monthly.
F280-D: The facility will follow residents' care plans and document toileting episodes in CareTracker to ensure compliance, monitored quarterly by the MDS coordinator.
F312-D: The facility will provide necessary services for residents unable to carry out activities of daily living, adjusting care plans and documenting toileting episodes for monitoring compliance quarterly.
F323-G: The facility will ensure the environment is free of accident hazards and update care plans to prevent residents from receiving hot liquids or food without supervision. Hot liquid assessments will be done quarterly.
F371-E: The facility will serve food under sanitary conditions with dietary staff inserviced annually and upon orientation to prevent food contamination.
F412-D: The facility will provide routine and emergency dental services, scheduling appointments and transportation as needed, with quarterly reviews by the MDS coordinator.
F441-D: The facility will provide infection control practices including proper storage of oxygen and nebulizer supplies, mandatory staff inservices on hygiene, and bimonthly compliance monitoring by the DON.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 9
Date: Jul 17, 2012
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation regarding concerns at the facility.
Complaint Details
The inspection included a complaint investigation related to Resident #4's injury from spilled hot coffee and other care concerns.
Findings
The facility failed to notify the physician timely after a resident sustained burns from spilled hot coffee, failed to provide medically-related social services for dental care, failed to maintain sanitary conditions in food service and housekeeping, failed to follow care plans for toileting and ADL assistance, and failed to maintain proper infection control practices.
Deficiencies (9)
483.10(b)(11) The facility failed to notify the physician timely after Resident #4 sustained burns from spilled hot coffee and delayed treatment orders and reassessments.
483.15(g)(1) The facility failed to provide medically-related social services to address Resident #8's dental pain and did not follow up on dental appointments.
483.15(h)(2) The facility failed to maintain sanitary and comfortable conditions in resident rooms and common areas, including damaged doors and loose caulking.
483.20(d)(3), 483.10(k)(2) The facility failed to follow the care plan for Resident #28 by not providing toileting assistance every 2 hours as directed.
483.25(a)(3) The facility failed to provide necessary assistance with activities of daily living for Resident #28, including toileting and incontinence care.
483.25(h) The facility failed to provide adequate supervision and assistive devices to prevent accidents, resulting in Resident #4 spilling hot coffee and sustaining burns.
483.35(i) The facility failed to serve food under sanitary conditions, including staff handling glasses and plates improperly.
483.55(b) The facility failed to provide or obtain routine and emergency dental services for Resident #8 to meet his/her needs.
483.65 The facility failed to maintain infection control practices, including improper storage of oxygen equipment and failure to change gloves and wash hands during incontinence care for Residents #4, #18, #28, and #31.
Report Facts
Resident census: 30
Sample size: 13
Temperature of coffee: 158
Temperature of coffee: 140
Burn wound size: 2
Burn wound size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Administrative Nurse | Verified delayed notification and treatment of Resident #4's burns and care plan adherence. |
| Physician T | Physician | Provided treatment orders and guidance for Resident #4's burn wounds. |
| Nurse H | Nurse | Verified care plan instructions and lack of knowledge about Resident #8's dental pain. |
| Social Service Staff J | Social Service Staff | Verified attempts to arrange dental care for Resident #8. |
| Dietary Staff A | Dietary Staff | Observed improperly handling glasses and plates. |
| Dietary Staff B | Dietary Staff | Verified proper food handling procedures. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N080002 POC NLCK11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified as State ID N080002 ASPEN.
Findings
No deficiencies or findings are detailed in this document. It serves solely as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: N080002 POC O2OC11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including staff training on abuse reporting, privacy during treatments, dental care follow-up, incident reporting for a removed PEG tube, medication administration errors, and housekeeping sanitation protocols.
Deficiencies (12)
F0000: The facility will develop and implement a system to assure correction and continued compliance with regulations.
F225-D: Staff received inservice on reporting suspected misappropriation of resident property and investigation procedures.
F241-D: Nursing staff were trained on privacy policies during medical and nursing treatments, including insulin injections and glucometer tests.
F250-D: Social Services Designee visited resident #22 regarding dental care options; resident declined dentures and dental care but will be monitored.
F272-D: Facility will modify MDS significant change to reflect dental issues for resident #22 and improve oral assessment accuracy.
F282-D: Incident involving removed PEG tube; CNA reprimanded and removed from duties; staff reeducated on oral care and reporting protocols.
F309-D: Social Services Designee educated resident #34 on risks related to edema, unsafe footwear, and ambulation safety; monitoring and documentation planned.
F315-D: Nursing staff received inservice on catheter tubing and bag positioning to prevent contamination; compliance monitoring planned.
F323-E: Side rails removed for resident #10; assessments by therapy and nursing staff planned to determine need; janitor closet secured to prevent unauthorized access.
F412-D: Social Services Designee revisited dental care options with resident #22 who again declined care; monitoring and quarterly updates planned.
F425-D: Medication Aide G formally counseled on medication errors and proper label reading; monitoring by charge nurses, DON, and pharmacy consultant.
F441-F: Medication Aide G counseled on proper medication delivery including hand washing; housekeeping staff inserviced on cleaning and sanitizing protocols.
Report Facts
Complete Date: Nov 29, 2014
Complete Date: Nov 11, 2014
Complete Date: Nov 21, 2014
Complete Date: Nov 6, 2014
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N080002 POC XHPS11
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility Sandstone Heights ALF.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a placeholder or administrative record for the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N080002 POC GFR511
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at the facility.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation.
Findings
The facility identified deficiencies related to weight monitoring, assessment accuracy, catheter bag management, and lift use policies. Corrective actions include staff training, policy updates, and monitoring by the Director of Nursing and Administrator.
Deficiencies (4)
F0000: The facility will develop and implement a facility-wide system to assure compliance with regulations. A copy of this plan will be provided to the Quality Assurance and Assessment Committee.
F309-D: All nurses, CMAs, and CNAs will be inserviced on the weight monitoring policy and thorough, timely, accurate assessments as evidenced by the complaint investigation.
F315-D: Maintenance installed a hook to hang catheter bags off the floor or trash receptacles. Use and cleanliness of hooks will be monitored by charge nurses, DON, Administrator, and housekeeping.
F323-D: The lift policy was changed so the DON determines appropriate lifts for residents. The DON and Administrator will monitor safe and effective lift use, supported by staff training.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Gaines | Administrator | Submitted the Plan of Correction. |
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