Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sandstone Heights during CMS and state inspections, most recent first.
The facility did not consistently implement or update fall prevention interventions for several residents with a history of falls, including one with severe cognitive impairment who sustained a hip fracture, another with end-stage renal disease and repeated non-injury falls, and a third with paraplegia who experienced falls during transfers. Care plans were not updated after incidents, and required fall investigations were not always completed.
The facility did not accurately submit required PBJ staffing data, as the reported information failed to reflect 24-hour licensed nursing coverage that was actually provided according to schedules and payroll records. Administrative staff confirmed the discrepancy, and no PBJ policy was available.
Several residents with histories of falls, including those with cognitive impairment, end-stage renal disease, and paraplegia, experienced multiple fall events without subsequent updates to their care plans. Despite facility policy requiring care plan revision after each fall, new interventions were not added following incidents resulting in injuries and hospitalizations. Staff interviews confirmed inconsistent practices regarding care plan updates after falls.
Surveyors identified unsanitary food storage and preparation practices, including the use of cookie sheets and frying pans with caked-on residue, a rusted and greasy metal rack, and improper storage of wet towels and unlabeled containers in the refrigerator. Dietary staff confirmed these conditions, noting that contaminated surfaces came into direct contact with food and that food and drinks were left uncovered and unlabeled, contrary to facility policy.
Failure to Implement and Update Fall Prevention Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that fall prevention interventions were implemented and updated for multiple residents with a known history of falls, resulting in repeated incidents and injuries. One resident with severe cognitive impairment and osteoporosis experienced several falls, including one that resulted in a fractured hip requiring hospitalization and surgery. Despite multiple documented falls, the resident's care plan was not updated with new interventions after each incident, and some falls were not investigated or addressed with root cause analysis as required by facility policy. Another resident with end-stage renal disease, diabetes, and a history of repeated falls also experienced multiple non-injury falls. The care plan for this resident was not updated with specific interventions following these incidents, and a fall risk assessment was not completed after one of the falls. The facility's documentation and interviews confirmed that interventions were not consistently identified or implemented after each fall, despite the resident's ongoing risk and repeated incidents. A third resident with paraplegia and moderate cognitive impairment, who was dependent on staff for transfers, was found on the floor after a fall and later reported sliding out of a wheelchair during a transfer. The care plan for this resident did not include updated fall prevention interventions after these events, and the facility failed to conduct a fall investigation after a staff-intercepted fall. Facility policies required fall investigations and the implementation of individualized interventions, but these were not consistently followed for the residents involved.
Failure to Accurately Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Federal regulatory agency through Payroll-Based Journaling (PBJ). Specifically, the PBJ Staffing Data Report for the first quarter of Fiscal Year 2024 indicated that the facility did not have 24-hour licensed nursing coverage on several dates. However, review of the nursing schedule and payroll data sheets for those dates showed that 24-hour nursing coverage was actually provided. During interviews, administrative staff confirmed that the coverage was present, but it was not accurately reflected in the PBJ report. Additionally, the facility was unable to provide a policy regarding Payroll-Based Journaling.
Failure to Revise Care Plans After Falls
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised after falls for multiple residents, resulting in a deficiency related to the development and implementation of appropriate interventions to prevent further falls. For one resident with severe cognitive impairment and a history of multiple falls, including incidents resulting in lacerations and a hip fracture, the care plan was not updated with new interventions following each fall event. Documentation showed that after several falls—some with injury and one with major injury requiring hospitalization and surgery—there were no corresponding updates or new interventions added to the resident's care plan, despite facility policy requiring such revisions after every fall. Another resident with end-stage renal disease, diabetes, and repeated falls experienced multiple non-injury falls, particularly after dialysis sessions. The care plan for this resident was not revised to address the specific circumstances or root causes identified in fall investigations, such as the removal of a non-slip mat or failure to use non-skid socks. The lack of care plan updates following these incidents was confirmed by facility staff and was inconsistent with the facility's policy, which mandates care plan revision after every fall. A third resident with paraplegia and a history of falls was also affected by this deficiency. After a documented fall and a separate incident where the resident slid from a wheelchair during a transfer, the care plan was not updated to reflect new interventions or strategies to prevent recurrence. Interviews with staff revealed inconsistent understanding of what constitutes a fall and when care plans should be updated, further contributing to the failure to implement timely and appropriate interventions following fall events.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen during a tour with a Dietary Aide. Thirteen cookie sheets and seven frying pans were found with brown, dried, caked-on substances on both the exterior and interior surfaces, making them unsanitizable. These pans were stacked in a manner that allowed the contaminated exterior of one pan to be in direct contact with the cooking surface of another. Additionally, a metal rack with four shelves was noted to have rust and greasy, sticky grime buildup, rendering it unsanitizable. Inside the refrigerator, two rolled-up wet towels were found on the bottom shelf, and three empty, open, unlabeled white plastic containers were on the top shelf, one of which contained an orange-yellow substance identified as rust from water dripping through the refrigerator vent. Six unlabeled and uncovered glasses of juice were also present in the refrigerator. The Dietary Aide confirmed these findings, stating that the pans had always been in this condition and that the brown substance would come into direct contact with food during preparation. She also explained that the towels and containers were used to catch water dripping from the refrigerator, and the orange discoloration was due to rust. The Dietary Manager corroborated these observations, acknowledging that the pans and skillets had been in this state since her employment and that the towels and uncovered food items should not be stored in the refrigerator. Facility policy documentation indicated that cross-contamination could occur through food contact surfaces, sponges, and cloth towels, and that food should be prepared using methods designed to be free of injurious organisms and substances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Little River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Estates | 14.5 mi | ★★★★★ | 0 | 0 |
| Sterling Village | 16.5 mi | ★★★★★ | 0 | 0 |
| Pleasant View Home | 17.6 mi | ★★★★★ | 0 | 0 |
| Mcpherson Operator, Llc | 19 mi | ★★★★★ | 0 | 0 |
| The Cedars | 19.8 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.