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Deficiency Records for Sandstone Millcreek
A list of the most recent deficiencies for Sandstone Millcreek. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sandstone Millcreek. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-03-11 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-31 | 2023-11-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-31 | 2023-11-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-08-31 | 2023-11-03 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-08-31 | 2023-11-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-31 | 2023-11-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-31 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-31 | 2023-11-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-31 | 2023-11-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-31 | 2023-11-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-31 | 2023-11-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-31 | 2023-11-03 | N |
| Respond appropriately to all alleged violations. | Health | 2023-08-31 | 2023-11-03 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-05 | 2023-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-05 | 2023-10-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-05 | 2023-10-06 | N |
| Meet other general requirements. | Fire Safety | 2023-09-05 | 2023-09-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-05 | 2023-09-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-05 | 2023-09-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-05 | 2023-09-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-05 | 2023-09-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-06 | 2022-02-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-12-06 | 2022-02-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-06 | 2022-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-06 | 2022-02-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-06 | 2022-02-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-06 | 2022-02-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-06 | 2022-02-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-06 | 2022-02-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-06 | 2022-02-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-06 | 2022-02-01 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2021-12-06 | 2022-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-06 | 2022-02-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-06 | 2022-02-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-06 | 2022-02-01 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-06 | 2022-02-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-06 | 2022-02-01 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-12-06 | 2022-02-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-06 | 2022-02-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-06 | 2022-02-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-06 | 2022-02-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-06 | 2022-02-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-08 | 2021-12-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-08-19 | 2019-10-07 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2019-08-19 | 2019-10-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-19 | 2019-10-07 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-08-19 | 2019-10-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-19 | 2019-10-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-19 | 2019-10-07 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-08-19 | 2019-10-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-19 | 2019-10-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-19 | 2019-10-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-08-19 | 2019-10-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-19 | 2019-10-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-19 | 2019-10-07 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-19 | 2019-10-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-08-19 | 2019-10-07 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-08-19 | 2019-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-19 | 2019-10-07 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-08-19 | 2019-10-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-19 | 2019-10-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-08-13 | 2019-09-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-13 | 2019-09-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-08-13 | 2019-09-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-13 | 2019-09-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-13 | 2019-09-06 | N |
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