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Deficiency Records for Sandy Health and Rehab
A list of the most recent deficiencies for Sandy Health and Rehab. 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 Sandy Health and Rehab. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-01 | 2023-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-16 | 2023-09-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-16 | 2023-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-16 | 2023-09-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-16 | 2023-09-30 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-08-16 | 2023-09-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-16 | 2023-09-30 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-08-16 | 2023-09-30 | Y |
| 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 | 2023-08-16 | 2023-09-30 | Y |
| 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 | 2023-08-16 | 2023-09-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-16 | 2023-09-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-16 | 2023-09-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-16 | 2023-09-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-16 | 2023-09-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-16 | 2023-09-30 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-16 | 2023-09-30 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-08-16 | 2023-09-30 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-16 | 2023-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-16 | 2023-09-30 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-16 | 2023-09-30 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-16 | 2023-09-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-16 | 2023-09-30 | Y |
| 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 | 2023-08-16 | 2023-09-30 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-08-16 | 2023-09-30 | Y |
| Keep complete, dated laboratory records in the resident's record. | Health | 2023-08-16 | 2023-09-30 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-08-16 | 2023-09-30 | Y |
| 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 | 2023-08-16 | 2023-09-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-16 | 2023-09-30 | Y |
| 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 | 2023-08-16 | 2023-09-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-16 | 2023-09-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-16 | 2023-09-30 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-08-16 | 2023-09-30 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-16 | 2023-09-30 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-08-16 | 2023-09-30 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-01 | 2023-09-01 | 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 | 2023-08-01 | 2023-09-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-01 | 2023-09-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-01 | 2023-09-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-01 | 2023-09-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-01 | 2023-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-01 | 2023-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-07 | 2022-04-08 | Y |
| 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 | 2022-03-07 | 2022-04-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-03-07 | 2022-04-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-07 | 2022-04-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-07 | 2022-04-08 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-07 | 2022-04-08 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-02-16 | 2022-03-18 | Y |
| 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 | 2022-02-16 | 2022-03-18 | Y |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-02-07 | 2022-03-04 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-13 | 2021-11-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-10-13 | 2021-11-27 | 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 | 2021-10-19 | 2021-11-26 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-10-19 | 2021-11-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-19 | 2021-11-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-10-19 | 2021-11-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-19 | 2021-11-26 | N |
| Post nurse staffing information every day. | Health | 2021-10-19 | 2021-11-26 | 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 | 2021-10-19 | 2021-11-26 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2021-10-19 | 2021-11-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-19 | 2021-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-11-26 | 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 | 2021-10-19 | 2021-11-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-19 | 2021-11-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-19 | 2021-11-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-19 | 2021-11-26 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-10-19 | 2021-11-26 | Y |
| 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 | 2021-10-19 | 2021-11-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-19 | 2021-11-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Meet other general requirements. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-13 | 2021-11-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-18 | 2019-09-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-18 | 2019-09-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-18 | 2019-09-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-18 | 2019-09-06 | 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 | 2019-07-18 | 2019-09-06 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-18 | 2019-09-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-18 | 2019-09-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-18 | 2019-09-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-18 | 2019-09-06 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-07-18 | 2019-09-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-18 | 2019-08-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-18 | 2019-08-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-07-18 | 2019-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-18 | 2019-07-19 | N |
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