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Deficiency Records for Sundance Creek Post Acute
A list of the most recent deficiencies for Sundance Creek Post Acute. 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 Sundance Creek Post Acute. 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? |
|---|---|---|---|---|
| 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 | 2024-09-18 | 2024-10-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-09 | 2024-09-16 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-09-09 | 2024-09-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-23 | 2024-09-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-23 | 2024-09-13 | 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 | 2024-08-23 | 2024-09-13 | 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 | 2024-08-23 | 2024-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-23 | 2024-09-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-23 | 2024-09-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-23 | 2024-09-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-08-23 | 2024-09-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-23 | 2024-09-13 | N |
| 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 | 2024-08-23 | 2024-09-13 | 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 | 2024-08-23 | 2024-09-13 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-08-23 | 2024-09-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-23 | 2024-09-13 | 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 | 2024-08-23 | 2024-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-23 | 2024-09-13 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2024-08-23 | 2024-09-13 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-08-23 | 2024-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-23 | 2024-09-13 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-08-23 | 2024-09-13 | 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 | 2024-08-26 | 2024-09-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-26 | 2024-09-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-08-26 | 2024-09-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-07-18 | 2024-08-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-18 | 2024-08-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-23 | 2024-08-02 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-05-31 | 2024-06-10 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-05-07 | 2024-05-20 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2024-02-07 | 2024-02-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-07 | 2024-02-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-06 | 2024-02-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-10 | 2024-01-20 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-10-20 | 2023-10-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-27 | 2023-10-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-22 | 2023-07-22 | 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 | 2023-01-19 | 2023-02-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-11 | 2023-02-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-12 | 2023-01-22 | Y |
| 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 | 2023-01-12 | 2023-01-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-17 | 2022-09-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-17 | 2022-09-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-16 | 2022-01-24 | 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 | 2021-12-16 | 2022-01-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-12-16 | 2022-01-24 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-16 | 2022-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-16 | 2022-01-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-16 | 2022-01-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-16 | 2022-01-24 | 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 | 2021-12-16 | 2022-01-24 | 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 | 2021-12-16 | 2022-01-24 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-12-16 | 2022-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-16 | 2022-01-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-16 | 2022-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-01-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-12-22 | 2022-01-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-12-22 | 2022-01-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-12-22 | 2022-01-04 | N |
| Use approved construction type or materials. | Fire Safety | 2021-12-22 | 2022-01-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-22 | 2022-01-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-12-22 | 2022-01-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-22 | 2022-01-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-22 | 2022-01-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2021-12-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-18 | 2021-12-27 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-03 | 2019-12-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-07 | 2019-12-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-07 | 2019-12-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-07 | 2019-12-05 | 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 | 2019-11-07 | 2019-12-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-07 | 2019-12-05 | N |
| 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 | 2019-11-07 | 2019-12-05 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-11-07 | 2019-12-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-07 | 2019-12-05 | N |
| Dispose of garbage and refuse properly. | Health | 2019-11-07 | 2019-12-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-07 | 2019-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-07 | 2019-12-05 | N |
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