A list of the most recent deficiencies for Haven of Sandpointe, LLC. 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? |
|---|---|---|---|---|
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-22 | 2023-11-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-22 | 2023-11-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-04 | 2022-09-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-04 | 2022-09-18 | 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 | 2022-08-04 | 2022-09-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-04 | 2022-09-18 | 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 | 2022-08-04 | 2022-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-04 | 2022-09-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-09-18 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-04 | 2022-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-04 | 2022-09-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-08-05 | 2022-09-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-05 | 2020-09-25 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-03-05 | 2020-09-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-03-05 | 2020-09-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-05 | 2020-09-25 | 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 | 2020-03-05 | 2020-09-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-03-05 | 2020-09-25 | N |
| Develop a communication plan. | Fire Safety | 2020-03-06 | 2020-04-24 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-03-06 | 2020-04-24 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-03-06 | 2020-04-24 | N |
| Establish methods for sharing information. | Fire Safety | 2020-03-06 | 2020-04-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-06 | 2020-04-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-06 | 2020-04-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-06 | 2020-04-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-03-06 | 2020-04-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-03-05 | 2020-04-20 | N |
| Respond appropriately to all alleged violations. | Health | 2020-03-05 | 2020-04-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-03-05 | 2020-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-05 | 2020-04-20 | N |
