Deficiency Records for Lifestream at Sun Ridge
Updated as of January 01, 2022
This is not the most recent data for Lifestream at Sun Ridge. For the most recent information, click here.
A list of the most recent deficiencies for Lifestream at Sun Ridge. 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? |
|---|---|---|---|---|
| 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 | 2021-07-09 | 2021-08-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-09 | 2021-08-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-09 | 2021-08-09 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-08 | 2021-08-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-08 | 2021-08-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-08 | 2021-08-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-08 | 2021-08-04 | N |
| Post nurse staffing information every day. | Health | 2021-07-08 | 2021-08-04 | 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 | 2021-07-08 | 2021-08-04 | 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 | 2021-07-08 | 2021-08-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-08 | 2021-08-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-05-16 | 2019-06-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-16 | 2019-06-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-05-16 | 2019-06-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-16 | 2019-06-21 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-05-16 | 2019-06-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-16 | 2019-06-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-05-16 | 2019-06-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-16 | 2019-06-21 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-04 | 2019-06-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-06-04 | 2019-06-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-04 | 2019-06-18 | 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 | 2018-03-01 | 2018-06-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-03-01 | 2018-06-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-01 | 2018-06-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-01 | 2018-06-07 | 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 | 2018-03-01 | 2018-06-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-03-01 | 2018-06-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-01 | 2018-05-17 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-03-01 | 2018-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-01 | 2018-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-01 | 2018-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-01 | 2018-05-17 | 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 | 2018-03-01 | 2018-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-01 | 2018-05-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-03-01 | 2018-04-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-03-01 | 2018-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-01 | 2018-04-16 | N |
