Deficiency Records for Sundance Skilled Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Sundance Skilled Nursing and Rehabilitation. 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-05 | 2023-11-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-11-13 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-10-05 | 2023-11-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-05 | 2023-11-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-27 | 2023-07-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-27 | 2023-07-27 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-06-27 | 2023-07-27 | 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 | 2022-11-17 | 2023-01-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-06 | 2022-12-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-06 | 2022-12-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-06 | 2022-12-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-06 | 2022-12-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-06 | 2022-12-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-06 | 2022-12-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-17 | 2022-12-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-17 | 2022-12-23 | 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 | 2022-11-17 | 2022-12-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-06 | 2022-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-06 | 2022-12-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-14 | 2022-07-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-14 | 2022-07-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-14 | 2022-07-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-14 | 2022-07-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-14 | 2022-06-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-19 | 2022-06-24 | 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 | 2022-05-19 | 2022-06-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-19 | 2022-06-24 | N |
| 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 | 2022-05-19 | 2022-06-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have an externally vented heating system. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-06-14 | 2022-06-22 | 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 | 2022-06-14 | 2022-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-14 | 2022-06-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-22 | 2022-03-21 | 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 | 2022-02-22 | 2022-03-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-22 | 2022-03-21 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-22 | 2022-03-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-22 | 2022-03-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-22 | 2022-03-21 | Y |
| 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 | 2022-02-22 | 2022-03-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-22 | 2022-03-21 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-02-22 | 2022-03-21 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-22 | 2022-03-21 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-22 | 2022-03-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-22 | 2022-03-21 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-18 | 2022-02-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-18 | 2022-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-18 | 2021-12-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-18 | 2021-12-31 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-11-18 | 2021-12-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-18 | 2021-12-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-18 | 2021-12-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-18 | 2021-12-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-11-18 | 2021-12-09 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-11-18 | 2021-12-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-18 | 2021-12-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-27 | 2021-11-18 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-10-27 | 2021-11-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-27 | 2021-11-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-27 | 2021-11-18 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-27 | 2021-11-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-10-27 | 2021-11-18 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-27 | 2021-11-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-27 | 2021-11-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-27 | 2021-11-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-27 | 2021-11-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-27 | 2021-11-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-27 | 2021-11-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-27 | 2021-11-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-27 | 2021-11-18 | 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 | 2021-10-27 | 2021-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-27 | 2021-11-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-27 | 2021-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-11-18 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-27 | 2021-11-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-27 | 2021-11-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-27 | 2021-11-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-10-27 | 2021-11-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-10-27 | 2021-11-18 | N |
