Deficiency Records for Sandpiper Healthcare and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Sandpiper Healthcare and Rehabilitation Center. 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 and implement an infection prevention and control program. | Health | 2023-11-20 | 2023-11-27 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-02-08 | 2023-03-10 | 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 | 2023-02-08 | 2023-03-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-02-08 | 2023-03-10 | 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 | 2023-02-08 | 2023-03-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-01-31 | 2023-01-31 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-05 | 2023-01-16 | 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 | 2023-01-05 | 2023-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-05 | 2023-01-16 | 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 | 2023-01-05 | 2023-01-16 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-01-05 | 2023-01-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-05 | 2023-01-16 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-05 | 2023-01-16 | 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 | 2023-01-05 | 2023-01-16 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-03-11 | 2021-04-15 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-02-04 | 2021-02-26 | 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 | 2021-02-04 | 2021-02-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-04 | 2021-02-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-02-04 | 2021-02-26 | 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 | 2021-02-04 | 2021-02-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-04 | 2021-02-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-02-04 | 2021-02-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-02-04 | 2021-02-26 | N |
| 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 | 2021-02-04 | 2021-02-26 | 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 | 2021-02-04 | 2021-02-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-04 | 2021-02-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-04 | 2021-02-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-15 | 2019-08-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-15 | 2019-08-05 | 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 | 2019-07-15 | 2019-08-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-15 | 2019-08-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-15 | 2019-08-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-15 | 2019-08-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-15 | 2019-08-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-15 | 2019-08-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-15 | 2019-08-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-06 | 2018-12-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-06 | 2018-12-01 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-06 | 2018-11-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-06 | 2018-11-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-11-06 | 2018-11-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-11-06 | 2018-11-12 | 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 | 2018-11-06 | 2018-11-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-06 | 2018-11-12 | N |
