Deficiency Records for Sanford Health and Rehabilitation Co
Updated as of April 01, 2024
A list of the most recent deficiencies for Sanford Health and Rehabilitation Co. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-20 | 2024-04-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-20 | 2024-04-02 | 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 | 2024-02-20 | 2024-04-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-20 | 2024-04-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-20 | 2024-04-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-20 | 2024-04-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-20 | 2024-04-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-20 | 2024-04-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-20 | 2024-04-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-20 | 2024-04-02 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-01-24 | 2024-02-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-24 | 2024-02-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-24 | 2024-02-02 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-01-24 | 2024-02-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-24 | 2024-02-02 | 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 | 2024-01-24 | 2024-02-02 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-12-29 | 2023-03-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-29 | 2023-03-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-29 | 2023-03-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-29 | 2023-03-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-29 | 2023-03-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-29 | 2023-03-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-29 | 2023-03-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-29 | 2023-03-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-29 | 2023-03-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-01 | 2022-12-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-12-01 | 2022-12-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-01 | 2022-12-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-01 | 2022-12-30 | 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 | 2022-12-01 | 2022-12-30 | 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 | 2022-12-01 | 2022-12-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-01 | 2022-12-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-01 | 2022-12-30 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-12-01 | 2022-12-30 | 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 | 2022-12-01 | 2022-12-30 | 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 | 2022-12-01 | 2022-12-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-01 | 2022-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-01 | 2022-12-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-01 | 2022-12-30 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-01 | 2022-12-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-01 | 2022-12-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-12-01 | 2022-12-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-01 | 2022-12-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-01 | 2022-12-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-01 | 2022-12-30 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-01 | 2022-12-30 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-01 | 2022-12-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-01 | 2022-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-09 | 2022-03-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-09 | 2022-03-22 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-06 | 2021-06-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-06 | 2021-06-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-06 | 2021-06-02 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-06 | 2021-06-02 | 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 | 2021-05-06 | 2021-06-02 | 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 | 2021-05-06 | 2021-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-06 | 2021-06-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-06 | 2021-06-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-06 | 2021-06-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-06 | 2021-06-02 | Y |
