A list of the most recent deficiencies for Sandstone Holladay. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-05 | 2022-06-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-05 | 2022-06-09 | 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 | 2022-05-05 | 2022-06-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-05 | 2022-06-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-05 | 2022-06-09 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-05-05 | 2022-06-09 | 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 | 2022-05-05 | 2022-06-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-05 | 2022-06-09 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-05-05 | 2022-06-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-05-05 | 2022-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-05 | 2022-06-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-05 | 2022-06-09 | 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 | 2022-05-05 | 2022-06-09 | 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 | 2022-05-04 | 2022-05-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-04 | 2022-05-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-04 | 2022-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-04 | 2022-05-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-12-05 | 2020-01-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-12-05 | 2020-01-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-05 | 2020-01-20 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-12-05 | 2020-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-05 | 2020-01-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-05 | 2020-01-17 | 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 | 2019-12-05 | 2020-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-05 | 2020-01-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-04 | 2020-01-16 | 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 | 2019-12-05 | 2020-01-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-04 | 2020-01-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-04 | 2020-01-09 | 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 | 2019-12-04 | 2019-12-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-17 | 2018-11-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-09-17 | 2018-11-07 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-09-17 | 2018-11-07 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-17 | 2018-11-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-17 | 2018-11-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-17 | 2018-11-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-09-17 | 2018-11-07 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-09-17 | 2018-11-07 | 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 | 2018-09-17 | 2018-11-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-17 | 2018-11-07 | 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 | 2018-09-17 | 2018-11-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-09-17 | 2018-11-07 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-09-17 | 2018-11-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-17 | 2018-11-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-17 | 2018-11-07 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-09-12 | 2018-10-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-12 | 2018-10-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-12 | 2018-10-17 | N |
