Deficiency Records for Sandstone South Lake
Updated as of July 01, 2023
This is not the most recent data for Sandstone South Lake. For the most recent information, click here.
A list of the most recent deficiencies for Sandstone South Lake. 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 | 2022-03-21 | 2022-05-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-21 | 2022-05-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-21 | 2022-05-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-21 | 2022-05-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-21 | 2022-05-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-21 | 2022-05-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-21 | 2022-05-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-21 | 2022-05-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-21 | 2022-05-06 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-21 | 2022-05-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-21 | 2022-05-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-21 | 2022-05-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-21 | 2022-05-06 | N |
| Provide appropriate foot care. | Health | 2022-03-21 | 2022-05-06 | 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 | 2022-03-21 | 2022-05-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-21 | 2022-05-06 | 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 | 2022-03-21 | 2022-05-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-21 | 2022-05-06 | 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 | 2022-03-21 | 2022-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-21 | 2022-05-06 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-03-21 | 2022-05-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-21 | 2022-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-21 | 2022-05-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-21 | 2022-05-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-21 | 2022-05-06 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2022-03-21 | 2022-05-06 | N |
| 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 | 2022-03-21 | 2022-05-06 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-21 | 2022-05-06 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-16 | 2022-04-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-16 | 2022-04-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-16 | 2022-04-10 | 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 | 2022-03-16 | 2022-04-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-16 | 2022-04-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-16 | 2022-04-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-16 | 2022-04-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-16 | 2022-04-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-11-20 | 2020-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-20 | 2020-01-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-26 | 2020-01-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-26 | 2020-01-17 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-11-26 | 2020-01-17 | 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 | 2019-11-26 | 2020-01-17 | N |
| 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 | 2019-11-26 | 2020-01-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-11-26 | 2020-01-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-26 | 2020-01-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-26 | 2020-01-17 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-26 | 2020-01-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-26 | 2020-01-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-26 | 2020-01-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-11-26 | 2020-01-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-26 | 2020-01-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-26 | 2020-01-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-26 | 2020-01-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-26 | 2020-01-17 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-11-26 | 2020-01-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-26 | 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 | 2019-11-26 | 2020-01-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-11-26 | 2020-01-17 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-11-26 | 2020-01-17 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2019-11-26 | 2020-01-17 | N |
| Provide or obtain dental services for each resident. | Health | 2019-11-26 | 2020-01-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-11-26 | 2020-01-17 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2019-11-26 | 2020-01-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-26 | 2020-01-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-11-26 | 2020-01-17 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-11-26 | 2020-01-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-26 | 2020-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-26 | 2020-01-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-26 | 2020-01-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-11-26 | 2020-01-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-11-20 | 2020-01-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-20 | 2020-01-13 | 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 | 2019-11-20 | 2019-12-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-20 | 2019-12-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-20 | 2019-12-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-20 | 2019-12-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-20 | 2019-12-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-29 | 2019-01-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-29 | 2019-01-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-29 | 2019-01-23 | N |
| Respond appropriately to all alleged violations. | Health | 2018-11-29 | 2019-01-23 | 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 | 2018-11-29 | 2019-01-23 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-11-29 | 2019-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-29 | 2019-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-29 | 2019-01-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-29 | 2019-01-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-11-29 | 2019-01-23 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-11-29 | 2019-01-23 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-11-29 | 2019-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-29 | 2019-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2019-01-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-11-29 | 2019-01-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-11-29 | 2019-01-23 | 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 | 2018-11-29 | 2019-01-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-29 | 2019-01-04 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-11-29 | 2019-01-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-11-29 | 2019-01-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-29 | 2019-01-04 | N |
