Sundance Inn Health Center

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (1) of five (5) residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure Resident #1's fracture (a broken bone), diagnosed 06/27/2026, was added to his diagnosis list. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.

Inspectors wroteBased on interviews and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and the facility failed to provide the notice of transfer or discharge required at least 30 days before the resident is transferred or discharged or provide notice as soon as practicable before transfer for 3 of 3 residents (Residents #1, #2, and #3) reviewed for Discharge Rights. The facility failed to give the representative of Resident #1 written documentation at least 30 days prior to discharge which informed them of the facility-initiated decision to discharge the resident and the right to appeal. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 1 resident (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's medication consent form was completed on the most recent consent for antipsychotic or neuroleptic medication treatment for Seroquel (an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and major depressive disorder) and available in the resident's medical record. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately inform or consult the physician and the resident's representative when there was a need to alter treatment for one (Resident #8) of three residents reviewed for physician notifications.1. The facility failed to ensure MA X and nursing staff alerted the physician that Resident #8 missed 7 doses of ear drop medication on 08/22/25 at 9:00 AM, 12:00 PM, 5:00 PM, 9:00 PM and 08/23/25 at 9:00 AM, 12:00 PM, 5:00 PM.2. The facility failed to ensure LVN G notified the physician that Resident #8 had missed 2 doses of ear drop medication on 08/28/25 at 9:00 AM and 12:00 PM.This failure placed residents at risk of a delay in treatment, and a worsening of their condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #92) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #92. This failure could place residents at risk of not having complete records after permanent discharge from the facility.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #12) of 8 residents reviewed for care plans. The facility failed to include Resident #12's PTSD (Post Traumatic Stress Disorder) in his care plan. This failure could place the residents at risk of not receiving services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received foot care that was consistent with professional standards of practice and treatment to prevent complications from conditions such as diabetes and assisting residents in making necessary appointments with qualified healthcare providers such as podiatrists and arranging transportation for 1 (Resident #7) of 10 residents reviewed for foot care. The facility failed to provide Resident #7 assistance with foot care leaving his toenails to be about an inch long on both feet. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the menu was followed for one of one meal (lunch on 08/27/25) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal on 08/27/25 by providing the pureed trays with lemon pudding for dessert and the regular trays with a cherry cream cheese swirl brownie for dessert. This failure could place residents at risk of weight loss, altered nutritional status and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #8) of 3 residents reviewed for accuracy of medical records. The facility failed to ensure Resident #8's missed doses of ear drops was documented accurately and completely on 08/22/25 and 08/23/25. This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication or a delay in services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA A allegedly physically and verbally assaulted her on 07/28/2025. An IJ (Immediate Jeopardy) was identified on 08/02/2025. The IJ began on 08/02/2025 and was removed on 08/03/2025. The facility took action to remove the IJ before the abbreviated survey began; however, all staff had not been trained on staff-to-resident abuse prevention. The IJ template was provided to the facility on [DATE] at 04:53 p.m. and signed by the ED. [...]

Inspectors wroteBase of observations, record reviews and interviews the facility failed to develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA A allegedly physically and verbally assaulted her on 07/28/2025. An IJ (Immediate Jeopardy) was identified on 08/02/2025. The IJ began on 08/02/2025 and was removed on 08/03/2025. The facility took action to remove the IJ before the abbreviated survey began; however, all staff had not been trained on staff-to-resident abuse prevention. The IJ template was provided to the facility on [DATE] at 04:53 p.m. and signed by the ED. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care. The facility did not provide showers or baths to Resident #1 as scheduled and requested on 07/26/2025. This failure can affect residents by decreasing their quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #2) whose environment was reviewed for safety hazards. Nursing staff failed to properly discard and remove a syringe used for insulin (a hormone essential for individuals with insulin insufficiency, such as diabetics, to convert food into energy and maintain blood sugar levels) administration from Resident #2's room. This deficient practice could affect residents exposed to syringes and could contribute to avoidable accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 1 nursing treatment carts out of 3 nursing carts reviewed for storage. The facility failed when on 06/09/2025 the nursing treatment cart was left unlocked and unattended by the Treatment Nurse when she entered the room to wash her hands and when wound care was provided to Resident #3. This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 4 resident (Resident #2) reviewed for privacy, in that: CNA C and CNA D did not completely close Resident #2's privacy curtain while providing incontinent care on 4/11/25. This failure could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (R#8) reviewed for misappropriation of resident property. The facility failed to ensure that Resident #8 was not subject to financial misappropriation or exploitation from Housekeeper E from the time period 11/10/2024 to 11/11/2024. Housekeeper E accepted a check for $350 from Resident #8. This deficient practice was determined to be Past Non-Compliance from 11/10/2024 to 11/11/2024, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure had the potential to affect the residents in the facility by placing them at risk for misappropriation of resident property.

Inspectors wroteBased on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 8 residents (Resident #8) reviewed for abuse, neglect, exploitation, or mistreatment and report to one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. The facility failed to report to a law enforcement entity of an allegation of exploitation on 11/10/2024, where Housekeeper E received a check in the amount of $350 from Resident #8. This failure had the potential to affect the residents in the facility by placing them at risk for exploitation and/or misappropriation of resident property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure environment remains as free of accident hazards as is possible; for residents for 1 of 8 units (unit 800) observed for environment, in that: 1. The facility failed to ensure potential hazards Clorox (disinfecting wipes) were locked up and kept out of resident rooms. This failure could place residents at risk of a diminished quality of life due to an unsafe environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 5 residents (Residents #86) reviewed for dignity. The facility failed to ensure the urinary collection bag for Resident #86's catheter was covered with a privacy bag. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 6 residents (Resident #18) who were reviewed for accommodation of needs. The facility failed to ensure Residents #18's call lights were placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan to meet the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #30) of 6 residents reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #30's active wounds to right heel, left foot second toe, and a contracted right hand. This failure could place residents of risk for not receiving appropriate care and treatment, lack of skin/wound interventions, a delay in treatment, a decline in health, and hospitalization.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident #42) of 6 residents reviewed for medication errors in that: The facility transcribed a medication (hydralazine a medication used to treat high blood pressure) be given oral for a resident who was to receive her medications per her gastrostomy tube. The failure could cause residents who receive medications by gastrostomy tube at risk for aspiration and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 1 resident (Resident #1) reviewed for infection control, in that: While providing incontinent care for Resident #1, CNA A touched the trash can with her bare hands and did not wash her hands before putting her gloves on and starting to provide care. CNA B did not sanitize or wash her hands in between change of gloves. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the refrigerator and freezer were dated, labeled, and not expired. 2. The facility failed to ensure dishes and cookware were washed in the dishwasher with the appropriate sanitation procedures. These failures could affect residents by placing them at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one Staff (CNA A) of three staff observed caring for a COVID positive resident and one staff (MA B) of three staff observed during medication pass for infection control in that: 1. CNA A failed to wear the recommended PPE when answering a call light for Resident #15, a COVID positive resident on isolation. 2. MA B failed to prevent contamination of the cap and eyedrop bottle for Resident #33. MA B cross-contaminated her medication cart by placing Resident #33's eye drop bottle, and nasal spray box on her bedside table then into the cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that re to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident # 71) of twenty residents reviewed for care plans. The facility failed to develop a comprehensive care plan to address Resident # 71's oxygen via nasal canula and bipap machine use which was being administered by the facility. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one resident (Residents #69) of three residents reviewed for ADL care. The facility failed to ensure Residents #69 was provided showers as scheduled. These failures could place residents at risk of not receiving personal care services and of having a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for one of four residents (Resident # 71) reviewed for respiratory care. The facility failed to ensure Resident # 71 had physician orders for oxygen via nasal canula which was administered by the facility. The facility failed to ensure Resident # 71 had physician orders for bipap machine (a type of ventilator that helps people with respiratory disease breath during sleep) which was administered by the facility. The facility failed to ensure Resident # 71's oxygen humidifier was changed weekly per facility policy. [...]