Sundance Skilled Nursing and Rehabilitation

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that clean linens were provided to residents on a daily basis. Specifically, the facility failed to ensure clean hand towels and washcloths were provided to residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the environment were free of accidents and hazards for one (#11) of two residents reviewed for accidents out of 41 sample residents and three of three emergency crash carts. Specifically, the facility failed to:-Ensure Resident #11 was assessed to determine if he was safe to smoke independently after an incident of unsafe smoking; and,-Ensure medical grade power strips were readily available in the crash carts (a specialized, mobile, and organized unit of trays and drawers on wheels containing essential life-saving equipment and medications).

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of two medication carts. Specifically, the facility failed to ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.

Inspectors wroteBased on observations, record review and interviews, the facility failed to consistently serve food that was palatable in taste. Specifically, the facility failed to ensure resident food was palatable in taste and temperature.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure necessary maintenance repairs were communicated and completed in a timely manner in the kitchen area.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#69) of two residents reviewed for personal property out of 41 sample residents was able to retain their personal belongings. Specifically, the facility failed to receive consent from Resident #69 or his responsible party before disposing of his personal belongings after the resident was discharged to the hospital.

Inspectors wroteBased on record review and interviews, the facility failed to consider resident and family group views and act upon grievances and recommendations. Specifically, the facility failed to provide the residents the opportunity to share views, grievances, and recommendations to dietary related issues in the resident council meetings.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide ongoing programs to support choices of activities and engaging programming based on the comprehensive assessment and care plan that were designed to meet the interests of and support the physical, mental, and psychosocial well-being of two (#46 and #55) of three residents reviewed for activities out of 41 sample residents. Specifically, the facility failed to offer and provide personalized meaningful activity programs for Resident #46 and Resident #55 as documented in their care plans.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received treatment treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#67) of two residents reviewed out of 41 sample residents. Specifically, the facility failed to:-Ensure physician's orders were obtained for Resident #67's insulin pump and that the insulin pump was being appropriately monitored; -Ensure Resident #67's blood glucose (sugar) levels were being monitored; and,-Ensure Resident #67 received a carbohydrate-controlled diet, per her request.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevent of additional pressure injuries for one (#46) of two residents out of 41 sample residents. Specifically, the facility failed to:-Ensure Resident #46, who had pressure injuries, was repositioned and provided incontinence care in a timely manner; and,-Ensure staff consistently implemented care planned pressure injury prevention interventions for Resident #46.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for two (#24 and #67) of three residents reviewed for respiratory care out of 41 sample residents. Specifically, the facility failed to:-Ensure the physician's order matched the resident's preference for oxygen administration for Resident #24; and,-Ensure there was a physician's order for oxygen use for Resident #67.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#37) of two residents out of 41 sample residents. Specifically, the facility failed to: -Ensure a complete and thorough pain assessment was completed that identified Resident #37's history of pain and its treatment, history of addiction, characteristics of pain and the impact of pain on the resident's quality of life; -Identify Resident #37's goals for pain management and acceptable level of pain; -Identify Resident #37's locations of pain; and, -Ensure Resident #37's location of pain was consistently identified when administering pain medication to the resident.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#30) of three residents reviewed for ancillary services out of 41 sample residents received dental services timely. Specifically, the facility failed to: -Ensure Resident #30 was provided timely emergency dental services after reporting tooth pain; and, -Ensure Resident #30 was offered routine dental care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure meals were served according to the resident's preferences for one (#37) of five residents out of 41 sample residents. Specifically, the facility failed to offer food choices according to Resident #37's preferences.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure suction equipment was maintained in a sanitary manner.

Inspectors wroteBased on observations and interviews, the facility failed to have an adequately equipped call system to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff area. Specifically, the facility failed to ensure all parts of the call light system were functioning properly in the common bathroom near the main dining room and the day room on the first floor.

Inspectors wroteBased on observations and interviews the facility failed to have adequate outside ventilation by means of a window or mechanical ventilation or a combination of the two for two out of three common bathrooms and two resident bathrooms, affecting eight residents. Specifically the facility failed to ensure the ventilation fans were clean and in good repair.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents received adequate supervision out of 14 sample residents. Specifically, the facility failed to ensure Resident #1 was not able to access hazardous chemicals. Resident #1, who was admitted to the facility on [DATE], had a history of dementia and of wandering within the facility. On [DATE] at 1:40 p.m., Resident #1 was able to obtain a bottle of a cleaning chemical that was located in a residential hallway on a maintenance cart that was unsecured and unsupervised. Resident #1 was found by certified nurse aide (CNA) #1 holding the bottle containing a cleaning chemical. Resident #1 was observed to have a blue substance on his lips, which was determined by the facility to be consistent with the contents of the bottle. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure resident's medical supplies for catheter irrigation were labeled, dated and stored in a sanitary environment.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for one (#17) of three out of 18 sample residents. Specifically, the facility failed to ensure records were provided timely upon request for Resident #17 from a court appointed guardian.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain personal hygiene for one (#11) of five residents out of 18 sample residents. Specifically, the facility failed to provide incontinence care timely for Resident #11.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide the necessary treatment and services for pressure injuries for one (#8) of three residents out of 18 sample residents. Specifically, the facility failed to implement interventions for Resident #8 who had a pressure injury.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents were free from accidents and hazards for one (#2) of four residents reviewed for falls of 18 sample residents. Specifically, the facility failed to for Resident #2: -Ensure the resident received adequate supervision to prevent repeated falls; -Implement care plan interventions timely, consistently and effectively to prevent resident falls including ensuring the resident had a fully functional call light within reach; anticipating the resident's care needs for toileting, wanting to transfer to go out to smoke or to lay down to rest; -Ensure the resident consistently had nonslip footwear; and, -Reassess the effectiveness of fall prevention methods following repeated falls where interventions failed to prevent repeated falls.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the residents had a right to to be informed of the results or actions taken regarding concerns during resident council meetings. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to ongoing food concerns.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in three medication carts and one medication room. Specifically the facility failed to: -Ensure medication or treatment carts were locked when the licensed nurse was not present; -Ensure multiple use vials were properly labeled; -Ensure medications were disposed of appropriately; -Ensure medication carts were maintained and clean; and, -Ensure medications were stored in an approved refrigerator

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident environment was free from accident hazards and adequate supervision was provided for one (#13) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to provide adequate supervision for Resident #13 after a fall with suspected injury on 11/14/22, to ensure he did not fall again two hours later while awaiting a mobile x-ray.

Inspectors wroteBased on record review and interviews the facility failed to ensure residents were kept free from unnecessary medications for three (#2, #14 and #49) of five residents reviewed for unnecessary medications out of 33 sample residents. Specifically, the facility failed to: -Have consents signed prior to psychotropic medication administration for Resident #2, #14 and #49; and, -Have behavior tracking in place for Residents #2 and #14.