Sundance Inn Health Center

In the surveyor’s words

From the most serious findings on record at Sundance Inn Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 3, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF607Aug 3, 2025

  Base 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. […]

• Actual harm, isolatedF689Jun 10, 2022

  Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision and assistive devices for 1 of 4 Residents (Resident #1) reviewed for accidents and hazards, in that: NA A failed to adequately supervise Resident #1 when she pushed her in the wheelchair which resulted in Resident #1 falling face first onto the ground hitting her face and head and requiring a trip to the emergency room for evaluation. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: cerebral infarction (stroke). […]

• No harm, potential for more than minimal, widespreadF812Apr 20, 2023

  Based 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. Findings include: 1. Observation and interview on [DATE] at 8:28 AM with the Dietary Manager (DM) revealed the following food items in the refrigerator, as identified by the DM: - Three containers of ranch dressing, with one opened and used. […]

• No harm, potential for more than minimal, patternF628Apr 30, 2026

  Based 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… […]