Sundance Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Sundance Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Oct 27, 2021

  Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections. Record review revealed the facility was in outbreak status as of 10/2/21, when a staff member tested positive for COVID-19. On 10/18/21, another staff member tested positive for COVID-19 and on 10/19/21, four residents tested positive for COVID-19. […]

• Immediate jeopardy, widespreadF886Oct 27, 2021

  Based on interviews and record review, the facility failed to test residents, facility staff, individuals providing services under arrangement and volunteers for COVID-19 which had the potential to affect all 59 residents residing in the facility at the time of the survey. Record review and interview revealed the facility failed to follow outbreak testing guidance when a staff member was symptomatic and had a positive POC (point-of-care) test on 10/2/21, creating a situation for the likely transmission of highly infectious COVID-19. […]

• Immediate jeopardy, isolatedF689Aug 15, 2025

  Based 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. […]

• Actual harm, isolatedF600Jun 27, 2023

  Based on record review and interviews the facility failed to keep six residents (#6, #3, #5, #7, #10 and #11) free from resident to resident physical abuse of nine residents reviewed out of 13 sample residents. The facility failed to ensure there was an effective plan to monitor, or provide increased oversight and effective interventions to protect residents from Resident #6's behavior. Resident #6 physically assaulted at least three residents, between 3/19/23 and 6/11/23. Four additional residents complained of Resident #6's behavior in the facility's abuse investigations. This included Resident #3 who told a staff member during an interview that he had been hit by Resident #6. There was no further investigation of this allegation. […]

• Actual harm, isolatedF600Feb 22, 2022

  Based on record review and interviews, the facility failed to ensure three residents (#5, #7 and #3) of five residents reviewed, out of 16 sample residents were kept free from neglect. The facility failed to ensure Resident #5 and Resident #7 were not neglected by staff and were provided the care and services required to maintain the highest practicable well-being. Specifically, Resident #5 and Resident #7's call lights were not answered for over two hours on 1/27/22, as evidenced by the call light record, resident and staff interviews. Resident #5 expressed fear and anxiety about having her call light answered timely in the future, if she had an emergency or fell . Resident #7 reported her legs and feet had gone numb, seated on the toilet on 1/27/22, waiting for help. […]