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🔎 Sundance Inn Health Center

Inspection Results


Inspection Overview

Sundance Inn Health Center has been cited for a total of 36 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2025-04-11
Correction Date: 2025-04-12
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from the wrongful use of the resident's belongings or money.

Survey Date: 2025-04-11
Correction Date: 2025-04-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2025-04-11
Correction Date: 2025-04-12
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2025-04-11
Correction Date: 2025-04-12
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2024-06-27
Correction Date: 2024-08-02
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2024-06-27
Correction Date: 2024-08-02
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-06-27
Correction Date: 2024-08-02
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-06-27
Correction Date: 2024-08-02
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-05-31
Correction Date: 2024-06-28
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2023-06-08
Correction Date: 2023-06-09
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-04-20
Correction Date: 2023-04-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-04-20
Correction Date: 2023-04-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2023-04-20
Correction Date: 2023-04-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-04-20
Correction Date: 2023-04-21
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-04-20
Correction Date: 2023-04-21
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-06-10
Correction Date: 2022-06-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2022-06-10
Correction Date: 2022-06-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-06-10
Correction Date: 2022-06-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2022-06-10
Correction Date: 2022-06-11
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2022-03-04
Correction Date: 2022-03-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-03-04
Correction Date: 2022-03-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Survey Date: 2022-03-04
Correction Date: 2022-03-05
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-03-04
Correction Date: 2022-03-05
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-03-04
Correction Date: 2022-04-11
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2021-03-03
Correction Date: 2021-03-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2021-03-03
Correction Date: 2021-03-04
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2021-03-03
Correction Date: 2021-03-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-03-03
Correction Date: 2021-03-04
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-03-03
Correction Date: 2021-03-04
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2021-03-03
Correction Date: 2021-03-04
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2020-08-04
Correction Date: 2020-08-05
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2020-08-04
Correction Date: 2020-08-05
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2020-08-04
Correction Date: 2020-08-05
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2019-11-21
Correction Date: 2019-12-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-11-21
Correction Date: 2019-12-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: B

Provide a bathroom in or located near each resident’s room.

Survey Date: 2019-11-21
Correction Date: 2019-12-13
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**