Sundance Inn Health Center

Penalties

• Aug 3, 2025 — Fine ($6,364)

Inspection findings

1. Apr 30, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected May 4, 2026 · CMS health inspection

2. Apr 17, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Apr 20, 2026 · CMS health inspection

3. Aug 28, 2025 Fire Safety · 14 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Sep 30, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0687 Quality of Life and Care Deficiencies

     Provide appropriate foot care.

     Corrected Oct 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Sep 30, 2025 · CMS fire safety

4. Aug 3, 2025 Health · 4 findings
   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Aug 4, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Aug 4, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Aug 4, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Aug 4, 2025 · CMS health inspection

5. Jun 9, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Jun 10, 2025 · CMS health inspection

6. Apr 11, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Apr 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Nov 11, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Apr 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Apr 12, 2025 · CMS health inspection

7. Jun 27, 2024 Health · 6 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

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

     Corrected Aug 2, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Aug 2, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Aug 2, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Aug 2, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Aug 10, 2024 · CMS fire safety

8. May 31, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 28, 2024 · CMS health inspection

9. Apr 20, 2023 Health · 8 findings
   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Apr 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Apr 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Apr 21, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Apr 21, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 21, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Apr 26, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Apr 26, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Apr 26, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• HOOPER, GRADY — corporate officer, NOT APPLICABLE, since 12/01/2015
• POMEROY, WILLIAM — operational/managerial control, NOT APPLICABLE, since 05/01/2020
• POMEROY, WILLIAM — adp of the snf, NOT APPLICABLE, since 05/01/2020
• COMAL HEALTH CARE CENTER LTD. CO. — operational/managerial control, NOT APPLICABLE, since 05/01/2020
• COMAL HEALTH CARE CENTER LTD. CO. — adp of the snf, NOT APPLICABLE, since 04/04/2025