Sunset Manor

Based on observation, interview, the facility's Diet Manual, the facility's policies for Menu Planning and Portion Control, and the facility's 2023 Spring/Summer Menus for Week 2, Wednesday; the facility failed to ensure the residents on Mechanical Soft and Puree diets received the portion sizes per the approved menu at lunch on Wednesday, July 26, 2023. This had the potential to affect 23 of 53 residents receiving meals from the kitchen. Findings include: The facility's Diet Manual, dated 2008, included the following: . Mechanical Soft (Dental Soft) Diet A Mechanical Soft or Dental Soft Diet is used for individuals who have difficulty chewing regular textured foods. Foods that are difficult for the individual to chew are chopped, ground, shredded and/or soft cooked to facilitate chewing and ease of swallowing. Dysphagia Puree (Level 1) Diet The Dysphagia Puree (Level 1) Diet is used only for individuals who have severe chewing and/or swallowing problems. All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase. Pureed Diet menus follow the foods on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, resident record review, and a facility policy titled Weight Monitoring, the facility failed to ensure Resident Identifier (RI) #55 received an Ensure supplement as ordered with meals. This deficient practice affected RI #55 one of two residents sampled for nutrition. Findings include: A facility policy titled Weight Monitoring with a revised date of 04/2023 documented: . Compliance Guidelines: . 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: . c. Developing and consistently implementing pertinent approaches . RI #55 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #55's physician orders for July 2023 documented an order dated 05/23/2023 for RI #55 to receive eight (8) ounces of Ensure supplement with all meals. RI #55 was observed during the supper meal on 07/25/2023 at 5:38 PM in RI #55's room. RI #55's meal tray was not served with eight ounces of Ensure supplement. RI #55 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of a facility policy titled, Cleaning Dishes/Dish Machine, the facility failed to ensure that food dish pans were allowed to air dry prior to stacking and storing. This had the potential to affect 67 of 67 residents receiving meals from the kitchen. Findings include: A review of an undated policy Titled, Cleaning Dishes/Dish Machine revealed: .9. Allow dishes to air dry .10 .inspect for cleanliness and dryness . On 09/23/19 at 5:45 p.m., during the initial tour of the kitchen with Employee Identifier (EI) #4 Dietary Manager, an observation was made of two separate stacks of food pans stored on the shelf under the prep table. The food pans were nesting one on top of the other. The surveyor asked EI #4 to remove several pans, one at a time, from the stack. Each pan removed was noted to have clear wet substance running off. EI #4 then stated, Well, you got me. They are all wet. EI #4 removed the wet pans from the shelf and took the wet pans to the dish washing area. On 09/25/19 at 3:30 p.m., an interview with (EI) #4 was conducted. EI #4 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, a facility policy titled, Garbage Disposal and the 2017 Food Code the facility failed to ensure that the outside garbage disposal area was free of debris. This had the potential to affect all 69 residents residing in the facility Findings include: A policy titled, Garbage Disposal Revised September 2018 documented: .will be observed for continued compliance by Maintenance and Housekeeping departments . A review of the 2017 Food Code U.S. Public Health Service documented: . 5-501.15 Outside receptacles . (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insects and rodent attraction and harborage are minimized and effective cleaning is facilitated around and . under the unit . On 09/25/19 at 11:46 a.m. an observation with Employee Identifier (EI) #4, Dietary Manager, was made of trash items on the ground behind the 2 dumpster's, just off of the concrete pad. Items noted were 4 blue gloves, 2 clear bottles, several paper items, and a clear plastic item. A white plastic fork and a white plastic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, medical review, and a facility policy titled Standard Precautions: Infection Control, the facility failed to ensure a Licensed Practical Nurse (LPN), Employee Identifier (EI) #3, washed her hands or used hand sanitizer after she removed her gloves, touched the top of the waste container on the left side of the medication cart with both hands, and prior to touching Resident Identifier (RI) #24's medication cup, on the medication tray on top of the medication cart. This affected one of two Licensed Nurses and one of three residents observed during medication pass. Findings Include: A review of a facility policy titled Standard Precautions Infection Control, with a date implemented of 11/28/2017, revealed . Policy Explanation and Compliance Guidelines: . (p. 1) e. Perform hand hygiene: . vi. After removing gloves . (p. 5) After touching . contaminated items; immediately after removing gloves . On 9/25/19 at 8:17 a.m., the surveyor observed EI #3, a LPN, apply gloves on both of her hands, crush RI #24's medication in a plastic sleeve, and put RI #24's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical records, interviews, and a facility document titled, Comprehensive Resident Assessment (Minimum Data Set), the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) was completed on three sampled residents after being admitted to hospice. This affected Resident Identifier's (RI) #2, 43 and 115, three of six facility residents on hospice. Findings Include: A review of a facility policy titled Comprehensive Resident Assessment (Minimum Data Set), with an implemented date of 10/01/1991, documented: The facility shall conduct a comprehensive, accurate .assessment of each resident's functional capacity .2. Promptly after significant change in the resident's physical or mental condition . 1. RI #2 was admitted to the facility on [DATE]. On 08/28/2018 at 11:10 a.m., a review of RI #2's Physician Order, dated 05/12/2018, revealed a new medical diagnosis of Failure to Thrive and an order to admit RI #2 to hospice with a diagnosis of Degenerative Disease of the Nervous System…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of a facility policy titled, Medications Multi-Dose Vials, the facility failed to ensure Resident Identifier (RI) #16's vial of insulin contained an opened date on the vial and package containing RI #16's insulin. This deficient practice affected RI #16, one of 7 residents observed during medication administration. Findings Include: A review of a facility policy titled, Medication Multi-Dose Vials Revised 01/29/13, revealed: .POLICY: To assure safety and infection control when multi-dose vials are utilized. PROCEDURE: 1. When a multi-dose vial (MDV) is opened initially, it should be dated. 2. There is a 28 day limitation on the use of MDV Insulins. RI #16 was readmitted to the facility on [DATE] with diagnoses including, Chronic Kidney Disease. On 08/28/18 at 10:43 a.m. during a medication pass, Employee Identifier (EI) #4, Licensed Practical Nurse (LPN), was observed administering medications to RI #16. EI #4 took a package containing Novolog insulin from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, medical record reviews and review of facility policies titled, Glove Usage and Handwashing/Hand Sanitizing, the facility failed to ensure: 1. a licensed nurse did not place gloves, a vial of medication and Resident Identifier (RI) #55's nebulizer mask on unclean surfaces during medication pass and 2. a licensed nurse washed her hands before preparing RI #59's medications and before applying her gloves to break one of RI #59's medications. These deficient practices affected RI #55 and RI #59, two of seven residents, and two of four nurses observed during medication administration. Findings Include: RI #55 was admitted to the facility on [DATE]. On 08/28/18 at 8:26 a.m. during a medication pass, the surveyor observed Employee Identifier (EI) #5, Licensed Practical Nurse (LPN), enter RI #55's room and lay a pair of gloves and a vial of nebulizer medication on RI #55's overbed table. EI #5 then entered the bathroom, washed her hands, walked back to the table and applied the gloves…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.