Sun West Choice Healthcare & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, staff interviews and policy review, the facility failed to protect the rights of three residents (#38, #24, #23, #11) to be free from abuse from other residents (#39, #22, #10). The deficient practice could result in residents being physically or emotionally harmed.Findings include: -Regarding Resident #38 and #39 Resident #38 was re-admitted to the facility March 30, 2022, with diagnoses that included Alzheimer’s Disease, Dementia in other diseases classified elsewhere, Unspecified Severity, with other Behavioral Disturbance, Hypertension, Depression, Schizoaffective Disorder, and Unspecified Mood [Affective] Disorder. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. A care plan dated January 26, 2023, revealed Resident #38 was an elopement risk/wanderer related to impaired safety awareness, potential for behavior problem…

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 clinical record reviews, staff interviews and reviews of facility policies and procedures, the facility failed to ensure care and services that adhere to accepted standards related to medications administration was provided to one resident (#125). The deficient practice could result in resident not receiving the necessary treatment needed. Findings include: Resident #125 was admitted on [DATE] with diagnoses of dementia, hypertension, atrial fibrillation, and depression. The care plan initiated on April 7, 2024 revealed the resident had altered cardiovascular status hypertension, atrial fibrillation, trans ischemic attack history. The goal was that the resident will remain free from signs and symptoms of hypertension. Interventions included give antihypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate, and effectiveness, notify physician of any signs and symptoms of cardiovascular complications: nausea, vomiting, shortness of breath,…

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 record review, staff interviews, and policy review, the facility failed to ensure an abnormal lab results for one resident (#91) were promptly communicated to the provider. The deficient practice could result in complications and/or worsening of resident's health. Findings include: Resident #91 was admitted on [DATE] with diagnoses of dementia, dysphagia, type 2 diabetes mellitus, and psychotic disorder. The ADL (activities of daily living) care plan dated July 26, 2024 revealed the resident had ADL self-care performance deficit related to dementia, impaired mobility and UTI (urinary tract infection). Interventions included for staff to provide up to extensive assistance with bed mobility, dressing, toilet use, transfers, personal hygiene and locomotion on and off unit. Another care plan dated July 26, 2024 included that the resident had bowel/bladder incontinence related to dementia and impaired mobility. Intervention included to monitor/document for signs/symptoms of UTI. The late entry NP (nurse…

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 closed clinical record review, staff interview, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure the MDS (Minimum Data Set) assessment was accurate for one resident (#121). The sample size was 25. The deficient practice could result in an inaccurate assessment and resident not receiving the appropriate care and services needed. Findings include: Resident # 121 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, down syndrome, restlessness and agitation, adult failure to thrive, essential (primary) hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, hyperlipidemia, syndrome of inappropriate secretion of antidiuretic hormone, hyperkeratosis of [NAME], and personal history of urinary (tract) infections. An admission Minimum Data Set (MDS) dated [DATE] for Resident # 121 included that the Brief Interview for Mental Status (BIMS) was not conducted because the resident was rarely/never understood.…

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 clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure that comprehensive care plans were developed for one resident (#121) using oxygen therapy. The deficient practice could result in residents needs based on the comprehensive assessment not being met. Resident # 121 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, down syndrome, restlessness and agitation, adult failure to thrive, essential (primary) hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, hyperlipidemia, syndrome of inappropriate secretion of antidiuretic hormone, hyperkeratosis of [NAME], and personal history of urinary (tract) infections. An admission Minimum Data Set (MDS) dated [DATE] for Resident # 121 included that the Brief Interview for Mental Status (BIMS) was not conducted because the resident was rarely/never understood. The assessment included that the resident had an ok short- and long-term memory with…

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 review of clinical records, staff interviews, and facility policies and procedures, the facility provided a psychotropic medication for Bipolar disorder for one resident (#72) without a diagnosis of Bipolar disorder: Findings include: Resident # 72 was admitted on [DATE] with diagnoses that included unspecified fracture of right calcaneus, subsequent encounter for fracture with routine healing, other viral pneumonia, other coronavirus as the cause of diseases classified elsewhere, acute respiratory failure with hypoxia, urinary tract infection, site not specified, type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic neuropathy, asthma, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, chronic kidney disease, stage 4 (severe), long term (current) use of insulin, obesity, depression, long term (current) use of anticoagulants, fibromyalgia, and dysphagia. Review of the clinical record revealed no…

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 observations, staff interviews, and policy reviews, the facility failed to ensure that maintenance and housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior was provided for 7 residents (#24, #63, #11, #74, #31, #41, and #76). The census was 124. The deficient practice could result in resident rooms not having a homelike environment. Findings include: An observation was conducted on January 3, 2022 at 9:45 AM. The hallway and room of resident #24 and resident #63 were noted to have a foul odor. Under the window to the exterior wall of the residents' room and closest to resident #24's bed, wall paper was observed peeling from the base of the window downward to the floor in 2 areas. Behind the wallpaper that was peeling was an open hole in the wall. The hole was observed to be approximately 8 to 10 inches in width and 4 to 6 inches in height. The closet space provided for resident #24 had closet fixture pieces that were wire-like that were on the floor inside that closet, and broken plastic brackets inside of the closet. On the floor near…

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 clinical record reviews, facility documentation, staff interviews, and facility policy and procedures, the facility failed to ensure a copy of the written notice of transfer/discharge for two of two residents (#76 and #37) was sent to the Office of the State Long Term Ombudsman. The deficient practice could result in the ombudsman not being notified of resident transfers/discharges. Findings include: -Resident #76 was admitted to the facility on [DATE] with diagnoses that included sepsis, major depression, and anxiety. A Brief Interview for Mental Status (BIMS) dated August 31, 2021 indicated the resident was cognitively intact with a score of 11. Review of the progress notes revealed the following: -On October 16, 2021 at 10:17 p.m. change of condition: symptoms or signs of condition change: altered mental state. -On October 16, 2021 at 10:37 p.m. resident refused medications and was noted to have altered mental state. Slurring words or not answering. Leaning over in wheelchair. Nurse Practitioner…

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 clinical record reviews, staff interviews, review of facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for 8 residents (#27, #64, #75, #33, #52, #66, #63, and #37), by failing to conduct the Brief Interview for Mental Status (BIMS) and for one resident (#75) regarding hospice. The sample size was 25 residents. The deficient practice could result in not identifying necessary care needs and treatment. Findings include: -Resident #27 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance and major depressive disorder. Review of the resident's quarterly MDS assessment dated [DATE] revealed that the assessment was coded that the Brief Interview for Mental Status (BIMS) should be attempted with the resident, however, this section was not completed. The staff interview for mental status was also not completed. -Resident #64 was admitted to 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 clinical record reviews, resident and staff interviews, and facility policies and procedures, the facility failed to ensure adequate monitoring and supervision was provided for six residents (#s 107, 76, 41, 32, 83, and 82). The deficient practice could result in other residents being denied the right to privacy and personal space. Findings include: Resident #107 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance, anxiety, and major depressive disorder. Review of the care plan for elopement risk/wanderer dated February 25, 2021 revealed the resident wanders on the unit. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, and re-direct resident when he wanders. Review of progress notes revealed that…

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 clinical record review, staff interviews, and policy review, the facility failed to ensure advanced directive was accurately documented for one of two sampled residents (#27). The census was 124. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #27 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder, anemia and osteoarthritis. Review of the Advance Directive form in resident's #27 clinical record revealed that the resident does not want cardiac resuscitation measures (CPR) and does not want artificial nutrition (tube feeding) if unable to accept nourishment by mouth. The form also revealed that consent was received from the resident's family member on [DATE] and the form was signed by the facility representative on [DATE]. However, a physician's order dated [DATE] stated CPR/Full Code. Further review of the clinical record did not reveal the resident had…

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 clinical record review, resident and staff interviews, and facility policy and procedures, the facility failed to ensure that an allegation of sexual abuse for one resident (#32) was reported to the State Agency. The deficient practice could result in allegations of abuse not being reported as mandated by federal guidelines. Findings include: Resident #32 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, delusional disorders, and cognitive communication deficit. The admission Minimum Data Set assessment dated [DATE] included a brief interview mental status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS assessment also included the resident did not hallucinate or have delusions during the look-back period. During an interview conducted with the resident on January 3, 2022 at 10:14 a.m., resident #32 stated that there are two guys that come into her room. She said that one of the men that came into her room the day before yesterday and tried…

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 clinical record review, staff interviews, review of facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that a significant change in status Minimum Data Set (MDS) assessment was completed for one resident (#75) who was admitted on hospice services. The sample size was 25. The deficient practice could affect residents' continuity of care. Findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, senile degeneration of brain, and major depressive disorder. A physician order dated October 14, 2021 included an order for hospice to evaluate and treat. A hospice informed consent revealed the consent was signed by the resident's legal guardian for a start of benefits on October 14, 2021. Review of the physician order dated October 18, 2021 revealed the resident was with hospice, diagnosis senile degeneration of the brain. A review of the Care Plan initiated on October 18, 2021 revealed…

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, staff interviews, and facility policy, the facility failed to ensure infection prevention and control standards were maintained when handling one resident's (#70) medication during medication administration. The sample size was 6. The deficient practice could result in transmission of infection. Findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following an unspecified cerebrovascular disease affecting the right dominant side and essential hypertension. Review of the clinical record revealed a physician order dated November 9, 2021 for Atenolol 50 milligrams (mg) one tablet by mouth one time a day for hypertension. A medication administration observation was conducted on January 5, 2022 at 7:57 AM with a Registered Nurse (RN/ Staff #118). Staff #118 was observed preparing medications for resident #70. During the observation, the RN was observed to take out the resident's medication named Atenolol (antihypertensive)…

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.