Sutton Community Home, Inc.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 (F) Based on record review and interview, the facility failed to revise the Care Plan (Comprehensive -CCP - written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), to add interventions for a fall for one Resident (Resident 6) and to update Care plan with new interventions for 2 Residents (Resident 1, and Resident 3 ) of 6 sampled residents. The facility census was 22.Findings are: A. A record review of the admission record revealed that Resident 6 was admitted to the facility on [DATE] with the diagnosis of Anxiety Disorder (the body's natural response to stress, characterized by feelings of unease, worry, or fear), Atrial Fibrillation (an irregular, often rapid heart rhythm (arrhythmia) where the heart's upper chambers (atria) quiver out of sync with the lower chambers), Dementia with psychotic Disturbance (involves cognitive decline combined with delusions (false beliefs) or…

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.

Licensure Reference Number 175 NAC 12.006.7(C) Based on interviews and record review, the facility failed to identify hand washing as a systemic issue prior to the survey, and to correct previously cited quality issues. This had the potential to affect all 20 residents residing at the facility at the time of the survey. The facility census was 20.Findings are:In a record review of the facility's Medicare.Gov. Nursing Home Compare website (A public website that provides information to help consumers find and compare the quality of Medicare and/or Medicaid certified nursing homes across the country) on 12.22.2025 at 9:32 AM, revealed prior infection control deficiencies on 6.11.2021, 7.26.2022, 9.14.2023, and 9.12.2024. In a record review of the facility Quality Assurance & Performance Improvement Program (QAPI) dated 8.13.2013 with a revised date of July 2025 revealed a focus area to include monitoring the efficacy and outcomes for the Infection Prevention (IP) program. The guiding principles included: Uses QAPI to make decisions and guide day-to-day operations. Focuses on systems…

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 Licensure Reference Number 175 NAC 12-006.18Based on observations, interviews, and record reviews, the facility staff failed to ensure hand hygiene was performed during meal service, during catheter cares for Resident 15, and during wound care for Resident 7. This practice had the potential to affect all residents in the facility. The facility census was 20 at the time of survey. Findings are: Record review of facility policy titled Service Staff and Serving the Meal, dated 2/9/2010 revealed the Infection Preventionist will provide staff with training on hand hygiene and PPE. Record review of the facility policy titled Hand Hygiene, dated 8/17/25 revealed hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) and to perform hand hygiene before putting on gloves and after glove removal. A. During an observation on 12/16/2025 at 11:47 AM Dietary Aide (DA) – D served lunch trays in the dining room,…

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 Licensure Reference Number 175 NAC 12-006.9(D)Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) was coded accurately for 1 (Resident 8) of 5 sampled residents for PASARR's (Preadmission Screening and Resident Review -that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Level 2 screening is triggered by evidence of a serious mental illness (MI), Intellectual or Developmental Disabilities (IDD) or condition related to Intellectual or Developmental Disabilities (RC) as defined by state and federal). The facility census was 20. Findings are: Record review of Resident 8's annual MDS dated [DATE] revealed the resident was admitted to the facility on [DATE], had a PASARR (Preadmission Screening and Resident Review) Level 1 preliminary screening (federally mandated screening for all…

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 Licensure Reference Number 175NAC 12-006.11(E) Based on observation, record review, and interview; the facility failed to ensure food items were stored and labeled per the Food Code, and failed to perform hand hygiene as required during meal service to prevent the potential for foodborne illness. This had the potential to affect all residents who ate food prepared in the kitchen. All residents residing in the facility received food and used dishes from the kitchen. The facility census was 23. Findings are: A. A record review of a facility policy titled Food Receiving and Storage and dated 2014 revealed all foods stored in the refrigerator or freezer will be covered, labeled, and dated. The policy also stated that wrappers of frozen foods must stay intact until the time of thawing. In an observation on 9/9/2024 from 9:15 AM to 9:40 AM the following was observed in the kitchen food storage areas: -In the main kitchen double door refrigerator: a clear round plastic container ¾ full of light [NAME]-pink moist…

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.

Licensure Reference Number 175NAC 12-006.04 (A)(ii) Based on record reviews and interviews, and observations; the facility and failed to ensure that pre-employment health history screenings were reviewed to prevent the potential for the transmission of contagious diseases for 4 of 4 sampled staff. The facility census was 23. Findings are: A record review of an undated and untitled list of facility employees revealed that Dietary Aide-H (DA-H) had a hire date of 6/24/2024. A record review of a document titled Medical History and Screening Form that was undated revealed that it was signed by DA-H. A record review of a document titled Medical History Questionnaire revealed the document listed DA-H's name and had a date of 6/24/2024. A record review of an undated and untitled list of facility employees revealed that Nurse Aide-I (NA-I) had a hire date of 6/24/2024. A record review of a document tilted Medical History and Screening Form that was undated revealed that it was signed by NA-I and not dated. A record review of a document titled Medical History Questionnaire revealed 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.

Licensure Reference Number 12-006.09(I) Based on record reviews, interviews, and observations the facility failed to develop, evaluate, and monitor interventions to prevent further elopement for 2 residents (Resident 11 and 12) of 5 sampled resident. The facility census was 23. Findings Are: Record review of a facility policy titled Elopements and Wandering Residents dated 6/20/2023 revealed interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident). A record review of an admission Record dated 9/9/2024 revealed the facility admitted Resident 12 on 10/13/2021 with diagnoses that included mild cognitive impairment (when a person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough…

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.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record reviews and interviews, the facility failed to ensure 1 (Resident 12) of 5 sampled residents were monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being while taking an antipsychotic medication. The facility census was 23. Findings are: A record review of a facility policy titled Use of Psychotropic Medications and dated 12/04/2022 revealed residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS, a test that measures for extra pyramidal or involuntary body movements which is a side effect of taking an antipsychotic medication), performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication and as needed. A record review of an admission Record dated 9/9/2024 revealed the facility admitted Resident 12 on 10/13/2021 with diagnoses that included mild cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions 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.

LICENSURE REFERENCE NUMBER 175 NAC 12.006.17 Based on observation, record review and interview: the facility failed to prevent potential cross contamination between residents as hand hygiene was not completed during the provision of cares for Resident 6. In addition, staff failed to cleanse/sanitize re-useable care equipment between residents use. This practice had the potential to affect 6 residents (Residents 8, 12, 14, 15, 4 and 2) who routinely used the lift. The facility census was 24 and the total sample size was 20. Findings are: A. Review of the facility policy titled Hand Hygiene with revision/reviewed date of 8/2/23, revealed the facility considered handwashing/hand hygiene the primary method of preventing the spread of infections and included the following situations in which handwashing/hand hygiene was to be completed: -before and after direct contact with residents; -when hands are visibly soiled or dirty (with soap and water); -before and after assisting a resident with personal cares; -before and after assisting a resident with toileting; -before handling soiled…

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 LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and interview; the facility failed to provide timely toileting assistance/incontinence management for 1 (Resident 6) of 2 sampled residents who required assistance with activities of daily living. The facility census was 24. Findings are: Review of Resident 6's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 7/26/23 indicated the resident was admitted [DATE] with diagnoses of anemia, heart failure, diabetes, respiratory failure and depression. The assessment further indicated the resident required extensive assist for bed mobility, dressing, and toileting and was always incontinent of bowel and bladder. Review of Resident 6's undated current Care Plan revealed the resident had a self-care deficit related to an amputation above the right knee. The following interventions were identified: -extensive staff assist with bed mobility and dressing; -total staff assistance 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.

Licensure Reference Number 175 NAC 12-006.10 Based on interview and record review; the facility failed to follow practitioner orders related to administration of blood pressure (bp) medications in accordance with indicated parameters. The total sample size was 20 and the facility census was 24. Findings are: Review of Resident 6's Medication Administration Record (MAR) dated 8/2023 revealed the following orders: -Norvasc (medication used to treat high bp 5 milligrams (mg) daily. Hold if systolic bp (bp is measured in 2 numbers. The first number is called the systolic and measures the pressure in your arteries when you heart beats. The second number, the diastolic, is the pressure in the arteries between heartbeats) is less than 90 and the diastolic is less than 60. Further review revealed the medication was administered despite these parameters on 8/7/23 (bp was 127/59) and on 8/16/23 (bp was 107/50); and -Coreg (medication used to treat high bp) 25 mg twice a day. Staff were to hold the medication if systolic bp was less than 90 and diastolic bp was less than 60 and if heart rate…

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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, record review and interview; the facility failed to provide safe storage of medications for 1 (Resident 6) of 20 residents sampled. The facility census was 24. Findings are: A. Review of the facility policy Medication Storage with a revised/reviewed date of 6/9/23 revealed the following: -all drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms); -only authorized personnel will have access to the keys to the locked compartments; and -during a medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage area/cart. B. During an observation on 9/12/23 at 8:16 AM, Resident 6 remained in bed in the resident's room. The resident had received a breakfast meal tray and the tray had been placed on a bedside table next to the resident. Prepared medications consisting of Colace (medication used to treat constipation), Effexor (medication used to treat depression),…

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.