Sunset Home

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to dispose of perishable foods in the dry storage pantry and walk in fridge. These failures could place residents at risk for consuming hazardous expired food and developing foodborne illnesses who received food from the kitchen. Findings Included: Observation in the kitchen on 05/27/25 at 9:36 am revealed a bag of white bread with the use by date of 02/26/25. Observation on 05/27/25 in the kitchen at 9:36 am revealed a bag of tortillas with the use by date of 04/18/25. Observation on 05/27/25 in the kitchen at 9:36 am revealed a bag of buns with the use by date of 05/07/25. Observation on 05/27/25 in the kitchen at 9:36 am revealed a tray of four mayo bottles all marked with the expiration date of 04/29/25. In an interview with [NAME] E on 05/29/25 at 1:22 pm she revealed that she had been trained on what to do with expired foods.…

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 record review the facility failed to use appropriate alternatives prior to installing a side or bed rails, assess the resident for risk of entrapment, review the risk and benefits, and obtain informed consent prior to installation for 3 out of 15 residents (Residents #63, #80, and #100) reviewed for bedrails. The facility failed to assess and get signed consents for Residents #63, #80, and #100 prior to installing bed rails. This deficient practice could affect residents who utilized bed rails by placing them at risk for unintended entrapment of the head, neck, or limbs, restraints, and injuries. The findings included: Record review of Resident #63's face sheet dated 05/29/25 reflected a 72 -year-old male who was admitted to the facility on [DATE] with relevant diagnoses of dementia, cellulitis (major infection of the skin), cognitive communication deficit (a generalized inability to understand and communicate due to disease state), anxiety and insomnia (inability to sleep…

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, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 15 residents (Resident #80) observed for resident rights. The facility failed to ensure Resident #80 was served her meal and provided assistance to eat at the same time as the other residents. The facility failed to ensure that they were engaging Resident #80 while assisting her with lunch. This failure could place residents at risk of lowered self-esteem, depression, and frustration. Findings included Record review of Resident #80's face sheet dated 05/29/25 reflected a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Dementia (chronic brain degeneration), Edema (excessive fluid retention around parts of the body), pulmonary embolism (lung clots), Epileptic seizures, and Cognitive communication deficit (a generalized inability to understand and communicate due to disease state). Record review of Resident #80's quarterly MDS dated…

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 record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates for 1 of 4 medication carts reviewed. During observation of MC A, Resident #16's Artificial Tears had an expiration date of 08/2024. This failure could lead to medication not being effective, and therefore impacting resident health. Findings included: Record review of Resident #16's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included chronic kidney disease, hypertensive heart failure, need for assistance with personal care, anxiety disorder, dry eye syndrome unspecified lacrimal gland (dryness of the cornea and conjunctiva caused by a deficiency in tear production), and xeroderma of left upper eyelid (excessively dry skin). Record review of Resident #16's Prescription Order reflected she had been prescribed Natural…

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 record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to properly seal, label, and date food products in dry storage and the walk-in freezer. These failures placed residents at risk of exposure food contamination and food-borne illness. Findings included: Observation on 4/9/2024 at 9:00 AM in the kitchen's dry storage room reflected 6 individual 6-pound cans of pineapple with dented sides and dented seams. The cans were observed in the canned food rack with the entirety of the remaining canned good items; 1 item of vanilla wafers removed from its original container and stored in an unsealed plastic bag, without a date to signify when the item was removed from its original package or when the item was supposed to expire; 1 item of granola cereal removed from its original container and stored in a plastic bag, without a date to signify when the item was removed from its original package 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Resident # 80) reviewed for resident assessments. The facility failed to ensure Resident #80's medication assessment for high-risk drug classes reflected Resident #80 took antiplatelet medication. This failure could place residents at-risk for inadequate care due to inaccurate assessments. Findings include: A record review of Resident #80's face sheet, dated 04/11/2024, reflected a [AGE] year-old female admitted to facility on 01/17/2024. Resident #80's diagnoses included other heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and hypertension (High blood Pressure). A record review of Resident #80's admission MDS dated [DATE] reflected Resident #80 had a BIMS score of 09 indicating moderately…

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 record review, the facility failed to develop a comprehensive care plan for one resident (Resident #3) of six reviewed. A) The facility failed to ensure Resident #3's Comprehensive Care Plan reflected her risk for skin breakdown and a stage 2 pressure ulcer to the right upper buttocks. This failure could place a resident at risk for errors in provider care, poor wound healing/worsening wound/skin conditions. Findings included: Review of Resident #3's undated face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: essential hypertension (elevated blood pressure), unspecified fracture of the left hip, hematuria (blood in the urine), and diarrhea. Review of Resident #3's weekly nursing assessment dated [DATE] reflected Resident #3 had completely limited mobility to her upper and lower extremities. Resident #3 required a wheelchair for mobility. Resident #3 did have pressure relieving devices in use for her chair and bed.…

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, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation The facility failed to ensure food was stored properly in the walk-in freezer and walk-in refrigerator. There was food that had been expired and food that had not been labled or dated. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings include: Observations on 11/22/2023 at 9:20 am of poster titled FIRST IN FIRST OUT posted on the outside of the walk in refrigerator informing the staff to label food the day food was received and when it should be used. Store food so labels are clearly visible and use products expiring first. Check food expiration dates and throw away at or before expiration. During an observation of the walk-in freezer on 11/22/2023 at 9:23 am multiple boxes of food were observed laying on the floor including an opened box of hamburger meat, pies, French fries,…

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 record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents ( Resident #3 and #4) reviewed for infection control, in that:. LVN A failed to use a clean, unused gauze to wipe Resident #3 and #4's fingers before collecting a blood specimen for a blood sugar check. LVN A re-used a contaminated alcohol pad to wipe both Resident #3 and 4's fingers prior to taking a blood sample. This failure could result in the spread of diseases to residents which could result in decreased quality of life, illness, and hospitalization. Findings include: Review of Resident #4's face sheet dated 11/22/2023, reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: Type 2 Diabetes (blood sugar regulation disorder), Hypertension (high blood pressure),…

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 record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for 1 of 3 medication carts that were reviewed for pharmacy services. This deficient practice placed the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics not reconciled every shift. The findings include: 1.During an observation and record review on 2/16/23 at 11:30 a.m., an inspection of the medication cart on Hope Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures with the following dates: 2/1/23, 2/2/23, 2/3/23, and 2/4/23. During an interview on 2/16/23 at 11:30 a.m., LVA A stated she was aware of 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.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food storage. The DS failed to ensure all items in the walk-in refrigerator and freezer were covered, labeled, dated, and discarded prior to their expiration date. These failures placed residents at risk of foodborne illness. Findings included: Observations on 02/13/2023 at 8:51 AM of poster titled FIRST IN FIRST OUT posted on the outside of the walk in refrigerator informing the staff to label food the day food was received and when it should be used. Store food so labels are clearly visible and use products expiring first. Check food expiration dates and throw away at or before expiration. Observations of the walk-in refrigerator on 02/13/2023 from 8:52 AM to 9:17 AM revealed the following: 1. Five heads of cabbage uncovered and undated sitting in white plastic bin. 2. One brown cardboard box, opened, uncovered, and undated, containing approximately 75 sliced…

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, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 of one resident (Resident #15) reviewed for respiratory care, in that: The facility failed to: A.) Resident #15's tubing has not been changed since 1/27/23. B.) Resident #15's oxygen tubing was laying on the floor next to the Resident on 2/14/23 and 2/15/23. These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Resident #15 Review of the facility's policy Safety Items, dated 12/9/2022 revealed, .Oxygen tubing must be changed out weekly on Oxygen concentrators and nebulizers Oxygen tubing must be bagged when not in use .Oxygen tubing must be dated with the date that it was changed. Use a piece of tape and write the date on it; place the tape on the bag . Record Review of Resident #15's face sheet dated…

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.