Sunset Health Care Center

Inspectors wroteBased on observation, interview, and record review, facility staff failed to propel four (Resident #3, #7, #24, and #111) out of six residents in a wheelchair in a manner to ensure resident safety. The facility census was 114. 1. Review of the facility's policies showed staff did not provide a policy for wheelchair safety. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/14/25, showed staff assessed the resident as: -Cognitively impaired; -Required partial to moderate assistance for ambulation greater than 50 feet; -No wheelchair. Observation on 05/28/25 at 9:11 A.M., showed Licensed Practical Nurse (LPN) E propelled from the 200 secured unit to the 100 hallway to the scale, weigh the resident, and return the resident to the 200 hallway. [...]

Inspectors wroteBased on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds. The facility census was 114. 1. Review of the resident's trust fund account for July 2024 through April 2025, showed an average monthly balance of $199,493.16, which required a surety bond of $300,000.00. Review of the Department of Health and Senior Services (DHSS) database, showed the facility has an approved non-cancelable Escrow Agreement Account in the amount of $250,000.00. During an interview on 05/28/25 at 1:42 P.M., the business office manager (BOM) said he/she is responsible for resident funds and ensuring the bond is sufficient. He/She said he/she is aware their bond needs to be increased. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when staff failed to complete hand hygiene between glove changes during wound care for three residents (Resident #4, #28,and #216) of three sampled residents with wounds and when staff failed to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed in accordance with their policy and on file for three employees (Certified nurse aide (CNA) N, Maintenance assistant, and Housekeeper O) out of ten employee files reviewed. The facility census was 114. 1. Review of the facility's Standard Precautions policy, dated October 2022, showed the policy did not contain direction or guidance for hand hygiene between glove changes. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for four (Resident #19, #28, #47, #91 and #109) of twelve sampled residents. The facility census was 114. 1. Review of the facility's Comprehensive Person-Centered Care Plan (CCP) policy, dated October 2019, showed: -Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team (IDT) will provide care; -All disciplines will collaborate to develop a plan of care that meets residents' needs, preferences and goals; -CCP contains services provided, preferences, ability and goals for admission, desired outcomes, and care level guidelines; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet residents' interests, for the residents who reside on a secured unit. The facility census was 114. 1. Review of the facility's policy titled, Activities, dated 09/14/23, showed: -Facility is to provide an ongoing program to support residents in their choice of activities based on their comprehensive evaluation, care plan, and preferences; -Facility-Sponsored group, individual, and dependent activities will be designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the facility; -Each resident's interest and needs will be evaluated on a routine basis; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to keep Resident #2 from striking Resident #1 twice to the chest. The facility census was 114. The administrator was notified on 3/27/25 of past Non-Compliance, which occurred on 3/22/25 when Resident #1 struck Resident #2 to the chest twice. Staff immediately separated the residents, assessed the residents, notified the resident's physician, moved Resident #1 to a different hallway, put Resident #2 on one on one, and in-serviced nursing staff on abuse and neglect. Staff corrected the deficient practice on 3/25/25. 1. Review of the facility's Abuse prevention policy, dated 10/21/22, showed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an appropriate emergency discharge notice when staff failed to have an appropriate location to transfer one resident (Resident #2) to when he/she was ready to discharge from the hospital. The facility census was 114. 1. Review of the facility's Discharge and Transfer - Involuntary Policy, reviewed 10/07/2021, showed transfer and discharge includes movement of a resident to a bed outside of the facility whether that bed is in the same physical plant to not. The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless specific criteria are met. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 107. 1. Review of the dietary supervisor's (DS) personnel records, showed a hire date of 6/13/23 and promoted to the dietary supervisor on 10/22/23. Review showed the records did not contain documentation of prior dietary manager experience in a long-term care facility and certification or other education required for the director of nutritional services position. Review showed the DS had a course start date of 11/02/23 in an on-line Nutrition and Foodservice Professional Training Program. Review showed the DS had an estimated program completion date of 11/01/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. Facility staff also failed to record substitutions made to the menus. The census was 107. 1. Review of the facility's Menu Alternates and Substitutions policy, reviewed 11/27/23, showed the policy did not contain guidance related to substitutions for preplanned menu items. Review of the facility's Menu Substitution Form showed the last documented food substitution was dated 11-23. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain kitchen equipment and surfaces in a clean sanitary manner to prevent the potential for cross-contamination. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff failed to sanitize kitchen wares in a manner to prevent contamination, and to store dishwares in a manner to prevent cross-contamination when staff stacked dishwares together wet. Facility staff failed to ensure hair/beard coverings remained in place during the preparation of resident meals to prevent the potential for food contamination. The facility census was 107. 1. Review of the facility's Nutritional Services Sanitation policy, reviewed 11/27/23, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 107. 1. Review of the facility's policies showed staff did not provide a policy for specialized training for the Infection Preventionist. During an interview on 01/05/24 at 10:15 A.M., the Director of Nursing (DON) said they do not currently have a certified IP. The Assistant Director of Nursing (ADON) is currently acting as the IP and their Regional Corporate Nurse (RNC), who is a certified IP, and himself/herself oversee IPC. He/She said he/she is not certified. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide residents with a dignified environment when staff did not keep residents' personal information private, allowed one resident (Resident #72) to wear the same soiled clothes for three days, left one resident (Resident #30) exposed, did not speak in a dignified manner for one resident (Resident #12) and changed the residents' smoking times for two residents (Resident #76 and #102) for staff convenience. The facility census was 107. 1. Review of the facility's Residents' [NAME] of Rights, showed staff are to treat residents with dignity and respect and are to keep residents' personal information private. 2. Observation on 01/03/24 at 11:40 A.M., Licensed Practical Nurse (LPN) K stood in the dining room with Certified Nursing Assistant (CNA) L and discussed an incident between two residents. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to accurately complete entrapment assessments, bedrail assessments, obtain physician orders, obtain consents for the use of bed rails for four residents (Resident #4, #30, #69 and #102). The facility census was 107. 1. Review of facility's policies showed staff did not provide a bed rail policy. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/01/23, showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Parkinson's (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) and Epilepsy (a seizure disorder); -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to destroy medications in a timely manner for five current residents (Resident #41, #56, #81, #89, #92) and three discharged residents (Resident #463, #464, and #465). The facility census was 107. 1. Review of the facility's Disposal of Medications and Medication-Related Supplies policy, Revised [DATE], showed all discontinued medication will be immediately removed form the resident's active medication and stored in separate locked area for up to 90 days or as required by applicable law, and then destroyed by a manner in accordance with applicable state and federal laws. 2. Observation on [DATE] at 12:50 P.M., showed a storage closet at end of 400 hallway contained two pink basins with 33 total medication cards, one large ziplock bag with 16 medication cards, and a large plastic tub with 89 medication cards. [...]

Inspectors wroteBased on interview and record review, facility staff failed to document communication between the facility and their hospice provider for three (Resident #4, #5 and #102) out of five sampled residents who received hospice services. The facility census was 107. 1. Review of the facility's Hospice Services Agreement, dated 05/03/2023, showed hospice will prepare and maintain complete medical records for hospice patients receiving services in accordance with this agreement and will include all treatments, progress notes, authorizations, physicians orders and other pertinent information. Review showed copies of all documents of services provided by hospice will be filed and maintained in the medical record. 2. Review of Resident's #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/01/23, showed: -Recived hospice services; [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of resident transfers to the hospital for four sampled residents (Resident #39, #56, #58 and #92). The facility census was 107. 1. Review of the facility's Discharge/Transfer-Involuntary Policy, last review 10/07/21, showed the policy did not include direction for staff to notify the ombudsman for resident discharge or transfer. 2. Review of an email dated, 01/02/23 at 1:42 P.M., from the Long Term Care Ombudsman Program Director showed the facility does not send him/her monthly notifications of discharged or transferred residents. 3. Review of Resident #39's medical record showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post required nurse staffing information to include the facility name, resident census, total number of staff and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 107. 1. Review of the facility's policies showed the facility did not have a policy for staffing and scheduling Postings. Observation on 01/02/22 at 10:30 A.M., showed staff did not post the required nurse staffing information to include the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift by the front entrance. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide refunds of personal funds to residents from the facility operating account in a timely manner for four (Resident #361, #362, #371, and #373) discharged from the facility. The facility census was 107. 1. Review of the Facility's Resident Trust Fund policy, undated, showed: -The facility is required to maintain the resident trust account balance as a positive account at all times; -Any account that reflects a negative balance must be addressed immediately to the administrator and Treasury Analyst, to be resolved immediately; -An internal audit of the resident trust will be completed on a quarterly basis by the corporate office. 2. Review of the facility's maintained Accounts Receivable Report from 01/01/23 through 01/03/24, showed the following residents with personal funds held in the facility operating account: [...]

Inspectors wroteBased on observation and nterview, facility staff failed to provide meals that were served at a safe and appetizing temperature for three sampled residents (Resident #1, Resident #2, and Resident #3). The facility census was 110. 1. Observation on 10/20/23 at 11:59 A.M., showed the internal temperature of the chicken tenders for Resident #1 measured 95º F upon service to the resident. During an interview on 10/20/23 at 11:01 A.M., Resident #1 said the meals served were cold. Observation on 10/20/23 at 12:14 P.M. showed the internal temperature of the chicken tenders for Resident #2 measured 99º F upon service to the resident. During an interview on 10/20/23 at 11:12 A.M., Resident #2 said meals were cold every time they were served. Observation on 10/20/23 at 12:18 P.M. showed the internal temperature of the chicken tenders for Resident #3 measured 97º F upon service to to the resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to appropriately sanitize manually and mechanically washed dishes to prevent cross-contamination. The facility census was 109. 1. Review of the facility's Sanitation-Warewashing policy, dated 04/01/16, showed: -Dinnerware and supplies shall be washed and sanitized according to food safety practices and regulatory guidelines as follows: 1. All dinnerware, utensils, preparation and service supplies shall be washed and sanitized in the pot sink and/or through use of commercially approved dish machine. 4. Test strips shall be available for the pot sink and low temp dish machine sanitizer. Results shall be checked and recorded daily. Observation on 07/06/22 at 10:22 A.M., showed staff washed kitchenware in the three-compartment sink. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to maintain a clean, safe, and comfortable homelike environment when staff failed to adequately maintain residents' rooms, common areas and hallways clean and in good repair. The facility census was 109. 1. Observation on 7/5/22 at 10:30 A.M., showed room [ROOM NUMBER] to have floor tiles with a raised black stain in the spaces between the tiles. The toilet had multiple brown smears on the toilet and tank. The door jams were heavily rusted and pitted. Observation also showed holes in the window screen. Observation on 7/5/22 at 10:40 A.M., showed room [ROOM NUMBER] to have bathroom door jams that were rusted with holes in the door jam. The base of the toilet had black stains around it. Observation on 7/5/22 at 10:45 A.M., showed room [ROOM NUMBER] to have a strong smell of urine and sticky floors. [...]

Inspectors wroteBased on record review and interview, the facility staff failed to follow their policy to ensure they completed the required Nurse Aide (NA) Registry (a registry that is a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property) check prior to start date for seven out of 10 sampled employees. The facility census was 109. 1. Review of the facility's Background Investigations policy, undated, showed: -Federal and State law require the facility to perform pre-employment criminal history, dependent adult abuse, and founded child abuse background checks; -Offers of employment will be conditional upon successful completion of the background checks; -Employees may not begin working until the facility has received a successful background result; -For further information, see the separate Pre-Employment Screening policy. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for two (Resident #64 and #110) sampled residents. The facility's census was 109. 1. Review of facility's bed hold policy dated 03/2017 showed: - Our facility shall inform residents and/or resident representative upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed hold policy; - Upon a resident being transferred for hospitalization or for a therapeutic leave, the resident and resident representative will be provided information on the Facility Bed Hold Policy within 24 hours of the hospitalization or therapeutic leave; - A copy of the bed hold acknowledgement will be filed in the resident's record. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the up to date and current number of actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 109. 1. The facility did not provide a written policy for review. Observation on 7/6/22 at 08:00 A.M. showed the daily staff assignment posting did not contain the actual hours worked by direct care nursing staff. Observation on 7/7/22 at 08:15 A.M. showed the the daily staff assignment posting did not contain the actual hours worked by direct care nursing staff Observation on 7/8/22 at 08:15 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria including Coronavirus Disease 2019 (COVID-19), when staff failed to perform proper hand hygiene after they touched their facemasks, and during incontinence care for two residents (Resident #35 and #45). Additionally, the facility staff failed to properly store a catheter bag for one resident (Resident #31) and ensure all employees were screened appropriately for tuberculosis (TB) by failure to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed and on file for three out of ten employee files reviewed. The facility census was 109. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to implement interventions and monitor for illegal drug use for two residents, with a history of prior illegal substance use (Resident #1 and Resident #2), when illegal drugs and paraphernalia were found in their rooms. Additionally, facility staff failed to provide safe Hoyer lift transfers for three residents (Residents #35, #95, and #107) in a manner to prevent accidents. The facility census was 109. 1. The facility records did not contain a policy for illegal substance abuse. Review of Resident #1's Annual Minimum Data Set (MDS) a federally mandated assessment tool, dated 6/12/22, showed staff assessed the resident as follows: -Cognitively intact; -Totally dependent with two plus person assist for bed mobility, transfers, dressing and toileting; -Nonverbal communication, yes or no questions; -Active diagnoses: [...]