Sunset Home

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensured each resident received adequate supervision for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was free from accidents. Resident #1 eloped from the facility on 3/20/25, was able to obtain access to a truck at a private residence near the facility. Resident #1 was involved in an accident and was transported to the ER on [DATE]. The facility failed to ensure Resident #1 checked out when leaving the facility and was monitored to ensure he returned. The process to get back in the facility after 10:00 PM (when the doors were locked) required him to have a phone to call the nurses station to be let in, Resident #1 did not have a phone. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]