Sunset Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent one of the three sampled residents, (Resident #1) from accidents and hazards when Resident #1 eloped from the facility and was found by a nearby business laying on the ground. The resident was transported to the hospital and found to have fractured in his/her left arm. The facility census was 29. Review of the facility's Elopement Protocol, dated April 2006 showed:Elopement, for the purpose of these guidelines is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety needs, and therefore at risk for injury outside the confines of the facility, has left the facility without knowledge of staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 23. Review of the facility's Cleaning of Workspaces policy, dated May 2015 showed:-Walls, doors, vents and ceiling must be free from chipped and/or peeling paint and must be kept in good repair;-Walls, doors, vents and ceilings must be washed at least twice a year;-Heavily soiled surfaces must be cleaned more frequently;-Cabinets should be washed with detergent solution and warm water every week and more often if needed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure there was a Registered Nurse (RN) providing services at least 8 consecutive hours a day, 7 days a week consistently for the months of January, February, and March 2025. The facility census was 23. A facility staffing policy was requested and none was provided. Review of the Payroll Based Journal (PBJ) Staffing Data Report showed the facility is responsible for submitting staffing data through the PBJ .This data is available through facility's PBJ Staffing Data Report that can be obtained through CMS' survey system. This report must be utilized by surveyors on at least every recertification survey. The report contains information about overall direct care staffing levels as well as if an RN was onsite for 8 hours a day. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to post the daily staffing sheets to included the amount of hours scheduled to work for both licensed and non-licensed nursing staff and additionally failed to have it in an area unobstructed from the public view. The facility census was 23. The facility did not have a policy regarding the posting of daily census and staffing sheets. Observation on 7/22/25 at 2:15 P.M., showed the daily census and staffing sheets were hung on a clip board on a wall and behind a decorative tall Christmas tree in the front lobby which was obstructing the view from the public to see the daily census and staffing sheets of the facility. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accurately label medication and to facilitate consideration of precautions and safe administration, when nursing staff failed to write the opened date on three insulin pens for two of the 12 sampled residents (Resident #6, #9) The facility census was 23. Review of the facilities Diabetic Infection Control policy, not dated, states:- All multiple dose insulin vials will be assigned to individual residents, labeled appropriately, and dated when opened. Review of NovoLog injection flexpen manufacture guidelines states:- The NovoLog(R) FlexPen(R) you are using should be thrownaway after 28 days, even if it still has insulin left in it. Review of instructions for use of Lantus prefilled pen states:- Only use the pen for up to 28 days after its first use. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all services being provided met professional standards of quality of care for one resident (Resident #3) out of the 12 sampled residents. When CMT A failed to clarify medication parameters of when to hold digoxin (an antiarrhythmic medication) if the resident's heart rate dropped below a certain number (standards of quality of care recommend holding this medication for a pulse rate of 60 or below), and additionally failed to clarify with the charge nurse if a dose of digoxin should be administered or held while the resident had a heart rate of 54 (normal heart rate for adults is 60-100 beats per minute); placing the resident at risk for negative impact to their safety and well-being. The facility census was 23. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide competency assessments in accordance with their facility assessment, when they failed to ensure 7 of 7 randomly selected nurse aides, had competency assessments at hire and every 6 months thereafter. This potentially effected all residents. The facility census was 33. The facility did not provide a policy for competency and education. Review of the Facility assessment dated [DATE] showed: -Competencies will be tested every 6 months and those indicated by star will be tested at hire, for nursing staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. This deficiency had the potential to affect all residents. The facility census was 33. The facility did not provide a policy regarding RN coverage. Review of the facility staffing and time sheets showed no RN in the facility within a 24 hour time period on: -July: 20th and 21st. -August: 3rd and 4th. During an interview on 08/14/24 at 11:30 A.M. the Administrator said: -The facility had a waiver for RN coverage so she did not worry about not having a RN in the facility on those days. -There facility used two staffing agencies that provided RN coverage at times. -There was an add on-line for a RN. -There was a RN on call 24 hours a day, 7 days a week, either the Director of Nursing or a Corporate Nurse. -There is no care that requires a RN. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to maintain a clean and sanitary kitchen, did not ensure refrigerator and freezer temperatures were checked daily, did not ensure proper function of dishwasher by testing and logging it daily, did not use sanitizer solution on kitchen food preparation surfaces, staff did not practice sanitary hand washing skills, and did not ensure proper storage and labeling of foods. Additionally the facility failed to ensure food temperatures were logged and measured during meal service and cooking. The facility census was 33. Review of facility policy, handwashing, dated May 2015, showed: -If using gloves, remove gloves; -Roll down paper towels; -Turn on water and run until warm; -Wet hands and forearms with warm water; [...]

Inspectors wroteBased on record review and interview, the facility failed to accurately show the residents' correct code status in the resident's medical record when the code status did not match in all areas of the resident's medical record. This affected two of the 12 sampled residents (Residents #185 and #28). The facility census was 33. Review of facility policy, Advance Directive, undated, showed: -The facility will respect advance directives in accordance with state law; -Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; [...]

Inspectors wroteBased on interviews and record review, the facility failed to follow the written policy to check the Nurses Aide (NA) registry prior to hire for three of 5 sampled staff members. The facility census was 33. Review of the undated abuse and neglect policy showed: Before a prospective employee is allowed to work with the residents, a complete background check will be completed; The facility will not employ an individual who has a finding entered on the state nurse aide registry. 1. Review of Dietary Aide (DA) B personnel file showed the following: - He/She was hired 6/22/23 to work as a DA in the kitchen; - No completed NA registry check. 2. Review of Nurses Aide (NA) A's personnel fie showed the following: - He/She was hired 7/6/23 to work as an NA; - No completed NA registry check. 3. Review of the Director of Nurses (DON) personal file showed the following: [...]

Inspectors wroteBased on interviews and record review the facility failed to document and provide two residents (Resident #13 and #14), with written notice of transfer when the residents were transferred to local hospitals. the facility census was 33. The facility staff did not provide a policy regarding transfers. 1. Review of Resident #13's quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 8/4/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment; - He/She required substantial assistance to get dressed, use the toilet and to bathe; - Diagnoses included: Bipolar disorder (mood swings that range from depression to very happy), Atrial Fibrillation ( a disorder in which the heart does not beat correctly), epilepsy (seizure disorder), and Chronic Obstructive Pulmonary Disease (COPD). [...]

Inspectors wroteBased on interviews and record review the facility failed to document and provide two residents (Resident #13 and #14), with a notice of bed hold policy when the residents were transferred to local hospitals. The facility census was 33. Review of the undated bed hold policy showed: - All residents and guardians will be notified of bed hold guidelines; - Notification will be given upon admission and at the time of transfer to the hospital. 1. Review of Resident #13's quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 8/4/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment; - He/She required substantial assistance to get dressed, use the toilet and to bathe; - Diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for three of the 12 sampled residents (Residents #2, #20 #30,). The census was 33. The facility did not provide a policy on Care Plans. 1. Review of Resident #30's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff ) dated 7/30/24 showed: -Brief Interview of mental status (BIMS) of 15, indicated no cognitive loss -Set up assistance of staff for Activities of Daily Living (ADLs: activities done in a day to care for oneself) -Diagnoses of : Chronic Obstructive Pulmonary Disease (COPD: A lung disease that causes breathing problems and restricted airflow.) Chronic Atrial Fibrillation (Afib: [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure staff developed and updated care plans consistent with resident's specific conditions and needs which affected one of 12 sampled residents (Resident #2). Additionally, the facility failed to conduct quarterly care plan meetings to discuss the residents plan of care. This deficient practice affected two of 12 sampled residents, (Resident #13 and #17). The facility census was 33. Review of the facility policy, MDS and Care Planning guidelines, dated September 2013, showed: [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to provide meaningful activities for five of 12 sampled residents (Resident #17, #21, #2, #13, #20). The facility census was 33. Review of the undated activity policy said: - Activities services will plan, organize and carry out a program of activities to meet the individual needs of the residents; - The Activities Director (AD) plans and organizes individual activities and group activities; - A calendar of events will be posted on the activity bulletin board; - All staff are responsible to assist residents to the activity - The AD will develop an activity calendar to include a wide variety of activities to include spiritual, physical, emotional, cognitive, sensory, recreational, and work service related activities; - Activities will be planned for men and women and large and small groups. 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff obtained and followed complete and accurate physician orders for the administration of continuous positive airway pressure (CPAP: a type of ventilator that uses mild air pressure to keep breathing airways open while you sleep) for one resident . Additionally, the facility failed to label, date and clean the CPAP machines for 2 residents (Resident #30 and Resident #28) and failed to label and date open containers of distilled water for use in the CPAP machines for one resident (Resident #28) out of 12 sampled residents. The facility census was 33. Review of the undated facility provided policy on Oxygen Equipment Cleaning Guidelines showed: -Oxygen equipment will be cleaned to ensure safety in handling and administering oxygen. -Connectors must be cleaned after each resident use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the residents size and weight, and additionally failed to complete quarterly assessments side rail and entrapment assessments (Resident #20, #13, #14, and #21), and failed to obtain a physician's order prior to installation (Resident #20, #13, and #14), failed to obtain informed consent (Resident #13, #14, and #21) for four of the 12 sampled residents (Resident #20, #13, #14, and #20). The facility census was 33. Review of facility policy, bed rails, undated, showed: -Once bed rail observation is completed, the facility will print the observation and review associated risks and benefits with the resident and/or resident representative. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two nurse aides (NA) completed a nurse aide training program within four months of his/her employment in the facility. The census was 33. The facility did not provide a policy on education and Certified Nurse Aide training. Review of the Facility Assessment, completed by facility staff, dated 6/27/24 showed: -Nursing staff must have a license/certification current and verifiable with the State of Missouri. NA's will be hired with the certainty they will be in a Certified Nursing Assistant class within 120 days. Review of employee files showed the following: -Nurse Aide (NA) A date of hire 7/6/2023 -no competency evaluation -Certification issued 5/24/2024 -NA B date of hire 3/14/2024 -no competency evaluation -no certification issued Review of the Missouri CNA Registry on 8/14/24 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year, failed to provide nurse aide's annual individual performance review or evaluation, failed to provide the required annual competency of Dementia Care, and failed to implement a tracking system for monitoring training hours. This effected 5 of the 7 sampled nurse aides (Certified Nurse Aide; (CNA) E and CNA F) and had the potential to effect all staff and residents. The facility's census was 33. The facility did not provide a policy regarding staff education. Review of the Facility assessment dated [DATE] showed: -Competencies will be tested every 6 months and those indicated by star will be tested at hire, for nursing staff. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature when hot food was not served at an appetizing temperature for four of twelve sampled residents (Resident #2, #13, #21, and #185) . The facility had a census of 33. Review of facility policy, Food Temperatures, dated May 2015, included hot foods should be at least 120 degrees Fahrenheit when served to the resident. 1. Review of Resident #2's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/13/24, showed: -He/She had moderate cognitive impairment; -He/She had clear speech and was able to make-self understood and understand others; -He/She was dependent on a wheelchair and walker; -He/She required set up or clean up assistance with eating; [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure they had a back flow preventer device (a device used to keep toxins from backing up into the facility's potable water supply) on all shower hoses. The facility census was 31. 1. Observation on 8/13/24 at 1:13 P.M., showed the shower hose in the shower room across from room six did not have a back flow preventer. During an interview on 8/13/24 at 1:13 P.M., the Maintenance Supervisor said he did not know all shower hoses needed to have a back flow preventer device.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they had an effective pest control program when the facility had gnats in the corridors and brown recluse spiders in the sprinkler riser room. The facility census was 31. 1. Review of the pest control logs showed no specific treatments for spiders or gnats. Observation on 8/13/24 at 2:43 P.M. showed the sprinkler riser room was a ten by ten by eight foot room. The room had at least five living spiders that moved around the room as the surveyor entered the room and at least a dozen dead spiders in various levels of decay (some were just the exoskeleton) also lay on the wall and floor. During an interview on 8/13/24 at 2:43 P.M. the Maintenance Supervisor said he did not think they had a specific routine for spiders in their pest control program. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least 12 hours of nurse aide in-service education per year, failed to provide the required annual competency of Dementia Care and other required training's,and failed to prove education was completed from indicators of the Quality Assurance meetings. This effected 5 of the 7 sampled nurse aides (Certified Nurse Aide; (CNA) F, G,E, D and NA A) and had the potential to effect all staff and residents. The facility's census was 33. The facility did not provide a policy for education. Review of the Facility assessment dated [DATE] showed: -Competencies will be tested every 6 months and those indicated by star will be tested at hire, for nursing staff. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide trauma informed care to one sampled resident (Resident #30) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). The facility census was 33. The facility did not provide a policy on Trauma Informed Care. Review of Resident #30's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff ) dated 7/30/24 showed: -Brief Interview of mental status (BIMS) of 15, indicated no cognitive loss -Set up assistance of staff for Activities of Daily Living (ADLs: activities done in a day to care for oneself) -Diagnoses of : Chronic Obstructive Pulmonary Disease (COPD: A lung disease that causes breathing problems and restricted airflow.) Chronic Atrial Fibrillation (Afib: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident (Resident #1) out of sampled five residents, received necessary care and treatment in accordance with professional standards of practice to attain or maintain the highest practicable physical, mental, or psychosocial well-being; when the facility staff failed to obtain further testing orders from the physician or send the resident for a medical evaluation until nine days after an unwitnessed fall, causing a delay in treatment for a right hip fracture. This resulted in the staff not treating the resident's pain appropriately and placing the resident at risk for further injury of the leg and hip when the facility staff continued to transfer the resident to and from chair to bed without ensuring professional standards of care were completed first. The facility census was 33. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia and did not review it annually. The facility also failed to ensure facility staff were informed on the facility's Water Management Plan. The facility was 35. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: - Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, and other opportunistic waterborne pathogens (e.g. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for all residents of the facility, when the staff did not keep rooms clean, floors throughout the building clean and in good repair, doors and walls in all the hallways and in resident rooms scuffed with missing paint, missing closet doors, and an overall un-cleanliness about the building which affected all of the facility's three residence halls, all common areas of the facility and outside around the entire building. The facility census was 35. The facility did not provide a policy regarding their daily cleaning check list or deep clean schedule, nor did the facility provide a policy regarding the stripping and waxing of facility floors, nor did the facility provide a policy on painting or repairs of the building or grounds maintenance. 1. [...]

Inspectors wroteBased on record review, and interview, the facility failed to ensure 3 of 16 sampled residents who required staff assistance (Resident #16, #18, #35) received assistance with grooming, and one resident (Resident #16) received incontinence care in a timely manner. The facility census was 35. Review of the facility provided undated policy for A.M. Care (Early Morning Care) showed in part: -Purpose is to provide cleanliness, comfort and neatness. Review of the facility provided undated policy: Nails, Care Of (Fingers and Toes) showed in part: -To provide cleanliness, comfort, prevent the spread of infection. -The nurse assistants may perform nail care on the residents who are not at risk for complication of infection . Review of the facility provided undated policy: Perineal Care showed in part: -Purpose is to cleanse the perineum and prevent infection and odor. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure there was an adequate number of staff to perform duties to enhance the residents' quality of life when the facility offered no current restorative nursing program for any residents, and failed to have licensed nursing coverage 24 hours a day. This affects the health and wellbeing of every resident in the building. The facility census was 35. Review of the facility staffing on 1/6/23, showed: -No staffing policy was provided by the facility. Review of the facility restorative nursing schedule and resident list on 1/6/23, showed: - No residents actively engaged in any restorative nursing program in the facility. Review of the Centers for Medicare and Medicaid Services 4th Quarter PBJ Staffing Data Report as of 1/10/23 showed: [...]

Inspectors wroteBased on interview, Centers for Medicare and Medicaid Services [NAME] Report 1705D, and staffing record review, the facility failed to provide the services of a Registered Nurse (RN), other than the Director of Nursing (DON), for eight consecutive hours per day, seven days a week. This affected all the residents in the facility. The facility census was 35. The facility did not provide a policy for RN coverage. 1. Review of the facility's Payroll Based Journal (PBJ) report for Quarter 4 showed: - No RN hours in the month of July, 2022 on: - Saturday, 7/2; - Sunday, 7/3; - Monday, 7/4; - Saturday, 7/9; - Sunday, 7/10; - Saturday, 7/16 - Saturday, 7/23; - Sunday, 7/24; - Saturday, 7/30 - Sunday, 7/31. - No RN hours in the month of August, 2022 on: - Saturday, 8/6; - Sunday, 8/7; - Saturday, 8/13; - Sunday, 8/14; - Saturday 8/20; - Sunday, 8/21; - Saturday, 8/27; - Sunday, 8/28; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance to professional standards of food service safety when staff failed to fully date opened items, discard leftover timely and failed to ensure all areas of the kitchen and food storage areas remained clean. The facility census was 35. Review of facility policy regarding storage of dry food and supplies, dated May 2015 included: -Shelving is to be kept clean and free of rust and chipped paint -Open boxes are to be effectively re-resealed. -Bulk crackers, cereal, cookies, pasta, etc. are to be stored and properly labeled in sealed containers. -Food grade plastic bags are to be tightly closed after being opened. -Food should be dated when stocked after delivery. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed a Level II PASARR (a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment.). This affected one of 12 sampled residents (Resident #22). The facility census was 35. 1. The facility did not provide a policy for completing Level I (Pre-admission Screening for Mental Illness/Mental Retardation or Related Condition) and Level II PASARRs. Review of Resident #22's Level I nursing facility pre-admission screening for mental illness/mental retardation or related conditions, dated 2/13/15, showed: -Section B. Level 1 screening criteria for serious mental illness: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff developed, implemented and updated a comprehensive, person-centered care plan which affected one resident (Resident #4) by not addressing care resident preferences regarding personal care. The care plans were not written with person-specific goals with measurable objectives and times frames in order to evaluate the resident's progress towards obtaining his/her goals. The facility census was 35. Review of the facilities undated Comprehensive Care Plan Policy that was provided showed: - The purpose to provide an individualized comprehensive care plan that includes measurable goals and time frames specific to the resident's needs and choices. [...]