Sunset Lake Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, and staff interviews, the facility to follow proper sanitation and food handling practices in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, resident, resident representative and staff interviews, the facility failed to provide care and services to meet the needs for Activities of Daily Living (ADL) for 2 (Residents #275 and #276) of 5 residents reviewed for assistance with ADL.

Inspectors wroteBased on observation, review of the clinical record, review of the facility policy and procedures and resident and staff interviews, the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident's physical, mental, and psychosocial well-being for 2 (Residents #29 and #48) of 3 reviewed for involvement in the activity programs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment and provide adequate supervision to prevent multiple falls for 1(Resident #65) of 3 residents reviewed for accident.

Inspectors wroteBased on observation, review of facility policy and procedure and staff and resident interviews, the facility failed to ensure sufficient nursing staff to meet residents' needs for 4 (Residents #9, #17, #29, #37) of 34 sampled residents.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to ensure staff followed infection prevention interventions when entering the room of 1 (Resident #1) of 1 resident observed on enhanced barrier precautions and failed to change the dressing as ordered to prevent catheter related infections for 2 (Residents #69 and #173) of 2 residents reviewed with Peripherally Inserted Central Catheters.

Inspectors wroteBased on record review, review of facility's policy and procedure, resident, resident representative and staff interviews, the facility failed to develop and communicate a resident centered baseline care plan to meet the needs of 1 (Residents #273) of 3 newly admitted residents reviewed.

Inspectors wroteBased on observation, clinical record review, staff and resident interview, the facility failed to provide the appropriate care and services to prevent a decline in range of motion for 1(Resident #55) of 3 residents reviewed with a limitation in range of motion (ROM).

Inspectors wroteBased on record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to protect residents' right to be free from neglect by failing to ensure the safety of residents during emergency evacuation ahead of hurricane [NAME] landfall, a major category 3 hurricane with winds of 120 miles per hour. On 10/8/24 the facility evacuated 112 residents. Due to heavy traffic related to the large scale evacuation, 96 residents traveled approximately 197 miles for eight hours to two receiving facilities. The facility neglected to ensure residents on the buses/vans received necessary medications, food, or hydration, during the transfer to receiving facilities and failed ensure staff were available during transport. [...]

Inspectors wroteBased on record review and interviews with residents, residents representative and staff, the facility failed to ensure appropriate transportation, availability of assistive devices, and adequate supervision of dependent residents during emergency evacuation related to hurricane [NAME] a major category 3 storm. This failure affected all 112 residents evacuated from the facility and resulted in the emergency transfer of 2 residents (#7 and #9) to the hospital and unaddressed excruciating pain for 1 resident (#19). Resident #19 had multiple fractures and wore a neck brace. Facility staff inappropriately laid the resident across two seats on a coach bus for a 197 miles trip that lasted approximately seven hours, causing excruciating pain and suffering. Resident #7 was wheelchair bound and required a full body mechanical lift for transfers. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility's administration failed to utilize its resources effectively to prevent the neglect of residents by failing to develop and implement an effective Emergency Plan emergency plan, including contingency planning for evacuation transportation and failing to adequately train and verify competency of staff to respond to natural disasters including emergency evacuation procedures in a safe and orderly manner. This failure resulted in avoidable serious harm of residents #7, #9 and #19 and created a likelihood of serious injury of 112 residents during emergency evacuation on 10/8/24 ahead of category 3 hurricane [NAME] landfall. Resident #19 had multiple fractures and suffered excruciating pain when staff inappropriately laid her across two seats for approximately 197 miles and seven hours during transport to the receiving facility. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to implement corrective actions for identified quality deficiencies related to staff training and competency to respond appropriately to natural disasters to prevent the neglect of residents during natural disasters and emergency evacuation of residents. On 10/8/24 the facility did not ensure the safety of 112 residents during emergency evacuation ahead of category 3 hurricane [NAME] landfall. The facility did not ensure transportation to meet the needs of wheelchair and stretcher bound residents and failed to staff each transport bus or van with nursing staff to ensure residents safety, provision of care and administration of necessary physician ordered medications. [...]

Inspectors wroteBased on interview, record review the facility failed to ensure the Facility Assessment was complete and involved input from facility staff and ensured documentation of how the facility informed staff of the current Comprehensive Emergency Management Plan (CEMP)

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure 3 ( Licensed Nurses N, HH, and I) of 5 sampled nurses reviewed received training and were competent in checking the function of the wander alert bands (alert staff when a resident leaves a designated safe area) to prevent cognitively impaired residents unsafe wandering and elopement.

Inspectors wroteBased on record review, review of facility's policy and procedure, and staff interviews, the facility failed to immediately report an alleged violation involving neglect for 1 (Resident #7) of 3 residents reviewed for accident to the appropriate officials, including to the State Survey and Certification agency (The Agency for Health Care Administration), and Adult Protective Services in accordance with State law.

Inspectors wroteBased on record review, review of the policies and procedures, and staff and family interviews, the facility failed to implement appropriate interventions, including adequate supervision to prevent avoidable falls, including fall related major injuries for 1 (Resident #74) of 3 residents reviewed who sustained multiple falls at the facility. The failure to implement appropriate interventions to prevent falls and fall related injuries resulted in Resident #74 sustaining preventable falls, including falls with major injury requiring transfer to a higher level of care.

Inspectors wroteBased on observations, interviews, records review, and facility policy review the facility failed to review the risks and benefits of bed rails or to attempt alternative interventions prior to bed rail (side rail) installation with the resident/representative for 4 residents, (#1, #66, #74, and #28) of 4 residents reviewed for bed rails.

Inspectors wroteBased on observation and staff interviews the facility failed to ensure a safe environment for for 1 Resident (Resident #69) of 5 residents observed.

Inspectors wroteBased on records review, interviews, and review of facility policies the facility failed to file a federal report of an unwitnessed fall which resulted in a fracture requiring hospitalization for 1 (Resident # 16) of 4 reviewed for reporting requirements.

Inspectors wroteBased on record review, review of facility's policy and procedure, resident and staff interview, the facility failed to develop an individualized comprehensive care plan describing services to be furnished to meet the needs of 1 (Resident #73) of 2 sampled residents with an indwelling Foley catheter.

Inspectors wroteBased on record review, review of facility's policy and procedure, staff and resident interviews, the facility failed to ensure timely revision, and resident participation in care plan to meet the needs of 1 (Resident #39) of 5 residents reviewed for care plan.

Inspectors wroteBased on observation, record review, staff, and resident interview, the facility failed to provide the necessary assistance for showers for 1 (Resident #51) of 2 sampled dependent residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, clinical record review and resident and staff interviews the facility failed to provide care and services, including application of splints to prevent a decline in range of motion for 1 (Resident #97) of 1 dependent resident with limited range of motion.

Inspectors wroteBased on observations, clinical record review, interviews, and facility policy review the facility failed to ensure effective coordination for implementation of timely intervention to prevent weight loss for 1 (Resident #16) of 5 residents reviewed for nutrition.

Inspectors wroteBased on record review, staff and resident interview, the facility failed to provide the resident and the representative, if applicable, with a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions for 6 (Resident #69, #79, #287, #288, #387, and #389) of 9 residents reviewed for baseline care plans. This has the potential to cause confusion as to the care expected to be provided by the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure alarmed exit doors in the building were functioning properly to prevent cognitively impaired residents assessed as elopement risk from leaving a safe area without supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly act upon the care concerns and grievances of the resident council.

Inspectors wroteBased on observation, clinical record review, policy and procedure review, and staff and resident interview, the facility failed to handle urinary catheter (a tube inserted into the bladder to drain urine) bag and tubing in accordance with infection control standards of practice (guidelines used in healthcare settings to prevent the spread of infection) for 1 (Resident #9) of 2 residents sampled with indwelling catheters.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to follow through with Consultant Pharmacist recommendations for gradual dose reduction of psychotropic medications for 1 (Resident #7) of 5 residents reviewed for unnecessary medications. The failure to ensure gradual dose reductions has the potential for residents to continue to receive medications that are no longer necessary.

Inspectors wroteBased on record review, facility policy review and staff and resident interview, the facility failed to ensure advance directives related to healthcare decision making was correctly documented in the resident record for 1 (Resident #1) of 24 residents sampled for advance directives. This has the potential to lead to confusion when making decisions related to resident care and choices.