Sunset Manor Conv Hosp

Inspectors wroteBased on interview and record review, the facility failed to evaluate and determine the level of care needed for one of three residents (Resident 1) as indicated in the facility policy and procedure titled, Transfer and Discharge (including AMA). This deficient practice resulted in Resident 1 arriving at the facility and being sent back to General Acute Care Hospital (GACH) Emergency Department (ER). A review of the facility's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (DM-a chronic condition where blood sugar levels are too high) with diabetic chronic kidney disease (occurs when high blood sugar harms the tiny blood filters in the kidneys), and dependance of renal dialysis (HD-use of external machine and dialyzer [filter] to clean blood through an access point in an arm or leg). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of two sampled residents (Residents 1 and 48) in accordance with the facility's policy and procedure (P&P) titled Call Lights: Accessibility and Timely Response. These failures had the potential to delay meeting Residents 1 and 48's needs and placed the residents at risk for fall or accident/injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure policies and procedures (P&P) on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) were implemented for two of two sampled residents (Residents 12 and 64) by failing to: a. Ensure Resident 12's Advance Healthcare Directive Acknowledgement Form (ADAF-form that indicated a resident or resident's representative were informed of their rights regarding medical treatments, Advance Directive formulation, and whether an AD was created) was not missing information and completely filled out. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent unnecessary use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) according to the facility's policy and procedure and the resident's care plan for two of five sampled residents (Residents 1 and 73) by failing to: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a specific and individualized resident-centered care plan to meet the residents' needs for two of two sampled residents (Residents 14 and 26) by failing to:a. Develop a care plan for Resident 14 who was on enhanced barrier precaution (EBP, infection control measures to prevent the spread of multidrug resistant organisms [MDRO]). b. Develop a care plan for Resident 26 for the use of antibiotic therapy (medications used to treat and prevent infections caused by bacteria). These failures had the potential for Residents 14 and 26 not to receive necessary care, treatment, and services to address the residents' specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the resident's care plan for one of one sampled resident (Resident 73) to reflect Pneumocystis Jirovecii Pneumonia (PJP, life-threatening fungal lung infection) prophylaxis in accordance with the facility's Policy and Procedure (P&P) on comprehensive care plan. This failure had the potential to not provide Resident 73 with necessary care and services and compromise Resident 73's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure non-English speaking (refers to an individual who cannot speak or understand or have difficulty speaking or understanding the English language) residents were provided with a communication board/device in a language that the resident understood for one of one sampled resident (Resident 2). This failure had the potential to affect Resident 2's communication with staff resulting in delay in the provision of care, treatment and service to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Foley Catheter (FC, a thin, flexible, rubber or plastic tube used to drain urine from the bladder) was secured on the resident's thigh in accordance with the facility's Policy and Procedure (P&P) Indwelling Catheter Use and Removal, for one of two sampled residents (Resident 27). This failure had the potential to result in catheter-related complications for Resident 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) had an oxygen in use warning sign posted outside the room for one of one sampled resident (Resident 26). This failure placed Resident 26, facility staff and visitors at risk of the dangers of accidental fire and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bed rails/siderails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 64). This failure placed Resident 64 at risk for entrapment and injury from the use of bed rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one of two laundry dryers in a safe, operating, and sanitary condition for residents. This failure had the potential to result in spread of infection and posed as potential fire hazard.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the care plan for one of three sampled residents (Resident 1) by failing to ensure Resident 1 did not have clutter around Resident 1's bed. This deficient practice placed Resident 1 at risk for falls and injuries from excessive clutter surrounding Resident 1's bed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) received mail and other packages within 24 hours of delivery. This deficient practice violated Resident 1's right to receive mail promptly (delivery of mail or other materials to the resident within 24 hours of delivery) and had the potential to impact Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing staff implemented person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of two sampled residents (Resident 2) by failing to monitor Resident 2's symptoms of increased confusion/physical abusive towards staff. These deficient practices had the potential to place Resident 2 at risk of not receiving the individualized care services to attain or maintain highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurse implemented the facility's Policy and Procedure (P&P) titled Medication Orders by failing to indicate the severity of the pain level for the pain medication order for one of two sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk of not receiving the optimal therapeutic effect (desirable and beneficial effects resulting from a medical treatment) of the medication, which had the potential to impair Resident 1's wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Resident 30, 31 and 34) and/or their representatives were provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only go into effect if the person cannot communicate his/her own wishes) when: a. Resident 34 did not receive information regarding AD. b. Resident 30's AD Acknowledgement Form was filled out inaccurately. c. Resident 31's AD Acknowledgement Form was filled out inaccurately. These failures had the potential to result in Residents 30, 31, and 34 and/or their representatives to not be informed of their rights and receive unwanted and/or unnecessary life-sustaining care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure irregularities identified from the monthly drug regimen review reported by the facility's pharmacist were acted upon for two of five sampled residents (Residents 20 and 34): a. Resident 34's pharmacist recommendation to order laboratory test to monitor the increased risk of rhabdomyolysis (a serious medical condition of a breakdown of muscle tissue, releasing harmful substances into the bloodstream) was not acted upon. b. Resident 20's pharmacist recommendation to discontinue Benadryl (medication to treat pain and itching) was not acted upon. These deficient practices had the potential for unnecessary medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one facility kitchen. During initial tour of the kitchen, a 22-ounce (oz) bottle of basil pesto sauce was observed with an unreadable best by or used by date. This deficient practice had the potential for improper food storage, which could lead to foodborne illnesses (illness caused by consuming contaminated food or beverages) to the residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of one sampled resident (Resident 55). This failure had the potential to result in resident not receiving assistance in a timely manner when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective communication method to one of two non-English speaking sampled residents (Resident 7). This failure had the potential for the resident not to receive necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician's order to keep the resident's both heels to free float (technique where the heels were completely elevated off the surface) for one of three sampled residents (Resident 7). This failure had the potential risk for Resident 7 to develop pressure injury (PI, localized damage to the skin and/or underlying tissue usually over a bony prominence) and delayed healing of existing PI.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for one of one sampled resident (Resident 34), who required and received hemodialysis (treatment for kidney failure that removes waste and extra fluids from the blood) four times a week, by failing to ensure staff followed Resident 34's physician's order for fluid restrictions of 1200 milliliters (ml- unit of measurement) a day. This deficient practice had the potential for Resident 34 to experience fluid overload (excessive amount of fluid in the body) and difficulty breathing that can compromise the Resident 34's health.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three sampled residents (Resident 6) whose primary language was Spanish, the binding arbitration agreement (AA, a private process where disputing parties agree that one or several other individuals can plan about the dispute) was fully understood by the resident and was presented in a language Resident 6 understand. This deficient practice had the potential for the resident to not be fully informed and make an informed decision on whether to enter into such agreement.

Inspectors wroteBased on observation, interview, and review the facility's waiver request, the facility failed to ensure one of 28 resident's room in the Sub Acute Unit accommodated no more than four residents in a multiple resident room. room [ROOM NUMBER] had five beds to accommodate five residents. This deficient practice had the potential risk for privacy concerns and crowded condition in the room.

Inspectors wroteAmended : 5/13/2025. The facility submitted a Revised Room Waiver Request Letter dated 5/12/2025. Based on observation, interview and record review, the facility failed to ensure 9 of 28 rooms (Rooms 16,19, 20, 21, 22, 25, 26, 27 and 32) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential to impact resident's safety and the ability of staff to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Hand Hygiene, and Management of C. Difficile (a type of bacteria that can cause diarrhea) Infection, by failing to ensure staff washed their hands with soap and water after providing care for one of five sampled residents (Resident 2), who had C. Diff. This deficient practice had the potential to result in cross-contamination (the transfer of harmful bacteria from one person, object, or place to another) and the spread of infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment as indicated in the facility's policies and procedures (P&P) titled, Preventive Maintenance Program, and Safe and Homelike Environment, for one of three sampled residents (Resident 1) by failing to: 1. Ensure the Maintenance Director (TMD) had a schedule of maintenance services for Resident 1's bed remote control coil line (coiled remote-control cord). 2. Ensure Certified Nurse Assistant 2 (CNA 2) prevented Resident 1 from grabbing onto Resident 1's damaged/broken bed remote control coil hanging on Resident 1's right bed side rail (an adjustable bar attached to a bed to help patients/residents move around) during care. [...]

Inspectors wroteBased on observation, interview, and recorded review, the facility failed to maintain the resident's bed remote control coil line (coiled remote-control cord) in safe operating condition for one of three sampled residents (Resident 1). The hard plastic covering of Resident 1's bed remote control coil line was damaged and pointed out. This failure resulted in a laceration (a wound when skin, tissue, and/or muscle was torn or cut open) on Resident 1's inner right hand between the thumb and index finger (also known as the pointer finger, or first finger) measuring 2 centimeters (cm-unit of measurement) in length, by 0.2 cm in width and by 0.2 in depth. Cross Reference :

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection control/prevention surveillance program for two of two sampled residents (Resident 1 & Resident 2) by failing to: a. Initiate a scabies line list immediately after Resident 1 was confirmed to have scabies from a positive skin scrapping test result. b. Ensure that Infection Control measures were implemented when Resident 2 was identified to be highly suspicious of scabies. This deficient practice compromised infection control measures to prevent the potential spread of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to professional standards of practice for one of five sampled residents (Resident 2), when Resident 2 ' s medication was left unattended at Resident 2 ' s bedside. This deficient practice had the potential to result in mismanagement of Resident 2 ' s medication for pain management and placed the resident at risk for adverse (untoward) consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices as outlined in the facility ' s policy for Coronavirus Prevention and Response when one of two Certified Nursing Assistants (CNA 2) went inside a Covid-19 (Coronavirus, a highly contagious respiratory disease caused by SARS-CoV-2 virus that spreads from person to person and can cause mild to severe respiratory illness) isolation (to separate people who are sick) room of Resident 5 without wearing the required Personal Protective Equipment (PPE). This deficient practice had the potential to spread COVID-19 throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Nail Care, for one of three sampled (Resident 3) by failing to: 1. Ensure assigned Certified Nursing Assistants (CNAs) trimmed and cleaned the fingernails of Resident 3, who had contractures (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) to his left and right hands. 2. Ensure assigned CNAs notified assigned Licensed Vocational Nurses (LVNs) regarding Resident 3's long and overgrown toenails. 3. Ensure assigned LVNs notified the Social Services Director (SSD) that Resident 3 needed to be referred and seen by a podiatrist (medical specialists who help with problems that affect your feet or lower legs) for cleaning and trimming of Resident 3's long and overgrown toenails. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for two of two sampled residents (Resident 2 and Resident 270) by failing to: a. Ensure a call light to accommodate a resident's mobility limitations was provided when Resident 270 was unable to move Resident 270's bilateral upper arms and hands. b. Ensure call light was within reach for Resident 2 who was assessed as high risk for fall as indicated in the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response and the resident's care plan. These failures had the potential to result in Resident 270 and Resident 2 being unable to notify staff for needs and possibly, an emergency.

Inspectors wroteBased on interview and record review the facility failed to provide information of Advance Directive (AD, written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) for two of two sampled residents (Residents 45 and 47) in accordance with facility's policy titled Residents' Rights Regarding Treatment and Advance Directives. These failures had the potential for Residents 45 and 47 to receive treatment and services against the residents' will.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for the resident's suprapubic catheter (a hollow, flexible tube used to drain urine from the bladder through a cut in the abdomen) and indwelling catheter (a medical device that helped drain urine from the bladder) as ordered by the physician and as indicated in the resident's plan of care for two of four sampled residents selected for catheter care area (Resident 15 and Resident 11). These failures had the potential to result in catheter-related complications for Resident 15 and Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's Policy and Procedure (P&P) for enteral feeding (tube feeding that supplies nutrients and fluids to the body if unable to safely chew or swallow) for two of three sampled residents (Residents 2 and 274 ) when: a. Gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) dressing for Resident 2 was not changed per protocol. b. Enteral feeding was left ongoing while Resident 274 was lying flat on the bed. These failures had the potential for infection for Resident 2 and complication of aspiration (when food/liquid enter a resident's airway and lungs by accident) for Resident 274 .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 30 and 274) receiving oxygen therapy were provided respiratory care and resident safety in accordance with the facility's policy and procedure titled Oxygen Administration and Sudden Respiratory Distress Differential Diagnosis, by failing to: a. Ensure Resident 30's nasal cannula tubing (flexible plastic tubing used to deliver oxygen through the nostrils) was kept in covered in plastic bag when not in use and not rolled and inserted to the handle of the oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen). b. Ensure Resident 274 had a spare tracheostomy tube (tube inserted from an opening in the neck into the trachea [windpipe]) readily available at bedside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt appropriate alternatives prior to installing a side or bed rail for two of two sampled residents (Residents 17 and 170). This deficient practice had the potential for accidents that could lead to injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary and comfortable environment and prevent the development and transmission of communicable diseases and infection for five of five sampled residents ( Residents 35, 8, 61, 42 and 274), when the facility failed to: a. Ensure wound care was performed to Resident 35 in a manner that would prevent introduction of potentially contaminated material into the wound. b. Ensure curtains were changed during deep cleaning for two (Residents 8 and 61) of 28 rooms in the facility. c. Ensure the IPN changed gloves and perform hand hygiene after touching Resident 42's indwelling catheter (foley catheter - a tube inserted in the bladder to drain urine into a drainage bag). d. [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate and implement a care plan for one of one sampled resident (Resident 274) when Resident 274 has a left lateral (side) mid foot unstageable (bed sore that occurred when there was prolong pressure on a specific area to the skin resulting in an open wound. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) selected for language/communication care area was provided with Passy-Muir Valve (PMV, allow tracheostomy [a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck] patients to produce speech sounds) for effective communication. This failure had the potential for Resident 2 to not receive necessary care and services due to lack of effective communication aids.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow own policy and procedure (P&P) for pressure injury (PI, injuries to the skin and tissue below that are due to pressure on skin for long periods of time) prevention for one of one sampled residents (Resident 274). Resident 274's bilateral heel protectors (cushioned heel protectors that assist in reducing pressure in heels which can decrease the risk of pressure damage) were not on per Medical Doctor's (MD) order. Resident 274 who had a left lateral (side) mid foot unstageable (bed sore that occurs when there is prolong pressure on a specific area to the skin resulting in an open wound. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for one of five sampled residents (Resident 48) with pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) by failing to turn and reposition Resident 48 every two hours as indicated in the facility's policy and procedure (P&P) titled Turning and Repositioning and Resident 48's care plan. This failure had the potential to lead to further skin breakdown (damage to the skin's surface), infection, worsening, and/or delayed wound healing for Resident 48.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right-hand splint (a medical device that supported and protected joints and its surrounding structures and worked by positioning the hand and wrist correctly) was maintained and properly applied in accordance with the facility's policy and procedure titled, Restorative Nursing Programs and resident's care plan for one of three sampled residents (Resident 16) selected for position mobility care area. This deficient practice placed Resident 16 at risk for contractures and had the potential to cause decline in Resident 16's physical function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise and follow policy and procedure (P&P) for Hoyer Lift (mechanical device that is operated by two people and used to lift and transfer residents safely) for one of one sampled resident (Resident 274) by failling to ensure 2 staff memberd operated the Hoyer lift to lift Resident 274 from the resident's bed. Resident 274 was left suspended in the air, unsupervised when Certified Nurse Assistant 2 (CNA 2) walked away from the Hoyer Lift to close the currtain. This failure had the potential to result in Resident 274 to sustain a serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision or touching assistance during meals for one of one sampled resident (Resident 19) with weight loss. This deficient practice had the potential to lead to further weight loss for Resident 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date the midline intravenous catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm used to administer medication into the bloodstream) for one of one sampled resident (Resident 45) in accordance with the facility's policy titled Peripheral Intravenous Catheter Insertion, Maintenance and Removal and resident's care plan. This failure had the potential to result in infection to Resident 45 and worsen the residents' health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment and care planning tool) dated 1/11/2024 assessment reflected an accurate assessment of the discharge destination for two of two sampled residents (Residents 68 and 67) by failing to ensure : a. Resident 68 who was discharged to a Skilled Nursing Facility (SNF - an inpatient rehabilitation and medical treatment center staffed with trained medical professionals) was coded in the MDS assessment as being discharged to home. b. Resident 67 who was discharged to home was coded in the MDS assessment as being discharged to a General Acute Care Hospital (GACH). [...]

Inspectors wroteBased on observation, interview and review of the facility's room waiver request, the facility failed to ensure one of 28 residents' room, accommodated no more than four residents in a multiple resident room (room [ROOM NUMBER]). room [ROOM NUMBER] had five beds to accommodate five residents in the Sub Acute Unit. This deficient practice had the potential risk for privacy concerns and crowded condition in the room.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 14 of 28 rooms (Rooms 15, 16, 17, 19, 20, 21, 22, 23, 25, 26, 27, 32, 33 and 35) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential to impact resident's safety and the ability of staff to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record for one of five sampled residents (Resident 1) contained an accurate description of the actual experiences of Resident 1 by failing to ensure: 1. Details regarding an incident with the mechanical lift (a device used by staff to transfer residents from a bed to a chair or other similar places) which occurred on 1/19/24 were documented in Resident 1's medical record. 2. Details regarding dislodgement of Resident 1's intravenous line (IV; a soft, flexible tube placed inside a vein, usually in the hand or arm, and used by health care providers to give a person medicine or fluids) on 1/2/24 were documented in Resident 1's medical record. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure on reporting of alleged abuse violation, by failing to ensure one of one Certified Nursing Assistant (CNA 2) report abuse allegation on Resident 1 to the facility's abuse coordinator. This deficient practice resulted in the delay of investigation of the alleged abuse allegation and had the potential to result in violation of Resident 1's right to be free from abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1). Resident 1 ' s treatment orders for skin rashes were ordered on 10/12/23 and was not started until four days later on 10/16/23. This deficient practice resulted in delayed treatment and healing of Resident 1 ' s skin rashes.