Sunset Nursing and Rehabilitation Center, Inc

Inspectors wroteThe facility policy Resident Rights and Responsibilities, dated 01/13/2025, documented the facility services provided to the resident demonstrated the belief in dignity and worth of every individual. The facility provided the resident with optimal nursing and psychosocial care. Every effort is made by the staff to meet the resident's individual needs and requirements. The facility policy Facility Incident/Abuse Investigation and Reporting, dated 09/2025, documented personnel must report any resident incident or suspected incident immediately to the Supervisor/Administrator. The facility would investigate instances of alleged resident abuse to ensure the physical and mental well-being of the resident. The facility would conduct an immediate and thorough investigation, upon discovery of sexual abuse. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. [...]

Inspectors wroteBased on record review and interviews during the abbreviated (#2639795) survey, the facility failed to ensure allegations of abuse, are reported immediately, but not later than two (2) hours after the allegation is made, to the Administrator of the facility and the New York State Department of Health in accordance with State law for three (3) of three (3) incidents of alleged abuse (10/05/2025, 10/09/2025 and 10/23/2025) involving Resident #1. Specifically, Resident #1 was witnessed engaging in sexually inappropriate behavior with Residents #3 and #4 who did not have capacity to consent on 10/05/2025, 10/09/2025, and 10/23/2025 and the incidents were not reported by the facility to the New York State Department of Health or local law enforcement. Additionally, the incident on 10/09/2025 was not reported to the Administrator until 10/24/2025. [...]

Inspectors wroteBased on record review and interviews during the abbreviated (#2639795) survey, the facility failed to ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for three (3) of eight (8) residents reviewed (Residents #1, #3, and #4). Specifically, on 10/05/2025, 10/09/2025, and 10/23/2025, Resident #1 was witnessed by visitors and/or staff engaging in sexually inappropriate behavior with Residents #3 and #4, who did not have capacity to consent. There was no documented evidence the incidents were thoroughly investigated to determine abuse and to protect residents from further abuse during the investigation. [...]

Inspectors wroteBased on record review and interviews during the abbreviated survey (#2639795) the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, administration failed to ensure residents were free from abuse, neglect and exploitation; and failed to ensure policies and procedures were properly identified, communicated, and consistently implemented. This failure resulted in Immediate Jeopardy in the areas of F600 Free from Abuse and Neglect, F609 Reporting of Alleged Violations, and F610 Investigation/Prevent/Correct Alleged Violation.

Inspectors wroteBased on observations, record review, and interviews during the abbreviated (2639795) survey, the facility did not ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for three (3) of seven (7) residents (Residents #1, #8, and #9) reviewed. Specifically, Residents #1, #8, and #9 had behavioral symptoms related to diagnoses of dementia and were not cared for in a dementia-informed manner with a personalized plan of care and interventions.

Inspectors wroteBased on record review and interviews during the abbreviated survey (#2639795) the facility's governing body did not establish and implement policies regarding the management and operation of the facility. Specifically, there was not consistent communication between the governing body and the facility Administrator to ensure regulatory compliance. Deficiencies identified during the abbreviated survey included three Immediate Jeopardies in Free from Abuse and Neglect (F600), Reporting of Alleged Violations (F609), and Investigate/Prevent/Correct Alleged Violations (F610).

Inspectors wroteBased on record review and interviews during the abbreviated survey (#2639795), the facility did not comply with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standard and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide requested accident and incident reports including abuse incident documentation when requested by the New York State Department of Health surveyor in a timely manner.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (1) of three (3) medication carts (Unit A cart) and two (2) of two (2) medication rooms (Units A and B) reviewed. Specifically, the Unit A medication cart had one opened and undated insulin pen, one opened and undated multidose eye drop, and one opened and expired multidose eye drop; and the medication refrigerator temperatures on Units A and B were not consistently monitored.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for one (1) of one (1) resident (Resident #99) reviewed. Specifically, Resident #99 was independent with activities of daily living and was not allowed to shave independently.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 6/23/2025 -6/27/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for one (1) of three (3) units (A Unit) reviewed. Specifically, the ice/water dispenser in the A Unit dining room had standing fluids backed up in the drip tray and a public drinking fountain located at the A Unit nurses' station had standing fluids in the drink well.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (Lunch meals on 6/24/2025 and 6/25/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 6/24/2025 and 6/25/2025. Additionally, nine (9) of fifteen (15) anonymous residents during a resident council meeting and one (1) resident (Resident #12) interviewed stated the food did not taste good and was cold.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not 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 one (1) of one (1) resident (Resident #75) reviewed. Specifically, Resident #75 was on transmission-based precautions (contact precautions) and Housekeeper #9 cleaned Resident #75's room without wearing all required personal protective equipment, did not remove gloves or perform appropriate hand hygiene upon leaving the room, and cleaned another resident's room while wearing the same gloves; [...]

Inspectors wroteBased on observations and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not maintain an effective pest control program so that the facility was free of pests in the main kitchen. Specifically, mouse droppings were observed in the kitchen dry storage room.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 10/30/2023-11/6/2023, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety in the main kitchen. Specifically, pans, trays, the exhaust hood, and floors in the main kitchen were unclean; and the reach in cooler contained sandwiches that were not labeled or dated.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00323453 and NY00306251) surveys conducted 10/30/2023-11/6/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 4 residents reviewed (Resident #95). Specifically, Resident #95's bed, overbed table, and power strip had dried debris build-up and the floor on the side of the bed next to the overbed table and nightstand was coated with dried, brown-colored debris.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 10/30/2023-11/6/2023, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #74) reviewed. Specifically, Resident # 74 developed a facility acquired pressure ulcer and had a low air loss mattress (a specialty mattress used to relieve pressure and provide airflow) and the settings on the mattress were not consistent with the physician ordered settings.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00323453) surveys conducted 10/30/2023-11/6/2023, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #95) reviewed. Specifically, Resident #95 had a history of falls and did not have their wheelchair or rolling walker available as planned.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 10/30/2023-11/6/2023, the facility did not ensure residents maintained acceptable parameters of nutritional status for 2 of 5 residents (Resident #81 and 102) reviewed. Specifically, Resident #81's hydration needs were not reassessed by clinical nutrition staff after they had urinary tract infections (UTI). Resident #102 had a significant weight loss, was not reweighed, did not have their nutritional needs reassessed, did not receive fortified milk as recommended by the registered dietitian (RD), and did not receive adaptive feeding equipment as planned.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00306251) surveys conducted 10/30/2023-11/6/2023, the facility did not ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #25) reviewed. Specifically, Resident #25 exhibited a behavioral disturbance, and a plan was not developed or implemented to prevent reoccurrence and ensure the safety of staff and other residents.

Inspectors wroteBased on observation, record review and interview during the recertification and extended surveys conducted from 7/13/21- 7/21/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Residents #28 and #22) reviewed. Specifically, Resident #28 was observed in their room with a peanut can that contained 8 cigarette butts with ashes. Resident #28 reported that after smoking the resident would routinely bring the peanut can with cigarette butts and ashes into the facility and empty the contents into a plastic trash can in the unit kitchenette across from their room. The housekeeper reported the plastic trash can routinely contained smoked cigarette butts and ashes and that they had not reported this finding to anyone. [...]

Inspectors wroteBased on interview and record review during the recertification survey conducted from 7/13/2021 to 7/21/2021, the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible for 4 of 5 residents (Residents #2, 17, 78, and 80) reviewed. Specifically, Residents #2, 17, 78, and 80 had significant weight loss and were not reassessed timely by clinical nutrition staff and there was no documented evidence the medical provider was made aware of the weight loss.

Inspectors wroteBased on observation, interview and record review during the recertification and extended survey conducted from 7/13/21-7/21/21 the facility did not 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 and to help prevent the development and transmission of COVID-19 for 2 of 8 residents (Residents #21 and 80) and 8 facility staff. Specifically, Resident #80's urinary catheter drainage bag was observed resting on the floor. Staff providing care for Resident #21, who was on transmission based precautions, was observed not performing hand hygiene or wearing their face mask appropriately. Staff were observed wearing face masks below their nose or not wearing the required face masks.

Inspectors wroteBased on observation, record review and interview during the recertification and extended surveys conducted 7/13/21-7/21/21, the facility did not ensure residents had the right to be free from physical restraints not required to treat the resident's medical symptoms for 1 of 2 residents (Resident #61) reviewed. Specifically, Resident #61 had a wheelchair seat belt in place without a physician order, a restraint assessment, parameters for use of the seat belt including frequency of releasing the restraint, and ongoing re-evaluation of the need for the restraint.

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 5 residents (Resident #61) reviewed. Specifically, Resident #61's comprehensive care plan (CCP) did not reflect the use of anticoagulation (blood thinner) and include interventions to ensure the resident received appropriate monitoring.

Inspectors wroteBased on observation, record review and interview during the recertification and extended survey conducted from 7/13/21-7/21/21, the facility did not ensure a resident with an indwelling catheter received the necessary services and treatment for catheter use for 1 of 4 (Resident #38) residents reviewed. Specifically, Resident #38 did not have physician orders in place for an indwelling urinary catheter (tube to drain urine).

Inspectors wroteBased on record review and interview during the recertification and extended survey conducted from 7/13-7/21/21, the facility did ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 1 of 5 residents (Resident #83) reviewed. Specifically, there was no documented evidence Resident #83's medication regime review was performed monthly by a licensed pharmacist.

Inspectors wroteBased on observation, record review and interview during the recertification and extended surveys conducted from 7/13/21- 7/21/21, the facility did not make available clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for all 95 residents of the facility. Specifically, upon survey entrance, resident-identifiable information including form CMS-802, Matrix for Providers, and an alphabetical listing of all residents was not provided to the Department of Health (DOH) in a timely manner. Additional information needed from the facility within one hour, four hours and 24 hours of entrance was not provided in a timely manner.