Sunset Park Healthcare

Inspectors wroteBased on interview and record review, the facility failed to protect the rights of one of two sampled residents (Resident 1) to be free from financial abuse according to facility's policy and procedures (P&P) titled, Gifts, Gratuities, and Payments, reviewed 3/2025, when Licensed Vocational Nurse (LVN) 1 over the course of three days, made several purchases including reserving a hotel room for LVN 1 and charged Resident 1's credit card during the month of 2/2026. Resident 1 did not authorize the purchases. As a result, Resident 1 was upset because LVN 1 charged $1213.02 to Resident 1's credit card without the resident's permission.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of accident hazards by failing to:Ensure Resident 1 was assisted with at least two-person assist during mobility and transfer according to Resident 1's Minimum Data Set (MDS - resident assessment tool). Ensure Resident 1 was evaluated and assessed by a licensed nurse after Resident 1 slipped on the floor while giving shower according to facility's policy and procedures (P&P) titled, , Falls - Clinical Protocol, and Falls and Fall Risk, Managing. This deficiency resulted in Resident 1's fall and had the potential to place the resident at risk for recurrent falls.

Inspectors wroteBased on observation, interview and record review the facility failed to have call device (a mechanism used by residents to promptly communicate with staff) within reach for three of five sampled residents (Resident 2, 3 and 4). This failure had the potential to result in an accident and/or injury, and/or delay resident care. [...]

Inspectors wroteBased on interview and record review, the facility failed to permit residents to receive visitors according to the facility ' s policy and procedures (P&P) titled, Visitation and Resident Rights, for one of four sampled residents, Resident 1. This deficient practice violated residents ' rights regarding visitation. Cross Reference F656.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 1), regarding visitation rights and conflicts between Resident 1 ' s Family Member 1 and Resident 1 ' s Family Member 2 (FM 2). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for one of six sampled residents (Resident 38) risk of entrapment. 2. Developed a CP for two of six sampled residents (Resident 36 and Resident 43)'s behavior. These deficient practices had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the resident's hearing at the highest attainable level and obtain the hearing aids timely for one of one sampled residents (Resident 15). This failure resulted in Resident 15 getting angry, not able to watch television (TV) every day, and having a hard time communicating with facility staff.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident receive appropriate treatment and services to increase, prevent, or maintain the range of motion (ROM- the extent of movement of a joint) and mobility for three of four sampled resident (Resident 11, Resident 43, Resident 37) according to the facility policy and procedures (P&P) titled, Resident Mobility and Range of Motion. This deficient practice had the potential to place residents at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and concurrent record review, the facility failed to ensure 1 of 1 sampled residents (Resident 25) in need of dental service. This failure had the potential to cause the Resident pain, discomfort, weight loss, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure [NAME] 2 followed its Recipe for Parika Beef for week 4 Saturday, when [NAME] 2 scooped Knorr Beef Bouillon with a spoon without ensuring the proper measurement. This deficient practice had the potential to result in ineffective nutritional value and elevated salt intake which could result in elevated blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure leftover tuna was stored in the refrigerator 2. Ensure staff personal bottle of water was not stored in the residents kitchen refrigerator 3. Ensure multiple food items with expiration dates were disposed 4. Ensure multiple food items were labeled with expiration dates or used by dates 5. Ensure debris did not collect on paper towel dispenser 6. Handwashing/eye washing station sink was clean 7. Six cutting knives were clean 8. Ensure eight of 17 resident trays were not cracked and chipped. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed guidelines on wearing Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses, PPE may include respirators, gloves, overalls, boots, disposable gowns, and goggles) when providing care to three of five sampled residents (Resident 11, Resident 37, Resident 43) who were on enhanced barrier precautions (utilized to prevent the spread of multi-drug resistant organisms) room. This deficient practice placed residents, staff, and visitors at risk for acquiring and transmitting infections and diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Repair leaking pipe under the kitchen sink. 2. Maintain maintenance repair logs and schedules. These failures had the potential to cause mold (a soft, green or gray growth that develops on old food or on objects that have been left for too long in warm, wet air) to grow that can cause the residents to become ill.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure nine of nine Resident rooms (Rooms 1, 2, 3, 4, 5, 6, 8, 11, and 12) met the 80 square feet (sq. ft. -unit of measure) requirement per resident according to federal regulation by 2. Ensure a bariatric bed (a heavy-duty, typically wider bed designed to accommodate individuals who are significantly overweight) did not impede the free movement of staff and one of three resident (Resident 148). This deficient practice resulted in impeding the free movement of Resident 148 and had the potential to impede the free movement of staff and guests.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident and/or responsible party (RP) was informed and consented in advance, of the risks and benefits of psychotherapeutic medications (used to treat a variety of mental health conditions by affecting brain chemistry and behavior) for one of three sampled residents (Resident 35) reviewed for psychotropic medications (a medication which are available on prescription to treat a certain type of mental health problems). This deficient practice violated resident/RP's right to make an informed decision regarding the use of psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a bariatric bed (a heavy-duty, typically wider bed designed to accommodate individuals who are significantly overweight) did not impede the free movement of staff and one of three resident (Resident 148). This deficient practice resulted in impeding the free movement of Resident 148 and had the potential to impede the free movement of staff and guests.

Inspectors wroteBased on interview and record review, the facility failed to make prompt efforts to resolve the resident ' s grievance concerning missing/lost personal belongings of property by failing to list belongings inventory upon admission for one of two sampled residents (Resident 37). This deficient practice resulted in Resident 37's missing clothes and personal belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents were free of unnecessary physical restraint, for one of four sampled residents (Resident 38) when: 1. Resident 38's middle bed frame was low with a sagging mattress that restricted Resident 38 from getting out of bed. 2. Resident 38 was observed with a bedside table parked alongside Resident 38 while he was in bed that restricted the resident's movement. This deficient practice resulted in unnecessary restraint and placed the resident at risk of entrapment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a background checks and screening on applicants for positions with direct access to residents was completed for two of 12 sampled employees reviewed according to facility's Policy and Procedures (P&P) titled, Background Screening Investigation. This deficient practice placed all 41 residents in the facility at risk of violence, theft and other safety issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain a safe and functional environment for one of six sampled residents (Resident 38) by ensuring that there are no items that may cause him an injury according to Resident 38's behavior of putting objects on his mouth. 2. Properly evaluate one of six sampled residents (Resident 36)'s elopement (the act of leaving a facility unsupervised and without prior authorization) risk assessment (a numerical score used to determine the likelihood of a person, often a patient in a care setting, leaving a facility without authorization or staff knowledge) These deficient findings had the potential to place the residents at increased risk for injuries and accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff labeled an open date (indicates how long a medication is safe to use once the container has been opened) of ipratropium-albuterol (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) inhalation solution and Atrovent sulfate (medication used to help with difficulty breathing in people) inhalation solution for two of six sampled residents (Resident 11 and Resident 32). This deficient practice had the potential to compromise the effectiveness of the medications, leading to potential complications related to the management of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to: A. Ensure one of five sampled residents, (Resident 38)'s diclofenac cream medication (used to treat pain and other symptoms of arthritis of the joints such as inflammation, swelling, stiffness, and joint pain) was properly stored and secured per the facility's policy and procedures (P&P) titled Medication Labeling and Storage reviewed by the facility on 4/2025. B. Ensure pill cutters assigned one of to two medication Carts (Medication Cart 1 ) was maintained clean and sanitized. These deficient practices had the potential to lead to medication under and/or overdosing which could result in serious injury, harm, and death and had the potential to compromise the safety and effectiveness of medications. These deficient practices also had the potential to spread infection and/or diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was palatable and of nutritive value for two of 38 residents (Residents 14 and 25) This deficient practice had the potential for residents to have poor meal intake and could lead to weight loss.

Inspectors wroteBased on observation, interview and record review facility failed to ensure facility did not leave a breakfast tray within reach of one out of two Residents (Resident 28) who was at risk for aspiration (food, liquid, or other foreign material enters the airway and lungs instead of the stomach), requiring 100% feeding assistance from facility staff. This deficient practice potential to result in choking, aspiration pneumonia (lung infection resulting from foreign material entering the airways), resulting in serious injury or death.

Inspectors wroteBased on observation interview facility failed to ensure 1 out of 2 interviewed Residents (Resident1) was provided a fortified CCHO diet (Consistent carbohydrate diet: meals contain carbohydrate-rich foods in fairly equal amounts which help maintain stable blood sugar levels) regular texture, Regular liquid consistency, double portion protein for breakfast and dinner for weight and nutritional management as per physician's order. This deficient practice had the potential to result in hypoglycemia (low blood sugar) due to lack of food, malnutrition, organ failure, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer call lights timely for two of two sample residents (Residents 148 and 25) when needing assistance with activities of daily living (ADL) from facility staff. This failure resulted in the residents getting angry.

Inspectors wroteBased on observation, interview and record review, Facility failed to provide a sanitary, and comfortable environment for residents, staff, and the public by failing to ensure waste equipment was not overflowing with waste in the waste disposal area. This deficient practice had the potential to result in the rapid growth and infestation of disease-causing organisms such as bacteria, insects, vermin, respiratory diseases, infections and air pollution.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Resident rooms did not accommodate no more than four residents per room for two of eight Resident rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedures titled Requesting, Refusing and/or Discontinuing Care and Treatment, reviewed March 2025, for one of three sampled residents (Resident 1). By failing to notify Resident 1 ' s physician of the resident ' s refusal to take prescribed tuberculosis (TB, a contagious disease caused by the bacteria Mycobacterium tuberculosis, which typically affects the lungs) medications: 1. Isoniazid (used to treat TB and/or prevent its return) 300 milligrams (mg, metric unit of measure) refused on 4/9/25, 4/12/25, 4/13/25, 4/25/25, and 5/2/25. 2. Pyridoxine 50 mg (treats vitamin B6 deficiency) refused on 4/9/25, 4/12/25, 4/13/25, 4/25/25, and 5/2/25. 3. Rifampin (antimicrobial medication used to kill TB bacteria in the body) 300 mg refused on 4/20/25, 4/25/25, and 5/2/25. [...]

Inspectors wroteBased on record review and interview, the facility failed to follow their own Policy and Procedure (P&P) by failing to ensure one of three sampled residents (Resident 1), physician had educated Resident 1 or her Responsible Party (RP) about the risks and benefits of taking mirtazapine (an antidepressant used to treat major depressive disorder). This deficient practice had the potential to result in Resident 1 in receiving a medication that she (Resident 1) was not well informed about.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of a resident-to-resident altercation and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of five sampled residents (Resident 1 and Resident 2). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 1 and Resident 2. Cross Reference F610.

Inspectors wroteBased on record review and interview, the facility failed to implement its abuse policy and procedure by failing to investigate a resident-to-resident altercation between two of five sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Cross Reference F609.

Inspectors wroteBased on observation, interview, and record review, for one out of four residents (Resident 3), the facility failed to ensure the enteral feeding (liquid nutrition -a medical procedure that delivers nutrients, medications, and or fluids directly into the gastrointestinal [GI] tract) bottle/container was: 1. Labeled time when the feeding was hung up. 2. The enteral feeding was disposed/discarded after 48 hours as per facility's policy and procedures and the manufacturer's guidelines to prevent the growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food), as well as toxins. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of four residents received the correct therapeutic dose (of oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) as ordered by the physician This deficient practice placed Resident 4 at risk of oxygen poisoning (lung damage that happens from breathing in too much extra (supplemental) oxygen.) and had the potential to negatively impact the Resident 4 ' s health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe its infection control policy for one out of three sampled residents (Resident 1) by failing to ensure the licensed nurse did not administer Resident 1 a pill/medication that had fallen onto the floor. This deficient practice resulted in the contamination of Residents 1's medication and had the potential to cause gastrointestinal illnesses and possibly hospitalization.

Inspectors wroteBased on interview and record review the facility failed to protect one of four sampled residents (Resident 1) and from verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents; including harassing, mocking, yelling, cussing, or threatening) by failing to ensure Licensed Vocational Nurse 2 (LVN2) did not engage in a verbal altercation with Resident 1 and cuss at Resident 1. As a result, Resident 1 was exposed to verbal abuse from LVN2, placing the Resident 1 at risk for psychosocial harm, mental anguish (suffering) and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to inform one of four sampled residents (Resident 1) and Resident 1's representative/family/responsible party that Resident 1 would be discharged from Skilled Nursing Facility 1 (SNF1) to SNF2 before 5/16/2024. This deficient practice resulted in SNF1 transferring Resident 1 to SNF2 on 5/16/2024. Resident 1 became aggressive towards staff and difficult to manage at SNF2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and food handling practices in the kitchen by failing to ensure one of three staff (Cook 1) wore a hairnet and gloves while working in the kitchen area while preparing food. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness in all 41 medically compromised facility residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 13 resident rooms (rooms [ROOM NUMBERS]) accommodated no more than four residents in each room. Both rooms [ROOM NUMBERS] had six residents in each room. This deficient practice had the potential to affect the delivery of care and safety of the residents especially during an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for ten out of the 13 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 8, 9, 11, and 12). Of the ten Resident rooms, nine rooms consisted of three beds each and two rooms consisted of six beds in each room. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 1) by: 1. Failing to ensure an accurate post-fall assessment was performed. 2. Failing to perform an assessment and interdisciplinary team meeting after Resident 1 was found on the floor. This deficient practice had the potential to result in miscommunication among staff about Resident 1 ' s fall risk.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure facility staff provided 1:1 monitoring and supervision to prevent repeated falls for Resident 1 in accordance with the facility ' s policy and procedures titled, Falls and Fall Risk, Managing, dated, 3/2018. The facility identified Resident 1 as a high risk for falls. As a result, on 10/1/2023-Resident 1 fell out of his wheelchair (WC) while sitting in the lobby of the facility and suffered a laceration (a deep cut or tear in the skin) and bleeding above the right eyebrow. Resident 1 was transferred to the General Acute Care Hospital (GACH) and treatment provided for the laceration.

Inspectors wroteBased on interviews and record review the facility failed to ensure physician ' s order for Ativan (psychotropic medication [any medication capable of affecting the mind, emotions, and behavior] to treat anxiety) to be administered as necessary (PRN), did not exceed 14 days for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures titled Antipsychotic Medication Use dated 12/2016. As a result, Resident 1 received PRN Ativan for 22 days for the month of 9/2023, with the potential to result in the use of unnecessary psychotropic medication, undesired side effects and adverse consequences including a decline in quality of life and functional capacity for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan that reflected the assessment and immediate needs including interventionst that addressed fall risk for one of four sampled residents (Resident 3). This deficient practice had the potential for Resident 3 to not receive appropriate care and treatments specific to his needs including interventions to prevent falling.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure four of four sample residents (Resident 9, Resident 18, Resident 131 and Resident 134) were fed in a dignified manner. This deficient practice had the potential to affect the residents' self-esteem and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light (a device used by a resident to signal for assistance from the facility's staff) was within reach for four out of four residents (Residents 7, 330, 331, and 326). This deficient practice had the potential for delay in responding to the necessary care and services by facility staff , increasing residents' risk for skin breakdown, skin irritation, and falls.

Inspectors wroteBased on interview and record review, the facility failed to have a dedicated director of nursing (DON) and registered nurse (RN) supervisor whose hours were not shared with a second facility. This failure had the potential to affect resident care, clinical outcomes, and assessment.

Inspectors wroteBased on observation, interviews and record review, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services when Dietary Aide 1 failed to describe how to manually wash dishes correctly. This failure had the potential to result in unsafe and unsanitary food preparation and production, and a potential for food-borne illness affecting all residents who received foods from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1) follow portion size as written on the menu for residents on mechanical soft and regular diet. Residents on mechanical soft and regular diet received inaccurate portion. 2) follow instructions as written on the tray card for residents on NAS (no added salt) diet. With two trays marked NAS on the tray card, each had a salt packet. These deficient practices had the potential for residents to receive wrong protein and caloric intake when not following the menu, which could result in undernutrition or overnutrition and further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was served at appetizing temperatures and as recommended per its policy. This deficient practice had the potential to result in decreased food intake and affect the nutrition needs for the residents who ate at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective infection control program was maintained, as evidenced by: 1) Certified Nursing Assistant (CNA 1) did not perform hand hygiene when indicated. 2) Housekeeping staff (HKS 1) did not properly take off personal protective equipment (PPE - personal protective equipment, including isolation gown, gloves, face mask, face shield, and goggles) before exiting Resident 331's red zone room (an area/room of the facility where COVID-19 positive residents are placed during quarantine to control the spread of infection). These deficient practices had the potential for cross-contamination, resulting in spreading infections to the residents and staff in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for two out of two residents (Resident 329 and 331), as evidenced by: 1) Resident 329 did not have adequate space for personal belongings 2) Resident 331's room furniture was in poor condition These deficient practices had the potential to negatively impact the comfort level and quality of life of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sample residents (Resident 133) was free from physical restraints. This failure resulted in a violation of the Resident 133's right to be free from restraints.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a care plan was developed for 1) Restraints or personal preference of resident bed against the wall for one of two sample residents (Resident 133). 2) Psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) for two of four sample residents (Resident 12 and Resident 133). This deficient practice had the potential to result in a delay in monitoring the restraints or personal preferences and a delay in recognizing signs and symptoms of side effects associated with psychotropic medication use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss (LAL) mattress (mattress designed for pressure reducing which is used to prevent and treat pressure wounds) was set up correctly for one of two sampled residents (Resident 18). This deficient practice had the potential to contribute to the worsening of pressure wound and/or delay wound healing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 8) received the accurate flow rate of oxygen according to physician's order. This deficient practice had the potential to result in complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the requirement for no more than four residents per room for two of 13 rooms (room [ROOM NUMBER] and 12). This deficient practice had the potential to result in inadequate space to provide sufficient nursing care and privacy for the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that ten of 13 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 8, 9, 11, and 12) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential to have inadequate space for resident care and mobility.