Sunset Rehabilitation and Health Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was properly secured during transportation, conduct pre-trip safety inspections prior to transporting a resident in the facility van, conduct transportation van inspections, prevent staff from placing personal items on a resident's wheelchair, and ensure facility transportation staff were educated on driver safety training for one of three residents (R1) reviewed for accidents in a sample of 11. These failures resulted in R1's wheelchair tipping backward during transport on 7/3/26, requiring emergency hospital treatment, causing R1 excruciating pain, and R1 sustaining an acute nondisplaced fracture at the anterolateral aspect of the right ninth rib.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one resident (R8) of three residents reviewed for abuse in a sample of eleven.

Inspectors wroteBased on interview and record review, the facility staff failed to report abuse immediately to the Administrator and the Administrator failed to report the abuse within two hours to the State Agency for 1 of 3 residents (R8) reviewed in the sample of eleven.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse Policy to thoroughly investigate an allegation of resident-to-resident abuse and failed to update the Care Plan for two of three residents (R8 and R10) reviewed for investigating abuse in the sample of eleven.

Inspectors wroteBased on interview and record review, the facility failed to follow therapeutic diet orders for one resident (R1) of 4 reviewed for therapeutic diets in a total sample of eight. Therapeutic Diet Policy, dated 12/2024, documents, Therapeutic diets shall be prescribed by the Attending Physician. The admission Policy, dated 12/2024, documents Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least Type of diet. R1's Electronic Health Record documents R1 was admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus, Dementia, Chronic Obstructive Pulmonary Disease, and Hypertension. R1's Hospital Discharge orders, dated 4/20/26, documents R1's diet order as Carbohydrate Controlled Diet. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative when the facility changed a resident's primary physician choice for one of three residents (R1) reviewed for Resident Rights in the sample of eightFindings include:The facility's Resident Rights Policy, dated 12/24, documents, Each resident will have autonomy and choice, to the maximum extent possible, about how each resident wishes to live his/her everyday life and receipt of care, subject to the community's policies and procedures as long as those policies so not violate any requirement. Resident rights include but are not limited to: Choose a physician and treatment and participate in decisions and care planning. R1's admission Orders, dated 4/2/24, document V11 (Physician) was R1's Primary Care Physician on admission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately supervise a resident while handling a hot beverage and failed to have a policy regarding the use and supervision of hot beverages for one of three residents (R1) reviewed for accidents in the sample of three. These failures resulted in R1 sustaining a burn to the right thigh after spilling a hot beverage in his lap. This past noncompliance occurred on October 20, 2025 and was corrected the same day.

Inspectors wroteBased on interview and record review, the facility failed to provide post-fall assessments, identify injury, and thoroughly investigate incidents to identify the root cause and implement interventions to potentially prevent further events per policy for 2 of 3 residents (R1, R3) reviewed for falls in a sample of 6.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse to the Administrator for one resident (R2) of three residents reviewed for abuse in a total sample of three.

Inspectors wroteBased on interview and record review the facility failed to investigate allegations of abuse thoroughly for one (R1) of one residents reviewed for physical abuse in a sample of seven.

Inspectors wroteBased on interview and record review, the facility failed to perform ongoing clinical assessments for a resident experiencing an acute medical condition (R1); one of four residents reviewed for clinical assessment, in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the correct textured diet to one of four residents (R1), a resident with a documented diagnosis of dysphasia, in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep a clean and sanitary kitchen; dispose of outdated food; date and label opened food items; include thaw dates for supplements; correctly cool down potentially hazardous food and keep a log of the temperatures; and label and date food storage containers holding bulk food stuffs. This has the potential to affect all 75 residents living in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a residents Physician Orders matched their Practitioner Order for Life-Sustaining Treatment (POLST) for Cardio-Pulmonary Resuscitation (CPR) code status for one of 24 residents (R66) reviewed for Advanced Directives in the sample of 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a dietician's recommendation for weight loss, provide a resident with a physician ordered calorie supplement, implement a care plan for weight loss and complete physician ordered weekly weights for two of four residents (R43, R66) reviewed for nutrition in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date oxygen tubing, place an oxygen sign on resident doors, and ensure a nebulizer facemask and tubing was changed weekly for three of three residents (R5, R34, R56) reviewed for oxygen therapy in the sample of 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) of Olanzapine (Antipsychotic medication) for one of three residents (R34) reviewed for antipsychotic medications in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change gloves and perform hand hygiene while providing incontinent care and implement Enhanced Barrier Precautions (EBP) for a resident with an open wound, for two of 18 residents (R5, R56) reviewed for infection control in the sample of 37.

Inspectors wroteBased on record review and interview, the facility failed to formulate Advanced Directives on admission and document current Advanced Directives within the care plan and within the physician's order sheets for five of six residents (R1, R3, R5, R9, and R10) reviewed for advanced directives in the sample of 13. These failures resulted in facility staff failing to provide CPR (Cardiopulmonary Resuscitation) to a resident (R1) with no Advanced Directive, who was found unresponsive in his room. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8-2-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.

Inspectors wroteBased on record review, observation, and interview, the facility failed to perform pressure ulcer risk assessments as directed by the facility's policy, failed to perform daily skin checks, failed to develop and implement pressure relieving interventions, failed to develop a pressure ulcer care plan, failed to assess a pressure ulcer weekly, and failed to perform pressure ulcer treatments as directed by the physician for one of two residents (R7) reviewed for pressure ulcer development in the sample of 13. These failures resulted in R7's right and left heel pressure ulcers deteriorating from stage one pressure ulcers to an unstageable pressure ulcer to the right heel and a stage three pressure ulcer to the left heel.

Inspectors wroteBased on observation, record review, and interview, the facility failed to keep a urinary catheter insertion site clean every shift for one of one resident (R7) reviewed for urinary catheter care in the sample of 13.

Inspectors wroteBased on record review and interview, the facility failed to obtain scheduled IV (Intravenous) antibiotics from the pharmacy for one of three residents (R8) reviewed for pharmacy services in the sample of 13.

Inspectors wroteBased on record review and interview, the facility failed to administer a resident's physician ordered IV (Intravenous) antibiotic for one of three residents (R8) reviewed for medication errors in the sample of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately supervise a resident (R1); and failed to prevent resident-to-resident sexual and physical abuse for six of six residents (R1, R2, R5, R6, R10, and R11) reviewed for abuse in the sample of 50. These failures resulted in R1, a resident with a history of sexual aggression, sexually assaulting (R2, R5, and R11) on multiple occasions, R1 sexually groping a resident (R10), and R1 physically assaulting a resident (R6). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7-14-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring.

Inspectors wroteBased on record review and interview, the facility failed to implement their Abuse policies and procedures to identify and report resident-to-resident suspected crimes and abuse immediately to the local law enforcement, the Administrator, the residents' representatives, and the State Agency for six of six residents (R1, R2, R5, R6, R10, and R11) reviewed for reporting of abuse in the sample of 50. These failures resulted in these residents being subjected to further criminal sexual and physical assault from the perpetrator (R1). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7-14-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement their Abuse policies and procedures to thoroughly investigate all alleged violation of abuse, failed to prevent further abuse from occurring while the investigation was in progress, failed to implement measures to provide safety and supervision to prevent further abuse, and failed to submit a final report of the investigation report to the State Agency within five working days for six of six residents (R1, R2, R5, R6, R10, and R11) reviewed for protection from abuse in the sample of 50. These failures resulted in R1 having continual unsupervised access to the residents on two hallways and the dining rooms to where R1 has resided (R2-R10 and R12-R50) after R1 had sexually and physically assaulted R2, R5, R6, R10 and R11 on multiple occasions. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent two residents with wandering behaviors (R8 and R38) from entering resident's room and infringing on resident's privacy for five of five residents (R3, R4, R9, R46, R47) reviewed for resident rights in the sample of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure above the bed lighting was in working condition and room temperatures were kept at comfortable levels for two of three residents (R3 and R9) reviewed for a comfortable and homelike environment in the sample of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals to all the residents seated together at the same time, during meal time for one resident (R50), and failed to sit next to and allow a resident to eat independently for one resident (R48). This applies to 2 residents (R50 and R48) reviewed for meal service.

Inspectors wroteBased on interview and record review, the facility failed to give the appropriate notices for Medicare Part A for three (R23, R54 and R231) of three residents reviewed for Medical Part A Services in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to obtain a new level II PASRR (Preadmision Screening and Resident Review) for a new diagnosis of serious mental illness for two residents (R27 and R50 ) out of four residents reviewed for PASRRs in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II (R22) and failed to obtain a new Level I Screening after expiration (R70) for two of four residents (R22 and R70) reviewed for PASARRs in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a Comprehensive Care Plan for one (R45) of 19 residents reviewed for Care planning in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident transferred out of bed for one (R9) of six residents reviewed for activities of daily living in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had a device in place to prevent skin breakdown and prevent further contraction of a left hand contracture for one resident (R8) out of two resident reviewed for range of motion in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to screen and identify triggers for two of two residents (R45 and R62) reviewed for Trauma Informed Care in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to obtain a Physician/Prescriber response to the Pharmacist's Medication Regimen Review/MRR for one of six residents (R22) reviewed for unnecessary medications in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to identify target behaviors and gain consent to warrant the use of antipsychotic medication for one resident (R50), and failed to attempt a gradual dose reduction for an antipsychotic medication for one resident (R22), out of five residents reviewed for unnecessary medications in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to revise Care Plans for three residents (R9, R27, and R45) of 19 residents reviewed for Care Planning in the sample of 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the nutritional needs by offering a menu balanced in protein and calories for a resident on a Vegetarian Diet. This has affected one (R9) of three residents in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement pressure relieving interventions, failed to develop a pressure relieving care plan after being assessed as high risk for pressure ulcer development, and failed to immediately develop a pressure ulcer care plan once a pressure ulcer developed for one of three residents (R1) reviewed for facility acquired pressure ulcers in the sample of three. These failures resulted in R1 developing an unstageable, painful, deep tissue pressure ulcer to the left heel, after R1 had a decline in ADLs (Activities of Daily Living) following a left hip fracture.

Inspectors wroteBased on record review and interview, the facility failed to complete a significant change in condition MDS (Minimum Data Set) Assessment within 14 days of a change in condition for one of three residents (R1) reviewed for a change in condition in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fingernail care and facial hair grooming for one of three residents (R1) reviewed for ADL (Activities of Daily Living) dependence in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Fall Prevention policy to immediately assess a resident after a fall, document a fall in the resident record, and develop fall interventions immediately after a fall for one of three residents (R1) reviewed for falls with injury in the sample of three.

Inspectors wroteBased on interview and record review, the Facility failed to protect one resident (R6) from ongoing sexual abuse by two staff members, for one of three residents reviewed for sexual abuse. This failure resulted in R6 discharging from the Facility, relapsing on drugs, and requiring admission to an in-patient treatment center. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 9/5/23, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.

Inspectors wroteBased on interview and record review, the Facility failed to report a sexual allegation of abuse for one (R6) of three Residents reviewed for abuse in the sample of three. This failure has the potential to affect all Residents 67 residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants received a minimum of 12 hours of in-service training over the past year, and dementia-specific training was administered. These failures have the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to conduct quarterly Quality Assurance meetings. This failure has the potential to affect all 60 residents within the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents with Dementia were engaged in therapeutic activities to meet their individual cognitive abilities and provide staff with the appropriate training to meet the needs of residents with Dementia. These failures have the potential to affect all 14 residents (R48, R111, R12, R28, R24, R34, R18, R17, R13, R45, R36, R21 and R57) residing on the facility's Special Care Unit.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure privacy during toileting for one of 15 residents reviewed (R57) for privacy in a sample of 44.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a known diagnosis of Dementia with Aggression and Behavioral Disturbances was supervised by staff and prevent resident to resident physical abuse, for one of one residents (R18) reviewed for abuse in a sample of 44.

Inspectors wroteBased on record review and interview, the facility failed to revise a plan of care and develop recommendations for interventions related to weight loss and falls for one of 15 residents (R21) reviewed for Care Plan Revision, in a sample of 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement services to maintain and/or improve range of motion limitations for two of three residents (R43, R44) reviewed for limitations in range of motion in the sample of 44.

Inspectors wroteBased on interview, observation, and record review, the facility failed to document a rationale for a decline of a gradual dose reduction suggestion, monitor for behaviors that warrant the use of an antipsychotic medication, document consistent adverse behaviors to justify the continued use of an antipsychotic medication, and conduct a psychotropic medication evaluation as directed by the facility's policy, for two of three residents (R2 and R45) reviewed for antipsychotic medications in the sample of 44.