Sunset Ridge Post Acute

Inspectors wroteBased on observation, interview and document review, the facility failed to comply or establish compliance with all applicable Federal, State, and local laws, regulations, and codes, specifically concerning:(1) not being properly permitted for construction/electrical change activities within the building with the local building department;(2) not completing the change of ownership license application with the State Survey Agency;(3) by not completing the change of ownership license application with the State Survey Agency, the facility has prevented their Centers for Medicare Medicaid Services (CMS) certification change of ownership from proceeding to completion; and(4) not timely notifying the State Survey Agency with all Administrator changes at this facility.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to maintain a safe and comfortable room temperature for 1 of 8 sampled residents (Resident 1). The deficient practice had the potential to cause discomfort, dehydration, heat-related illness, and reduce the quality of life for the residents.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to maintain professional boundaries and protect a resident from verbal abuse for 1 of 3 sampled residents (Resident 1). This deficient practice had the potential for residents to experience emotional and physical harm.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure fingernail care was provided for 4 of 40 sampled residents (Resident 10, 13, 12 and 9). The deficient practice had the potential for residents not to receive nail care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician order for Pressure Relief Ankle Foot Orthosis (PROFO - a specialized medical device used to relieve pressure and support the ankle and foot) boots were implemented as ordered for 2 of 40 sampled residents (Resident 10 and 9). The deficient practice had the potential for not limiting the progression of contractures of limited mobility residents and heel protection.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a physician order for monthly urinary catheter change was completed for 1 of 40 sampled residents (Resident 12). The deficient practice had the potential for a resident to develop a urinary tract infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician order was obtained for a Peripherally Inserted Central Catheter (PICC - a long, flexible tube inserted into a vein in the upper arm and threaded to a large vein in the chest near the heart) line and heparin lock (Heplock - a small, flexible tube inserted into a vein to maintain access for intermittent intravenous (IV) infusions) care, maintenance, and the dressing change per facility standards for 1 of 40 sampled residents (Resident 1). The deficient practice had a potential for placing a resident at risk for IV insertion site infections. Findings Include: Resident 1 (R1) was re-admitted on [DATE], with diagnoses including urinary tract infection and chronic respiratory failure. On 08/19/2025 at 10:00 AM, R1 was observed with two IV lines. [...]

Inspectors wroteBased on interview, record review, and document review, the facility failed to provide medication for glaucoma (abnormal high pressure in the eye) as ordered by a physician for 1 of 40 sampled resident (Resident 185). The deficient practice could result in poor control of glaucoma and potential loss of vision.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) enhanced barrier precaution (EBP - a set of infection control practices designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) was maintained during care for 1 of 40 sampled residents (Resident 1), and 2) provisions in the water management program was implemented. The deficient practice had potential for microbial infection to develop and spread within the facility. Findings Include: 1) Resident 1(R1) was re-admitted on [DATE], with diagnoses including urinary tract infection and pneumonia gram negative bacteria. R1's physician's order dated 08/17/2025, documented Enhance Barrier Precaution: Tracheostomy, ventilator, Gastrostomy tube and indwelling foley catheter. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the air conditioning unit in 2 of 12 resident room halls (1300 Hall and 2300 Hall) was maintained in good working condition. The deficient practice had the potential for the temperature to be at an uncomfortable level.

Inspectors wroteBased on interview, record review and document review the facility failed to ensure a resident was kept safe from abuse for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential for the resident to experience emotional distress and physical harm.

Inspectors wroteBased on interviews, record review, and document review the facility failed to ensure abuse policies and procedures were implemented for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to put residents at risk of physical or psychosocial harm.

Inspectors wroteBased on observations and interview, the facility failed to ensure a resident was treated with dignity and respect by facility staff directing the resident to urinate in their incontinence brief for 1 of 16 sampled residents (Resident 3). The deficient practice had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on record review and interview, the facility failed to clarify discrepancies in the appeal decision resulting in a resident being discharged and lacked documented evidence of well-coordinated discharge planning for 1 of 16 sampled residents (Resident 4). The deficient practice had the potential for a resident not to receive the necessary skilled therapy to improve functional ability and provide the necessary provisions for continuation of care.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure showers were provided as scheduled for 1 of 16 sampled residents (Resident 14). The deficient practice had the potential to increase skin breakdown, infections, odor and bacteria buildup.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure two free standing portable oxygen cylinders were safely stored. The deficient practice had the potential to prevent avoidable accidents and increase concerns of potential harm to residents and the facility overall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were secured for 1 of 6 sampled residents (Resident #19). This deficient practice had the potential to result in other residents having access to the medication.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the menu was followed for a breakfast service. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1) a dietary aide's purse was not being stored with resident food in the dry storage area of the kitchen, 2) a hairnet was donned prior to entering the kitchen, 3) hand washing was performed when entering the kitchen or prior to donning gloves, 4) beverages were covered when traveling down hallways, 5) food was stored at safe temperatures, and 6) thermometers were properly sanitized between foods during the taking of temperatures. This deficient practice placed residents at risk for food-borne infectious illnesses.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 4 of 4 dining rooms maintained a comfortable home-like environment by storing medical equipment in the dining areas. The deficient practice had the potential to affect all residents who wish to eat in the dining areas.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure 1) expired medications were removed from 1 of 5 inspected medication carts and 1 of 2 inspected medication storage rooms, 2) an unsealed medication was removed from 1 of 5 inspected medication carts, and 3) discontinued medications were removed from 1 of 5 inspected medication carts. This deficient practice has the potential to place residents at risk of receiving medications that were no longer at a safe level of efficacy.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure residents were informed both orally and in writing prior to or upon admission of the rules related to leaving on pass. This deficient practice had the potential to affect the entire facility population of 129 residents.

Inspectors wroteBased on clinical record review, document review and interview, the facility failed to ensure a resident or resident representative was provided information about the right to formulate an advanced directive for 1 of 29 sampled residents (Resident #84). The deficient practice has the potential to deprive residents of their right for self-determination. Findings Include: Resident #84 Resident #84 was admitted to the facility on [DATE], with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, and severe persistent asthma with acute exacerbation. Resident #84's clinical record lacked documented evidence of an advance directive or information provided to the resident or the resident's representative about the right to formulate an advanced directive. [...]

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure a care plan was developed for 1) a resident receiving hospice services (Resident #57), 2) a resident dependent on a respirator (Resident #69), and 3) a resident with anxiety (Resident #15) for 3 of 29 sampled residents. This deficient practice has the potential to deprive residents of receiving appropriate care.

Inspectors wroteBased on observation, interview, and document review the facility failed to meet professional standards of medication administration and ensure medications were not left, unsecured, at a resident's bedside for 1 of 4 residents observed for medication administration (Resident #82). The deficient practice placed the patient at risk for not receiving needed medication.

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure a code status of do not resuscitate (DNR) was not documented as full code in the electronic health record for 4 of 29 sampled residents (Resident #57, #75, #40, and #347). This deficient practice had the potential to result in a resident with DNR status being given life-saving measures during an emergent event.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure an ordered therapeutic diet was on the resident meal card and provided to 1 of 29 sampled residents (Resident #89). This deficient practice placed the resident at risk for not receiving an appropriate diet to maintain nutritional needs.

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to obtain Dialysis Communications forms for a resident receiving hemodialysis for 1 of 29 sampled residents (Resident #198). This deficient practice potentially places residents at risk for not receiving continuity of care.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to discontinue a medication after receiving an order to discontinue the medication for 1 of 29 sampled residents (Resident #4). This deficient practice resulted in the resident receiving an unnecessary medication.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication's side effects were monitored, a psychotropic medication's related behaviors were monitored, and an as needed psychotropic medication was limited to 14 days for 1 of 29 sampled residents (Resident #15). This deficient practice placed residents at risk for not receiving appropriate medications for their overall health status.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than 5 percent (%). There were 31 opportunities and 6 medication errors. The medication error rate was 19.35%.

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure resident records were complete and accurate for 1 of 29 sampled residents (Resident #80). The deficient practice had the potential for the resident not receiving appropriate care and/or medications.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for a resident with chronic wounds for 1 of 29 sampled residents (Resident #292) and hand hygiene was performed during medication administration for 1 of 4 residents observed during medication administration (Resident #82). The deficient practice had the potential for spreading infectious illnesses to all residents.

Inspectors wroteBased on employee record review, document review and interview, the facility failed to ensure an employee completed training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation (abuse training) for 1 of 35 sampled employees (Employee #8). The deficient practice had the potential to place residents at risk for abuse and neglect. Findings Include: Employee #8 Employee #8 with a title of Certified Nursing Assistant and a hire date of 10/17/2023. Employee #8's record lacked documented evidence abuse training had been completed. On 09/25/2024 at 1:19 PM, the Director of Human Resources confirmed Employee #8 was hired on 10/17/2023 and had not completed abuse training since hire. [...]

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure pain medications were administered as prescribed for 1 of 15 sampled residents (Resident 1). This deficient practice had the potential to cause a resident to have uncontrolled pain and a diminished quality of life.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1) the oven was maintained in sanitary conditions, 2) an expired meal product was discarded, 3) open meal products were labeled, 4) nourishment room was maintained in sanitary conditions, and 5) nourishment room food items in the refrigerator were labeled, dated, and expired items were discarded. The deficient practice had the potential to affect the residents' health by exposing them to potentially hazardous foods.

Inspectors wroteBased on interview and document review, the facility failed to ensure the views and recommendations of the resident group were acted upon, and the response and rationale were communicated back to the resident group. The failed practice had the potential to affect the quality of life and health status of residents.

Inspectors wroteBased on observation, interview and document review, the facility failed to securely store medication in the hallway and six resident rooms in 3 of 3 hallways in the Valley of Fire unit. The deficient practice had the potential for residents, visitors, and staff members to gain unauthorized access to medications and for residents to self-administer medication that could interact with facility prescribed medication, which can adversely affect a resident's health.

Inspectors wroteBased on observation and interview the facility failed to inform a resident of the medical justification for placing the resident on transmission-based precautions (TBP) for 1 of 31 sampled residents (Resident 10). The deficient practice led to miscommunication, the lack of residents' knowledge of their care arrangements, and had the potential for psychosocial harm.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure the facility had a process in place to identify and refer residents for pre-admission screening and resident review (PASARR) level two for 1 of 31 sampled residents (Resident 30). The deficient practice had the potential to deprive residents with appropriate behavioral health services.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure: 1) The medication was available during the medication pass for 1 of 31 sampled residents (Resident 341). 2) The Medication Administration Record (MAR) was not signed off before medication administration for 1 of 31 sampled residents (Resident 341) occurred. These deficient practices had led to a missed medication dose, and the failure to accurately document the medication administration could potentially have resulted in medication errors, falsified medication records, altered therapeutic benefits, medication underdosing or overdosing, and adverse reactions.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a newly identified pressure ulcer was reported to the physician and treatment orders were obtained and carried out for 1 of 31 sampled residents (Resident #437). The deficient practice placed the resident at risk for wound complications such as infection or worsening of the pressure ulcer.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a spray bottle of chemical cleaner, a bottle of wound cleanser, and a portable oxygen cylinder were safely stored. The deficient practice had the potential to prevent avoidable accidents and increase concerns of potential harm to residents and the facility overall.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure physician orders for the utilization and size of an indwelling Foley catheter were obtained and transcribed for 1 of 31 sampled residents (Resident 23), and the correct Foley size order was verified and inserted as ordered for 1 of 31 sampled residents (Resident 47). This deficient practice could potentially increase the risk of catheter-related complications, including urinary tract infections, patient discomfort, trauma, and pain.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to complete timely assessments and interventions addressing resident's weight loss and a physician was notified for one of the 31 sampled residents (Resident 47). This deficient practice could have potentially led to a deprivation of essential care and a deterioration in overall health.

Inspectors wroteResident 42 (R42) R42 was admitted on [DATE] with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, and dysphagia following cerebral infarction. A physician's order dated 07/31/2023, documented Glucerna with Carbsteady 1.2 calories at 85 cubic centimeters (cc) per hour for 20 hours from 6:00 PM to 2:00 PM via percutaneous endoscopic gastrostomy (PEG) tube to provide 1700mL/2040kcal. A quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) (screening measure for cognitive condition) score of 00, which meant R42 was severely impaired. On 09/20/2023 at 11:27 AM, R42 was lying in bed with the head of bed elevated. The tube feed pump was on and running with a formula of Glucerna with Carbsteady 1.2 calories, infusing at 85 cc per hour. [...]

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the peripherally inserted central catheter (PICC) or midline dressing was changed as scheduled for four sampled residents (Residents 8, 47, 79, and 390). This deficient practice could potentially lead to serious complications, such as bloodstream infections, clot formation, or other adverse health outcomes.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure an intravenous antibiotic was administered as scheduled following a physician's order for 1 of 31 sampled residents (Resident 132). The deficient practice had the potential to cause adverse effects related to toxic levels of the medication.

Inspectors wroteBased on observation, interview, and document review, the facility failed to transport clean linen in a sanitary manner for one unsampled resident and follow their Transmission-Based Precaution (TBP) practice for 1 of 31 sampled residents (Resident 10). The deficient practice had the potential to contaminate clean linen and spread communicable infections or organisms that can affect the well-being of residents.