Sunset Villa Healthcare

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 2 (R #3 and R #37) of 5 (R #1, R #3, R #15, R #37, and R #48) residents reviewed for unnecessary medications, when staff failed to:1. Ensure that as needed psychotropic medications are limited to only 14 days or indicate the duration of the as needed (PRN) order for R #3 and R #37.2. Ensure monitoring for possible side effects of an anti-psychotic medication for the duration of the order for R #3. These deficient practices could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment accurately reflected residents' clinical status for 2 (R #2 and R #31) of 4 (R #2, R #4, R #9, and R #31) residents reviewed for assessments. This deficient practice could likely result in the residents' needs not being met.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen (plan to manage a person's medication) was free from unnecessary drugs by ensuring residents receiving diuretic therapy were appropriately monitored for edema for 1 (R #48) of 5 (R #3, R #5, R #15, R #43, and R #48) residents reviewed for unnecessary medication. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #48) of 5 (R #3, R #5, R #15, R #43, and R #48) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 2 (R #5 and R #48) of 5 (R #3, R #5, R #15, R #43 and R #48) residents reviewed for care plans when staff failed to develop: 1. A care plan with goals and interventions for R #5's diagnosis of type 2 diabetes mellitus (DM2, a condition results from insufficient production of insulin, causing high blood sugar). 2. A care plan with goals and interventions for R #48's:-Use of an anticoagulant (medication that prevents blood from clotting) medication,-Diagnosis of edema (swelling caused by excess fluid). This deficient practice could likely result in proper care not being provided to residents.

Inspectors wroteBased on record review and interview, the facility failed to provide quality of care when staff failed to monitor 1 (R #48) of 5 (R #3, R #5, R #15, R #43, and R #48) residents reviewed for edema. These deficient practices could likely result in residents not getting the treatment needed and/or potentially worsening conditions.

Inspectors wroteBased on observation and interview, the facility failed to ensure the call light was in working order for 1 (R #4) of 3 (R #2, R #4, and R #8) residents reviewed during random observation of the facility. If the facility is not ensuring a working call light system, then residents and staff are unable to request immediate assistance when needed.

Inspectors wroteBased on record review and interview, the facility failed to report allegations of abuse and neglect to the State Agency within twenty-four hours for 3 (R #1, R #2, and R #3) of 5 (R #1, R #2, R #3, R #4, and R #6) residents reviewed for abuse and neglect. If the facility fails to report allegations of abuse and neglect to the State Agency, then the State Agency is unable to ensure residents are free from abuse and neglect.

Inspectors wroteBased on record review and interview, the facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 3 (R #1, R #5, and R #6) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record review and interview, the facility failed to keep residents free from abuse for 1 (R #1) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed for abuse when Certified Nurse Aide (CNA) #1 was verbally abusive to R #1. This deficient practice led to R #1 feeling embarrassed.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wrotePast Non-Compliance Based on record review, and interview, the facility failed to prevent neglect for 1 (R #24) of 1 (R #24) resident reviewed for abuse and neglect when staff failed to complete rounds (process where nursing staff checks on the status or condition of each resident) timely. This deficient practice likely resulted in R #24 laying on the floor in his room after a fall for approximately three hours.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections). This failed practice has the potential to affect all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24. This deficient practice could likely result in the spread of infectious diseases. A. On 02/03/25 at 6:00 am, during a random observation of the facility, signs indicated enhanced barrier precautions were on the doorways of rooms 102, 109, 110, and 120. B. Record review of the facility's Infection Prevention and Control Program Policy and Process Surveillance and Reporting policy, revision date of 06/2020, revealed the following: 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This failed practice has the potential to affect all 45 residents in the facility. Residents identified on the matrix provided by the Administrator on 02/03/25. This deficient practice could likely result in the inappropriate use of antibiotics that can lead to resistance of multi-drug resistant organisms.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 3 (R #5, R #24, and R #34) of 6 (R #1, R #5, R #17, R #24, R #34, and R #39) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 2 (R #5 and R #24) of 6 (R #1, R #5, R #17, R #24, R #34, and R #39) residents reviewed for pain medication management. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who had completed and signed a consent form for influenza (flu, infection of the nose, throat and lungs caused by a virus) vaccine actually received the vaccination for 1 (R #9) of 5 (R #7, R #9, R #10, R #14, and R #27) residents reviewed for immunizations. If residents are not vaccinated appropriately for influenza, then they have a higher likelihood of contracting the illness and spreading the flu to other residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to offer COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations to 4 (R #7, R #9, R #10, and R #14) of 5 (R #7, R #9, R #10, R #14, and R #27) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents getting COVID-19.

Inspectors wroteBased on observation and record review, the facility failed to ensure privacy was provided for 1 (R #1) of 1 (R #1) residents reviewed when they failed to ensure personal privacy while dressing in her room. This deficient practice is likely to cause residents to feel exposed and unimportant.

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable and homelike environment that was in good condition for 1 (R #5) of 1 (R #5) resident reviewed for a homelike environment by not repairing the wall and the blinds in his room. Failure to maintain and provide a comfortable environment is likely to result in residents feeling unimportant and undervalued.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 2 (R #34 and R #38) of 3 (R #24, R #34, and R #38) residents reviewed for care plans. If baseline care plans are not accurate then residents may not get the appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident because of medical care or lack of medical care).

Inspectors wroteBased on observation and record review, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for dressing for 1 (R #1) of 1 (R #1) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview, the facility failed maintain adequate hydration for 1 (R #24) of 1 (R #24) resident reviewed for dehydration when staff failed to: 1. Offer R #24 a drink when staff enter his room, 2. Document and monitor R #24's fluid intakes daily. If residents are not assisted with hydration support, then residents are likely to experience dehydration which could lead to other health problems.

Inspectors wroteBased on observation and interview the facility failed to ensure medications were labeled with a proper open date or expiration date. These deficient practices are likely to negatively impact the health of all residents, if staff administered or used potentially compromised or contaminated medications.

Inspectors wroteBased on record review and interview, the facility failed to prevent an accident for 2 (R #1 and #6) of 2 (R #1 and #6) residents reviewed for falls: 1. When the facility failed to ensure R #1, who was a fall hazard, was not left alone while in the restroom. 2. When therapy failed to use a gait belt for R #6. 3. When the facility failed to immediately assess R #6 following the fall to check for injuries. These deficient practices likely resulted in R #1 and R #6 having falls with injuries that required treatment at the hospital.

Inspectors wroteBased on observation and interview, the facility failed to ensure all medication carts were locked while not in use. This deficient practice had the potential to affect all 19 people residing in rooms 100-111 as identified by the resident census provided by the Administrator on 06/06/24 by allowing unauthorized persons access to their medications and personal health information.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 2 (R #1 and #3) of 2 (R #1 and #3) residents reviewed for baseline care plans. This deficient practice could likely result in a decline in the residents' conditions due to staff not being aware of the care residents need.

Inspectors wroteBased on record review and interview, the facility failed to update and implement a comprehensive person-centered care plan for 1 (R #2) of 1 (R #2) residents reviewed for comprehensive care plans when the facility failed to have a current plan in place. Failure to have a current comprehensive person-centered care plan in place may result in staff not understanding and implementing the needs and treatments of residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure 3 (R #'s 3, 43, and 51) of 3 (R #'s 3, 43, and 51) residents reviewed for behavioral health concerns received necessary behavioral health care to meet residents needs when staff failed to: 1. Refer R #3 for psychiatric services when staff observed depressive symptoms and R #3 verbalized feelings of depression. 2. Ensure R #43 was receiving psychiatric service to include psychotherapy (talk therapy) to manage depressive symptoms. 3. Refer R #51 for behavioral health services when he was exhibiting disruptive behaviors which resulted in R #51 being transferred to the hospital and not allowed to return to the facility. 4. Document and monitor for depressive symptoms on the Treatment Administration Record (TAR) for R #3 and R #43 despite staff being aware that these residents had depressive symptoms. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1(R #1) of 4 (R #1-4) residents reviewed received treatment and care in a timely manner and in accordance with professional standards of practice when the facility failed to identify a change in condition and adequately assess R #1 when she informed the nurse that she thought she was having a stroke and then demonstrated unexplained significant weakness during transfer. Several hours later, R #1 became unresponsive and hypoxic (low oxygen in blood). This deficient practice likely resulted in R #1 experiencing a delay in treatment.

Inspectors wroteBased on record review and interview, the facility failed to effectively manage pain for 1 (R #3) of 2 (R #'s 3 and 57) residents reviewed for pain when staff did not assess for pain and provide pain treatment. This deficient practice likely resulted in R #3 experiencing long periods of pain without sufficient relief. A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses: 1. Pain. 2. Osteoarthritis (Inflammation of one or more joints). 3. Muscle wasting and atrophy (A progressive and degeneration or shrinkage of muscles or nerve tissues). B. Record review of R #3's pain summary, dated January 2024, revealed R #3 experienced the following pain levels: - A score of 0 to 1 means the resident had no pain; 2 to 3 means mild pain; 4 to 5 means discomforting, moderate pain; 6 to 7 means distressing, severe pain; [...]

Inspectors wroteBased on interview, the facility failed to have a qualified therapeutic recreation specialist or an activities professional direct the the activity program in the facility for all the residents who resided in the facility. If the facility is not providing activity programs for residents to participate in then residents are likely to get bored and their interests not being met.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the kitchen were stored properly. 2. Ensure the kitchen refrigerators were clean. 3. Ensure the drain under the stove and the side of the oven are free from grime and dirt. These deficient practices are likely to affect all 49 residents identified on the resident census list provided by the Administrator on 03/02/24. If the facility does not follow food safety guidelines, then they are likely to expose residents to food borne illnesses.

Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health (the emotions and behaviors that affect your overall well-being) care training for 31 Certified Nursing Assistants (CNAs # 1-31) out of 31 (# 1-31) CNAs in the facility. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being.

Inspectors wroteBased on record review and interview, the facility failed to promote residents' choices for 2 (R #'s 5 and 32) of 2 (R #'s 5 and 32) residents reviewed for choices when staff failed to: 1. Ensure medical appointments were not missed due to lack of transportation for R #5. 2. Ensure R #32 was taken outdoors per her preference. These deficient practices are likely to result in the resident's personal choices, needs, and preferences not being honored.

Inspectors wroteBased on interview and record review, the facility failed to assist or provide an opportunity for residents to organize a facility resident council for all 49 residents as listed on the Resident Census provided by the Administrator on 03/02/24. This deficient practice is likely to result in residents not feeling heard or feeling as if their concerns are not important.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, comfortable, and homelike environment. This deficient practice is likely to affect all 49 residents living in the facility as listed on the Resident Census provided by the Administrator on 03/02/24. Failure to maintain the building in a clean and comfortable manner is likely to prevent residents from enjoying everyday activities.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident care plans were revised for 5 (R #'s 29, 31, 34, 37, 44) of 5 (R #'s 29, 31, 34, 37, 44) residents reviewed for care plans when staff failed to: 1. Conduct quarterly care plan meetings as required for R #29. 2. Update a care plan to reflect antipsychotic medication (medications that mainly treat psychosis-related conditions and symptom) use and falls for R #31. 3. Update a care plan to reflect information regarding falls for R #37. 4. Update a care plan to accurately reflect information regarding falls, removal of catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), and the use of fall mat (a mat placed on the floor beside a resident's bed in case a resident falls out of bed) for R #44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of care for 1 (R #3) of 2 (R #'s 3 and 35) residents reviewed when staff failed to schedule an magnetic resonance imaging (MRI; medical imaging technique that uses a magnetic field and radio waves to create detailed images of the organs and tissues in your body) appointment for R #3 per physician orders. If the facility is not scheduling MRI appointments per physician orders, then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance for baths and showers for 2 (R #'s 24 and 32) of 2 (R #'s 24 and 32) residents reviewed for ADL care when staff failed to: 1. Offer R #'s 24 and 32 at least three showers a week. 2. Document when a resident refused any bath or shower. These deficient practices are likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an on-going program of activities designed to meet the interests and well-being for 7 (R #'s 6, 9,16, 29, 30, 32, and 33) of 7 R #'s 6, 9,16, 29, 30, 32, and 33) residents reviewed for activities when staff failed to: 1. Offer one-to-one activities to residents that stay in their rooms or are bed bound for R #'s 6, 9,16, 29, 30, 32, and 33. If residents are not provided or encouraged to attend or participate in activities that meet their interests, are enjoyable, and enhance their social and emotional well-being, then they are likely to experience an increase in boredom, isolation, and depression.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's hearing was maintained with functioning hearing aides for 1 (R #24) of 1 (R #24) resident. This deficient practice is likely to result in the resident not being able to understand when people communicate with her and her needs not being met.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure they had sufficient staff to meet the needs of all 49 residents residing in the facility when staff failed to offer baths or showers to residents as scheduled. This deficient practice is likely to negatively impact the comfort, the dignity, and the health of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility monitored for the use of psychotropic medications (any medication that affects brain activity associated with mental processes and behavior) for 1 (R #'s 17 and 37) of 3 (R #'s 17, 31, and 37) residents reviewed when staff failed to attempt to gradually reduce the dose (lower dose/quantity of medication administered) for a psychotropic medication. This deficient practice is likely to result in residents being administered unnecessary medication and being over medicated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and other medical supplies were not expired. This deficient practice is likely to result in medications losing their potency.

Inspectors wroteBased on observation and interview, the facility failed to maintain confidential records by leaving medical information visible to other residents, visitors, and unauthorized staff for 25 (R #'s 2, 7, 10, 12, 13, 16, 17, 21, 22, 24, 29, 30, 31, 32, 33, 35, 36, 37, 39, 43, 44, 46, 47, 55, and 56) residents out of all 49 residents listed on the facility census provided by the Administrator on 03/02/24. This deficient practice would likely result in residents not having confidentiality of their medical information.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a functioning call light system for 1 (R #28) of 1 (R #28) residents reviewed for call lights. If the facility fails to have call lights that are not functioning, residents cannot call staff in case of an emergency or get their needs met by the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide training for 2 certified nurse aides (CNAs #6 and #7) of 5 CNAs ( #1, 2, 5, 6, and 7) on the facility's policies and procedures for reporting abuse or neglect. This failure had the potential to affect all 49 residents as indicated on the facility census provided by the administrator on 03/02/24. This deficient practice is likely to result in staff not knowing what constitutes abuse or neglect or how to report abuse or neglect. A. Record review of the facility staffing list revealed the following: 1. CNA #6 was hired on 03/01/23. 2. CNA #7 was hired on 03/01/23. B. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of no less than 12 hours per year for 1 (CNA #5) of 5 (CNA #1, #2, #5, #6, and #7) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aide's not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to allow 1 (R #51) of 1 (R #51) resident to return to the facility after a hospitalization on 12/05/23. If the facility fails to allow a residents to return to the facility then residents are likely to feel unwanted and feeling as if they have no place to go.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #32) of 1 (R #32) residents reviewed by not providing restorative physical therapy service devices as ordered by a physician. This deficient practice is likely to result in residents having a decreased in mobility and pain, causing psychosocial harm and despair.

Inspectors wroteThis was cited as past non-compliance Based on record review and interview, the facility failed to ensure 1 (R #5) of 1 (R #5-9) residents reviewed for elopement risks received the appropriate supervision to prevent or minimize the risk of elopement (an unauthorized departure of a patient from an around-the-clock care setting.) This deficient practice could likely put residents of elopement.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents obtained routine dental care for 1 (R #30) of 1 (R #30) residents reviewed for dental services. This failure is likely to result in the resident experiencing pain and potential weight loss.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide assistive devices for 1 (R #28) of 1 (R #28) residents reviewed during dining observation. If residents are not provided special eating equipment as needed, then residents might be unable to consume their meals and beverages and is likely to result in weight loss, malnutrition, and dehydration.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff offered COVID-19 (a highly infectious viral disease) vaccinations to 1 (R #35) of 5 (R #'s 2, 6, 21, 29, and 35) residents reviewed for COVID-19 vaccines. This deficient practice could likely result in residents at risk of exposure to COVID-19 related infections.