Sunview Respiratory and Rehabilitation

Inspectors wroteBased on resident and staff interviews, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need. Number of residents sampled: 104.

Inspectors wroteBased on observations, staff interviews, review of records and facility policy, the facility failed to ensure expired medications were discarded for 1 (Resident #109) of 104 residents. The deficient practice could result in adverse drug reactions.

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to protect the resident's (#444) right to be free from sexual abuse by another resident (#3) on March 18, 2025 . when R3, an adult was found performing a sexual act on R444, a minor. The facility failed to specifically to (1) address R444's inappropriate interactions with staff; (2) provide supervision when the minor was noted to spend time with a cognitively impaired resident; and, (3) identify sexual contact between a minor and an adult as sexual abuse. When a minor has been the victim of molestation or statutory rape it has the potential to cause long lasting effects, psychological trauma and post traumatic stress disorder. As a result, the situation of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. [...]

Inspectors wroteBased on interviews and record review the facility failed to implement policies and procedures to prohibit and prevent abuse for one resident (R)444 when (1) Staff failed to identify non consensual sexual acts between R444 and R3 as sexual abuse; (2) Report the abuse within the time frame required by State law and federal requirements; and, (3) Conduct a thorough investigation. The failure of the facility to recognize non consensual sexual acts between minors and adults has the potential to put all minors in the facility at risk for serious psychosocial harm such as post traumatic stress disorder or psychological trauma. As a result, the situation of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. [...]

Inspectors wroteBased on interviews, records, and policy review, the facility's QAPI program did not show it is actively addressing all care and services for residents. Specifically, the facility failed to: (1) Conduct a root cause analysis to identify why the sexual abuse incident between residents occurred; (2) Clearly define the problem or outline specific actions to fix it, including measurable goals, timelines, how effectiveness would be evaluated, and who is responsible; (3) Identify specific changes to policies, procedures, or practices that were or will be put in place; and, (4) Set up ongoing monitoring with clear baselines, target goals, and timelines. Because of these gaps, the facility did not implement clear corrective actions or provide appropriate staff training, which may lead to weak systems for identifying, assessing, and responding to potential sexual abuse incidents.

Inspectors wroteBased on record reviews, staff interviews, and review of facility policy and procedure, the facility failed to ensure an allegation of sexual abuse was reported in accordance with federal requirements when the facility failed to (1) Report the allegation of abuse to the State Agency, local law enforcement, adult protective services and department of children services immediately but no later than within 2 hours; (2) Failed to provide an accurate 5 day report; and, (3) Take appropriate corrective actions for one of one resident (R)#444 investigated for alleged sexual assault. The deficient practice resulted in the facility putting residents at for further abuse and placed the residents at risk for harm.

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure an allegation of sexual abuse was thoroughly investigated for two residents (#444 and #3). The deficient practice could result in an allegation of sexual abuse not being investigated timely and/or possible ongoing abuse of a resident.

Inspectors wroteBased on clinical record review, staff interviews, resident interviews, facility documentation, and policies and procedures, the facility failed to protect one resident's (#2) right to be free from physical abuse by another resident. The census was 110. The deficient practice could result in continued abuse, and further abuse of other residents

Inspectors wroteBased on clinical record review, observations, staff interviews, and policies and procedures, the facility failed to ensure that a request for a modification of a health care institution was approved by the state agency prior to establishing a dialysis center and provided dialysis treatment(s) from March 1, 2024 through March 07, 2025 to 9 residents (#17, 10, 13, 15, 8, 20, 4, 6, and 11) inside the facility. The deficiency may result in non compliance with federal, state, and local laws and professional standards.

Inspectors wroteBased on observation, clinical record review, staff and resident interview, and facility policy review, the facility failed to ensure medication were not left at bedside for two residents (#62 and #71) who were not assessed to be clinically appropriate to self-administer medications. The deficient practice could result in medication not administered correctly or medication not taken by the resident.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy review, the facility failed to ensure that care and services was provided to related to a change in condition for one resident (#168); and, failed to ensure failed to ensure the leg rests for tilt-in-space mobility device was put on for one resident (#31) as recommended. The deficient practice could result in the resident's medical needs not being met/treated appropriately and in a timely manner. Findings nclude: -Resident #168 was admitted on [DATE] from the hospital with diagnoses that included urinary tract infection, pneumonia, type 2 diabetes mellitus (DM), urinary tract infection, and pneumonia. [...]

Inspectors wroteBased on observations, staff interviews, and facility documentation and policy review, the facility failed to ensure food items were dated when opened; failed to ensure food readily available for resident use were not expired; and, failed to ensure that the ceiling air vents above the food tray line and the kitchen ice machine were clean. The deficient practices increase the potential for foodborne illness.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure proper hand hygiene was conducted during medication administration. The deficient practice could result in contamination.

Inspectors wroteBased on clinical record review, observations, interviews, and policy review, the facility failed to ensure one resident (#72) was treated with dignity and respect. The deficient practice could result in resident's self-esteem and self-worth not maintained, honored and valued.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure there was physician order for the oxygen use for two sampled residents (#219 and #168). The deficient practice could result in unnecessary oxygen use for the resident.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to ensure the resident representative (RR) was notified in writing of a transfer to the hospital for one resident (#6). The deficient practice could result in the RR not being informed of changes in resident status.

Inspectors wroteBased on documentation, staff interviews, and facility policy and procedures, the facility failed to ensure bed-hold policy or notice was provided to resident or resident representative prior to or upon transfer to hospital for one resident (#6). The deficient practice may result in residents and/or their representatives not being able to return to the facility. informed of the bed-hold policy.

Inspectors wroteBased on clinical record review, staff interview, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure that an MDS (Minimum Data Set) assessments for two residents (#105 and #50) were accurate. The deficient practice has the potential to affect continuity of care.