A list of the most recent deficiencies for Sun City Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-02 | 2023-01-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-02 | 2023-01-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-02 | 2023-01-23 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-02 | 2023-01-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-02 | 2023-01-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-12-02 | 2023-01-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-02 | 2023-01-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-02 | 2023-01-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-02 | 2023-01-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-02 | 2023-01-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-12-02 | 2023-01-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-02 | 2023-01-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-02 | 2023-01-20 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-12-02 | 2023-01-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-06 | 2021-11-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-08-06 | 2021-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-11-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-08-06 | 2021-10-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-06 | 2021-10-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-06 | 2021-10-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-06 | 2021-10-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-06 | 2021-10-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-06 | 2021-10-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-06 | 2021-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-06 | 2021-10-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-06 | 2021-10-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-06 | 2021-10-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-06 | 2021-10-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-06 | 2021-10-01 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-06 | 2021-10-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-08-06 | 2021-09-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-06 | 2021-09-15 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-08-06 | 2021-09-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-06 | 2021-09-15 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-08-06 | 2021-09-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-06 | 2021-09-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-06 | 2021-09-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-05-16 | 2019-07-10 | N |
| Respond appropriately to all alleged violations. | Health | 2019-05-16 | 2019-07-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-16 | 2019-07-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-16 | 2019-07-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-16 | 2019-07-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-05-16 | 2019-07-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-05-16 | 2019-07-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-05-16 | 2019-07-10 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-05-16 | 2019-07-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-16 | 2019-07-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-16 | 2019-07-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-22 | 2019-06-18 | N |
