A list of the most recent deficiencies for Sunset Manor Conv Hosp. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-11-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-28 | 2023-08-07 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-28 | 2023-08-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-31 | 2023-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-09-20 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-22 | 2021-11-16 | 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 | 2021-10-22 | 2021-11-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-22 | 2021-11-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-10-22 | 2021-11-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-22 | 2021-11-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-22 | 2021-11-16 | N |
| Post nurse staffing information every day. | Health | 2021-10-22 | 2021-11-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-22 | 2021-11-16 | 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 | 2021-10-22 | 2021-11-16 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-10-22 | 2021-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-22 | 2021-11-16 | N |
| Keep all essential equipment working safely. | Health | 2021-10-22 | 2021-11-16 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2021-10-22 | 2021-11-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-10-22 | 2021-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-20 | 2021-10-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-07-22 | 2021-08-04 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-05-10 | 2019-06-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-05-10 | 2019-06-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-10 | 2019-06-18 | 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 | 2019-05-10 | 2019-06-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-10 | 2019-06-18 | 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 | 2019-05-10 | 2019-06-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-10 | 2019-06-18 | 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 | 2019-05-10 | 2019-06-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-10 | 2019-06-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-10 | 2019-06-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-13 | 2019-06-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-13 | 2019-06-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-13 | 2019-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-13 | 2019-06-05 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-05-04 | 2018-06-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-05-04 | 2018-06-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-04 | 2018-06-08 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-05-04 | 2018-06-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-05-04 | 2018-06-08 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-05-04 | 2018-06-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-05-04 | 2018-06-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-04 | 2018-06-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-05-04 | 2018-06-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-04 | 2018-06-08 | 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 | 2018-05-06 | 2018-06-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-05-06 | 2018-06-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-05-06 | 2018-06-05 | N |
| Respond appropriately to all alleged violations. | Health | 2018-05-06 | 2018-06-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-06 | 2018-06-05 | 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 | 2018-05-06 | 2018-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-06 | 2018-06-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-06 | 2018-06-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-06 | 2018-06-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-05-06 | 2018-06-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-06 | 2018-06-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-06 | 2018-06-05 | 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 | 2018-05-06 | 2018-06-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-05-06 | 2018-06-05 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-05-06 | 2018-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-06 | 2018-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-06 | 2018-06-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-05-06 | 2018-06-05 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2018-05-06 | 2018-06-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-05-06 | 2018-06-05 | N |
