A list of the most recent deficiencies for Sunset Park Healthcare. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-18 | 2023-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-10-27 | Y |
| 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 | 2023-10-05 | 2023-10-27 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-12 | 2023-09-30 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-05-22 | 2023-06-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-22 | 2023-06-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-22 | 2023-06-06 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-30 | 2022-09-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-30 | 2022-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-30 | 2022-06-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-30 | 2022-06-13 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-26 | 2022-06-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-19 | 2022-06-06 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-19 | 2022-06-06 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-01-25 | 2022-02-25 | 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 | 2022-01-25 | 2022-02-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-25 | 2022-02-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-27 | 2022-02-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-27 | 2022-02-24 | 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 | 2022-01-27 | 2022-02-24 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-01-27 | 2022-02-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-27 | 2022-02-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-27 | 2022-02-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-27 | 2022-02-24 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-01-27 | 2022-02-24 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-01-27 | 2022-02-24 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-01-27 | 2022-02-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-27 | 2022-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-24 | 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 | 2022-01-27 | 2022-02-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-01-27 | 2022-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-09 | 2022-02-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-28 | 2022-01-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-11 | 2021-12-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-11 | 2021-12-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-07 | 2021-12-17 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Establish methods for sharing information. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Meet other general requirements. | Fire Safety | 2019-05-10 | 2019-06-05 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-05-03 | 2019-06-04 | 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 | 2019-05-03 | 2019-06-04 | 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 | 2019-05-03 | 2019-06-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-03 | 2019-06-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-03 | 2019-06-04 | 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 | 2019-05-03 | 2019-06-04 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2018-04-28 | 2018-06-14 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-04-28 | 2018-06-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-04-28 | 2018-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-28 | 2018-06-14 | 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 | 2018-04-28 | 2018-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-28 | 2018-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-28 | 2018-06-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-04-28 | 2018-06-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-28 | 2018-06-14 | 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 | 2018-04-28 | 2018-06-14 | 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 | 2018-04-28 | 2018-06-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-04-28 | 2018-06-14 | 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 | 2018-04-28 | 2018-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-28 | 2018-06-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-04-28 | 2018-06-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-04-28 | 2018-06-14 | N |
| Keep all essential equipment working safely. | Health | 2018-04-28 | 2018-06-14 | 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 | 2018-04-28 | 2018-06-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-04-28 | 2018-06-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Develop a communication plan. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Establish methods for sharing information. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-04-28 | 2018-05-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-28 | 2018-05-28 | 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 | 2019-05-03 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-03 | Not Fixed | N |
