A list of the most recent deficiencies for Sunset Home. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-04 | 2023-12-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-04 | 2023-12-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-04 | 2023-12-22 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-11-16 | 2023-12-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-16 | 2023-12-16 | 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 | 2023-11-16 | 2023-12-16 | 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 | 2023-11-16 | 2023-12-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-16 | 2023-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-16 | 2023-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-16 | 2023-12-16 | 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 | 2023-11-16 | 2023-12-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-16 | 2023-12-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-11-16 | 2023-12-16 | 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 | 2023-11-16 | 2023-12-16 | 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 | 2023-11-16 | 2023-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-16 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-11-16 | 2023-12-16 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-11-22 | 2023-12-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-11-22 | 2023-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-22 | 2023-12-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-22 | 2023-12-16 | 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 | 2023-07-17 | 2023-08-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-17 | 2023-08-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-10 | 2023-08-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-10 | 2023-08-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-10 | 2023-08-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-10 | 2023-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-10 | 2023-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-10 | 2023-08-03 | Y |
| 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 | 2023-07-10 | 2023-08-03 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-07-10 | 2023-08-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-27 | 2023-04-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-27 | 2023-04-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-27 | 2023-04-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-28 | 2023-03-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-28 | 2022-11-22 | 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 | 2022-10-28 | 2022-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-28 | 2022-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-28 | 2022-11-22 | 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 | 2022-10-28 | 2022-11-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-28 | 2022-11-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-26 | 2022-11-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-26 | 2022-11-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-26 | 2022-11-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-26 | 2022-11-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-29 | 2022-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-29 | 2022-06-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-28 | 2022-05-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-28 | 2022-05-24 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-28 | 2022-05-24 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-10-20 | 2021-11-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-20 | 2021-11-12 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-10-20 | 2021-11-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-18 | 2021-11-04 | Y |
| 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 | 2021-09-30 | 2021-11-03 | 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 | 2021-09-30 | 2021-11-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-30 | 2021-11-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-08 | 2021-09-29 | Y |
