Deficiency Records for Sunset Rehabilitation and Hlth C
Updated as of August 01, 2022
This is not the most recent data for Sunset Rehabilitation and Hlth C. For the most recent information, click here.
A list of the most recent deficiencies for Sunset Rehabilitation and Hlth C. 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 and implement an infection prevention and control program. | Health | 2022-05-25 | 2022-06-24 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-25 | 2022-06-24 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-25 | 2022-06-24 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-25 | 2022-06-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-05 | 2022-04-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-05 | 2022-04-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-03-25 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-17 | 2022-03-25 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-17 | 2022-03-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-06 | 2022-03-15 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-03-06 | 2022-03-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-06 | 2022-03-15 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-11-01 | 2021-12-10 | N |
| Establish methods for sharing information. | Fire Safety | 2021-11-01 | 2021-12-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-01 | 2021-12-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-11-01 | 2021-12-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-01 | 2021-12-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-01 | 2021-12-10 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-19 | 2021-11-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-11 | 2021-09-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-11 | 2021-09-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-24 | 2021-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-24 | 2021-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-24 | 2021-09-30 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-07-13 | 2021-07-15 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-07-13 | 2021-07-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-13 | 2021-07-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-24 | 2021-07-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-01 | 2021-06-25 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-05-07 | 2021-05-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-07 | 2021-05-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-07 | 2021-05-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-01-21 | 2021-02-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-24 | 2019-11-22 | 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 | 2019-10-24 | 2019-11-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-24 | 2019-11-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-24 | 2019-11-22 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-24 | 2019-11-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-24 | 2019-11-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-24 | 2019-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-24 | 2019-11-22 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-24 | 2019-11-22 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2019-10-24 | 2019-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-24 | 2019-11-22 | 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 | 2019-10-24 | 2019-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-24 | 2019-11-22 | 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 | 2019-10-24 | 2019-11-22 | 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 | 2019-10-24 | 2019-11-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-24 | 2019-11-22 | 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 | 2019-10-24 | 2019-11-22 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-10-24 | 2019-11-22 | 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 | 2019-10-24 | 2019-11-22 | N |
| 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 | 2019-10-24 | 2019-11-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-24 | 2019-11-22 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-10-24 | 2019-11-22 | 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 | 2019-10-24 | 2019-11-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Develop a communication plan. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Establish methods for sharing information. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-10-24 | 2019-11-22 | 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 | 2019-10-24 | 2019-11-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-09-27 | 2018-11-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-09-27 | 2018-11-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-09-27 | 2018-11-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-27 | 2018-11-20 | 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 | 2018-09-27 | 2018-11-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-27 | 2018-11-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-09-27 | 2018-11-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-27 | 2018-11-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-09-27 | 2018-11-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-09-27 | 2018-11-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-09-27 | 2018-11-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-27 | 2018-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-27 | 2018-11-14 | 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 | 2018-09-27 | 2018-11-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-09-27 | 2018-11-14 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-27 | 2018-11-14 | 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 | 2018-09-27 | 2018-11-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-27 | 2018-11-14 | 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 | 2018-09-27 | 2018-11-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-27 | 2018-11-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-09-27 | 2018-11-14 | 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 | 2018-09-27 | 2018-11-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-09-27 | 2018-11-14 | 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 | 2018-09-27 | 2018-11-14 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-09-27 | 2018-11-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-09-27 | 2018-11-14 | 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 | 2018-09-27 | 2018-11-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-09-26 | 2018-10-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-26 | 2018-10-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-09-26 | 2018-09-28 | N |
