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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-01 | 2023-12-25 | Y |
| 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 | 2023-12-01 | 2023-12-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-01 | 2023-12-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-01 | 2023-12-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-01 | 2023-12-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-01 | 2023-12-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-01 | 2023-12-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-12-01 | 2023-12-25 | 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 | 2023-12-01 | 2023-12-25 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-12-01 | 2023-12-25 | 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 | 2023-12-01 | 2023-12-25 | 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 | 2023-12-01 | 2023-12-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-05 | 2023-12-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-12-05 | 2023-12-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-05 | 2023-12-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-05 | 2023-12-25 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-29 | 2023-11-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-29 | 2023-11-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-29 | 2023-11-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-29 | 2023-11-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-05 | 2023-09-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-05 | 2023-09-22 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2023-07-05 | 2023-07-19 | Y |
| 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 | 2023-01-10 | 2023-02-05 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-10-20 | 2022-11-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-20 | 2022-11-15 | 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 | 2022-10-20 | 2022-11-15 | 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 | 2022-10-20 | 2022-11-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-10-20 | 2022-11-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-20 | 2022-11-15 | 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 | 2022-10-20 | 2022-11-15 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-10-20 | 2022-11-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-20 | 2022-11-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-20 | 2022-11-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-10-20 | 2022-11-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-20 | 2022-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-20 | 2022-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-20 | 2022-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-20 | 2022-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-12 | 2022-07-23 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-07-02 | 2022-07-18 | 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 | 2022-07-02 | 2022-07-18 | Y |
| 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 |
| 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 |
