A list of the most recent deficiencies for Sunset Home Inc. 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 pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-19 | 2023-11-03 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-16 | 2023-10-02 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-07-31 | 2023-08-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-31 | 2023-08-31 | 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 | 2023-07-31 | 2023-08-31 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-07-11 | 2023-08-17 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-07-11 | 2023-08-17 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-07-11 | 2023-08-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-11 | 2023-08-17 | 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 | 2023-07-11 | 2023-08-17 | N |
| 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 | 2023-07-11 | 2023-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-11 | 2023-08-17 | 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 | 2023-07-11 | 2023-08-17 | 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 | 2023-07-11 | 2023-08-17 | 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 | 2023-07-11 | 2023-08-17 | 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 | 2023-07-11 | 2023-08-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-11 | 2023-08-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-11 | 2023-08-17 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-07-11 | 2023-08-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-11 | 2023-08-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-07-11 | 2023-08-17 | 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 | 2023-05-24 | 2023-06-16 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-24 | 2023-06-16 | 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 | 2023-03-16 | 2023-04-14 | Y |
| 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 | 2023-03-16 | 2023-04-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-01 | 2022-03-11 | 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 | 2022-02-01 | 2022-03-11 | 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 | 2022-02-01 | 2022-03-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-01 | 2022-03-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-10 | 2022-02-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-10 | 2022-02-04 | 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 | 2022-01-10 | 2022-02-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-10 | 2022-02-04 | 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 | 2022-01-10 | 2022-02-04 | 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 | 2022-01-10 | 2022-02-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-10 | 2022-02-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-10 | 2022-02-04 | 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 | 2022-01-10 | 2022-02-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-23 | 2021-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-23 | 2021-12-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-09-08 | 2020-09-18 | N |
| Respond appropriately to all alleged violations. | Health | 2020-09-08 | 2020-09-18 | 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 | 2020-09-08 | 2020-09-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-09-08 | 2020-09-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-09-08 | 2020-09-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-09-08 | 2020-09-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-09-08 | 2020-09-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-09-08 | 2020-09-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-09-08 | 2020-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-08 | 2020-09-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-02-11 | 2020-03-17 | N |
