Deficiency Records for Sunset Villa Healthcare
Updated as of May 01, 2024
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Deficiency Records for Sunset Villa Healthcare
A list of the most recent deficiencies for Sunset Villa Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sunset Villa 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-03-06 | 2024-04-03 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-06 | 2024-04-03 | 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 | 2024-03-06 | 2024-04-03 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-03-06 | 2024-04-03 | 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 | 2024-03-06 | 2024-04-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-06 | 2024-04-03 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-06 | 2024-04-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-06 | 2024-04-03 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-06 | 2024-04-03 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-03-06 | 2024-04-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-03-06 | 2024-04-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-06 | 2024-04-03 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-03-06 | 2024-04-03 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-03-06 | 2024-04-03 | 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 | 2024-03-06 | 2024-04-03 | 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 | 2024-03-06 | 2024-04-03 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-06 | 2024-04-03 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-03-06 | 2024-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-06 | 2024-04-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-06 | 2024-04-03 | N |
| 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 | 2024-03-06 | 2024-04-03 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-06 | 2024-04-03 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-03-06 | 2024-04-03 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-03-06 | 2024-04-03 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-03-06 | 2024-04-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-06 | 2024-04-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-06 | 2024-04-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-06 | 2024-04-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-06 | 2024-04-03 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-03-06 | 2024-04-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-06 | 2024-04-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-02 | 2023-03-03 | 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 | 2023-02-02 | 2023-03-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-02 | 2023-03-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-02 | 2023-03-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-02 | 2023-03-03 | 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 | 2023-02-02 | 2023-03-03 | N |
| Post nurse staffing information every day. | Health | 2023-02-02 | 2023-03-03 | 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 | 2023-02-02 | 2023-03-03 | 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 | 2023-02-02 | 2023-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-02 | 2023-03-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-02 | 2023-03-03 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-02-02 | 2023-03-03 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-02 | 2023-03-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-26 | 2023-02-21 | 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 | 2023-01-26 | 2023-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-26 | 2023-02-21 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-01-26 | 2022-02-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-01-26 | 2022-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-26 | 2022-02-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-01-26 | 2022-02-18 | N |
| Post nurse staffing information every day. | Health | 2022-01-26 | 2022-02-18 | 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 | 2022-01-26 | 2022-02-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-02-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-18 | 2022-02-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-01-18 | 2022-02-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-18 | 2022-02-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-02 | 2021-07-01 | Y |
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