Inspection Reports for Sunset Home Inc

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 06/29/2020.

All deficiencies cited in the prior inspection have been corrected as of the compliance date of 07/10/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was a Targeted Infection Control Survey/COVID-19 Focused Survey conducted by the Kansas Department on Aging and Disability Services on behalf of CMS to evaluate infection control practices related to COVID-19.

The facility failed to implement recommended infection control practices to prevent the spread of COVID-19 by not providing a private room for a dialysis resident (R1) who left the facility three times a week, placing other residents at risk of infection.

The document is a Plan of Correction submitted in response to deficiencies related to infection control and isolation procedures following an inspection.

The facility moved Resident R1 to a private isolation room on 06/29/2020 and implemented monitoring and transmission-based protocols including PPE use to ensure proper isolation and infection control.

An offsite revisit survey was conducted on 05/16/2019 for all previous deficiencies cited on 03/11/2019.

All deficiencies have been corrected as of the compliance date of 04/10/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

Licensure Resurvey of an Assisted Living/Residential Health Care Facility conducted on 4/30/19, 5/01/19, 5/05/19, 5/06/19, and 5/07/19.

The facility was found deficient in multiple areas including failure to inform residents of current rates and fees, incomplete advance directives documentation, inaccurate functional capacity screens, incomplete negotiated service agreements lacking signatures and nurse identification, inadequate emergency management plans and preparedness, and non-compliance with tuberculosis screening requirements.

This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.

The Plan of Correction outlines corrective actions for multiple deficiencies related to catheter care, restorative plans, staff training, insulin and bowel protocols, medication administration, and documentation compliance.

The inspection was conducted as a Health Resurvey and Complaint Investigations related to multiple complaint numbers (#138423, #138604, #138677, and #138816).

The facility was found deficient in multiple areas including failure to revise care plans for catheter care, inadequate supervision of restorative dressing and grooming programs, failure to provide standardized catheter care, incomplete nurse aide in-service education, failure to identify and report medication irregularities, failure to administer medications as ordered, and failure to provide infection prevention and control related to indwelling urinary catheter care.

The inspection was triggered by complaint investigations #138423, #138604, #138677, and #138816.

An offsite survey was conducted to follow up on a deficiency cited during the 10/30/18 abbreviated survey.

The previously cited deficiency was found to be corrected and the facility was placed back into compliance effective 11/29/18.

The inspection was conducted as a complaint investigation (#133461) focusing on infection prevention and control practices at the facility.

The facility failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of disease and infection by not changing gloves during perineal care for three sampled residents, placing them at risk for continued urinary tract infections (UTIs).

The citation represents findings from complaint investigation #133461 regarding infection prevention and control.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective November 29, 2018.

A desk review was conducted for the deficiencies cited on August 28, 2018.

The deficiencies cited on August 28, 2018, were corrected as of the compliance date of September 26, 2018.

This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior complaint-related inspection.

The plan outlines corrective actions including assigning aides to scheduled baths, mandatory nursing education on restorative care and documentation, monitoring call light responses, and hiring an interim Director of Nursing until a new D.O.N. starts.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be a 'F' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective September 26, 2018.

The inspection was conducted as a complaint investigation covering multiple complaint numbers (#132116, #132315, #132147, #131526, #131513, and #131622).

The facility failed to provide necessary personal hygiene services, consistent restorative services to maintain or improve mobility, sufficient nursing staff to respond timely to call lights, and failed to employ a full-time registered nurse as director of nursing. These deficiencies placed residents at risk for poor hygiene, decline in mobility, unmet needs, and unsupervised nursing care.

The inspection was triggered by complaint investigations #132116, #132315, #132147, #131526, #131513, and #131622.

An offsite revisit survey was conducted on 05/21/2018 for all previous deficiencies cited on 02/14/2018.

All deficiencies have been corrected as of the compliance date of 03/16/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.

All previously cited deficiencies were corrected as of the revisit date, with corrections documented for multiple regulatory provisions.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.

The Plan of Correction outlines immediate interventions and corrective actions for multiple deficiencies including resident admission notices, activity preference assessments, oral care, care plan updates, weight monitoring, hydration practices, and staff competency testing.

Licensure resurvey and complaint investigation conducted at Sunset Home Inc, an Assisted Living/Residential Health Care Facility in Concordia, Kansas, including investigation of Complaint #126213.

The inspection found multiple deficiencies including permitting a resident (#187) to stay in an unapproved detached building while receiving licensed health care services, failure to thoroughly investigate and report a potential neglect incident involving resident #187, incomplete negotiated service agreements for resident #185, failure to provide health care services by qualified staff according to standards for resident #187, improper labeling of over-the-counter medications, and failure to conduct required emergency preparedness reviews and drills.

Complaint #126213 investigated related to resident #187 who experienced an unwitnessed fall and medication overdose incident on 12/10/17. The facility failed to conduct a thorough investigation, failed to report the allegation of potential neglect to the Department, and lacked licensed nurse assessment documentation of the resident's condition change.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective 2018-03-16.

The inspection was a Health Resurvey to evaluate compliance with Medicaid/Medicare coverage and liability notice requirements, care plan timing and revision, activities programming, quality of care, and nutrition/hydration status.

The facility failed to provide Medicaid-eligible residents the opportunity to appeal Medicare non-coverage decisions, failed to update and individualize care plans and activities for several residents, did not maintain adequate oral care for one resident, failed to assess and document edema for one resident, and did not provide adequate fluid intake for another resident.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report indicates that the previously cited deficiency under regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of 07/18/2017. No other deficiencies or uncorrected issues are noted.

The inspection was conducted as a complaint investigation (#117032) regarding the facility's failure to provide adequate supervision to prevent accidents, specifically related to a resident elopement incident.

The facility failed to ensure adequate supervision and a safe environment for Resident #1, who eloped from the facility through an unsecured door and was found outside. The resident had severe cognitive impairment and was identified as an elopement risk, but the facility's interventions and security measures were insufficient to prevent the incident.

The complaint investigation found that Resident #1, who had severe cognitive impairment and was at risk for elopement, left the facility without staff knowledge through an unsecured door and was found outside. The facility failed to provide adequate supervision and secure the environment to prevent this incident.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective July 18, 2017.

This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at the facility.

The plan addresses elopement risks by implementing one-to-one supervision, staff education on elopement procedures, resident education, use of wander guards, and securing exits with key pads and alarms. The Director of Nursing will report progress to the Quality Assurance committee for three months.

This Plan of Correction is related to a complaint investigation identified as Sunset Home complaint 06202017.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report confirms that the deficiencies previously cited under regulations 483.12(a)(1) and 483.12(a)(3)(4)(c)(1)-(4) were corrected as of 03/17/2017.

An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The facility was found not in substantial compliance, with conditions constituting immediate jeopardy to resident health or safety related to F223 and F225. Enforcement remedies including denial of payment for new admissions were imposed.

The inspection was conducted as a complaint investigation triggered by allegations of resident to resident sexual abuse involving Resident #1 and Resident #5, including inappropriate touching incidents.

The facility failed to ensure residents were free from resident to resident sexual abuse by Resident #1, who inappropriately touched Resident #5 on two occasions, placing opposite gender residents in immediate jeopardy. The facility implemented one-on-one supervision and other interventions to abate the immediate jeopardy.

The complaint investigations #112233, #112458, and #112635 involved allegations of sexual abuse by Resident #1 against Resident #5 on two occasions in February 2017, including inappropriate touching and pinching. The incidents were reported to staff and the state, but documentation and protective measures were initially inadequate.

This document is a Plan of Correction submitted in response to deficiencies identified in the Sunset Home complaint dated 03/13/2017.

The plan outlines corrective actions including 1:1 supervision until referral to a Geri-Psych unit, staff education on resident placement to avoid harm, behavior assessments on admission and quarterly, ongoing staff training on abuse, neglect, and exploitation (ANE) policies, and administrative audits of new hire paperwork for compliance.

This Plan of Correction addresses deficiencies cited in response to the Sunset Home complaint dated 03/13/2017.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report confirms that the deficiencies previously cited under regulations 483.10(f)(2) and 483.75(o)(1) were corrected as of the revisit date, November 9, 2016.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'E' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective November 9, 2016.

The inspection was conducted as a result of complaint investigations #105422 and #105423 regarding residents' grievances about call lights not being answered in a timely manner.

The facility failed to respond to 4 of 4 residents' grievances about call lights not being answered timely and failed to answer 22 of 32 residents' call lights within the facility's stated 10-minute response time. The Quality Assessment and Assurance Committee did not effectively address or implement corrective plans regarding this issue.

The visit was complaint-related, triggered by grievances from 4 residents about call lights not being answered timely. The complaints were substantiated as the facility failed to respond to grievances and failed to answer call lights within the expected timeframe.

This document is a Plan of Correction submitted in response to deficiencies noted in the Sunset Home complaint dated 10/11/2016.

The plan addresses deficiencies and grievances taken to the facility's Quality Assurance Committee on 10/17/2016, including revisions to the grievance policy, staff education, logging and reporting of grievances, and auditing for compliance.

This Plan of Correction is related to the Sunset Home complaint dated 10/11/2016.

This report documents a revisit conducted to verify that previously reported deficiencies have been corrected and to confirm the dates when corrective actions were completed.

The revisit confirmed that the deficiencies identified in the prior survey were corrected as of 07/21/2016, with corrections documented for specific regulation numbers.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

All deficiencies previously cited were corrected as of the revisit date, with each correction completed and documented under the respective regulation numbers.

This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.

The report confirms that the previously cited deficiency related to regulation 28-39-158(a) was corrected as of 07/21/2016. No other deficiencies or uncorrected issues are noted.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.

The plan outlines corrective actions including hiring a Certified Dietary Manager, staff education on food safety and hygiene practices, and ongoing audits and in-services to ensure compliance with care and safety standards.

The inspection was conducted as an Assisted Living/Residential Healthcare Licensure resurvey to assess compliance with regulatory requirements.

The facility failed to employ a full-time qualified dietary manager for its residents and failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen, placing residents at risk for nutritional deficiencies and food-related illnesses.

The inspection was conducted as a Health Resurvey and complaint investigation related to citations #100664, #95461, and #101555.

The facility failed to employ a full-time qualified dietary manager for the 36 residents receiving meals from the facility kitchen, placing residents at risk of not having their nutritional needs met.

The visit was a complaint investigation involving citations #100664, #95461, and #101555. The deficiency related to dietary services was substantiated by observations and interviews.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection conducted on 06/22/2016.

The Plan of Correction outlines corrective actions for multiple deficiencies including resident care follow-up, incident reporting, resident dignity and meal assistance, bowel protocol adherence, resident hygiene, medication diagnosis documentation, food safety, linen handling, and environmental cleaning. Staff education, audits, and monitoring are planned to ensure compliance.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.

The report documents that all previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies have been corrected by 08/18/2015.

This document is a Plan of Correction submitted in response to a complaint investigation at Sunset Home, addressing deficiencies related to abuse allegations, staff training, and medical director responsibilities.

The facility implemented corrective actions including suspension of alleged perpetrators, mandatory abuse inservices for staff, revised abuse policies, and ensured medical director involvement in quality assurance meetings. The plan outlines ongoing compliance measures and staff monitoring.

This Plan of Correction addresses a complaint investigation involving allegations of abuse at the facility. The facility responded with corrective actions including suspension of alleged perpetrators and enhanced staff training.

An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The facility was found not to be in substantial compliance with participation requirements, with conditions constituting immediate jeopardy to resident health or safety from June 11, 2015 through July 24, 2015. Enforcement remedies including denial of payment for new admissions were imposed.

The inspection was conducted as a complaint investigation (#89141) regarding allegations of abuse and failure to follow abuse policies at the facility.

The facility failed to investigate allegations of abuse for two residents by three staff members who continued to work during the investigation, placing residents in immediate jeopardy. The facility also failed to provide mandatory abuse prevention training to all staff, failed to provide required annual nurse aide in-service training, failed to designate a medical director with a current contract, and failed to maintain a quality assessment and assurance committee with a physician member.

The complaint investigation (#89141) was substantiated with findings that the facility failed to properly investigate abuse allegations and failed to follow abuse policies, resulting in immediate jeopardy to residents.

This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.

All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, April 25, 2015.

This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates when corrective actions were accomplished.

The report confirms that the deficiencies identified in the prior survey were corrected by the revisit date of 04/25/2015, with specific regulation citations noted for correction.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility is found to be in substantial compliance effective April 25, 2015.

The inspection was conducted as a Health Resurvey and Complaint Investigation #84288 to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including failure to post required abuse reporting information, failure to notify physician of resident's non-compliance with fluid restriction, failure to maintain resident dignity, failure to act on resident council recommendations, unsanitary conditions in bathrooms and equipment, incomplete care plans, improper resident positioning, inadequate pressure ulcer care, failure to monitor fluid intake, failure to monitor anticoagulant therapy, unsanitary food service practices, and inadequate infection control practices.

The inspection included a complaint investigation as indicated by the initial comments referencing Complaint Investigation #84288.

The inspection was a licensure resurvey of an Assisted Living/Residential Healthcare facility to assess compliance with state regulations.

The facility failed to post the name and telephone number of the state survey and certification agency for reporting abuse, neglect, and exploitation. Additionally, the facility did not provide a drainage system with a 2 inch air gap to prevent backflow into the ice machine.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at the facility.

The facility was cited for deficiencies related to abuse allegations, requiring development and implementation of a system to assure correction and compliance, including immediate reporting and investigation of abuse allegations and reporting to the State abuse hotline within 24 hours.

This Plan of Correction addresses deficiencies cited following a complaint investigation at the facility.

This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-08-15.

The report shows that the previously cited deficiency with regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) identified by ID prefix F0225 was corrected as of 2014-09-10.

The inspection was conducted as a complaint investigation (#78142) regarding an allegation of abuse at the facility.

The facility failed to thoroughly investigate and report an allegation of abuse involving Resident #1 to the state agency. Staff did not report or investigate the incident as required by facility policy and state law.

The complaint investigation found that Nurse Aide C allegedly hit Resident #1 with a slipper and tried to stuff it down the resident's throat on 8/10/14. Staff and administration failed to report or investigate the incident as required. The resident had moderate cognitive impairment and required extensive assistance. The facility's abuse and resident rights policies require immediate reporting and investigation, which was not followed.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found a most serious deficiency rated as a "D" level deficiency, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.

This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that deficiencies identified in prior surveys under regulations 483.15(f)(1) and 483.25(h) were corrected as of 02/26/2014.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report confirms that the deficiency identified under regulation 483.35(i) with ID prefix F0371 was corrected as of 02/08/2014.

The inspection was conducted as a complaint investigation (#72143) to evaluate concerns related to the facility's provision of activities and supervision to residents.

The facility failed to provide an ongoing program of activities tailored to the interests and well-being of Resident #1 and failed to provide adequate supervision to prevent Resident #1 from eloping from the facility.

The complaint investigation #72143 found deficiencies related to activities and supervision for Resident #1, including failure to provide individualized activities and failure to prevent elopement.

The visit was a licensure resurvey of the facility to assess compliance for renewal of the license.

The licensure resurvey resulted in a finding of no deficiency citations.

The inspection was conducted as a Health Resurvey and Complaint Investigation based on complaints #71829 and #71576.

The facility failed to store, prepare, and distribute food under sanitary conditions, including issues with kitchen floor tiles being buckled, cracked, scuffed, and discolored, and the ice machine lacking a proper air gap in the drain line.

The visit was triggered by complaints #71829 and #71576 and included a Health Resurvey.

This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report confirms that all previously identified deficiencies listed with their regulation numbers were corrected as of 12/05/2012.

This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.

The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.10(b)(11), 483.15(a), 483.15(b), 483.25, 483.35(i), 483.60(a),(b), and 483.60(b),(d),(e) were corrected as of 12/05/2012.

The inspection was conducted as a health resurvey of the facility to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including failure to notify the physician of changes in a resident's skin condition, failure to maintain resident dignity during insulin administration, failure to allow a resident to choose the number of baths, inadequate skin assessments and preventative care, unsanitary food service practices, improper medication order procedures by unauthorized staff, and outdated medications in the emergency kit.

This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection.

No Plan of Correction was required for the deficiency identified with tag F0000, as indicated in the document.

This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report for Sunset Home.

The plan outlines corrective actions including mandatory infection control training for nursing staff, skills checks, policy review, and monitoring of urinary tract infections, with progress reporting to the Quality Assurance committee.

This document is a Plan of Correction submitted by Sunset Home Inc in response to deficiencies cited during a prior inspection.

The Plan of Correction addresses multiple deficiencies related to resident care, including failure to properly assess and report bruising, maintaining resident privacy during injections, refusal of extra baths, infection control procedures, medication order protocols, and ensuring current drugs in the emergency kit.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.

The plan addresses replacement of damaged kitchen floor tiles and correction of the ice machine drain to comply with regulations, with assigned responsibilities and completion dates.

This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Sunset Home.

The plan outlines corrective actions to address deficiencies related to resident activities, medication management, and elopement risk, including increased supervision, enhanced communication, and policy updates.

This Plan of Correction is in response to a complaint investigation at Sunset Home.

This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.

The facility plans to develop and implement a system to assure correction and continued compliance with regulations, including posting the abuse hotline number and modifying the ice machine drain pipe to prevent contamination.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.

The Plan of Correction outlines corrective actions for multiple deficiencies including abuse hotline posting, fluid restriction compliance, wheelchair maintenance, environmental issues such as bathroom floor replacement and bath house coolness, therapy orders, pressure ulcer monitoring, infection control policies, and medication administration.