Inspection Reports for Sunset Home Inc
620 2ND AVENUE, CONCORDIA, KS, 66901-2727
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 18, 2020 found no deficiencies, confirming the facility was in compliance with all surveyed regulations. Prior inspections showed a mixed history with deficiencies primarily related to infection control, resident care documentation, and emergency preparedness. Complaint investigations substantiated issues including inadequate supervision leading to resident elopement, failure to prevent resident-to-resident abuse, and lapses in infection prevention practices. Enforcement actions included periods of immediate jeopardy with denial of payment for new admissions in 2015 and 2017, but fines or license suspensions were not listed in the available reports. The facility appears to have addressed many prior deficiencies over time, with recent inspections showing improvement and no new citations.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
20.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
237% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
26 residents
Based on a June 2020 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 18, 2020
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 06/29/2020.
Findings
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.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Abbreviated Survey
Census: 26
Deficiencies: 1
Date: Jun 29, 2020
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to implement infection prevention and control program elements including isolation of a dialysis resident who left the facility frequently, placing other residents at risk for COVID-19.
Report Facts
Census: 26
Dialysis frequency: 3
Residents at risk: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided information about dialysis resident and isolation status | |
| Physician G | Faxed order to isolate Resident R1 to a private room |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 29, 2020
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies related to infection control and isolation procedures following an inspection.
Findings
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.
Deficiencies (1)
Resident R1 was not initially placed in a private isolation room, requiring corrective action to ensure proper isolation and infection control.
Report Facts
Plan of Correction completion date: Jul 10, 2020
Statement of Deficiencies review date: Jul 9, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Teresa Shore | CEO | Submitted the Plan of Correction to KDADS |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 16, 2019
Visit Reason
An offsite revisit survey was conducted on 05/16/2019 for all previous deficiencies cited on 03/11/2019.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Renewal
Census: 11
Deficiencies: 8
Date: May 7, 2019
Visit Reason
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.
Findings
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.
Deficiencies (8)
Failure to ensure residents or their representatives were informed orally and in writing of the current rate for level of care and services.
Failure to develop and implement policies related to advance medical directives and maintain copies in medical records.
Failure to complete functional capacity screens that accurately reflect residents' functional status.
Failure to ensure negotiated service agreements included service descriptions, provider identification, payment sources, and signatures of all involved parties.
Failure to include the name of the licensed nurse responsible for implementation and supervision of health service plans in negotiated service agreements.
Failure to develop and post a detailed written emergency management plan including all required emergency situations.
Failure to conduct quarterly reviews of the emergency management plan with employees and residents and failure to conduct an annual emergency evacuation drill.
Failure to comply with tuberculosis screening guidelines for employees and residents, including missing symptom screens and timely skin testing.
Report Facts
Residents sampled: 3
Facility census: 11
Employees hired since last resurvey: 34
Employees reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #F | Administrator | Confirmed deficiencies related to admission agreements, negotiated service agreements, emergency preparedness, and nurse signatures. |
| Assisted Living Director #D | Assisted Living Director / Licensed Practical Nurse | Confirmed deficiencies related to admission agreements, functional capacity screens, negotiated service agreements, emergency preparedness, and TB testing. |
| Licensed Nurse #M | Licensed Nurse | Provided TB skin testing for residents. |
| Maintenance Director #I | Maintenance Director | Reported on emergency drill status and disaster reviews. |
| Maintenance Staff #K | Maintenance Staff | Reported on emergency drill status and disaster reviews. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Apr 10, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.
Findings
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.
Deficiencies (6)
Resident #4's Care Plan updated to include direction on catheter care by MDS Nurse; staff education on catheter care; monitoring compliance.
Residents #16 and #24 have passed away; restorative plans to be reviewed and updated; monitoring compliance.
All nursing staff required to complete in-services (12 hours training); suspension policy for non-compliance.
Resident #11 nursing staff educated on insulin protocol compliance; Resident #23 educated on bowel protocol; pharmacist to monitor documentation.
Resident #11 PCP contacted and parameters changed; medication administration review and reporting procedures established.
Resident #4 catheter cover placement and care plan update; staff education and compliance monitoring.
Report Facts
Training hours required: 12
Compliance monitoring duration: 3
Compliance monitoring duration: 6
Compliance monitoring duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Teresa Shore | CEO | Submitted the Plan of Correction to KDADS |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 9
Date: Mar 11, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations related to multiple complaint numbers (#138423, #138604, #138677, and #138816).
Complaint Details
The inspection was triggered by complaint investigations #138423, #138604, #138677, and #138816.
Findings
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.
Deficiencies (9)
Failure to revise Resident #4's care plan with specific staff direction for indwelling urinary catheter care.
Failure to provide necessary services to supervise and monitor dressing and grooming restorative programs for Residents #16 and #24.
Failure to provide standardized care for the urinary catheter for Resident #4.
Failure to ensure every nurse aide completed mandatory annual 12 hour in-service education.
Consultant pharmacist failed to identify and report medication irregularities for Residents #11 and #23.
Failure to administer insulin as ordered for Resident #11.
Failure to assess and provide medical intervention for Resident #23's constipation per physician's standing orders.
Failure to administer physician ordered insulin, blood pressure medication, and mood stabilizing medication for Resident #7.
Failure to provide sanitary indwelling urinary catheter care to prevent recurrent urinary tract infections for Resident #4.
Report Facts
Census: 31
Sample size: 11
Residents reviewed for ADLs: 6
Certified Nurse Aides: 6
Missing in-service education: 3
Days without documented bowel movement: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified catheter care deficiencies and medication administration issues. |
| Administrative Nurse E | Administrative Nurse | Verified lack of bowel movement documentation and follow-up. |
| Administrative Staff A | Administrative Staff | Acknowledged CNAs had not completed mandatory in-service education. |
| Nurse Aide P | Nurse Aide | Provided information on bowel movement documentation. |
| Nurse G | Nurse | Described bowel movement alert system and PRN medication administration. |
| Nurse H | Nurse | Discussed insulin administration and blood sugar monitoring. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 30, 2018
Visit Reason
An offsite survey was conducted to follow up on a deficiency cited during the 10/30/18 abbreviated survey.
Findings
The previously cited deficiency was found to be corrected and the facility was placed back into compliance effective 11/29/18.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Oct 30, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#133461) focusing on infection prevention and control practices at the facility.
Complaint Details
The citation represents findings from complaint investigation #133461 regarding infection prevention and control.
Findings
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).
Deficiencies (1)
Failure to change gloves during perineal care for residents #1, #2, and #3, risking transmission of infections.
Report Facts
Census: 38
Residents sampled: 3
Antibiotic treatment durations: 5
Antibiotic treatment durations: 7
Antibiotic treatment durations: 10
Antibiotic treatment durations: 7
Antibiotic treatment durations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide M | Observed failing to change gloves during perineal care and acknowledged the need to change gloves more often. | |
| Nurse Aide N | Observed failing to change gloves during perineal care and acknowledged the need to change gloves more often. | |
| Nurse Aide O | Observed failing to change gloves during perineal care and expressed concern about glove usage requirements. | |
| Administrative Nurse D | Administrative Nurse | Stated expectation that staff change gloves between soiled and clean tasks and noted failure to do so could contribute to UTIs. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 30, 2018
Visit Reason
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.
Findings
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.
Deficiencies (1)
A 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory of the report. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 11, 2018
Visit Reason
A desk review was conducted for the deficiencies cited on August 28, 2018.
Findings
The deficiencies cited on August 28, 2018, were corrected as of the compliance date of September 26, 2018.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 26, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior complaint-related inspection.
Findings
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.
Deficiencies (4)
Aids on each hall are assigned the baths scheduled for the residents on that hall and shift; documentation of baths given/refused and charge nurse oversight required.
Mandatory nursing education on restorative dressing, restorative exercise (ROM), and passive ROM provided; competency reviews and documentation training required.
Charge nurse to monitor call light response and assist; staff educated that all staff can assist in answering call lights; monitoring and reporting to QA planned.
Interim Director of Nursing hired from Agency Nursing until newly hired D.O.N. starts on October 22, 2018.
Report Facts
Plan of Correction completion dates: Sep 26, 2018
New D.O.N. start date: Oct 22, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 28, 2018
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiency found was a 'F' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 4
Date: Aug 28, 2018
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint numbers (#132116, #132315, #132147, #131526, #131513, and #131622).
Complaint Details
The inspection was triggered by complaint investigations #132116, #132315, #132147, #131526, #131513, and #131622.
Findings
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.
Deficiencies (4)
Failed to provide necessary services to maintain good personal hygiene for 3 of 5 sampled residents who did not receive bathing services as requested.
Failed to provide consistent restorative services to 3 of 5 sampled residents to maintain or improve mobility.
Failed to provide sufficient nursing staff to assure timely response to call lights for 3 sampled residents.
Failed to employ a registered nurse to serve as director of nursing on a full-time basis.
Report Facts
Census: 36
Call light response times: 14.49
Call light response times: 14.49
Call light response times: 14.54
Call light response times: 30.13
Call light response times: 12.19
Call light response times: 23.47
Call light response times: 10.42
Call light response times: 16.14
Call light response times: 22.49
Call light response times: 10.22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Verified bath aide quit without notice, confirmed staffing shortages and call light delays, stated no full-time director of nursing employed | |
| Medication Aide N | Medication Aide | Stated staffing shortages caused missed baths and did not answer call lights due to medication passing duties |
| Nurse G | Nurse | Stated resident should get daily showers but staffing shortages prevent this; was called to work floor as aide due to staff shortage |
| Nurse H | Nurse | Reported 17 of 36 residents required 2 staff assistance with ADLs and acknowledged staffing shortages |
| Medication Aide M | Medication Aide | Only medication aide on floor, had to come early to pass meds, did not answer call lights due to workload |
| Physical Therapy Staff GG | Physical Therapy Staff | Trained nurse aides on restorative programs, noted decline in residents due to staffing shortages |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 21, 2018
Visit Reason
An offsite revisit survey was conducted on 05/21/2018 for all previous deficiencies cited on 02/14/2018.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Apr 5, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies were corrected as of the revisit date, with corrections documented for multiple regulatory provisions.
Deficiencies (5)
Deficiency related to regulation 26-41-101 (f) (3)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-204 (i)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-104 (d)
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Mar 16, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
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.
Deficiencies (6)
Residents will be given form 10055 at admission and periodically reviewed.
Activity staff will perform activity preference assessments and update care plans accordingly.
Resident offered dental care per doctor; oral care assistance and staff education provided.
Activity staff to document participation in activities and update care plans with preferences.
Accurate resident weight monitoring and physician notification per standing orders.
Resident's water pitcher placement and hydration education for staff; competency testing.
Report Facts
Residents audited monthly: 10
Residents audited weekly: 5
Residents with completed assessments: 4
Competency testing deadline: Apr 30, 2018
Plan of Correction completion dates: Mar 8, 2018
Inspection Report
Renewal
Census: 17
Deficiencies: 6
Date: Mar 5, 2018
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (6)
Permitting resident #187 to stay in an unapproved detached building while providing licensed facility health care services.
Failure to ensure thorough investigation and reporting of potential neglect for resident #187 after an unwitnessed fall and medication incident.
Negotiated service agreement for resident #185 lacked description of services and identification of party responsible for payment.
Failure to ensure all health care services provided by qualified staff in accordance with acceptable standards of practice for resident #187, including licensed nurse assessments.
Failure to ensure licensed nurse or pharmacist placed full resident names on original, unbroken manufacturer’s packages of over-the-counter medications.
Failure to conduct quarterly reviews of the facility's emergency management plan with employees and residents and failure to conduct an annual emergency evacuation drill.
Report Facts
Resident census: 17
Medication packages lacking resident full name: 28
Medication dose: 4
Dates of inspection: 02/26/18, 02/27/18, 02/28/18, 03/01/18, and 03/05/18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #B | Administrator | Permitted resident #187 to stay in unapproved detached building; failed to ensure investigation and reporting of neglect; provided information on incident reports and emergency preparedness |
| Nurse #C | Facility Nurse | Interviewed regarding resident #187's condition and incident; confirmed deficiencies in negotiated service agreements and medication labeling |
| Certified Staff #F | Certified Medication Aide | Administered medications to resident #187 on 12/10/17; observed resident's condition during overdose incident |
| Nurse #I | Licensed Nurse | Assessed resident #187 after fall and overdose incident; documented hospital referral |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 14, 2018
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiency was a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Named as contact and signatory related to the plan of correction acceptance and survey findings. |
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 6
Date: Feb 14, 2018
Visit Reason
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.
Findings
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.
Deficiencies (6)
Failed to provide 3 residents the opportunity to choose whether to appeal Medicare non-coverage decisions and lacked documentation of cost information.
Failed to review and revise care plans for activities for 3 residents, placing them at risk for loneliness and boredom.
Failed to maintain adequate oral care for 1 resident, resulting in plaque buildup and dental issues.
Failed to provide individualized activity programs for 4 residents, limiting meaningful engagement.
Failed to assess, document, and notify physician of increased edema for 1 resident, despite care plan requirements.
Failed to provide adequate fluid intake for 1 resident, placing them at risk for dehydration.
Report Facts
Census: 37
Residents sampled: 14
Residents reviewed for nutrition and hydration: 3
Resident #19 weight: 90
Resident #28 average fluid intake January 2018: 270
Resident #28 average fluid intake February 2018 (first 13 days): 341
Resident #19 BNP lab result: 306
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 18, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3) previously cited
Report Facts
Deficiency correction date: Jul 18, 2017
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Date: Jun 20, 2017
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure the resident environment remained free from accident hazards and to provide adequate supervision to prevent accidents, resulting in Resident #1 eloping from the facility.
Report Facts
Census: 32
Residents reviewed for elopement risk: 3
Residents identified at risk for elopement: 7
BIMS score: 4
Outside temperature: 88
Date of MDS assessment: May 11, 2017
Date of care plan: May 10, 2017
Date of nurse note: Jun 9, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Documented assessment and care of Resident #1 after elopement | |
| Nurse B | Charge Nurse | Received call about Resident #1 outside and assisted in returning resident |
| Office Staff B | Found Resident #1 outside and brought resident back into the facility | |
| Office Staff C | Noticed Resident #1 outside and assisted in returning resident | |
| Administrative Staff D | Verified exit door alarm status and security measures | |
| Administrative Nurse E | Administrative Nurse | Verified elopement incident and failure of interventions |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 20, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiency was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person regarding the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 20, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at the facility.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Sunset Home complaint 06202017.
Findings
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.
Deficiencies (1)
Resident immediately placed on one to one while awake with staff until Assisted Living exits are secured; nursing staff educated on elopement procedures; assisted living residents educated on notifying nursing staff before letting SNF residents on the elevator; setting bench beside elevator removed.
Report Facts
Plan of Correction completion date: Jul 18, 2017
Plan of Correction submission date: Jun 20, 2017
Plan of Correction modification date: Aug 17, 2017
Reporting period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Teresa Shore | Administrator | Submitted the Plan of Correction to KDADS. |
| Caryl Gill | Modified the Plan of Correction on 08/17/2017. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 11, 2017
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 483.12(a)(1)
Deficiency related to regulation 483.12(a)(3)(4)(c)(1)-(4)
Report Facts
Deficiencies corrected: 2
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Mar 13, 2017
Visit Reason
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.
Findings
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.
Deficiencies (2)
Noncompliance with F223, "J", CFR 483.12
Noncompliance with F225, "K", CFR 483.12(a)(3)(4)(c)(1)-(4)
Report Facts
Denial of payment effective date: Apr 6, 2017
Provider agreement termination date: Sep 13, 2017
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as Complaint Coordinator and signatory of the report |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 2
Date: Mar 13, 2017
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure residents were free from resident to resident sexual abuse by Resident #1 involving inappropriate touching of Resident #5.
Failure to investigate and report allegations of abuse in a timely and thorough manner.
Report Facts
Census: 29
Opposite gender residents in Assisted Living: 14
Opposite gender residents in Nursing Center: 22
BIMS score: 8
Dates of incidents: 2
Date immediate jeopardy abated: Mar 9, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Nurse | Reported and described the incidents of inappropriate touching by Resident #1 and the facility's response. |
| Administrative Nurse A | Administrative Nurse | Provided information about Resident #1's history of inappropriate touching behaviors. |
| Nurse Aide F | Nurse Aide | Reported Resident #1's grabbing behavior and verbal responses. |
| Nurse Aide E | Nurse Aide | Described Resident #1's physical and behavioral status including inappropriate touching. |
| Nurse C | Nurse | Verified Resident #1's inappropriate touching behavior and awareness. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Mar 13, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in the Sunset Home complaint dated 03/13/2017.
Complaint Details
This Plan of Correction addresses deficiencies cited in response to the Sunset Home complaint dated 03/13/2017.
Findings
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.
Deficiencies (3)
Failure to ensure resident safety and proper supervision, requiring 1:1 supervision and placement in Geri-Psych unit.
Inadequate staff education and training on ANE policy and behavior assessments.
Lack of administrative oversight on new hire paperwork compliance.
Report Facts
Date corrective actions to be completed: Mar 17, 2017
Inspection Report
Follow-Up
Deficiencies: 2
Date: Nov 9, 2016
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 483.10(f)(2)
Deficiency related to regulation 483.75(o)(1)
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 11, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiencies cited at 'E' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Oct 11, 2016
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to promptly respond to residents' call light grievances and failure to answer call lights within a timely manner.
Failure to maintain a quality assessment and assurance program that effectively identified and corrected the call light response deficiencies.
Report Facts
Residents present: 32
Residents with call light response issues: 22
Call light non-responses: 193
Call light response time range: 12 to 52 minutes
Average response time range: 15 to 35 minutes
Sample residents expressing grievances: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide E | Nurse Aide | Stated residents' call lights should not be on for more than 2-5 minutes |
| Nurse Aide F | Nurse Aide | Stated residents' call lights should not be on for more than 5 minutes |
| Nurse C | Nurse | Stated residents' call lights should be answered in less than 5 minutes |
| Administrative Nurse A | Administrative Nurse | Stated aides and charge nurse have pagers; residents' call lights should not be on more than 10 minutes; administration did not carry pagers |
| Administrative Staff B | Administrative Staff | Stated last Quality Assurance meeting was 9/15/16; call light response time was not discussed; felt call lights should be answered within 10 to 15 minutes; stated nurse station computer alarms when call lights are activated |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Oct 11, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies noted in the Sunset Home complaint dated 10/11/2016.
Complaint Details
This Plan of Correction is related to the Sunset Home complaint dated 10/11/2016.
Findings
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.
Deficiencies (4)
Statement of deficiencies and noted grievances were taken to Q.A committee on 10/17/2016.
Grievance Policy reviewed and revised. Staff will be educated on revised policy at in-service on 10/27/2016.
Social Services or designee to keep log on grievances and progress of resolution and report to Q.A. committee monthly.
Grievance log to be audited by Administrator for compliance.
Report Facts
Correction completion date: Nov 9, 2016
Grievance policy education date: Oct 27, 2016
Quality Assurance Committee meeting date: Oct 17, 2016
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jul 21, 2016
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 28-39-158(a)
Deficiency related to regulation 26-43-206(d)
Inspection Report
Follow-Up
Deficiencies: 11
Date: Jul 21, 2016
Visit Reason
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.
Findings
All deficiencies previously cited were corrected as of the revisit date, with each correction completed and documented under the respective regulation numbers.
Deficiencies (11)
Deficiency under regulation 483.10(b)(11)
Deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency under regulation 483.15(a)
Deficiency under regulation 483.25
Deficiency under regulation 483.25(a)(3)
Deficiency under regulation 483.25(h)
Deficiency under regulation 483.25(l)
Deficiency under regulation 483.30(a)
Deficiency under regulation 483.35(i)
Deficiency under regulation 483.60(c)
Deficiency under regulation 483.65
Report Facts
Deficiencies corrected: 11
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 21, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
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.
Deficiencies (1)
Deficiency related to regulation 28-39-158(a) previously cited and corrected
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 22, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
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.
Deficiencies (2)
Failure to properly date or dispose of food items and improper wearing of hair nets by dietary staff.
Lack of notification and follow-up with physicians, inadequate reporting of bruises and skin tears, and failure to maintain dignity and respect of residents.
Report Facts
In-service date: Jun 30, 2016
Plan of Correction completion date: Jul 21, 2016
Next in-service date: Jul 28, 2016
Audit duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Teresa Shore | C.E.O./ Administrator | Submitted the Plan of Correction |
Inspection Report
Renewal
Census: 36
Deficiencies: 2
Date: Jun 22, 2016
Visit Reason
The inspection was conducted as an Assisted Living/Residential Healthcare Licensure resurvey to assess compliance with regulatory requirements.
Findings
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.
Deficiencies (2)
Failed to employ a full-time qualified dietary manager for the 36 residents receiving meals from the facility kitchen.
Failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchens in the facility, including issues with expired or unlabeled food products and improper hair covering by dietary staff.
Report Facts
Census: 36
Census: 25
Sample size: 3
Packages of pepper gravy mix: 3
Packages of instant base cream soup mix: 2
Boxes of Swiss Miss hot chocolate: 4
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Jun 22, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation related to citations #100664, #95461, and #101555.
Complaint Details
The visit was a complaint investigation involving citations #100664, #95461, and #101555. The deficiency related to dietary services was substantiated by observations and interviews.
Findings
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.
Deficiencies (1)
Failure to employ a full-time qualified dietary manager for the 36 residents receiving meals from the facility kitchen.
Report Facts
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff T | Dietary Staff | Not certified as a dietary manager but undergoing course and overseen by Registered Dietitian |
| Administrative Nurse E | Administrative Nurse | Provided information about Dietary Staff T's certification status |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 22, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Jun 22, 2016
Visit Reason
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.
Findings
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.
Deficiencies (9)
Failure to follow up with physician if no response regarding resident change of status (Resident #30).
Bruise on resident #32 not properly investigated and reported.
Staff not adequately educated on dignity and meal assistance policies.
Failure to properly document and follow bowel protocol and neuro checks (Resident #1 and #2).
Policies and procedures for resident hygiene, bathing, oral care, and meal assistance need review and staff education.
Care plans require auditing and appropriate interventions including gait belt usage.
Medication diagnosis (Dx) documentation incomplete for residents #18 and #30; monitoring for side effects inadequate.
Dietary staff need education on timely assistance, dignity at meals, food item dating, and hair net usage.
Policies for linens storage and transport, oxygen tubing storage, and environmental cleaning require review and staff retraining.
Report Facts
Plan of correction completion date: Jul 21, 2016
In-service education date: Jun 30, 2016
In-service education date: Jul 20, 2016
C.D.M. hire date: Jun 27, 2016
Audit frequency: 3
Audit frequency per week: 3
Audit frequency per week: 2
Audit frequency per week: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Teresa Shore | C.E.O./Administrator | Submitted the Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 16, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiencies cited at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jun 16, 2016
Provider agreement termination date: Sep 16, 2016
IDR request timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Sep 8, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report documents that all previously cited deficiencies identified in the CMS-2567 Statement of Deficiencies have been corrected by 08/18/2015.
Deficiencies (5)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4)
Deficiency related to regulation 483.13(c)
Deficiency related to regulation 483.75(e)(8)
Deficiency related to regulation 483.75(i)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 31, 2015
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to immediately suspend alleged perpetrators of abuse and ensure staff training on abuse policies.
Inadequate tracking and completion of mandatory staff inservices.
Lack of compliance with medical director duties including attendance at quality assurance meetings.
Report Facts
Date of corrective action completion: Aug 12, 2015
Date of corrective action completion: Aug 18, 2015
Date of corrective action completion: Jul 31, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Submitted the Plan of Correction and responsible for compliance |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 30, 2015
Visit Reason
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.
Findings
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.
Deficiencies (1)
Noncompliance with F225, CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and F226, CFR 483.13(c)
Report Facts
Denial of Payment for New Admissions Effective Date: Aug 20, 2015
Recommended Provider Agreement Termination Date: Jan 30, 2016
Civil Money Penalty Minimum Amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | LBSW, Complaint Coordinator | Signed the letter and noted as Complaint Coordinator for the Survey, Certification, and Credentialing Commission |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 5
Date: Jul 30, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#89141) regarding allegations of abuse and failure to follow abuse policies at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to investigate allegations of abuse for 2 residents by 3 staff members who continued to work during the investigation.
Failed to implement abuse policy by not providing mandatory staff in-service and allowing 3 employees with abuse allegations to continue working.
Failed to provide required 12 hours per year in-service education for 19 nurse aides employed for 1 or more years.
Failed to designate a physician to serve as medical director with a current contract outlining duties.
Failed to maintain a quality assessment and assurance committee with a designated physician and failed to develop and implement plans to correct quality deficiencies related to abuse allegations and medical director issues.
Report Facts
Census: 43
Employees: 136
Employees attended abuse in-service: 56
Nurse aides lacking required education hours: 19
Alleged perpetrators: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide H | Nurse Aide | Named in abuse allegation involving Resident #3; continued working after incident |
| Nurse Aide A | Nurse Aide | Named in abuse allegation involving Resident #1; continued working after incident |
| Nurse Aide B | Nurse Aide | Named in abuse allegation involving Resident #1; continued working after incident |
| Administrative Nurse F | Administrative Nurse | Acknowledged failure to follow abuse policy and staff continued working |
| Administrative Staff J | Administrative Staff | Verified lack of contract for medical director and failure to follow abuse policy |
| Nurse E | Charge Nurse | Did not send alleged perpetrators home after abuse reports |
| Nurse I | Charge Nurse | Did not send Nurse Aide H home after abuse report |
Inspection Report
Follow-Up
Deficiencies: 12
Date: Apr 25, 2015
Visit Reason
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.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, April 25, 2015.
Deficiencies (12)
Deficiency related to regulation 483.10(b)(5) - (10), 483.10(b)(1)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(c)(6)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(j)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 12
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 25, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates when corrective actions were accomplished.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 26-39-103 (b)
Deficiency related to regulation 26-40-305 (e)(1)(2)
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 26, 2015
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date of substantial compliance: Apr 25, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the plan of correction |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 12
Date: Mar 26, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #84288 to assess compliance with regulatory requirements.
Complaint Details
The inspection included a complaint investigation as indicated by the initial comments referencing Complaint Investigation #84288.
Findings
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.
Deficiencies (12)
Failed to post the name and telephone number of the state survey and certification agency to report abuse, neglect and misappropriation of property.
Failed to notify the physician of Resident #3's non-compliance with prescribed fluid restriction.
Failed to provide an environment that maintained or enhanced each resident's dignity for Resident #7 whose wheelchair was in disrepair.
Failed to act upon recommendations at the resident council meeting to maintain comfortable temperatures in the shower and whirlpool room.
Failed to maintain sanitary conditions in 4 resident bathrooms and a scale used to weigh residents.
Failed to develop a comprehensive plan of care for Resident #3 regarding physician ordered fluid restriction.
Failed to maintain highest practicable well-being related to improper positioning for Resident #5.
Failed to provide interventions to promote healing of a pressure ulcer for Resident #27.
Failed to provide sufficient fluid intake to maintain proper hydration for Resident #3 based on physician ordered fluid restriction.
Failed to monitor anticoagulant therapy for Resident #8 as directed by physician orders.
Failed to serve drinks under sanitary conditions and provide a drainage system with a 2 inch air gap to prevent backflow into the ice machine.
Failed to provide appropriate infection control practices during incontinent cares for Resident #27 and failed to implement proper hand hygiene measures to prevent infection transmission.
Report Facts
Census: 44
Fluid restriction: 2000
Fluid intake per shift: 1000
Fluid intake per shift: 600
Fluid intake per shift: 400
Pressure ulcer size: 3.5
Pressure ulcer size: 2.2
Pressure ulcer size: 2.5
Pressure ulcer tunnel depth: 6.4
Resident weight: 109
Weight loss percent: 4
Weight loss percent: 12
Albumin level: 2.7
Albumin level: 2
Albumin level: 2.3
Protime lab missing: 1
Inspection Report
Renewal
Census: 33
Deficiencies: 2
Date: Mar 19, 2015
Visit Reason
The inspection was a licensure resurvey of an Assisted Living/Residential Healthcare facility to assess compliance with state regulations.
Findings
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.
Deficiencies (2)
Failed to post the name and telephone number of the state survey and certification agency to report abuse, neglect, and exploitation.
Failed to provide a drainage system with a 2 inch air gap to prevent backflow into the ice machine.
Report Facts
Resident census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Administrative Nurse | Verified lack of posted abuse reporting information |
| Maintenance Staff J | Maintenance Staff | Confirmed no 2 inch air gap in ice machine drainage system |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 10, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at the facility.
Complaint Details
This Plan of Correction addresses deficiencies cited following a complaint investigation at the facility.
Findings
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.
Deficiencies (2)
For deficiencies cited, this facility will develop and implement a facility wide system to assure correction and continued compliance with the regulations.
Credible allegation of compliance: Upon allegations of abuse staff will report same to administrator and DON immediately and begin the documentation and investigation process. The alleged abuser shall be removed from caring for the resident. Statements shall be taken from those involved and witnesses. Abuse policy amended to require reporting to State abuse hotline within 24 hours.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Named as submitting the Plan of Correction and responsible for supervising compliance with abuse reporting. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 10, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-08-15.
Findings
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.
Deficiencies (1)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Aug 15, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#78142) regarding an allegation of abuse at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to thoroughly investigate and report an allegation of abuse for Resident #1.
Report Facts
Census: 49
Sample size: 3
MDS assessment date: May 19, 2014
Care plan date: Jun 16, 2014
Incident date: Aug 10, 2014
Policy dates: Jul 14, 2014
Policy dates: Nov 11, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide C | Nurse Aide | Alleged to have hit Resident #1 with a slipper and tried to stuff it down the resident's throat; continued to provide care without investigation. |
| Assistant Administrative Nurse E | Assistant Administrative Nurse | Verified the resident's allegation and failure to report or investigate the incident. |
| Administrative Nurse D | Administrative Nurse | Verified the resident's allegation and failure to report or investigate the incident. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 15, 2014
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiency rated as a "D" level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Author of the letter regarding the survey findings and plan of correction acceptance. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 26, 2014
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency under regulation 483.15(f)(1)
Deficiency under regulation 483.25(h)
Report Facts
Deficiencies corrected: 2
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 8, 2014
Visit Reason
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.
Findings
The report confirms that the deficiency identified under regulation 483.35(i) with ID prefix F0371 was corrected as of 02/08/2014.
Deficiencies (1)
Deficiency under regulation 483.35(i) previously cited
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Jan 27, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#72143) to evaluate concerns related to the facility's provision of activities and supervision to residents.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to provide an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of Resident #1.
Failed to provide adequate supervision to prevent accidents, including elopement, for Resident #1.
Report Facts
Census: 43
Sample size: 4
Elopement risk score: 2
Elopement duration: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Staff D | Stated Resident #1 has family visits | |
| Nurse C | Stated facility takes residents on van rides around holidays | |
| Nursing Staff A | Stated resident was assessed as elopement risk but no interventions started | |
| Administrative Nursing Staff B | Stated resident was assessed as elopement risk but no care plan to prevent elopement |
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 9, 2014
Visit Reason
The visit was a licensure resurvey of the facility to assess compliance for renewal of the license.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Jan 8, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation based on complaints #71829 and #71576.
Complaint Details
The visit was triggered by complaints #71829 and #71576 and included a Health Resurvey.
Findings
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.
Deficiencies (2)
Failed to store, prepare, and distribute food under sanitary conditions, including damaged kitchen floor tiles.
Ice machine lacked a 2 inch air gap in the drain line, risking backflow contamination.
Report Facts
Census: 43
Sample size: 11
Floor tiles damaged: 6
Floor tiles damaged: 12
Ice machines: 2
Air gap missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff A | Verified observation of damaged floor tiles | |
| Maintenance Staff B | Verified observation of missing air gap in ice machine drain line |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 5, 2012
Visit Reason
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.
Findings
The report confirms that all previously identified deficiencies listed with their regulation numbers were corrected as of 12/05/2012.
Report Facts
Deficiency corrections completed: 7
Inspection Report
Follow-Up
Deficiencies: 7
Date: Dec 5, 2012
Visit Reason
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.
Findings
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.
Deficiencies (7)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(a),(b)
Deficiency related to regulation 483.60(b),(d),(e)
Report Facts
Deficiencies corrected: 7
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 7
Date: Nov 5, 2012
Visit Reason
The inspection was conducted as a health resurvey of the facility to assess compliance with regulatory requirements.
Findings
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.
Deficiencies (7)
Failed to notify the physician of a change in the skin status for Resident #36.
Failed to provide care for 2 residents in a manner that maintained dignity and respect during insulin administration.
Failed to provide Resident #39 the right to choose the number of baths or showers received each week.
Failed to provide accurate skin assessments, reassessments, and preventative measures for Resident #36.
Failed to distribute and serve food in a sanitary manner.
Failed to ensure authorized licensed staff obtain physician telephone orders for Resident #32.
Failed to ensure medications in the emergency kit were not outdated.
Report Facts
Resident census: 39
Sample size: 21
Bruises count: 9
Medication dosage: 81
Medication dosage: 300
Emergency kit expiration date: Oct 31, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Assisted Resident #36 to ambulate and observed with bruises. | |
| Nurse D | Administrative Nurse | Verified insulin administration in hallway and medication order procedures. |
| Nurse E | Verified bruises on Resident #36 and lack of skin assessments. | |
| Nurse H | Notified physician of Resident #36's bruises and medication list. | |
| Nurse G | Administered insulin to residents in hallway. | |
| Staff F | Verified bath schedule and resident rights. | |
| Staff I | Verified resident rights to choose bath frequency. | |
| Staff J | Verified resident rights to choose bath frequency. | |
| Medication aide staff B | Received and recorded physician medication order, which is unauthorized. | |
| Nurse C | Verified only licensed nurses may take physician orders. | |
| Administrative Nurse D | Administrative Nurse | Verified medication aide staff are not allowed to obtain medication orders and confirmed expired emergency kit medication. |
| Nurse L | Observed coughing into gloved hand and assisting resident with eating without changing gloves. | |
| Nurse Aide K | Observed scratching shoulder with gloved hand and then handling resident's silverware. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 29, 2010
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection.
Findings
No Plan of Correction was required for the deficiency identified with tag F0000, as indicated in the document.
Deficiencies (1)
No Plan of Correction required for deficiency F0000
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N015006 POC C6IT11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report for Sunset Home.
Findings
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.
Deficiencies (1)
Infection control deficiencies related to peri care and glove changing protocol.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Teresa Shore | CEO | Submitted the Plan of Correction |
| Diana Melander | Added the Plan of Correction | |
| Caryl Gill | Modified the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: N015006 POC HXR521
Visit Reason
This document is a Plan of Correction submitted by Sunset Home Inc in response to deficiencies cited during a prior inspection.
Findings
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.
Deficiencies (7)
Resident #36 had bruising that was not found and assessed properly by staff, delaying physician and family notification.
Injections will only be administered in resident's rooms to maintain privacy and dignity.
Staff will not refuse resident requests for extra baths and will arrange coverage if needed.
Staff must report bruising or skin conditions to charge nurse and document appropriately; weekly skin checks by nurses and monthly RN assessments.
Staff must wash hands or use sanitizer and change gloves appropriately during dining assistance.
Only nurses may take doctor's orders over the phone; staff will be inserviced on this policy.
Emergency drug kit will be monitored for expiration dates and updated accordingly.
Report Facts
Complete Date: Nov 14, 2012
Complete Date: Dec 5, 2012
Complete Date: Nov 25, 2011
Complete Date: Nov 29, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N015006 POC JDIY11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
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.
Deficiencies (2)
Damaged kitchen floor tiles under the steamer and 3 compartment sink needing replacement.
Drain in the Sunroom ice machine not compliant; requires replacement with a 2 inch air gap.
Report Facts
Tiles to be replaced: 6
Tiles to be replaced: 12
Correction completion date: Feb 9, 2014
Correction completion date: Jan 10, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N015006 POC 74UD11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Sunset Home.
Complaint Details
This Plan of Correction is in response to a complaint investigation at Sunset Home.
Findings
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.
Deficiencies (3)
Facility will develop and implement a facility wide system to assure correction and continued compliance with the regulations.
Redirecting magazines and newspapers to a resident, providing TV Guide access, coordinating with doctor to adjust anti-depression medication, and increasing community outings.
Compiling a list of residents at risk of elopement, checking wandergard functioning twice daily, adding elopement risk review to care plan meetings, placing wandergard on motorized scooter, and counseling involved resident.
Report Facts
Complete Date: Feb 12, 2014
Complete Date: Feb 26, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Mary Jane Kennedy | Modified the Plan of Correction | |
| Irina Strakhova | Added the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N015006 POC LGGC11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
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.
Deficiencies (1)
Failure to maintain compliance with regulations requiring posting of abuse hotline number and proper drainage from ice machine.
Report Facts
Complete Date: Apr 8, 2015
Complete Date: Mar 27, 2015
Complete Date: Apr 25, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: N015006 POC UL9D11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
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.
Deficiencies (12)
Failure to post abuse hotline number appropriately
Non-compliance with fluid restriction orders for resident #3
Wheelchair support wings not removed as needed
Coolness issue in bath house environment
Bathroom floor covering in need of replacement
Fluid restriction orders not properly included in plan of care
Lack of therapy orders for positioning resident in wheelchair
Pressure ulcer information not communicated to dietician
Fluid restrictions not properly documented on MARs
Protime blood draw not done timely for resident #8
Ice machine drain pipe improperly installed risking contamination
Improper glove use and urinary drainage bag emptying procedures
Report Facts
Deficiency completion dates: 2015
Therapy frequency: 3
Protime recheck date: Apr 14, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction document |
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