Inspection Reports for
Sunset Home Inc
620 2ND AVENUE, CONCORDIA, KS, 66901-2727
Back to Facility ProfileDeficiencies (last 13 years)
Deficiencies (over 13 years)
17.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
87% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 39
Deficiencies: 14
Date: Mar 26, 2025
Visit Reason
Routine state inspection of Sunset Home Inc nursing facility to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during insulin administration, failure to prevent verbal abuse, inadequate reporting and investigation of abuse allegations, incomplete transfer documentation, failure to provide bed hold policy, inadequate pressure ulcer care, failure to ensure physician-ordered fluid intake, medication monitoring and administration issues, expired medications in use, lack of certified dietary manager, and infection control lapses.
Deficiencies (14)
F 0550: The facility failed to maintain dignity for residents R34 and R9 by administering insulin in the dining room with others present, risking embarrassment.
F 0600: The facility failed to keep resident R35 free from verbal abuse during transport, placing him at risk for fear or mental anguish.
F 0609: The facility failed to timely report suspected abuse and investigate allegations related to verbal abuse of resident R35, risking ongoing mistreatment.
F 0610: The facility failed to respond appropriately to allegations of verbal abuse of resident R35, delaying investigation and placing him at risk.
F 0622: The facility failed to document and communicate the transfer/discharge of resident R126 properly, risking delayed treatment at receiving institution.
F 0625: The facility failed to provide resident R126 or representative with a bed hold policy, risking inability to return to the same bed after transfer or leave.
F 0686: The facility failed to provide appropriate dressing for resident R11's open pressure ulcer on the left heel, risking pain or infection.
F 0690: The facility failed to ensure resident R10 had physician-ordered fluid intake, placing her at risk of ongoing urinary tract infections.
F 0692: The facility failed to provide adequate food and fluids to maintain resident R10's health, risking dehydration and urinary tract infections.
F 0756: The facility's consultant pharmacist failed to notify staff of lack of blood pressure monitoring for resident R34 as ordered, risking unnecessary medication.
F 0757: The facility failed to monitor resident R34's blood pressure as ordered, risking unnecessary medication.
F 0761: The facility failed to remove expired medications and failed to date an opened insulin pen, risking ineffective medication.
F 0801: The facility failed to provide a full-time certified dietary manager, risking inadequate nutrition for residents.
F 0880: The facility failed to maintain infection surveillance and improperly used PPE in hallways, risking exposure to infectious processes.
Report Facts
Residents census: 39
Sample residents reviewed: 13
Expired bisacodyl suppositories: 14
Losartan dosage: 100
Physician ordered fluid intake: 1920
Pressure ulcer size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified insulin administration policy, abuse reporting, transfer documentation, fluid intake orders, infection control issues |
| Certified Nurse Aide M | Certified Nurse Aide | Observed wearing PPE improperly in hallway |
| Certified Medication Aide S | Certified Medication Aide | Administered medications to R34 |
| Dietary Staff BB | Dietary Staff / Dietary Manager | Reported dietary manager not certified |
| Licensed Nurse I | Licensed Nurse | Administered insulin, verified wound care, and stated unawareness of fluid intake order |
| Licensed Nurse G | Licensed Nurse | Verified expired medications and disposed of them |
| Licensed Nurse H | Licensed Nurse | Verified insulin pen should be dated when opened |
| Certified Nurse Aide O | Certified Nurse Aide / Transportation Aide | Involved in verbal abuse incident with resident R35 |
Inspection Report
Routine
Census: 39
Deficiencies: 14
Date: Mar 26, 2025
Visit Reason
Routine inspection of Sunset Home Inc nursing facility to assess compliance with health, safety, and regulatory standards.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during insulin administration, failure to prevent verbal abuse, inadequate reporting and investigation of abuse allegations, incomplete transfer documentation, failure to provide bed hold policy, inadequate pressure ulcer care, failure to ensure physician-ordered fluid intake, medication management issues including expired medications and lack of monitoring, lack of certified dietary manager, and infection control lapses.
Deficiencies (14)
F 0550: The facility failed to maintain dignity for residents R34 and R9 by administering insulin in the dining room with others present, risking embarrassment.
F 0600: The facility failed to keep resident R35 free from verbal abuse during transport, placing him at risk for fear or mental anguish.
F 0609: The facility failed to timely report an allegation of verbal abuse from resident R35 to the administrator and state agency, risking ongoing abuse.
F 0610: The facility failed to thoroughly investigate the allegation of verbal abuse involving resident R35, risking ongoing mistreatment.
F 0622: The facility failed to document resident R126's transfer or discharge and communicate appropriate information to the receiving institution, risking delayed treatment.
F 0625: The facility failed to provide resident R126 or representative with a bed hold policy, risking inability to return to the same bed after transfer or leave.
F 0686: The facility failed to provide appropriate dressing for resident R11's open pressure ulcer on the left heel, risking pain or infection.
F 0690: The facility failed to ensure resident R10 had physician-ordered fluid intake, placing R10 at risk of ongoing urinary tract infections.
F 0692: The facility failed to ensure resident R10 had physician-ordered fluid intake, placing R10 at risk of dehydration and urinary tract infections.
F 0756: The facility's consultant pharmacist failed to notify the director of nursing or physician about lack of blood pressure monitoring for resident R34, risking unnecessary medication.
F 0757: The facility failed to monitor resident R34's blood pressure as ordered, risking unnecessary medication.
F 0761: The facility failed to remove expired medications and failed to date an opened insulin pen, risking ineffective medication.
F 0801: The facility failed to provide a full-time certified dietary manager, placing residents at risk for inadequate nutrition.
F 0880: The facility failed to maintain an infection monitoring surveillance plan and staff wore PPE improperly in hallways, risking infectious disease exposure.
Report Facts
Residents census: 39
Sample residents: 13
Expired bisacodyl suppositories: 14
Losartan dosage: 100
Physician ordered fluid intake: 1920
Pressure ulcer size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified insulin administration policy, abuse reporting, transfer documentation, and infection control issues |
| Certified Nurse Aide O | Certified Nurse Aide and Transportation Aide | Involved in verbal abuse incident with resident R35 |
| Certified Medication Aide S | Certified Medication Aide | Administered medications to resident R34 |
| Dietary Staff BB | Dietary Staff | Dietary manager, not certified |
| Licensed Nurse I | Licensed Nurse | Administered insulin and verified wound care |
| Licensed Nurse G | Licensed Nurse | Verified expired medications and disposed of them |
| Licensed Nurse H | Licensed Nurse | Verified insulin pen should be dated when opened |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Dec 16, 2024
Visit Reason
The inspection was conducted following a complaint/allegation regarding possible abuse, neglect, and exploitation involving Resident 1 (R1) being forced to go to bed against his wishes, resulting in bruising and distress.
Complaint Details
The complaint involved allegations that R1 was forced to bed by CNAs despite his refusal, resulting in bruising and distress. The allegation was substantiated by witness statements and observations. Staff involved were suspended and placed on a Do Not Return list. The facility notified police and conducted staff training on abuse and neglect.
Findings
The facility failed to promote R1's right to choose, respect his wishes, and treat him with dignity and respect. R1 was forcibly put to bed despite protest, resulting in physical resistance, bruising, and psychosocial impairment. Staff involved were suspended and an investigation was conducted.
Deficiencies (1)
F 0550: The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his rights. Staff forced R1 to go to bed against his wishes, causing physical and psychosocial harm.
Report Facts
Resident census: 38
Bruise measurements: 9
Bruise measurements: 7
Bruise measurements: 5
Bruise measurements: 4
Oxygen flow rate: 3
Aspirin dosage: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in forcing R1 to bed and related findings |
| CNA N | Certified Nurse Aide | Named in forcing R1 to bed and related findings |
| CNA O | Certified Nurse Aide | Witness who intervened and reported the incident |
| LN G | Licensed Nurse | Responded to incident and assessed R1 |
| Administrative Nurse D | Administrative Nurse | Investigated incident and provided statements |
| LN H | Licensed Nurse | Noted bruising on R1 during rounds |
| LN I | Licensed Nurse | Provided statements regarding R1's behavior |
| CNA P | Certified Nurse Aide | Provided statements on R1's behavior |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Oct 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in Resident 1 (R1).
Complaint Details
The investigation was complaint-related, focusing on pressure ulcer care deficiencies for Resident 1. The complaint was substantiated as the facility failed to prevent pressure ulcers and delayed appropriate interventions.
Findings
The facility failed to initiate a turning/repositioning program, provide a pressure reducing cushion for wheelchair use, or bilateral heel protectors for R1, resulting in the development of Stage 3 and Stage 4 pressure ulcers. This deficient practice placed R1 at risk for further skin breakdown, delayed healing, and infection.
Deficiencies (1)
F 0686: The facility failed to provide care consistent with professional standards to prevent pressure ulcer development in Resident 1, who developed Stage 3 and Stage 4 pressure ulcers due to lack of turning/repositioning program, pressure relieving devices, and heel protectors.
Report Facts
Resident census: 36
Pressure ulcer measurements: 5.6
Pressure ulcer measurements: 6.2
Pressure ulcer depth: 2.5
Pressure ulcer tunneling: 1.7
Braden Scale score: 16
Clindamycin dosage: 300
Augmentin dosage: 875
Wound vac negative pressure: 150
Tramadol administration: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Stated initial skin assessment was not completed correctly and was named in wound care communication |
| Licensed Nurse G | Licensed Nurse | Verified R1 did not have turning repositioning program or pressure reducing devices prior to wound development |
| Certified Nurses Aide M | Certified Nurses Aide | Stated R1 had not been on a turning/repositioning program prior to pressure ulcer development |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 3
Date: Jul 31, 2023
Visit Reason
The inspection was conducted following complaints regarding failure to provide written notification of roommate changes, failure to timely report suspected abuse, and failure to properly assess and obtain consent for bed rail use for Resident 1.
Complaint Details
The investigation was complaint-driven, focusing on failure to notify Resident 1 about roommate changes, failure to report suspected abuse timely, and failure to properly assess and consent for bed rail use. The complaints were substantiated as deficiencies were found.
Findings
The facility failed to notify Resident 1 and/or her representative in writing before assigning a new roommate, failed to timely report bruises of unknown origin as potential abuse to the State Agency, and failed to assess Resident 1 for safe bed rail use or obtain consent from her representative. These deficiencies placed Resident 1 at risk for miscommunication, psychosocial harm, unresolved abuse, and safety hazards.
Deficiencies (3)
F 0559: The facility failed to provide written notification, including the reason for the change, to Resident 1 and/or her representative before a new roommate was assigned. This placed Resident 1 at risk for decreased psychosocial well-being.
F 0609: The facility failed to timely report bruises of unknown origin on Resident 1 to the State Agency within the mandated timeframe. This placed Resident 1 at risk for unresolved and ongoing abuse and further injuries.
F 0700: The facility failed to assess Resident 1 for safe bed rail usage, failed to educate her representative on risks and benefits, and failed to obtain consent before using bed rails. This placed Resident 1 at risk for accidents and miscommunication.
Report Facts
Census: 37
Brief Interview for Mental Status (BIMS) score: 7
Bruise size: 5
Bruise size: 6
Bruise size: 6
Bruise size: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Interviewed Resident 1 about injury and reported to Administrative Nurse D |
| Administrative Nurse D | Administrative Nurse | Conducted investigation and reported injuries of unknown origin to State Agency |
| Social Services X | Social Services Staff | Responsible for family notifications regarding roommate changes |
| Maintenance U | Maintenance Staff | Reported Resident 1's comments about new roommate |
| Certified Nurse Aide M | Certified Nurse Aide | Reported procedure for injury of unknown origin |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 16
Date: Jul 11, 2023
Visit Reason
Annual inspection of Sunset Home Inc to assess compliance with regulatory requirements for nursing homes.
Findings
The facility had multiple deficiencies including failure to provide mail service on Saturdays, incomplete resident assessments, inadequate care planning, delayed CPR response, unsafe resident transfers, improper medication management, lack of infection control measures, and ineffective quality assurance processes.
Deficiencies (16)
F 0576: The facility failed to distribute resident mail on Saturdays, limiting residents' access to communication.
F 0636: The facility failed to complete comprehensive Minimum Data Set Section V Care Area Assessment Summaries for multiple residents, risking inaccurate care planning.
F 0637: The facility failed to complete a Significant Change Minimum Data Set for a resident with a significant decline in condition, risking inappropriate care.
F 0656: The facility failed to develop a care plan with meaningful fall prevention interventions for a resident with multiple falls, increasing risk of injury.
F 0657: The facility failed to review and revise a resident's care plan for safe transfers, placing the resident at risk for injury.
F 0678: The facility delayed initiating CPR for a full code resident by 12 minutes and lacked a system to ensure CPR-certified staff were always present, placing residents at immediate jeopardy.
F 0689: The facility failed to provide adequate assistance and safety with transfers for one resident and failed to identify and implement fall prevention interventions for another, risking injury.
F 0726: The facility failed to ensure licensed nurses possessed the knowledge and skills to provide CPR, risking inadequate resuscitative measures for full code residents.
F 0756: The facility failed to implement a process to acknowledge and respond to consultant pharmacist recommendations regarding antipsychotic medication use, risking unnecessary psychotropic medication.
F 0758: The facility failed to ensure appropriate indication and physician rationale for continued use of antipsychotic medication, risking unnecessary psychotropic medication.
F 0761: The facility failed to assess and record medication room refrigerator temperatures and failed to discard expired medication, risking residents receiving less potent or unintended medication effects.
F 0835: The facility administration failed to use resources effectively to maintain residents' highest practicable well-being, including failure to provide timely CPR, infection control, and quality assurance.
F 0867: The facility's Quality Assessment and Assurance program failed to identify multiple issues of concern, placing residents at risk for decreased quality of care and life.
F 0868: The facility failed to retain evidence that required Quality Assessment and Assurance members attended quarterly meetings, risking decreased quality of care.
F 0880: The facility failed to develop a water management plan to minimize risk of Legionella and other waterborne pathogens, placing residents at risk for infection.
F 0882: The facility failed to provide a designated and certified Infection Preventionist to manage the Infection Prevention and Control Program, placing residents at risk for infections.
Report Facts
Residents affected: 36
Sample size: 15
Days missing refrigerator temperature logs: 13
Days missing refrigerator temperature logs: 14
Days missing refrigerator temperature logs: 14
Days missing refrigerator temperature logs: 4
Fall risk score: 75
Antipsychotic medication dose: 0.25
Delay in CPR initiation: 12
Inspection Report
Census: 37
Deficiencies: 2
Date: May 24, 2023
Visit Reason
The inspection was conducted to assess compliance with nursing staff licensure requirements and administrative oversight related to nursing staff licensure at the facility.
Findings
The facility failed to ensure nursing staff possessed current licensure as required, specifically a Licensed Practical Nurse (LN G) worked with an expired license for multiple months. The facility also lacked a policy to track and ensure ongoing licensure for licensed nurses, placing residents at risk for inadequate care.
Deficiencies (2)
F 0726: The facility failed to ensure nursing staff possessed current licensure as required, with LN G working multiple days after her LPN license expired. This placed all residents at risk for not attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.
F 0835: The facility failed to provide adequate administrative oversight to monitor and ensure all nurses maintained active licenses, placing residents at risk for lack of quality nursing care.
Report Facts
Resident census: 37
Days LN G worked with expired license in January: 16
Days LN G worked with expired license in February: 12
Days LN G worked with expired license in March: 13
Days LN G worked with expired license in April: 14
Days LN G worked with expired license in May: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Practical Nurse | Named in findings for working with expired license. |
| Administrative Nurse D | Verified LN G worked with expired license and was unaware of expiration. | |
| Administrative Staff A | Stated facility lacked policy for ongoing licensure verification and expected staff to renew licenses themselves. |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 2
Date: Mar 16, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with care planning and restorative therapy requirements at Sunset Home Inc nursing facility.
Findings
The facility failed to provide timely and comprehensive care plan meetings and restorative therapy for four residents (R1, R2, R3, and R4). This placed these residents at risk for unmet needs and functional decline in activities of daily living.
Deficiencies (2)
F 0657: The facility failed to develop complete care plans within seven days of comprehensive assessments and did not hold timely care plan conferences for residents R1, R2, R3, and R4 within a ninety-day period.
F 0688: The facility failed to provide restorative therapy for residents R1, R2, R3, and R4 after discontinuing physical and occupational therapy, risking functional decline in activities of daily living.
Report Facts
Resident census: 43
Sample size: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Stated care plan conferences were missed and verified care plans should occur every ninety days |
| Restorative Aide GG | Restorative Aide | Reported being used as a floor aide and unable to perform restorative therapies |
| Certified Nursing Aide M | Certified Nursing Aide | Stated restorative services were not provided but CNAs were told to chart restorative services |
| Physical Therapy Assistant HH | Physical Therapy Assistant | Reported no restorative services available and residents regressed after therapy ended |
| Therapy Coordinator II | Therapy Coordinator | Reported frustration over lack of restorative therapy and CNA training |
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 9
Date: Jan 10, 2022
Visit Reason
Annual inspection of Sunset Home Inc nursing facility to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to provide appropriately fitted shoes to a resident, failure to provide required Medicare beneficiary notices, failure to provide bed hold policy to a hospitalized resident, failure to implement dietitian recommendations leading to significant weight loss, failure in pharmacist monitoring of antipsychotic medication use, improper preparation of pureed diets, unsafe food handling practices, and inadequate communication and documentation of hospice care plans.
Deficiencies (9)
F 0558: The facility failed to provide Resident 7 with appropriately fitted shoes, placing him at risk for falls.
F 0582: The facility failed to provide four residents with the required Medicare Advanced Beneficiary Notice including estimated costs, placing them at risk for uninformed decisions.
F 0625: The facility failed to provide Resident 8 or representative with written bed hold policy upon hospital transfer, risking loss of residency rights.
F 0692: The facility failed to implement the dietitian's recommendation to increase nutritional supplement for Resident 13, resulting in significant unintended weight loss of 11.47% in three months.
F 0756: The consultant pharmacist failed to report inappropriate diagnosis and lack of behavior monitoring for antipsychotic use in Resident 22, placing resident at risk for adverse effects.
F 0758: The facility failed to have an appropriate diagnosis or behavior assessment for antipsychotic medication use in Resident 22, risking adverse side effects.
F 0804: The facility failed to measure ingredients and serving sizes when preparing pureed diets, risking residents receiving nonnutritive food and inappropriate portions.
F 0812: The facility failed to store, distribute, and serve food in accordance with professional standards, including thawing different meats together, serving with contaminated gloves, and unlabeled ice cream, risking foodborne illness.
F 0849: The facility failed to establish and document routine communication and a hospice care plan for Resident 21, risking delayed or inadequate care due to lack of collaboration with hospice providers.
Report Facts
Resident census: 29
Sample size: 12
Weight loss percentage: 11.47
Weight loss percentage: 4.11
Med Pass supplement increase: 60
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 2020-06-29.
Findings
All deficiencies have been corrected as of the compliance date of 2020-07-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 29, 2020
Visit Reason
This document is a plan of correction submitted by the facility in response to deficiencies related to infection control and isolation procedures during the COVID-19 pandemic.
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)
F880-F: Resident R1 was moved to a private isolation room on 06/29/2020. Staff will monitor room assignments and use transmission-based precautions including PPE when caring for isolated residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for plan of correction assistance | |
| Teresa Shore | CEO | Submitted the plan of correction |
Inspection Report
Abbreviated Survey
Census: 26
Deficiencies: 1
Date: Jun 29, 2020
Visit Reason
The visit 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 assess infection control practices related to COVID-19.
Findings
The facility failed to implement recommended infection control practices by not providing a private room for a dialysis resident who left the facility three times a week, placing other residents at risk for COVID-19 infection.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to isolate a dialysis resident who left the facility three times a week, placing the resident's roommate and other residents at risk for COVID-19 infection.
Report Facts
Census: 26
Residents at risk: 25
Dialysis resident trips: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided statements regarding dialysis resident and isolation status | |
| Physician G | Physician | Faxed order to isolate dialysis resident to a private room |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 16, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-03-11.
Findings
All deficiencies have been corrected as of the compliance date of 2019-04-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 11
Deficiencies: 9
Date: May 7, 2019
Visit Reason
Licensure Resurvey at an Assisted Living/Residential Health Care Facility in Concordia, Kansas conducted over multiple days in late April and early May 2019.
Findings
The inspection identified multiple deficiencies including failure to inform residents of current rates, incomplete advance directives documentation, inaccurate functional capacity screens, incomplete negotiated service agreements, missing signatures on service agreements, lack of detailed emergency management plans, failure to conduct required emergency preparedness reviews and drills, and noncompliance with tuberculosis screening guidelines.
Deficiencies (9)
KAR 26-39-103(c) The Administrator failed to ensure residents or their representatives were informed orally and in writing of current rates for care and services.
KAR 26-39-102(b)(c) The Administrator failed to ensure policies and procedures for advance medical directives were implemented and copies maintained in medical records.
KAR 26-41-201(d) The Administrator failed to ensure functional capacity screens accurately reflected residents' functional status including assistive devices and fall history.
KAR 26-41-202(a) The Administrator failed to ensure negotiated service agreements included service descriptions, providers, and payment sources.
KAR 26-41-202(h) The Administrator failed to ensure all individuals involved in developing negotiated service agreements signed the agreements.
KAR 26-41-204(d) The Administrator failed to ensure negotiated service agreements contained the name of the licensed nurse responsible for health service plan implementation and supervision.
KAR 26-41-104(b) The Administrator failed to ensure a detailed written emergency management plan included all required topics such as flood, natural gas leak, water service loss, and missing resident plans.
KAR 26-41-104(d) The Administrator failed to ensure quarterly reviews of the emergency management plan with employees and residents and failed to conduct an annual emergency evacuation drill.
KAR 26-41-207(b)(5-6)(c) The Administrator failed to ensure compliance with tuberculosis screening guidelines for employees and residents, including timely symptom screening and two-step skin testing.
Report Facts
Census: 11
Employees hired since last resurvey: 34
Sampled residents: 3
Employees reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assisted Living Director #D | Licensed Practical Nurse | Confirmed deficiencies related to admission agreements, functional capacity screens, negotiated service agreements, and emergency management plan |
| Administrator #F | Confirmed multiple deficiencies including admission agreements, negotiated service agreements, emergency management plan, and TB compliance | |
| Maintenance Director #I | Provided information on disaster reviews and evacuation drills | |
| Maintenance Staff #K | Provided information on disaster reviews and evacuation drills | |
| Licensed Nurse #M | Provided tuberculosis skin testing for residents |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Apr 10, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection.
Findings
The Plan of Correction addresses multiple deficiencies related to catheter care, restorative care plans, nursing staff training, insulin and bowel protocol compliance, medication administration, and documentation. The facility outlines corrective actions including staff education, care plan updates, monitoring, and reporting to Quality Assurance over specified timeframes.
Deficiencies (7)
F657-D: Resident #4's care plan was updated to include catheter care directions. Staff education and skills checklist updates were implemented with ongoing monitoring.
F676-D: Residents #16 and #24 have passed away. Restorative care plans will be reviewed quarterly with ongoing evaluation and monitoring.
F690-D: Resident #4's care plan updated for catheter care with staff education and monitoring similar to F657-D.
F730-F: Nursing staff must complete 12 hours of in-service training by 4/10/2019. Non-compliant CNAs will be suspended until training completion.
F756-D: Nursing staff educated on insulin and bowel protocol compliance. Consultant pharmacist notified to identify missing documentation. Monitoring and reporting planned.
F757-D: PCP contacted for Resident #11 with updated parameters. Charge nurses to monitor bowel movements and medication administration with reporting protocols.
F880-D: Resident #4 catheter cover placement and care plan update with staff education and monitoring as in prior catheter care deficiencies.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 7
Date: Mar 11, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations for 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 failed to revise care plans adequately, provide necessary supervision for restorative programs, ensure proper catheter care, complete mandatory nurse aide in-service education, identify and report medication irregularities, administer medications as ordered, and maintain infection prevention standards, placing residents at risk for infections, inadequate care, and adverse medication effects.
Deficiencies (7)
F 657 Care Plan Timing and Revision: The facility failed to revise Resident #4's care plan to include specific staff directions for indwelling urinary catheter care, increasing risk for urinary tract infections.
F 676 Activities Daily Living (ADLs)/Mntn Abilities: The facility failed to supervise and monitor dressing and grooming restorative programs for Residents #16 and #24, risking decline in ADL function.
F 690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide standardized care for Resident #4's urinary catheter, including improper catheter bag positioning and lack of securing tubing, risking infection and injury.
F 730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to ensure 3 Certified Nurse Aides completed mandatory annual 12-hour in-service education, risking inadequate care for residents.
F 756 Drug Regimen Review, Report Irregular, Act On: The consultant pharmacist failed to identify and report medication irregularities for Residents #11 and #23, including missing insulin administration documentation and lack of bowel monitoring follow-up.
F 757 Drug Regimen is Free from Unnecessary Drugs: The facility failed to administer insulin as ordered for Resident #11, bowel management medication for Resident #23, and insulin, blood pressure, and mood stabilizing medications for Resident #7, risking adverse effects.
F 880 Infection Prevention & Control: The facility failed to provide sanitary indwelling urinary catheter care for Resident #4, including improper catheter bag positioning and lack of securing tubing, risking recurrent urinary tract infections.
Report Facts
Resident census: 31
Certified Nurse Aides missing annual in-service: 3
Insulin doses missing documentation: 5
Insulin doses missing documentation: 4
Insulin doses missing documentation: 10
Days without bowel movement: 11
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 30, 2018
Visit Reason
An offsite survey was conducted to verify correction of a deficiency cited on 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
Plan of Correction
Deficiencies: 2
Date: Nov 29, 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 addresses deficiencies related to infection control, including mandatory training for nursing staff on peri care and glove changing protocols, skills checks, and ongoing monitoring of urinary tract infections.
Deficiencies (2)
F0000 Statement of deficiencies will be taken to Sunset Homes quality Assurance/Assessment Committee on Nov. 15, 2018.
F880-D All nursing staff required to have mandatory training on infection control starting with nurse staff meeting on Nov. 15, 2018, including peri care and glove changing protocol with skills checks and policy review.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Oct 30, 2018
Visit Reason
Complaint investigation #133461 regarding infection prevention and control practices at the facility.
Complaint Details
Complaint investigation #133461 focused on infection prevention and control practices related to glove use during perineal care.
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 3 sampled residents, placing them at risk for continued urinary tract infections (UTIs).
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to change gloves during perineal care for Residents #1, #2, and #3, risking transmission of infections and continued UTIs.
Report Facts
Resident census: 38
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide M | Observed not changing gloves between soiled and clean tasks during perineal care. | |
| Nurse Aide N | Observed not changing gloves between soiled and clean tasks during perineal care. | |
| Nurse Aide O | Observed not changing gloves properly during perineal care. | |
| Administrative Nurse D | Administrative Nurse | Stated expectation that staff change gloves between soiled and clean tasks and noted failure to do so could cause UTIs. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 30, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found 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 effective November 29, 2018.
Deficiencies (1)
The facility had a 'D' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
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: 5
Date: Sep 26, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior complaint-related inspection.
Findings
The plan addresses deficiencies related to bath scheduling and documentation, nursing education on restorative care and documentation, call light response monitoring, and staffing changes including hiring an interim Director of Nursing.
Deficiencies (5)
F0000 Statement of deficiencies will be taken to the facility's QA committee on 09/13/18.
F677-E Aides on each hall are assigned baths scheduled for residents on that hall and shift. Aides will document baths given or refused and charge nurse will ensure all baths are given and documented during the shift.
F688-D Mandatory nursing education on restorative dressing, restorative exercise (ROM), and passive ROM was provided. Competency reviews and documentation training were conducted to ensure understanding.
F725-F Charge nurse will monitor call light response and assist if applicable. Staff were educated that all staff can assist in answering call lights and call light summaries will be reported to QA monthly.
F727-F Interim Director of Nursing hired from Agency Nursing to serve until newly hired Director starts on October 22, 2018.
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 investigation numbers (#132116, #132315, #132147, #131526, #131513, and #131622).
Complaint Details
The inspection was triggered by multiple 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, and sufficient nursing staff to respond timely to call lights. Additionally, the facility lacked a full-time registered nurse director of nursing.
Deficiencies (4)
F 677 ADL Care Provided for Dependent Residents. The facility failed to provide bathing services as requested for 3 of 5 sampled residents, resulting in poor personal hygiene.
F 688 Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide consistent restorative services to 3 of 5 sampled residents to maintain or improve mobility as care planned.
F 725 Sufficient Nursing Staff. The facility failed to provide sufficient nursing staff to answer call lights timely for 3 sampled residents, placing them at risk for unmet needs.
F 727 RN 8 Hrs/7 days/Wk, Full Time DON. The facility failed to employ a registered nurse to serve as director of nursing on a full-time basis.
Report Facts
Resident 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 |
|---|---|---|
| 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 | Reported staffing shortages and that baths were missed due to short staffing. |
| Administrative Staff A | Administrative Staff | Verified staffing shortages, call light delays, and lack of a full-time director of nursing. |
| Nurse Aide O | Nurse Aide | Reported not providing restorative services due to lack of training. |
| Physical Therapy Staff GG | Physical Therapy Staff | Trained nurse aides on restorative programs and noted decline in residents due to staffing shortages. |
| Medication Aide M | Medication Aide | Reported being the only medication aide passing medications and not answering call lights due to workload. |
| Nurse H | Nurse | Reported short staffing but stated staff worked through it. |
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 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 was found to be in substantial compliance effective September 26, 2018.
Deficiencies (1)
The facility had a 'F' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 21, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-02-14.
Findings
All deficiencies had been corrected as of the compliance date of 2018-03-16, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Apr 5, 2018
Visit Reason
This is a follow-up revisit inspection to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (5)
26-41-101 (f) (3): Previously cited deficiency corrected as of 04/05/2018.
26-41-202 (a): Previously cited deficiency corrected as of 04/05/2018.
26-41-204 (i): Previously cited deficiency corrected as of 04/05/2018.
26-41-205 (g) (3): Previously cited deficiency corrected as of 04/05/2018.
26-41-104 (d): Previously cited deficiency corrected as of 04/05/2018.
Inspection Report
Renewal
Census: 17
Deficiencies: 6
Date: Mar 5, 2018
Visit Reason
Licensure resurvey and complaint investigation at an assisted living/residential health care facility in Concordia, Kansas.
Complaint Details
Complaint #126213 was investigated related to neglect and failure to investigate and report an unwitnessed fall of Resident #187. The allegation was substantiated based on lack of licensed nurse assessment and failure to report to the Department.
Findings
The facility was found to have multiple deficiencies including permitting a resident to stay in an unapproved detached building while receiving licensed health care services, failure to thoroughly investigate and report a potential neglect incident, incomplete negotiated service agreements, failure to provide health care services by qualified staff according to standards, improper labeling of over-the-counter medications, and inadequate disaster and emergency preparedness.
Deficiencies (6)
K.S.A. 39-939(a): The Administrator permitted a Resident (#187) to stay in an unapproved detached building while providing licensed health care services as an assisted living facility.
KAR 26-41-101(f)(3)(C): The Administrator failed to ensure a thorough investigation and reporting of a potential neglect incident involving Resident #187 after an unwitnessed fall.
KAR 26-41-202(a): The Administrator failed to ensure the negotiated service agreement for Resident #185 included a description of services and identification of payment responsibility for outside resources.
KAR 26-41-204(i): The Administrator failed to ensure all health care services to Resident #187 were provided by qualified staff in accordance with acceptable standards, including licensed nurse assessments after medication administration and condition changes.
KAR 26-41-205(g)(3): The Administrator failed to ensure licensed nurse or pharmacist placed the full name of residents on all original, unbroken manufacturer’s packages of over-the-counter medications.
KAR 26-41-104(d): The Administrator failed to ensure quarterly reviews of the emergency management plan with employees and residents and failed to conduct an annual emergency evacuation drill with staff and residents.
Report Facts
Resident census: 17
Over-the-counter medication packages lacking resident full name: 28
Medication dose: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #B | Administrator | Permitted resident to stay in unapproved building; failed to ensure investigations, reporting, and emergency preparedness. |
| Nurse #C | Facility Nurse | Interviewed regarding resident care and incident; confirmed deficiencies in medication and emergency preparedness. |
| Certified Staff #F | Certified Medication Aide | Administered Ativan to Resident #187 and found resident passed out on floor. |
| Nurse #I | Licensed Nurse | Assessed Resident #187 after fall and called 911. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Feb 16, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection.
Findings
The plan outlines immediate interventions and corrective actions for multiple deficiencies including resident admission notices, activity preference assessments, oral care, activity documentation, weight monitoring, and hydration practices. Audits and competency testing are scheduled to ensure compliance and ongoing monitoring.
Deficiencies (6)
F582-F: Residents will be given form 10055 at admission and periodically reviewed to ensure notification practices are followed.
F657-D: Activity staff will perform preference assessments and update care plans at least every 3 months, with audits conducted monthly.
F676-D: Resident care plans updated for oral care needs; dental services offered yearly with refusals documented and staff competency tested.
F679-E: Activity staff will document resident participation daily and incorporate new activities monthly, with audits to ensure care plan updates.
F684-D: Accurate resident weights will be obtained weekly with physician notification for significant changes; staff educated and audited monthly.
F692-D: Resident water pitchers will be kept within reach; staff educated and competency tested with weekly audits for 4 weeks.
Report Facts
Residents audited monthly: 10
Residents audited weekly: 5
Resident charts audited monthly: 5
Competency testing completion date: Apr 30, 2018
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 6
Date: Feb 14, 2018
Visit Reason
Health resurvey to assess compliance with Medicare/Medicaid coverage, care plan timing and revision, activities, quality of care, nutrition, and hydration standards.
Findings
The facility failed to provide Medicaid-eligible residents with Medicare non-coverage appeal options, did not update or individualize care plans and activities for several residents, failed to maintain adequate oral care for one resident, did not assess and document edema for one resident, and failed to provide adequate hydration for another resident.
Deficiencies (6)
F582 Medicaid/Medicare Coverage: Facility failed to provide 3 residents the opportunity to appeal Medicare non-coverage decisions and lacked documentation of liability notice and cost information.
F657 Care Plan Timing and Revision: Facility failed to review and revise care plans for activities for 3 residents, lacking individualized activity plans and placing residents at risk for loneliness and boredom.
F676 Activities of Daily Living: Facility failed to provide necessary care to maintain adequate oral hygiene for 1 resident, who had significant plaque buildup and no assistance with teeth brushing.
F679 Activities Meet Interest/Needs: Facility failed to provide individualized activity programs for 4 residents, resulting in residents spending much time inactive and unengaged.
F684 Quality of Care: Facility failed to assess, document, and notify physician of edema for 1 resident with heart failure, despite orders for daily weight and edema monitoring.
F692 Nutrition/Hydration Status: Facility failed to provide and encourage adequate fluid intake for 1 resident, who consumed an average of 270-341 ml/day, below recommended levels.
Report Facts
Resident census: 37
Sample size: 14
Fluid intake average: 270
Fluid intake average: 341
BNP lab value: 306
Resident weight: 90
Inspection Report
Re-Inspection
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 Medicare and/or Medicaid.
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 accepted, and the facility was found to be in substantial compliance effective 2018-03-16.
Deficiencies (1)
The facility had a 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 18, 2017
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously cited deficiency under regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(d)(1)(2)(n)(1)-(3) deficiency was corrected as of 07/18/2017.
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 and a safe environment to prevent resident elopement.
Complaint Details
Complaint Investigation #117032 focused on the facility's failure to prevent Resident #1's elopement. The resident was found outside after leaving through unsecured doors. The complaint was substantiated by observations, interviews, and record reviews.
Findings
The facility failed to ensure adequate supervision and a secure environment for Resident #1, who eloped from the facility through an unsecured door and was found outside. The resident had documented cognitive impairments and elopement risk, but the facility's interventions and door security measures were insufficient.
Deficiencies (1)
483.25(d)(1)(2)(n)(1)-(3) The facility failed to ensure adequate supervision and accident hazard prevention when Resident #1 eloped from the facility through an unsecured door and was found outside. The resident had cognitive impairments and was identified as an elopement risk, but interventions and door security were inadequate.
Report Facts
Resident census: 32
Residents at risk for elopement: 7
Sampled residents reviewed: 3
Brief Interview for Mental Status (BIMS) score: 4
Outside temperature: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Documented finding Resident #1 outside and assessed the resident after elopement. | |
| Nurse B | Charge nurse on 6/9/17 who received call about resident outside and assisted resident back inside. | |
| Office Staff B | Found Resident #1 outside and brought him/her back into the facility. | |
| Office Staff C | Noticed Resident #1 outside on 6/19/17 and assisted resident back inside. | |
| Administrative Staff D | Verified exit doors had alarms except two unsecured doors on first floor. | |
| Administrative Nurse E | Verified resident eloped through unsecured door and interventions failed. |
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 deficiencies to be a "D" level deficiency constituting no actual harm 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 credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
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)
F323-D: Resident was not adequately supervised to prevent elopement. Immediate corrective actions include one-to-one supervision while awake and securing assisted living exits.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 11, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report confirms that all previously cited deficiencies have been corrected as of March 17, 2017.
Deficiencies (1)
Regulation 483.12(a)(1) deficiency was corrected by the revisit date. Reg. 483.12(a)(3)(4)(c)(1)-(4) deficiency was also corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Mar 17, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at the facility.
Findings
The plan addresses corrective actions for resident safety related to behavior management and abuse/neglect policies, including staff retraining, behavior assessments, and ongoing monitoring by the facility's Quality Assurance/Assessment Committee.
Deficiencies (4)
F223-J: Immediate initiation of 1:1 supervision until referral to Geri-Psych unit was implemented. Staff were educated to place the resident in a safe location to avoid injury and behavior-based therapy was planned. All staff were retrained on the abuse/neglect policy.
All residents will have Behavior Assessments completed on admission, quarterly, and with significant changes. Appropriate interventions will be implemented to avoid risk to others.
HR designee will train all new hires on the abuse/neglect policy prior to working, and staff will be re-educated twice yearly. The interdisciplinary team will monitor resident safety perceptions quarterly.
Administrator or designee will audit new hire paperwork for compliance and report findings to the Quality Assurance committee for immediate correction.
Report Facts
Corrective action completion date: Mar 17, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
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 and conditions constituted immediate jeopardy to resident health or safety related to F223 and F225 regulations. Enforcement remedies including denial of payment for new admissions were imposed.
Deficiencies (1)
The facility was not in substantial compliance with F223, "J", CFR 483.12 and F225, "K", CFR 483.12(a)(3)(4)(c)(1)-(4). Immediate jeopardy to resident health or safety was identified.
Report Facts
Denial of payment effective date: Apr 6, 2017
Provider agreement termination date: Sep 13, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter as Complaint Coordinator for the Survey, Certification, and Credentialing Commission. |
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 investigation involved allegations of sexual abuse by Resident #1 toward Resident #5 on two separate occasions in February 2017. The facility failed to prevent and properly document these incidents, placing residents in immediate jeopardy.
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. The facility placed opposite gender residents in immediate jeopardy due to this deficient practice.
Deficiencies (2)
483.12 Free from abuse/involuntary seclusion: The facility failed to protect residents from sexual abuse by Resident #1, who inappropriately touched Resident #5 on two occasions, placing opposite gender residents in immediate jeopardy.
483.12(a)(3)(4)(c)(1)-(4) Investigate/report allegations/individuals: The facility failed to ensure all alleged abuse violations were thoroughly investigated and reported timely, and failed to protect opposite gender residents from sexual abuse by Resident #1.
Report Facts
Census: 29
Opposite gender residents in Assisted Living: 14
Opposite gender residents in Nursing Center: 22
Complaint investigations referenced: 3
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 9, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report confirms that the previously reported deficiencies identified by regulation numbers 483.10(f)(2) and 483.75(o)(1) have been corrected as of the revisit date.
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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'E' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 11, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies noted in a complaint investigation at Sunset Home.
Complaint Details
This Plan of Correction is related to a complaint investigation at Sunset Home dated 10/11/2016.
Findings
The plan addresses grievances and deficiencies identified during the complaint investigation, including review and revision of grievance policies and implementation of logs and audits to ensure compliance.
Deficiencies (2)
F166-E: Statement of deficiencies and noted grievances were taken to the Quality Assurance committee on 10/17/2016. Grievance policy was reviewed and revised, with staff education planned for 10/27/2016.
F520-E: Statement of deficiencies and noted grievances were taken to the Quality Assurance committee on 10/17/2016. Grievance policy was reviewed and revised, with staff education planned for 10/27/2016.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Oct 11, 2016
Visit Reason
The inspection was conducted as a complaint investigation related to grievances from residents about call lights not being answered in a timely manner.
Complaint Details
The complaint investigations #105422 and #105423 found substantiated grievances from 4 residents about call lights not being answered timely, with documented failures in response times and lack of corrective action by the facility.
Findings
The facility failed to respond to grievances from 4 residents regarding call light response times and failed to answer 22 of 32 residents' call lights within a reasonable time frame, putting residents at risk. The Quality Assessment and Assurance Committee did not effectively address these issues.
Deficiencies (2)
483.10(f)(2) The facility failed to promptly resolve grievances related to call lights not being answered timely, with 22 of 32 residents' call lights unanswered within 10 minutes as per facility standards.
483.75(o)(1) The facility failed to maintain an effective Quality Assessment and Assurance Committee that identified and corrected deficiencies related to call light response times.
Report Facts
Resident census: 32
Call light unanswered instances: 193
Residents with call light response issues: 22
Sample residents expressing grievances: 4
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. Each deficiency is identified by regulation number and marked as completed.
Deficiencies (11)
483.10(b)(11) deficiency was corrected as of 07/21/2016.
483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected as of 07/21/2016.
483.15(a) deficiency was corrected as of 07/21/2016.
483.25 deficiency was corrected as of 07/21/2016.
483.25(a)(3) deficiency was corrected as of 07/21/2016.
483.25(h) deficiency was corrected as of 07/21/2016.
483.25(l) deficiency was corrected as of 07/21/2016.
483.30(a) deficiency was corrected as of 07/21/2016.
483.35(i) deficiency was corrected as of 07/21/2016.
483.60(c) deficiency was corrected as of 07/21/2016.
483.65 deficiency was corrected as of 07/21/2016.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 21, 2016
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously cited deficiencies have been corrected as of the revisit date. The corrective actions were completed and verified by the state surveyor.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected and the correction was completed on 2016-07-21.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jul 21, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address previously cited deficiencies and demonstrate substantial compliance with Federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions including hiring a Certified Dietary Manager, staff education on food safety and hygiene, weekly audits of hair net usage and food inventory dating, and ongoing in-service training on multiple care and safety topics.
Deficiencies (3)
S0000 plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. Deficiencies will be reviewed by the facility's Quality Assurance/Assessment Committee.
S0600-C Certified Dietary Manager hired with a start date of June 27, 2016. Dietary Department Manager is currently taking the C.D.M. class and progress will be monitored by the administrator.
S2350-F Items cited will be dated or disposed of. Dietary staff will be educated on proper hair net use and food product dating. Weekly audits of hair net use and inventory dates will be reported monthly to Quality Assurance for three months.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 21, 2016
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report shows that previously cited deficiencies identified by regulation numbers 28-39-158(a) and 26-43-206(d) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 28-39-158(a) deficiency was corrected by the revisit date.
Regulation 26-43-206(d) deficiency was corrected by the revisit date.
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 dietary services at the facility.
Complaint Details
The visit was a Health Resurvey and complaint investigation involving complaint numbers 100664, 95461, and 101555.
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)
28-39-158(a) Dietary services. The facility failed to employ a full-time qualified dietary manager for the 36 residents receiving meals from the facility kitchen. Dietary Staff T was not certified as a dietary manager but was undergoing training and supervised by a Registered Dietitian.
Report Facts
Census: 36
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 22, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be 'F' level, 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 was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The survey identified 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 2
Date: Jun 22, 2016
Visit Reason
This inspection was a licensure resurvey of an Assisted Living/Residential Healthcare facility to assess compliance with dietary services and food preparation regulations.
Findings
The facility failed to employ a full-time qualified dietary manager and failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Several food items lacked expiration dates and staff did not fully comply with hair covering policies.
Deficiencies (2)
28-39-158(a) Dietary services. The facility failed to employ a full-time qualified dietary manager for 36 residents receiving meals from the facility kitchen.
26-43-206(d) Food preparation. The facility failed to store, prepare, distribute, and serve food under sanitary conditions, including use of food without expiration dates and improper hair covering by staff.
Report Facts
Resident census: 36
Resident census: 25
Sample size: 3
Inspection Report
Plan of Correction
Deficiencies: 11
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 of Correction outlines corrective actions for multiple deficiencies including resident care, medication documentation, incident reporting, hygiene, meal assistance, and environmental safety. Staff education, policy revisions, audits, and monitoring are planned to address these issues.
Deficiencies (11)
F157-D Resident #30 was taken to the doctor on 2016-06-17. Policy and procedure will be revised to include follow-up if no response from the physician, and nursing staff will be educated on reporting changes in resident status.
F225-D Bruise on resident #32 will be investigated and reported to the state. Nursing staff will be educated on incident investigation and reporting of bruises or skin tears of unknown origin.
F241-D Staff will be educated on policy and procedure regarding resident dignity and meal assistance, with audits conducted during meals to ensure compliance.
F309-D Locking brake installed for resident #2. Nursing staff will be educated on bowel protocol and neuro checks documentation, with audits and monitoring by charge nurse and Director of Nursing.
F312-E Policy and procedure for resident hygiene, bathing, meal assistance, and oral care will be reviewed and staff educated accordingly.
F323-E Coffee pot replaced in sunroom and warmer relocated to kitchen. Antilock mechanism installed for wheelchair for resident #2. Care plans will be audited and staff educated on gait belt usage.
F329-D Residents #18 and #30 will have diagnoses for all medications documented and monitored for side effects. Policy and procedure reviewed and nursing staff educated on medication documentation.
F353-E Dietary and department heads will monitor dining area to ensure timely assistance and dignity. Nursing staff will be educated on notification of physician on condition changes and follow-up.
F371-F All food items will be dated or disposed of. Dietary staff will be educated on proper dating of food items and wearing of hair nets, with audits conducted.
F428-D Residents #18 and #30 diagnoses will be documented on all medications by nursing staff. Consultant pharmacist reviewed medication diagnoses on 2016-06-30.
F441-F Policy and procedure for linens storage and transport and oxygen tubing storage will be reviewed and staff retrained. Environmental services will audit linen transport and room cleaning weekly.
Report Facts
Plan of Correction completion date: Jul 21, 2016
In-service date: Jun 30, 2016
Consultant Pharmacist review date: Jun 30, 2016
C.D.M. hire date: Jun 27, 2016
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 16, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Inspection Report
Follow-Up
Deficiencies: 0
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
All previously reported deficiencies identified on the CMS-2567 and Plan of Correction were corrected by 08/18/2015 as documented in this revisit report.
Report Facts
Correction completion date: Aug 18, 2015
Follow-up survey completion date: Jul 30, 2015
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jul 31, 2015
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 is in response to a complaint investigation involving allegations of abuse and related deficiencies.
Findings
The facility addressed multiple deficiencies related to abuse allegations, staff inservices, and medical director responsibilities. Corrective actions include suspension of alleged perpetrators, mandatory abuse inservices, and ensuring compliance with medical director contract duties.
Deficiencies (6)
F0000: The facility will develop and implement a facility-wide system to assure correction and continued compliance with regulations.
F225-J: The facility suspended alleged perpetrators immediately and conducted mandatory abuse inservices to review abuse policies and reporting responsibilities.
F226-F: The abuse policy was revised to require immediate suspension of alleged perpetrators until investigation completion, with procedures for timely reporting to the Abuse Hotline.
F497-F: CNA staff will continue yearly performance reviews including competency evaluations, and staff must complete required inservices to remain scheduled to work.
F501-F: The facility has a current contract with a medical director who is responsible for attending quarterly Quality Assurance meetings.
F520-F: The medical director contract requires attendance at quarterly Quality Assurance meetings, with consequences for noncompliance and administrator responsibility for contracting replacements.
Report Facts
Date of contract with medical director: Jul 22, 2015
Date of suspension and inservices: Jul 21, 2015
Date of inservice completion deadline: Aug 18, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Submitted the Plan of Correction and responsible for compliance |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 5
Date: Jul 30, 2015
Visit Reason
Complaint Investigation #89141 was conducted due to allegations of abuse and failure to investigate abuse allegations involving residents.
Complaint Details
The complaint investigation revealed failure to investigate abuse allegations involving residents #1 and #3, and failure to remove alleged perpetrators from work immediately. The facility allowed staff accused of abuse to continue working, violating abuse policies and placing residents in immediate jeopardy.
Findings
The facility failed to investigate abuse allegations for two residents and allowed alleged perpetrators to continue working, placing residents in immediate jeopardy. The facility also failed to provide mandatory abuse prevention training, failed to provide required nurse aide in-service education, lacked a designated medical director with a current contract, and failed to maintain a quality assessment and assurance committee with appropriate physician involvement.
Deficiencies (5)
F225: The facility failed to investigate allegations of abuse for two residents and allowed three staff members accused of abuse to continue working, placing residents in immediate jeopardy.
F226: The facility failed to implement abuse policies by not providing mandatory staff in-service training and allowing three employees with abuse allegations to continue working.
F497: The facility failed to provide the required 12 hours per year of in-service education for 19 nurse aides employed for one or more years.
F501: The facility failed to designate a physician to serve as medical director and lacked a current contract outlining the medical director's duties.
F520: The facility failed to maintain a quality assessment and assurance committee with a designated physician, failed to identify and correct quality deficiencies related to abuse policy violations, and lacked a current medical director contract.
Report Facts
Resident census: 43
Employees: 136
Employees attended abuse in-service: 56
CNAs employed 1+ years: 19
CNAs currently employed: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide H | Nurse Aide | Named in abuse allegation involving Resident #3; continued working after alleged abuse. |
| Nurse Aide A | Nurse Aide | Named in abuse allegation involving Resident #1; continued working after alleged abuse. |
| Nurse Aide B | Nurse Aide | Named in abuse allegation involving Resident #1; continued working after alleged abuse. |
| Administrative Nurse F | Administrative Nurse | Acknowledged failure to follow abuse policy and staff continued working after allegations. |
| Administrative Staff J | Administrative Staff | Acknowledged failure to follow abuse policy and lack of current medical director contract. |
| Nurse E | Charge Nurse | Reported abuse allegations and did not send alleged perpetrators home. |
| Nurse I | Charge Nurse | Received report of abuse and allowed alleged perpetrator to continue working. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 30, 2015
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 to be in substantial compliance with participation requirements and conditions constituted 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)
The facility was noncompliant with F225, CFR 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and F226, CFR 483.13(c), resulting in substandard quality of care.
Report Facts
Denial of payment effective date: Aug 20, 2015
Termination recommendation date: Jan 30, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Signed the report and provided contact information |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 25, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies from the survey completed on 2015-03-24.
Findings
The report documents that previously reported deficiencies identified by regulation numbers 26-39-103 (b) and 26-40-305 (e)(1)(2) were corrected as of the revisit date 2015-04-25.
Deficiencies (2)
Regulation 26-39-103 (b) deficiency was corrected by 2015-04-25.
Regulation 26-40-305 (e)(1)(2) deficiency was corrected by 2015-04-25.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 25, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-03-26.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Mar 27, 2015
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 developed and implemented corrective actions to assure compliance with regulations, including posting the abuse hotline number and modifying the ice machine drain pipe to prevent contamination.
Deficiencies (3)
S0000: The facility will develop and implement a system to assure correction and continued compliance with regulations and provide the deficiency list to the Quality Assurance Committee for review.
S0105-F: The abuse hotline number has been posted in the main hallway and added to the admission packet to ensure compliance with abuse reporting requirements.
S1358-F: The ice machine drain pipe was modified to ensure any backup spills over the drain bell without contacting the ice machine drain, with maintenance oversight to assure future compliance.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 12
Date: Mar 26, 2015
Visit Reason
Health Resurvey and Complaint Investigation #84288 conducted to assess compliance with resident rights, care, and facility conditions.
Complaint Details
The inspection was triggered by a complaint investigation #84288.
Findings
The facility failed to post required abuse reporting information, notify physicians of resident condition changes, maintain resident dignity, address resident grievances, maintain sanitary conditions, develop comprehensive care plans, provide necessary care and services, monitor fluid restrictions, monitor anticoagulant therapy, maintain sanitary food service, and implement infection control practices.
Deficiencies (12)
F156: Facility failed to post the name and telephone number of the state survey and certification agency for reporting abuse, neglect, and misappropriation of property for 44 residents.
F157: Facility failed to notify Resident #3's physician of non-compliance with prescribed 2000 cc/day fluid restriction.
F241: Facility failed to maintain dignity for Resident #7 whose wheelchair was in disrepair with torn padding.
F244: Facility failed to act on resident council recommendations to maintain comfortable temperatures in the shower and whirlpool room for 44 residents.
F253: Facility failed to maintain sanitary conditions in 4 resident bathrooms and a resident wheelchair scale with damaged flooring and unclean scale.
F279: Facility failed to develop a comprehensive care plan for Resident #3 regarding physician ordered fluid restriction.
F309: Facility failed to maintain appropriate positioning for Resident #5 who leaned to the right in wheelchair without positioning device.
F314: Facility failed to provide interventions to promote healing of a Stage 4 pressure ulcer for Resident #27, including timely dietician involvement and pressure relief measures.
F327: Facility failed to implement and monitor the 2000 cc/day fluid restriction for Resident #3 as ordered by the physician.
F329: Facility failed to monitor anticoagulant therapy for Resident #8 by not obtaining physician ordered protime lab in February.
F371: Facility failed to serve drinks under sanitary conditions by touching drinking surfaces and lacked a 2 inch air gap drainage system on ice machine to prevent backflow.
F441: Facility failed to provide appropriate infection control during incontinent care for Resident #27 and failed to implement proper hand hygiene to prevent infection transmission for all residents.
Report Facts
Resident census: 44
Fluid restriction: 2000
Fluid intake per shift: 1000
Fluid intake per shift: 600
Fluid intake per shift: 400
BIMS score: 14
BIMS score: 6
BIMS score: 5
BIMS score: 10
Pressure ulcer size: 3.5
Pressure ulcer size: 2.2
Pressure ulcer size: 2.5
Pressure ulcer tunnel depth: 6.4
Lab albumin: 2.7
Lab albumin: 2
Lab albumin: 2.3
Weight: 109
Weight loss: 4
Weight loss: 12
Medication administration: 10
Medication administration: 16
Inspection Report
Enforcement
Deficiencies: 1
Date: Mar 26, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
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, resulting in a finding of substantial compliance effective April 25, 2015.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
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 required abuse reporting information for residents and family. Additionally, the facility did not provide a drainage system with a 2 inch air gap to prevent backflow into the ice machine.
Deficiencies (2)
26-39-103 (b) Exercise of Resident Rights: The facility failed to post the name and telephone number of the state survey and certification agency to report abuse, neglect, and exploitation for the 33 residents.
26-40-305 (e)(1)(2) P E - Plumbing and piping systems: The facility failed to provide a drainage system with a 2 inch air gap to prevent backflow into the ice machine for the 33 residents.
Report Facts
Resident census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse A | Verified lack of posted abuse reporting information | |
| Maintenance Staff J | Stated the ice machine drainage system had no 2 inch air gap to prevent backflow |
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 CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously cited deficiency under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiencies were corrected by the revisit date of 09/10/2014.
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 #78142 found that the facility did not report or investigate an allegation that Nurse Aide C hit Resident #1 with a slipper and tried to stuff it down the resident's throat. Staff including Assistant Administrative Nurse E and Administrative Nurse D failed to report or initiate an investigation despite the resident's statements and facility policy requirements.
Findings
The facility failed to thoroughly investigate and report an allegation of abuse involving Resident #1 to the state agency as required by policy and regulations.
Deficiencies (1)
F 225 - The facility failed to thoroughly investigate and report an alleged abuse violation to the state agency for Resident #1.
Report Facts
Resident census: 49
Sample size: 3
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 26, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the initial survey conducted on 2014-01-27.
Findings
The report confirms that deficiencies previously cited under regulations 483.15(f)(1) and 483.25(h) were corrected as of 2014-02-26.
Deficiencies (2)
Regulation 483.15(f)(1): Previously cited deficiency was corrected by the revisit date.
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 8, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as indicated in the facility's plan of correction.
Findings
The revisit confirmed that the deficiency identified under regulation 483.35(i) was corrected as of 02/08/2014. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
Regulation 483.35(i): Previously cited deficiency was corrected by the revisit date of 02/08/2014.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Feb 4, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Complaint Details
This Plan of Correction addresses deficiencies cited following a complaint investigation at the facility.
Findings
The facility identified issues related to resident activities, medication management, and elopement risk. The Plan of Correction outlines steps to address these deficiencies including enhancing resident engagement, coordinating medical care, and improving elopement risk monitoring.
Deficiencies (3)
F-000 For deficiencies cited, this facility will develop and implement a facility wide system to assure correction and continued compliance with the regulations.
F-248 The facility will redirect outdoor magazines and provide daily local newspapers and TV Guide to a resident to improve engagement. Staff will ensure preferred TV programming and coordinate with the doctor to manage depression medication.
F-323 The facility compiled a list of residents at risk for elopement and will review it monthly. Wandergard functioning and door checks will continue as per policy, and a wandergard was placed on a resident's scooter. Staff were counseled on safety issues.
Report Facts
Complete Date for F-000: Feb 12, 2014
Complete Date for F-248 and F-323: Feb 26, 2014
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
This report is based on complaint investigation #72143. The complaint was substantiated as the facility failed to meet regulatory requirements related to activities and supervision.
Findings
The facility failed to provide an ongoing program of activities tailored to the interests and well-being of Resident #1. Additionally, the facility failed to provide adequate supervision to prevent accidents, including elopement, for Resident #1.
Deficiencies (2)
483.15(f)(1) Activities requirement was not met as the facility failed to provide an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of Resident #1.
483.25(h) The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent accidents, including elopement, for Resident #1.
Report Facts
Resident census: 43
Sample size: 4
Elopement risk score: 2
Time resident was missing: 40
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 9, 2014
Visit Reason
The visit was a licensure resurvey to assess compliance with regulatory requirements for facility licensure renewal.
Findings
The licensure resurvey resulted in a finding of no deficiency citations for the facility.
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 and did not ensure proper functioning of one of two ice machines. Observations included damaged kitchen floor tiles and an improperly piped ice machine drain lacking a required air gap.
Deficiencies (2)
483.35(i) The facility failed to store, prepare, and distribute food under sanitary conditions for 43 residents and did not ensure proper functioning of one of two ice machines. Kitchen floor tiles were buckled, cracked, scuffed, and discolored with a dark substance in the cracks.
The small ice machine in the sun room 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 |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 5, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory citations.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 5, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date of 12/05/2012.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Nov 9, 2012
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 multiple deficiencies related to resident skin condition assessments, privacy during injections, resident bathing requests, infection control procedures, medication order protocols, and medication kit management. The facility outlines corrective actions and monitoring responsibilities to ensure compliance.
Deficiencies (7)
F157-D: Resident #36 had bruising that was not properly assessed or reported in a timely manner. Staff will conduct weekly skin checks and report any issues immediately to the physician.
F241-D: To maintain resident privacy and dignity, injections will only be administered in residents' rooms with staff instructed accordingly.
F242-D: Staff will not refuse resident requests for extra baths and will coordinate with nursing staff to accommodate these requests promptly.
F309-D: Staff will use bruise/pressure ulcer tools to document skin conditions and ensure proper reporting and monitoring by nursing staff.
F371-D: Staff will follow proper hand hygiene and glove use protocols during dining assistance to prevent infection.
F425-D: Only nurses will take doctor's orders over the phone; other staff will take messages for nurses to return calls.
F431-E: The medication E-Kit will be monitored for drug expiration with calendar flags and double checks to ensure all drugs are current.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Blochlinger | Administrator | Submitted the Plan of Correction |
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 7
Date: Nov 5, 2012
Visit Reason
Annual health resurvey inspection of Sunset Home Inc to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including failure to notify physician of skin status changes, failure to maintain resident dignity during insulin administration, failure to allow resident choice in bathing frequency, inadequate skin assessments and preventive care, unsanitary food service practices, improper medication order procedures, and outdated medications in the emergency kit.
Deficiencies (7)
483.10(b)(11) The facility failed to notify the physician of a change in skin status for Resident #36 as required by the care plan.
483.15(a) The facility failed to provide care for Residents #23 and #29 in a manner that maintained their dignity and privacy during insulin administration.
483.15(b) The facility failed to provide Resident #39 the right to choose the number of baths or showers received each week.
483.25 The facility failed to provide accurate skin assessments, reassessments, and preventative measures for Resident #36 to maintain highest well-being.
483.35(i) The facility failed to distribute and serve food in a sanitary manner on one observed day.
483.60(a),(b) The facility failed to ensure only authorized licensed staff obtained physician telephone medication orders for Resident #32.
483.60(b),(d),(e) The facility failed to ensure medications in the emergency kit were not outdated, posing a risk to residents.
Report Facts
Resident census: 39
Sampled residents: 21
Bruises observed: 9
Medication expiration date: Oct 31, 2012
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 cited in a prior inspection.
Findings
No Plan of Correction was required for the cited deficiency F0000 as indicated in the document.
Deficiencies (1)
F0000 deficiency cited with no Plan of Correction required.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015006 POC TV5L11
Visit Reason
This document is a plan of correction related to a prior deficiency report for Sunset Home ALF.
Findings
No deficiency details or findings are included in this document. It only references the plan of correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 13
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, medication administration, and infection control policies.
Deficiencies (13)
F0000: Facility will develop and implement a system to assure correction and continued compliance with regulations and provide deficiency list to Quality Assurance Committee.
F156-C: Abuse hotline number has been posted in the main hallway and added to admission packets; administrator will review postings for ongoing compliance.
F157-D: Fluid restrictions for resident #3 discontinued per physician orders; new policy distributed to staff and physician orders will be care planned and communicated.
F241-D: Support wings removed from resident's wheelchair; night shift will monitor wheelchair maintenance and staff will submit repair requests as needed.
F244-E: Investigating solutions to coolness in bath house; will report monthly to resident council on concerns and corrections.
F253-E: Bathroom floors needing replacement will be replaced by compliance date; housekeeping will report floor issues and maintenance will make repairs.
F279-D: Physician's order for fluid restriction will be included in plan of care with specific amounts and monitoring; DON responsible for compliance.
F309-D: Order received for Part B therapy positioning resident in wheelchair; DON and staff will monitor repositioning effectiveness weekly.
F314-D: Pressure ulcer information will be faxed to dietician; residents educated on risks of sleeping in recliners; refusals documented; skin nurse and DON will monitor weekly.
F327-D: Fluid restrictions will be placed on MARs; dietary staff informed of amounts; I&O sheets placed in rooms; DON responsible for compliance.
F329-D: Protime blood draw for resident #8 completed; night nurse will do daily 24-hour order checks; DON responsible for future compliance.
F371-E: Ice machine drain pipe modified to prevent contamination; staff inserviced on safe handling of water glasses; dietary manager and DON responsible.
F441-F: New policies on glove use and emptying urinary drainage bags established; staff training and monitoring planned; noncompliance will be disciplined.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015006 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified by State ID N015006.
Findings
No deficiencies or findings are listed in this Plan of Correction document. It contains no records or details of corrective actions.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N015006 POC IEMU11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Findings
The facility acknowledged deficiencies related to abuse allegations and outlined corrective actions including immediate reporting, investigation procedures, removal of alleged abusers from resident care, and amendment of abuse policies to ensure reporting to the State abuse hotline within 24 hours.
Deficiencies (3)
F-0000 For deficiencies cited, this facility will develop and implement a facility wide system to assure correction and continued compliance with the regulations.
F-225 Credible allegation of compliance: Upon allegations of abuse, staff will report immediately to the administrator and DON and begin investigation. The alleged abuser will be removed from resident care and statements taken from involved parties and witnesses.
The facility's abuse policy will be amended to require reporting every case of alleged abuse to the State abuse hotline within 24 hours of the incident.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N015006 POC JDIY11
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 replace damaged kitchen floor tiles and correct the drain installation in the Sunroom ice machine to comply with regulations. Responsibilities for these corrections are assigned to the maintenance supervisor and dietary manager.
Deficiencies (3)
F0000 For deficiencies cited, this facility will develop and implement a facility wide plan of correction and continued compliance with the regulations. A complete deficiency list will be provided to the Quality Assurance Committee for review and action.
F371 Credible allegation of compliance: The facility will replace 6 damaged tiles under the kitchen steamer and 12 damaged tiles under the 3 compartment sink. The maintenance supervisor will oversee installation and future reporting of tile issues.
The drain in the Sunroom ice machine will be replaced to comply with regulations, including a 2 inch air gap. The maintenance supervisor will ensure future installations meet regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015006 POC LWRO11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for a regulated care facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015006 POC OK8711
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for the facility identified as Aspen, State ID N015006.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N015006 POC OK8712
Visit Reason
This document is a plan of correction related to a prior inspection event identified as OK8712 for the facility with State ID N015006.
Findings
No deficiency records or findings are included in this plan of correction document.
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