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Deficiency Records for Sunset Manor Conv Hosp
A list of the most recent deficiencies for Sunset Manor Conv Hosp. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sunset Manor Conv Hosp. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-08-20 | 2024-09-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-13 | 2024-09-06 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-08-13 | 2024-09-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-24 | 2024-08-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-12 | 2024-05-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-04-12 | 2024-05-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-12 | 2024-05-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-12 | 2024-05-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-04-12 | 2024-05-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-12 | 2024-05-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-12 | 2024-05-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-04-12 | 2024-05-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-12 | 2024-05-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-12 | 2024-05-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-12 | 2024-05-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-04-12 | 2024-05-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-04-12 | 2024-05-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-12 | 2024-05-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-04-12 | 2024-05-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-12 | 2024-05-16 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-04-12 | 2024-05-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-04-12 | 2024-05-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-15 | 2024-05-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-04-15 | 2024-05-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-15 | 2024-05-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-15 | 2024-05-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-15 | 2024-05-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-15 | 2024-05-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-04 | 2024-04-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-06 | 2024-02-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-11-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-28 | 2023-08-07 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-28 | 2023-08-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-31 | 2023-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-09-20 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-10-21 | 2021-12-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-22 | 2021-11-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-22 | 2021-11-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-22 | 2021-11-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-10-22 | 2021-11-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-22 | 2021-11-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-22 | 2021-11-16 | N |
| Post nurse staffing information every day. | Health | 2021-10-22 | 2021-11-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-22 | 2021-11-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-10-22 | 2021-11-16 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-10-22 | 2021-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-22 | 2021-11-16 | N |
| Keep all essential equipment working safely. | Health | 2021-10-22 | 2021-11-16 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2021-10-22 | 2021-11-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-10-22 | 2021-11-16 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-05-10 | 2019-06-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-05-10 | 2019-06-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-10 | 2019-06-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-10 | 2019-06-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-10 | 2019-06-18 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-05-10 | 2019-06-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-10 | 2019-06-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-13 | 2019-06-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-13 | 2019-06-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-13 | 2019-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-13 | 2019-06-05 | N |
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