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Deficiency Records for Sunset Villa Post Acute
A list of the most recent deficiencies for Sunset Villa Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sunset Villa Post Acute. 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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-09-04 | 2024-09-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-30 | 2024-08-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-05 | 2024-07-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-05 | 2024-07-26 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-05-29 | 2024-06-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-27 | 2024-06-18 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-26 | 2024-06-18 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-26 | 2024-06-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-26 | 2024-06-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-27 | 2024-05-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-26 | 2024-04-18 | 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 | 2024-03-26 | 2024-04-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-26 | 2024-04-18 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-26 | 2024-04-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-26 | 2024-04-18 | N |
| Provide appropriate foot care. | Health | 2024-03-26 | 2024-04-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-26 | 2024-04-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-26 | 2024-04-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-26 | 2024-04-18 | 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 | 2024-03-26 | 2024-04-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-26 | 2024-04-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-03-26 | 2024-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-26 | 2024-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-26 | 2024-04-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-27 | 2024-04-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-27 | 2024-04-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-27 | 2024-04-18 | 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 | 2024-03-27 | 2024-04-18 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-03-27 | 2024-04-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-27 | 2024-04-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-27 | 2024-04-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-27 | 2024-04-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-11 | 2024-04-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-11 | 2024-04-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-11 | 2024-04-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-11 | 2024-04-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-21 | 2024-03-18 | 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 | 2024-02-21 | 2024-03-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-24 | 2024-02-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-24 | 2024-02-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-11 | 2023-12-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-18 | 2023-11-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-12 | 2023-10-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-20 | 2023-08-28 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-08-05 | 2023-08-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-05 | 2023-08-25 | Y |
| Keep all essential equipment working safely. | Health | 2023-08-05 | 2023-08-25 | Y |
| 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 | 2023-02-06 | 2023-03-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-03 | 2023-03-05 | Y |
| Keep all essential equipment working safely. | Health | 2023-02-03 | 2023-03-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-02 | 2023-02-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-03 | 2023-01-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-15 | 2022-12-22 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-10-27 | 2022-11-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-25 | 2022-11-07 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-08-04 | 2022-09-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-09 | 2022-07-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-09 | 2022-07-15 | 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 | 2022-05-09 | 2022-07-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-05-09 | 2022-06-29 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-05-09 | 2022-06-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-09 | 2022-06-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-09 | 2022-06-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-09 | 2022-06-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-09 | 2022-06-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-09 | 2022-06-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-05-09 | 2022-06-29 | N |
| Provide appropriate foot care. | Health | 2022-05-09 | 2022-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-09 | 2022-06-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-09 | 2022-06-29 | 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 | 2022-05-09 | 2022-06-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-09 | 2022-06-29 | N |
| Post nurse staffing information every day. | Health | 2022-05-09 | 2022-06-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-09 | 2022-06-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-09 | 2022-06-29 | 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 | 2022-05-09 | 2022-06-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-09 | 2022-06-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-09 | 2022-06-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-09 | 2022-06-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-05-09 | 2022-06-29 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-05-09 | 2022-06-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-09 | 2022-06-29 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-05-09 | 2022-06-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-09 | 2022-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-09 | 2022-06-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-09 | 2022-06-29 | 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 | 2022-05-09 | 2022-06-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-27 | 2022-06-27 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-10 | 2022-06-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-10 | 2022-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-06 | 2022-04-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-30 | 2022-04-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-30 | 2022-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-30 | 2022-04-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-07 | 2022-04-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-17 | 2022-04-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-28 | 2022-02-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-11-05 | 2021-12-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-14 | 2020-03-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-14 | 2020-03-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-02-14 | 2020-03-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-14 | 2020-03-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-02-14 | 2020-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-14 | 2020-03-24 | 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 | 2020-02-14 | 2020-03-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-14 | 2020-03-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-14 | 2020-03-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-14 | 2020-03-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-14 | 2020-03-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-14 | 2020-03-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-14 | 2020-03-24 | 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 | 2020-02-14 | 2020-03-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-14 | 2020-03-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-14 | 2020-03-24 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2020-02-14 | 2020-03-24 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2020-02-14 | 2020-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-14 | 2020-03-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-14 | 2020-03-03 | N |
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