Sun West Choice Healthcare & Rehab

In the surveyor’s words

From the most serious findings on record at Sun West Choice Healthcare & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Sep 3, 2024

  Based on record reviews, staff interviews and reviews of facility policies and procedures, the facility failed to ensure basic life support including CPR (cardio-pulmonary resuscitation) according to the physician order and the advance directives was provided for one resident (#56) prior to the arrival of the emergency medical personnel. The deficient practice resulted in the resident's advance directives not followed and delay in initiation of basic life support including CPR and risk for serious injury and harm. As a result, a condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The census was 134. Findings include: On [DATE] at 12:41 p.m., a condition of IJ was identified. […]

• Actual harm, isolatedF689Aug 28, 2023

  Based on clinical record review, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision was provided to one resident (#1) to prevent a fall with injury. The deficient practice resulted in a fall with injury. Findings include: Resident #1 was readmitted on [DATE] with diagnoses that included epilepsy, personal history of traumatic brain injury (TBI), hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side. A care plan initiated on March 29, 2023 included the resident had ADL (activities of daily living) self-care performance deficit related to TBI and was at risk for falls related to right sided weakness. […]

• No harm, potential for more than minimal, patternF600Aug 29, 2025

  Based on clinical record reviews, facility documentation, staff interviews and policy review, the facility failed to protect the rights of three residents (#38, #24, #23, #11) to be free from abuse from other residents (#39, #22, #10). The deficient practice could result in residents being physically or emotionally harmed.Findings include: -Regarding Resident #38 and #39 Resident #38 was re-admitted to the facility March 30, 2022, with diagnoses that included Alzheimer’s Disease, Dementia in other diseases classified elsewhere, Unspecified Severity, with other Behavioral Disturbance, Hypertension, Depression, Schizoaffective Disorder, and Unspecified Mood [Affective] Disorder. […]

• No harm, potential for more than minimal, patternF583May 5, 2022

  Based on review of the State Agency database, State Operations Manuel, clinical record review, staff interviews, and facility policies and procedures, the facility failed ensure that residents' private space was not photographed on a personal electronic device by a Certified Nursing Assistant. The deficient practice could result in further violations of privacy for residents. Findings include: Review of the State Agency database revealed that on April 29, 2022 at 5:16 pm a Certified Nursing Assistant (CNA/staff #69) submitted a complaint that contained 10 photographs. Four of the photos included residents' body parts including two imagines of residents' naked bottoms with open areas and redness. […]

• No harm, potential for more than minimal, patternF600May 5, 2022

  Based on review of the State Agency database, State Operations Manuel, clinical record review, staff interviews, and facility policies and procedures, the facility failed ensure that one staff member (#69) did not keep demeaning photographs of four vulnerable resident (#1, #2, #3, #4) on a personal electronic device. The deficient practice could result in further abuse of vulnerable residents. Finding include: Review of the State Agency database revealed that on April 29, 2022 at 5:16 pm a Certified Nursing Assistant (CNA/staff #69) submitted a complaint that contained 10 photographs. Four of the photos included residents' body parts including two imagines of residents' naked bottoms with open areas and redness. Another photograph included a resident's room with personal photographs. […]