Sunset Health Care Center

In the surveyor’s words

From the most serious findings on record at Sunset Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 30, 2025

  Based on observation, interview, and record review, facility staff failed to propel four (Resident #3, #7, #24, and #111) out of six residents in a wheelchair in a manner to ensure resident safety. The facility census was 114. 1. Review of the facility's policies showed staff did not provide a policy for wheelchair safety. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/14/25, showed staff assessed the resident as: -Cognitively impaired; -Required partial to moderate assistance for ambulation greater than 50 feet; -No wheelchair. […]

• No harm, potential for more than minimal, widespreadF801Jan 5, 2024

  Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 107. 1. Review of the dietary supervisor's (DS) personnel records, showed a hire date of 6/13/23 and promoted to the dietary supervisor on 10/22/23. Review showed the records did not contain documentation of prior dietary manager experience in a long-term care facility and certification or other education required for the director of nutritional services position. […]

• No harm, potential for more than minimal, widespreadF803Jan 5, 2024

  Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. Facility staff also failed to record substitutions made to the menus. The census was 107. 1. Review of the facility's Menu Alternates and Substitutions policy, reviewed 11/27/23, showed the policy did not contain guidance related to substitutions for preplanned menu items. Review of the facility's Menu Substitution Form showed the last documented food substitution was dated 11-23. 2. […]

• No harm, potential for more than minimal, widespreadF812Jan 5, 2024

  Based on observation, interview and record review, facility staff failed to maintain kitchen equipment and surfaces in a clean sanitary manner to prevent the potential for cross-contamination. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff failed to sanitize kitchen wares in a manner to prevent contamination, and to store dishwares in a manner to prevent cross-contamination when staff stacked dishwares together wet. Facility staff failed to ensure hair/beard coverings remained in place during the preparation of resident meals to prevent the potential for food contamination. The facility census was 107. 1. […]

• No harm, potential for more than minimal, widespreadF882Jan 5, 2024

  Based on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 107. 1. Review of the facility's policies showed staff did not provide a policy for specialized training for the Infection Preventionist. During an interview on 01/05/24 at 10:15 A.M., the Director of Nursing (DON) said they do not currently have a certified IP. The Assistant Director of Nursing (ADON) is currently acting as the IP and their Regional Corporate Nurse (RNC), who is a certified IP, and himself/herself oversee IPC. He/She said he/she is not certified. […]