Sunset Home Inc

In the surveyor’s words

From the most serious findings on record at Sunset Home Inc, in the surveyor’s own words.

• Immediate jeopardy, patternF678Jul 11, 2023

  The facility had a census of 36 residents. The sample included 15 residents, with one closed record for death, reviewed. Based on record review and interview, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 41, who desired resuscitative measures indicated by his full code status (code status determination for residents who wish to receive CPR). On [DATE] at 05:00 PM, Licensed Nurse (LN) G observed R41 with irregular respirations. At 05:10 PM, LN G checked on R41 again and identified R41 had no pulse or respirations. Without considering R41's code status or initiating CPR, LN G placed a call to R41's representative, who did not answer. […]

• Actual harm, isolatedF550Dec 16, 2024

  The facility identified a census of 38 residents with three residents reviewed for resident's rights. Based on record review, observation, and interview, the facility failed to promote Resident (R) 1's right to choose, failed to respect R1's wishes, and failed to treat R1 with dignity and respect. On 12/05/24 at approximately 09:30 PM, R1 sat in his room in his wheelchair. Certified Nurse Aide (CNA) O heard another CNA say R1 did not want to go to bed. CNA M and CNA N went into R1's room and made R1 go to bed despite his protest. R1 became resistant to the transfer from his wheelchair to the bed and started hitting and kicking out at CNA M and CNA N. R1 yelled, No, no, no, no, and Get out of here. […]

• Actual harm, isolatedF686Oct 19, 2023

  The facility identified a census of 36 residents with three residents reviewed for pressure ulcers. Based on record review, observation, and interview, the facility failed to provide Resident (R) 1 with care consistent with professional standards of practice to prevent pressure ulcer development. R1 admitted to the facility on [DATE] without any skin issues to her buttock but had crevices to her bilateral heels from previous pressure ulcers. The facility failed to initiate a turning/repositioning program, cushion for wheelchair, or bilateral heel protectors/offloading to prevent R1 from developing pressure ulcers. On 03/27/23 R1 obtained suspected deep tissue injuries to her left sacrum and bilateral heels. […]

• No harm, potential for more than minimal, widespreadF801Mar 26, 2025

  The facility had a census of 39 residents. Based on observation, interview, and record review the facility failed to provide the services of a full-time certified dietary manager for 39 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 03/24/25 at 09:00 AM, observation in the facility kitchen revealed three staff working, including Dietary Staff BB who stated she was the dietary manager. She stated she started about three months ago, and was not certified. Dietary Staff BB stated she had just started taking the classes for Certified Dietary Manager. On 03/26/25 at 02:32 PM, Administrative Staff A verified the facility's Dietary Manager was not certified. […]

• No harm, potential for more than minimal, widespreadF880Mar 26, 2025

  The facility had a census of 39 residents. Based on observation, record review, and interview, the facility failed to maintain an infection monitoring surveillance plan and Enhanced Barrier Protection (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) as staff wore gown and gloves (PPE - gowns, face shields and/or eyeglasses/goggles, and gloves) in the hallway. This deficient practice placed the residents at risk for exposure to infectious processes. Findings included: - On 03/25/25 at 08:25 AM, Certified Nurse Aide (CNA) M wore a yellow protective gown and gloves while pushing a resident in a wheelchair to the dining room. […]