Sunset Lake Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sunset Lake Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Dec 6, 2024

  46824 Based on record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to protect residents' right to be free from neglect by failing to ensure the safety of residents during emergency evacuation ahead of hurricane [NAME] landfall, a major category 3 hurricane with winds of 120 miles per hour. On 10/8/24 the facility evacuated 112 residents. Due to heavy traffic related to the large scale evacuation, 96 residents traveled approximately 197 miles for eight hours to two receiving facilities. The facility neglected to ensure residents on the buses/vans received necessary medications, food, or hydration, during the transfer to receiving facilities and failed ensure staff were available during transport. […]

• Immediate jeopardy, widespreadF689Dec 6, 2024

  Based on record review and interviews with residents, residents representative and staff, the facility failed to ensure appropriate transportation, availability of assistive devices, and adequate supervision of dependent residents during emergency evacuation related to hurricane [NAME] a major category 3 storm. This failure affected all 112 residents evacuated from the facility and resulted in the emergency transfer of 2 residents (#7 and #9) to the hospital and unaddressed excruciating pain for 1 resident (#19). Resident #19 had multiple fractures and wore a neck brace. […]

• Immediate jeopardy, widespreadF835Dec 6, 2024

  Based on observation, interviews, and record review, the facility's administration failed to utilize its resources effectively to prevent the neglect of residents by failing to develop and implement an effective Emergency Plan emergency plan, including contingency planning for evacuation transportation and failing to adequately train and verify competency of staff to respond to natural disasters including emergency evacuation procedures in a safe and orderly manner. This failure resulted in avoidable serious harm of residents #7, #9 and #19 and created a likelihood of serious injury of 112 residents during emergency evacuation on 10/8/24 ahead of category 3 hurricane [NAME] landfall. […]

• Immediate jeopardy, widespreadF867Dec 6, 2024

  Based on record review and staff interviews the facility failed to implement corrective actions for identified quality deficiencies related to staff training and competency to respond appropriately to natural disasters to prevent the neglect of residents during natural disasters and emergency evacuation of residents. On 10/8/24 the facility did not ensure the safety of 112 residents during emergency evacuation ahead of category 3 hurricane [NAME] landfall. The facility did not ensure transportation to meet the needs of wheelchair and stretcher bound residents and failed to staff each transport bus or van with nursing staff to ensure residents safety, provision of care and administration of necessary physician ordered medications. […]

• Actual harm, isolatedF689Mar 9, 2023

  Based on record review, review of the policies and procedures, and staff and family interviews, the facility failed to implement appropriate interventions, including adequate supervision to prevent avoidable falls, including fall related major injuries for 1 (Resident #74) of 3 residents reviewed who sustained multiple falls at the facility. The failure to implement appropriate interventions to prevent falls and fall related injuries resulted in Resident #74 sustaining preventable falls, including falls with major injury requiring transfer to a higher level of care. The findings included: The facility policy Falls-Clinical Protocol (revised 3/18) documented The physician will help identify individuals with a history of fall and risk for falling. […]