Sunset Manor Conv Hosp

In the surveyor’s words

From the most serious findings on record at Sunset Manor Conv Hosp, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 3, 2025

  Based on observation, interview, and record review, the facility failed to provide a safe environment as indicated in the facility's policies and procedures (P&P) titled, Preventive Maintenance Program, and Safe and Homelike Environment, for one of three sampled residents (Resident 1) by failing to: 1. Ensure the Maintenance Director (TMD) had a schedule of maintenance services for Resident 1's bed remote control coil line (coiled remote-control cord). 2. Ensure Certified Nurse Assistant 2 (CNA 2) prevented Resident 1 from grabbing onto Resident 1's damaged/broken bed remote control coil hanging on Resident 1's right bed side rail (an adjustable bar attached to a bed to help patients/residents move around) during care. […]

• No harm, potential for more than minimal, patternF558May 22, 2026

  Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of two sampled residents (Residents 1 and 48) in accordance with the facility's policy and procedure (P&P) titled Call Lights: Accessibility and Timely Response. These failures had the potential to delay meeting Residents 1 and 48's needs and placed the residents at risk for fall or accident/injury. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/28/2026 with diagnoses that included muscle wasting and atrophy, other abnormalities of gait (a person's manner of walking and mobility (the ability to move) and schizophrenia (a mental illness characterized by disturbances in thought). […]

• No harm, potential for more than minimal, patternF578May 22, 2026

  Based on interview and record review, the facility failed to ensure policies and procedures (P&P) on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) were implemented for two of two sampled residents (Residents 12 and 64) by failing to: a. Ensure Resident 12's Advance Healthcare Directive Acknowledgement Form (ADAF-form that indicated a resident or resident's representative were informed of their rights regarding medical treatments, Advance Directive formulation, and whether an AD was created) was not missing information and completely filled out. b. […]

• No harm, potential for more than minimal, patternF605May 22, 2026

  Based on interview and record review, the facility failed to prevent unnecessary use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) according to the facility's policy and procedure and the resident's care plan for two of five sampled residents (Residents 1 and 73) by failing to: a. Ensure the adverse side effects (unwanted or harmful effect) was monitored for the use of Divalproex ( mood stabilizer or treatment of seizures ), Clozapine (antianxiety medication to treat anxiety [group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]), Olanzapine (antipsychotic medication to treat mental disorder) oral tablet 5 milligrams (mg, unit of measurement) and Trazodone (antidepressant -… […]

• No harm, potential for more than minimal, patternF656May 22, 2026

  Based on interview and record review, the facility failed to develop a specific and individualized resident-centered care plan to meet the residents' needs for two of two sampled residents (Residents 14 and 26) by failing to:a. Develop a care plan for Resident 14 who was on enhanced barrier precaution (EBP, infection control measures to prevent the spread of multidrug resistant organisms [MDRO]). b. Develop a care plan for Resident 26 for the use of antibiotic therapy (medications used to treat and prevent infections caused by bacteria). These failures had the potential for Residents 14 and 26 not to receive necessary care, treatment, and services to address the residents' specific needs. Findings: a. […]