Sunset Ridge Post Acute

In the surveyor’s words

From the most serious findings on record at Sunset Ridge Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF808May 7, 2021

  Based on observation, interview, record review and document review, the facility failed to ensure the correct diet order was entered in the resident's medical record to prevent the resident from choking for 1 of 6 sampled residents (Resident #32) and failed to ensure the nursing staff checked food brought in by family members and resident representatives prior to being given to the residents who were on specialized/modified diets for 2 of 6 sampled residents (Resident #33 and #58). Findings include: 1) Resident 32 (R32) R32 was admitted on [DATE], with diagnoses including acute and chronic [CONDITION(S)] with hypercapnia, pneumonia, and chronic obstructive pulmonary disease. […]

• Actual harm, isolatedF607Jan 28, 2022

  Based on record review, interview, and document review, the facility failed to ensure a resident (victim of an alleged sexual abuse) was protected after the allegation was known by the facility's staff and, an allegation of sexual abuse was reported and investigated for 1 of 17 sample residents (Resident #10). Findings include: R10 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section G Functional Status of the Minimum Data Set (MDS) admission assessment dated [DATE], the quarterly assessments dated 08/04/2020, 11/03/2020, 02/03/2021, and the annual assessment dated [DATE], revealed R10 was totally dependent and unable to participate in any bathing activities, requiring two or more persons to support the activity. […]

• No harm, potential for more than minimal, widespreadF836Jun 15, 2026

  Based on observation, interview and document review, the facility failed to comply or establish compliance with all applicable Federal, State, and local laws, regulations, and codes, specifically concerning:(1) not being properly permitted for construction/electrical change activities within the building with the local building department;(2) not completing the change of ownership license application with the State Survey Agency;(3) by not completing the change of ownership license application with the State Survey Agency, the facility has prevented their Centers for Medicare Medicaid Services (CMS) certification change of ownership from proceeding to completion; and(4) not timely notifying the State Survey Agency with all Administrator changes at this facility. […]

• No harm, potential for more than minimal, widespreadF803Sep 27, 2024

  Based on observation, interview, and document review, the facility failed to ensure the menu was followed for a breakfast service. This deficient practice had the potential to affect all residents in the facility. Findings include: On 09/26/2024 at 8:31 PM, breakfast was delivered to residents in the Valley of Fire Unit to include cereal, fruit, pancakes and sausage. The Week At a Glance menu documented breakfast for Thursday would include assorted juice, choice of hot or cold cereal, cheesy eggs, hashbrowns, banana, toast, margarine or jelly, and milk or another beverage. […]

• No harm, potential for more than minimal, widespreadF812Sep 27, 2024

  Based on observation, interview, and document review, the facility failed to ensure 1) a dietary aide's purse was not being stored with resident food in the dry storage area of the kitchen, 2) a hairnet was donned prior to entering the kitchen, 3) hand washing was performed when entering the kitchen or prior to donning gloves, 4) beverages were covered when traveling down hallways, 5) food was stored at safe temperatures, and 6) thermometers were properly sanitized between foods during the taking of temperatures. This deficient practice placed residents at risk for food-borne infectious illnesses. Findings include: 1. Storage of personal items: On 09/23/2024 at 12:56 PM, located on a shelf containing food for residents, was a staff members purse. […]