Sunset Ridge Rehabilitation and Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 25, 2024

  Based on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that two residents (Resident 45 and 42) were free from sexual abuse perpetrated by one resident (Resident 6) out of 19 sampled residents. Findings include: A review of the current facility policy entitled Abuse Prevention Program, last reviewed by the facility January 2024, revealed that the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. A review of the facility policy entitled Identifying Types of Abuse last reviewed January 2024, revealed sexual abuse is non-consensual sexual conduct of any type with a resident. […]

• Actual harm, isolatedF686Apr 19, 2022

  Based on review of clinical records and select facility policy, observation, and resident and staff interviews, it was determined that the facility failed to consistently provide necessary care and services to promote healing of pressure sores for two residents (Resident 4 and 1) and prevent deterioration and infection, which required surgery and caused the resident increased pain for one resident (Resident 1) out of five sampled residents. Findings include: A review of the current facility policy entitled Pressure Ulcer/Injury Risk Assessment indicated that a resident-centered and interventions should be developed with the resident's stated wishes and goals. The care plan should be modified as the resident's condition changes, or if current interventions are inadequate. […]

• Actual harm, isolatedF689Mar 3, 2021

  Based on a review of clinical records, facility provided documentation and select investigative reports, observations and staff and resident interviews, it was determined that the facility failed to provide necessary staff supervision with activities of daily living (bathing) to prevent a fall resulting in a serious injury, a fractured left femur, for one out of seven sampled residents (Resident 32). Findings include: A review of the clinical record revealed that Resident 32 was admitted to the facility on [DATE], with diagnoses, that included muscle weakness, lack of coordination, abnormalities of gait and mobility, left [CONDITION(S)] (paralysis of one side of the body), [CONDITION(S)] (an eye disease causing vision loss) and [CONDITION(S)] (a disease which the immune system eats away at… […]

• No harm, potential for more than minimal, widespreadF803Mar 13, 2025

  Based on review of the facility's planned 4-week menu cycle and menu extensions, resident interviews, and staff interviews, it was determined the facility failed to ensure the planned menu was sufficiently reviewed and updated to ensure that the menu offered variety and avoid repetitive meal selections. Findings included: During a Resident Council meeting conducted on March 12, 2025, at 10:35 AM, with Residents 40, 45, 48, and 264, concerns were raised regarding the lack of variety in the facility's menu. Resident 48 reported that the menu was repetitive, and they get the same meats for days in a row and that the meals offered on the facility's always available menu were the same items rotated throughout the standard regular menu. […]

• No harm, potential for more than minimal, widespreadF812Mar 13, 2025

  Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, increasing the risk of contamination and foodborne illness in the dietary department Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]