Sunset Valley Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 12, 2022

  Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse for 8 of 40 residents (Residents #7, #11, #17, #20, #28, #29, #33 and #39) reviewed for abuse Resident #33 was the victim of sexual assault (as defined by Texas Penal Code Chapter 22) perpetrated by Resident #29 on 05/28/22. On 05/28/22 LVN B, LVN C, and CNA A heard Resident #33 in her room screaming, No Stop! LVN B, LVN C, and CNA A ran down the hall and into Resident #33's room. CNA A entered Resident #33's room first and witnessed Resident #29 holding both of Resident #33's legs in the air with one hand while using his other hand to penetrate Resident #33's vagina. […]

• Immediate jeopardy, isolatedF580Aug 26, 2024

  Based on interview, and record review the facility failed to immediately inform the resident's physician and resident representative of a significant change in the residents' physical status and the need to significantly alter the resident's treatment for 1 of 4 residents (Resident #1) reviewed for Change in Condition. The facility failed to correctly notify the physician and resident representative of the extent of one facility-acquired Stage IV pressure injury for Resident #1, thus delaying proper treatment for 2 days. An Immediate Jeopardy (IJ) was identified on 08/22/2024. The IJ Template was provided to the facility on [DATE] at 4:53PM. […]

• Immediate jeopardy, isolatedF686Aug 26, 2024

  Based on observation, interview, and record review the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident # 1) reviewed for contractures. The facility did not prevent the development of one facility-acquired Stage IV, exposed tendon, pressure injury for Resident #1. This failure could place residents at risk for worsening of an ulcer, infection, and a decreased quality of life. An Immediate Jeopardy (IJ) was identified on 08/04/2024. The IJ Template was provided to the facility on [DATE] at 4:00PM. […]

• Actual harm, isolatedF686Aug 29, 2023

  Based on interview, and record review, the facility failed to ensure that the resident with pressure ulcers receives appropriate treatment/services received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers, for 1 closed record (CR #1) of 2 residents reviewed for pressure ulcers. CR #1 acquired a pressure ulcer to her coccyx that deteriorated to a stage IV wound while residing at the facility. […]

• Actual harm, isolatedF692Aug 29, 2023

  Based on interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible, for one closed record (CR# 1) of 1 resident reviewed for weight loss. CR #1 had a significant weight loss of 57.7 pounds, a 14.7% body mass loss in less than 6 months, January 2023 to June 2023. The facility failed to develop and implement interventions to prevent weight loss and improve wound healing. This failure affected 1 discharged resident and placed other residents at risk for weight loss, wound healing and a decline in health. Findings included: Record review of CR's #1's Face Sheet indicated a [AGE] year-old female originally admitted to facility on 5/31/2012. […]