Sunset Villa Post Acute

In the surveyor’s words

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

• Immediate jeopardy, widespreadF925Nov 5, 2021

  Based on observation, interview and record review, the facility failed to maintain an effective pest control program by not adhering to its policy and procedure for having bimonthly pest control maintenance service to eradicate (destroy) and prevent cockroach (the presence of an unusually large number of cockroaches [roach-a small insect that can be carriers and spread infectious diseases]) rodent (mouse/rat) infestation. There were more than eight (8) live adult German cockroaches at different stages of life cycle (a small species of cockroach) throughout the facility's kitchen serving 163 residents. […]

• Immediate jeopardy, patternF760Apr 27, 2024

  Based on interview and record review, the facility failed to ensure that during the facility ' s pharmaceutical services transition to a new pharmacy provider the residents continued to receive medications as order by the physician without missing any doses and would be free from significant mediation errors for three of six sampled residents (Resident 1, 2 and 3). The facility failed to: 1. Ensure Resident 1, who was prescribed Clonazepam (a control medication in schedule IV [group of medicines has been associated with abuse, misuse and diversion] used to treat anxiety, panic attacks and seizures) 1.0 milligram ([mg] a unit of measurement) for anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness) manifested by severe panic and agitation that interfered with care,… […]

• Immediate jeopardy, isolatedF678Jun 16, 2026

  Based on interview, and record review, the facility's staff failed to immediately initiate Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of three sampled residents (Resident 1), when Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 1, who were CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), found Resident 1 unresponsive (a person is unconscious and fails to react to any external stimulation), not breathing and without a pulse on [DATE] at 12:21 a.m. […]

• Immediate jeopardy, isolatedF689Mar 30, 2022

  Based on observation, interview, and record review, the facility's failed to ensure one of one sampled resident (Resident A), who had a history of a suicide attempt by wrapping a telephone cord around his neck, was provided an environment free of cords to prevent Resident A from utilizing cords as a tool to attempt suicide. The facility failed to: 1. Ensure Resident A, who had a recent suicide attempt by wrapping a telephone cord around his neck, was not left alone in a room with multiple cords accessible to the resident with the door closed. 2. Have interventions in place to address Resident A's safety monitoring and removal of objects Resident A used previously to attempt suicide, including telephone cords, call light cords, and other objects Resident A could use to harm himself. 3. […]

• Actual harm, isolatedF697Oct 10, 2024

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had an unwitnessed fall, did not experience extreme pain for over two hours after she was found on the floor, before care and treatment were rendered, when: 1. Licensed Vocational Nurse 1 (LVN 1) failed to report to Resident 1 ' s physician, that Resident 1 had an unwitnessed fall, so that care instructions including an order for pain medication could be prescribed and administered. 2. LVN 1 failed to conduct a post-fall assessment of Resident 1 to determine if an injury occurred or to determine Resident 1 ' s pain level. 3. […]