SUNSET HEALTH CARE CENTER - Steele Chaffee Nursing Home Abuse Law

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265390

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

400 WEST PARK AVENUE
UNION, MO 63084

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0570 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Assure the security of all personal funds of residents deposited with the facility. Based on interview and record review, facility staff do not maintain an acceptable bond amount to cover the balance in the resident trust fund account. The facility census was 95. 1. Review of the facility trust fund records showed the average monthly balance of the trust fund account from (MONTH) (YEAR) to (MONTH) (YEAR) to be $44,672.54 which rounded to the nearest thousand as $45,000.00 (1.5 of that amount equaled $67,500). 2. Review of the facility’s trust fund balance, bond number PB 6, showed the bond amount to be $50,000. 3. During an interview on 11/27/18 at 11:56 A.M., the Business Office Manager said she did not realize the facility resident trust fund bond had to be 1.5 times the average monthly balance of the resident trust fund.
	F 0576 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Ensure residents have reasonable access to and privacy in their use of communication methods. Based on interview and record review, facility staff failed to deliver residents’ personal mail on Saturdays. The facility census was 95. 1. Review of the facility’s policy on mail, dated 2/1/16, showed mail will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility’s post office box (including Saturday deliveries). 2. During the group interview on 11/29/18 at 9:41 A.M., with 10 residents identified by the facility as alert and oriented, said they do not receive mail on Saturdays. 3. During an interview on 11/29/18 at 10:55 A.M., the business office manager said they receive mail on Saturdays, but they do not distribute the residents’ mail on Saturdays. 4. During an interview on 11/30/18 11:18 A.M., the administrator and Director of Nursing, said mail is supposed to be delivered to the residents on Saturday. They said the Business Office Manager is responsible to deliver the mail, but he/she does not work on the weekends.
	F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and record review facility staff failed to give appropriate Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notices (SNFABN,) and the CMS Notice of Medicare Non-Coverage (NOMNC) to three resident’s (Resident #28, #68, and #86) of three sampled residents. The facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 95. 1. The facility did not have a policy on SNFABN or NOMNC notices.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0570

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assure the security of all personal funds of residents deposited with the facility.

Based on interview and record review, facility staff do not maintain an acceptable bond
amount to cover the balance in the resident trust fund account. The facility census was
95.
1. Review of the facility trust fund records showed the average monthly balance of the
trust fund account from (MONTH) (YEAR) to (MONTH) (YEAR) to be $44,672.54 which rounded to
the nearest thousand as $45,000.00 (1.5 of that amount equaled $67,500).
2. Review of the facility’s trust fund balance, bond number PB 6, showed the bond amount
to be $50,000.
3. During an interview on 11/27/18 at 11:56 A.M., the Business Office Manager said she did
not realize the facility resident trust fund bond had to be 1.5 times the average monthly
balance of the resident trust fund.

F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure residents have reasonable access to and privacy in their use of communication
methods.

Based on interview and record review, facility staff failed to deliver residents’ personal
mail on Saturdays. The facility census was 95.
1. Review of the facility’s policy on mail, dated 2/1/16, showed mail will be delivered to
the resident within twenty-four (24) hours of delivery on premises or to the facility’s
post office box (including Saturday deliveries).
2. During the group interview on 11/29/18 at 9:41 A.M., with 10 residents identified by
the facility as alert and oriented, said they do not receive mail on Saturdays.
3. During an interview on 11/29/18 at 10:55 A.M., the business office manager said they
receive mail on Saturdays, but they do not distribute the residents’ mail on Saturdays.
4. During an interview on 11/30/18 11:18 A.M., the administrator and Director of Nursing,
said mail is supposed to be delivered to the residents on Saturday. They said the Business
Office Manager is responsible to deliver the mail, but he/she does not work on the
weekends.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review facility staff failed to give appropriate Center for
Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notices
(SNFABN,) and the CMS Notice of Medicare Non-Coverage (NOMNC) to three resident’s
(Resident #28, #68, and #86) of three sampled residents. The facility initiated discharge
from Medicare Part A Services when benefit days were not exhausted. The facility census
was 95.
1. The facility did not have a policy on SNFABN or NOMNC notices.

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)
Previous Versions Obsolete

Event ID: YL1O11

Facility ID: 265390

If continuation sheet
Page 1 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265390

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

400 WEST PARK AVENUE
UNION, MO 63084

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 1) 2. Review of Resident #28’s Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form showed staff documented: -Medicare part A Skilled Services started 6/6/18; -Last covered day of Part A Service 7/13/18; -The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident’s record showed the resident remained in the facility and did not contain any documentation the resident or resident representative was sent a CMS SNF ABN letter. 3. Review of Resident #68’s SNF Beneficiary Protection Notification Review form showed staff documented: -Medicare part A Skilled Services started 9/10/18; -Last covered day of Part A Service 10/26/18; -The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident’s record showed the resident remained in the facility and did not contain any documentation the resident or resident representative was sent a CMS SNF ABN or NOMNC letter. 4. Review of Resident #86’s SNF Beneficiary Protection Notification Review form showed staff documented: -Medicare part A Skilled Services started 8/24/18; -Last covered day of Part A Service 8/30/18; -The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident’s record showed the resident remained in the facility and did not contain any documentation the resident or resident representative was sent a CMS SNF ABN or NOMNC letter. 5. During an interview on 11/30/18 at 10:57 A.M., MDS Coordinator A said he/she and MDS Coordinator B send out the SNF ABN and/or NOMNC letters. He/She said they typically document in the nurses’ notes the letters are sent, but he/she does not always document it. They said they are unaware of a policy for sending out the letters. 6. During an interview on 11/30/18 at 11:18 A.M., the administrator, Director of Nursing, and Regional Nurse said the MDS Coordinators are responsible for sending the SNF ABN and/or NOMNC letters to the resident or resident representative. They said they are not aware of any policy for the letters and they expect staff to document when staff send the letters. The said Residents #28, #68, and #86 still reside in the facility and should have documentation to show the letters were sent in their records.
	F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to ensure notice of discharge/transfer letters were provided to the resident or his/her representative and the state Ombudsman for three of 19 sampled residents (Residents #29, #35, and #95). The census was 95. 1. Review of Resident #29’s medical record, showed staff documented the following:

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
2. Review of Resident #28’s Skilled Nursing Facility (SNF) Beneficiary Protection
Notification Review form showed staff documented:
-Medicare part A Skilled Services started 6/6/18;
-Last covered day of Part A Service 7/13/18;
-The facility/provider initiated the discharge from Medicare Part A Services when benefit
days were not exhausted.
The resident’s record showed the resident remained in the facility and did not contain any
documentation the resident or resident representative was sent a CMS SNF ABN letter.
3. Review of Resident #68’s SNF Beneficiary Protection Notification Review form showed
staff documented:
-Medicare part A Skilled Services started 9/10/18;
-Last covered day of Part A Service 10/26/18;
-The facility/provider initiated the discharge from Medicare Part A Services when benefit
days were not exhausted.
The resident’s record showed the resident remained in the facility and did not contain any
documentation the resident or resident representative was sent a CMS SNF ABN or NOMNC
letter.
4. Review of Resident #86’s SNF Beneficiary Protection Notification Review form showed
staff documented:
-Medicare part A Skilled Services started 8/24/18;
-Last covered day of Part A Service 8/30/18;
-The facility/provider initiated the discharge from Medicare Part A Services when benefit
days were not exhausted.
The resident’s record showed the resident remained in the facility and did not contain any
documentation the resident or resident representative was sent a CMS SNF ABN or NOMNC
letter.
5. During an interview on 11/30/18 at 10:57 A.M., MDS Coordinator A said he/she and MDS
Coordinator B send out the SNF ABN and/or NOMNC letters. He/She said they typically
document in the nurses’ notes the letters are sent, but he/she does not always document
it. They said they are unaware of a policy for sending out the letters.
6. During an interview on 11/30/18 at 11:18 A.M., the administrator, Director of Nursing,
and Regional Nurse said the MDS Coordinators are responsible for sending the SNF ABN
and/or NOMNC letters to the resident or resident representative. They said they are not
aware of any policy for the letters and they expect staff to document when staff send the
letters. The said Residents #28, #68, and #86 still reside in the facility and should have
documentation to show the letters were sent in their records.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

Based on interview and record review, the facility failed to ensure notice of
discharge/transfer letters were provided to the resident or his/her representative and the
state Ombudsman for three of 19 sampled residents (Residents #29, #35, and #95). The
census was 95.
1. Review of Resident #29’s medical record, showed staff documented the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265390

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

400 WEST PARK AVENUE
UNION, MO 63084

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	(continued… from page 2) – On 9/22/18, the resident went to the hospital via ambulance; – On 9/24/18, the resident returned to the facility; – Additional review showed the resident’s medical record did not contain discharge letters issued to the resident’s representative or a copy issued to the state Ombudsman. 2. Review of Resident #35’s medical record, showed staff documented the following: – On 10/31/18, the resident went to the hospital via ambulance; – On 11/2/18, the resident returned to the facility; – Additional review showed the resident’s medical record did not contain discharge letters issued to the resident’s representative or a copy issued to the state Ombudsman. 3. Review of Resident #95’s medical record, showed staff documented the following: – On 9/1/18, the resident went to the hospital via ambulance; – On 9/2/18, the resident discharged from the facility; – Additional review showed the resident’s medical record did not contain discharge letters issued to the resident’s representative or a copy issued to the state Ombudsman. 4. During an interview on 11/30/18 at 11:58 A.M., the administrator and the Director of Nursing said they are not aware discharge or transfer letters are to be sent to the resident representative and the Ombudsman and they have not sent any letters.
	F 0838 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Based on interviews and record reviews, the facility failed to show documentation of a facility-wide assessment. The census was 95. 1. Review of the facility’s Emergency and Disaster Preparedness binder on 11/29/18 at 2:00 P.M., showed the documentation did not contain a facility assessment. 2. During an interview on 11/29/18 at 2:30 P.M., the administrator said the facility assessment should be in the back of the Emergency and Disaster Preparedness binder, but the assessment was not in the binder when she looked for it. She said she does not have another copy at the facility. Additionally, the administrator said she called the Corporate Office, but they did not have a copy of it either.
	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Provide and implement an infection prevention and control program. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to administer the Two-Step [MEDICATION NAME] (TB) test appropriately, read the test, and documented the results of the test in a timely manner for two sampled residents (Residents #38 and #67) and failed to ensure a chest x-ray was completed for one resident (Resident #38), with a documented allergy to the [MEDICATION NAME] serum. The facility census was 95. 1. The facility policy and procedure titled [MEDICAL CONDITION] Surveillance and Control dated 01/01/14, shows the purpose is for the control and prevention of nosocomial [MEDICAL

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 2)
– On 9/22/18, the resident went to the hospital via ambulance;
– On 9/24/18, the resident returned to the facility;
– Additional review showed the resident’s medical record did not contain discharge letters
issued to the resident’s representative or a copy issued to the state Ombudsman.
2. Review of Resident #35’s medical record, showed staff documented the following:
– On 10/31/18, the resident went to the hospital via ambulance;
– On 11/2/18, the resident returned to the facility;
– Additional review showed the resident’s medical record did not contain discharge letters
issued to the resident’s representative or a copy issued to the state Ombudsman.
3. Review of Resident #95’s medical record, showed staff documented the following:
– On 9/1/18, the resident went to the hospital via ambulance;
– On 9/2/18, the resident discharged from the facility;
– Additional review showed the resident’s medical record did not contain discharge letters
issued to the resident’s representative or a copy issued to the state Ombudsman.
4. During an interview on 11/30/18 at 11:58 A.M., the administrator and the Director of
Nursing said they are not aware discharge or transfer letters are to be sent to the
resident representative and the Ombudsman and they have not sent any letters.

F 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Conduct and document a facility-wide assessment to determine what resources are
necessary to care for residents competently during both day-to-day operations and
emergencies.

Based on interviews and record reviews, the facility failed to show documentation of a
facility-wide assessment. The census was 95.
1. Review of the facility’s Emergency and Disaster Preparedness binder on 11/29/18 at 2:00
P.M., showed the documentation did not contain a facility assessment.
2. During an interview on 11/29/18 at 2:30 P.M., the administrator said the facility
assessment should be in the back of the Emergency and Disaster Preparedness binder, but
the assessment was not in the binder when she looked for it. She said she does not have
another copy at the facility. Additionally, the administrator said she called the
Corporate Office, but they did not have a copy of it either.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to administer
the Two-Step [MEDICATION NAME] (TB) test appropriately, read the test, and documented the
results of the test in a timely manner for two sampled residents (Residents #38 and #67)
and failed to ensure a chest x-ray was completed for one resident (Resident #38), with a
documented allergy to the [MEDICATION NAME] serum. The facility census was 95.
1. The facility policy and procedure titled [MEDICAL CONDITION] Surveillance and Control
dated 01/01/14, shows the purpose is for the control and prevention of nosocomial [MEDICAL

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265390

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

400 WEST PARK AVENUE
UNION, MO 63084

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.

	(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 3) CONDITION] transmission in the facility in order to eliminate [MEDICAL CONDITION] as a public health problem. Guidance shows all residents new to long-term care, who do not have documentation of a previous skin reaction, >10 millimeters (mm) , or a history of adequate treatment of [REDACTED]. If the initial result is 0-9 mm, the second test, which can be given after admission, should be given at least one week and no more than three weeks after the first test. Documentation of a chest x-ray ruling out active [MEDICAL CONDITIONS] within one month prior to admission, along with an evaluation to rule out signs and symptoms of [MEDICAL CONDITION], may be acceptable by the facility on an interim basis until the Mantoux PPD two-step test is completed. 2. Review of Resident #38’s admission Minimum Data Set (MDS), a federally mandated assessment, showed the resident was admitted to the facility on [DATE] from another facility. A second admission MDS dated [DATE] showed the resident was admitted from an acute care hospital. Review of the resident’s face sheet showed the resident is allergic to the TB test serum. Review of the resident’s medical record did not show documentation of a negative chest x-ray. During an interview on 11/30/18 at 10:40 A.M., the ADON said he/she is aware the resident has an allergy to the TB test serum and thought a chest x-ray had been done. The ADON was unable to find documentation of a negative chest x-ray. During an interview on 11/30/18 at 11:35 A.M., the DON said a chest x-ray should should be performed on a resident unable to receive TB test serum. 4. Review of Resident #67’s admission MDS, showed the resident was admitted to the facility on [DATE]. Review of the Physician order [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Staff read the rest on 10/26/18 and documented the results as 0 mm. Additionally, staff documented on the (MONTH) MAR indicated [REDACTED]. Further review of the resident’s medical record showed staff did not document they administered or read a second TB test. During an interview on 11/30/18 at 10:36 A.M., the ADON said it appeared staff did not carry over the order from the (MONTH) POS to the (MONTH) POS and must have been missed. During an interview on 11/30/18 at 11:33 A.M., the DON said the TB order should have been carried over from (MONTH) to November. The DON said he/she and the ADON are responsible for reviewing orders for change over each month and the night shift nurses are responsible for performing a daily check of the POS to be sure all orders have been addressed.