| 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 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNSET HEALTH CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 400 WEST PARK AVENUE | |||||||||
| 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 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 | |
| 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 | |
| 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 |
| 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 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNSET HEALTH CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 400 WEST PARK AVENUE | |||||||||
| 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 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 |
| 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 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNSET HEALTH CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 400 WEST PARK AVENUE | |||||||||
| 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 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 | |
| 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** |
| 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 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SUNSET HEALTH CARE CENTER | STREET ADDRESS, CITY, STATE, ZIP 400 WEST PARK AVENUE | |||||||||
| 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. | |