SUNSET HILLS HEALTH AND REHABILITATION CENTER

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Based on interview and record review, the facility failed to verify code status (FULL CODE
– if the heart stops beating or breathing ceases, all life saving methods are performed;
or NO CODE – do not resuscitate, no life prolonging methods are performed) by having
conflicting information in the medical record for one resident (Resident #75) and not
obtaining a signed code sheet for one resident (Resident #34). The sample size was 19. The
census was 73.
1. Review of Resident #75’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated [DATE], showed the following:
-No cognitive impairment;
-Extensive assistance required for mobility and personal care;
-[DIAGNOSES REDACTED].
Review of the medical record, showed an 8 inch by 11 inch green sheet of paper in the
front of the chart with black block letters that read FULL CODE. There was no facility
code status form in the chart.
Review of the physician’s orders [REDACTED].
Review of the care plan, dated [DATE], showed the following:
-Problem: Resident has chosen to be a do not resuscitate;
-Goal: Resident’s wishes will be followed;
-Approaches: DO NOT initiate CPR (cardio-pulmonary resuscitation) if found without a
heart beat or
respirations, notify family of death, notify funeral home and provide post mortem care.
2. Review of Resident #34’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance of staff required for most activities of daily living (ADLs);
-Upper extremity impairment on one side and lower extremity impairment on both sides;
-At risk for pressure ulcers;
-Gastrostomy ([DEVICE], a tube surgically inserted into the stomach to provide hydration,
nutrition and medications) tube;
-Indwelling catheter (a sterile tube inserted into the bladder to drain urine);
-Tracheotomy (Tube surgically inserted into the trachea for the purpose of breathing);
-[MEDICAL CONDITION] (A surgical procedure that brings one end of the large intestine out
through the abdominal wall);
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed an 8 inch by 11 inch sheet of green paper
with FULL CODE in the front of the record. There was no signed outside the hospital Do Not
Resuscitate (OHDNR) form found in the medical record. As late as 2:00 P.M. on [DATE], the
facility did not provide the resident’s OHDNR form.
Review of the resident’s care plan, updated [DATE], showed the following:
-Problem, code status is full code;
-Goal, resident’s wishes will be carried out;
-Approach, in the event of a respiratory or [MEDICAL CONDITION], initiate CPR;
-Notify physician/family of resident status.
Review of the resident’s POS, dated [DATE] through [DATE], showed the resident’s status as
full code.
3. During an interview on [DATE] at 9:00 A.M., the Director of Nursing said code status is

Based on interview and record review, the facility failed to issue a Skilled Nursing
Facility Advanced Beneficiary Notice (SNF ABN), a Centers for Medicare and Medicaid
Services (CMS) Form (a required notice to beneficiaries of covered skilled services
ending) when benefits were not exhausted and the resident remained in the facility, for
two of three sampled residents (Resident #30 and #61), who remained in the facility upon
discharge from Medicare Part A services. The facility’s census was 73.
1. Review of Resident #61’s medical record, showed:
– The resident’s Medicare Part A skilled services, start date of 12/29/18 and end date of
2/14/19;
– The facility initiated a discharge on 2/12/19 from Medicare Part A Services when benefit
days were not exhausted;
– No SNF ABN Form issued.
2. Review of Resident #61’s medical record, showed:
– The resident’s Medicare Part A skilled services, start date of 11/26/18 and end date of
12/20/18;
– The facility initiated a discharge on 12/18/18 from Medicare Part A Services when
benefit days were not exhausted;
– No SNF ABN Form issued.
3. During an interview on 4/2/19 at 10:45 A.M., the social worker said, at times, she
supplies the SNF ABN Form . She called the responsible party for Resident #30 and spoke to
Resident #61 in person. She did not issue the forms. She knows she should have provided
the ABN SNF Form and had access to them.
4. During an interview on 4/3/19 at 9:00 A.M., the administrator said she would expect the
SNF ABN Form to be provided when appropriate.

Based on interview and record review, the facility failed to establish a grievance policy

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Based on interview and record review, the facility failed to follow appropriate discharge
procedures and complete discharge and/or transfer documentation. This affected two of four
reviewed closed records (Residents #178 and #77). The census was 73.
1. Review of Resident #178’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/19/18, showed the following:
-admission date of [DATE];
-Cognitively intact;
-No behaviors;
-Required extensive assistance from staff for toileting, hygiene, dressing and transfers;

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Based on interview and record review, the facility failed to ensure residents with a
mental disorder and individuals with intellectual disability had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASARR) level II screen is required) as required
for four of 19 sampled residents (Residents #44, #33, #28 and #21). The census was 73.
1. Review of Resident #44’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Independent with most ADLs;
-Continent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
-No DA-124 level I screen found;
-No PASARR level II screen found.
2. Review of Resident #33’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
-No DA-124 level I screen found;
-No PASARR level II screen found.
3. Review of Resident#28’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Verbal behaviors occurred between one to three days of seven days observed;
-Required extensive assistance from staff for bed mobility, transfers, dressing and
toileting;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed no DA-124 level I screen found.
4. Review of Resident #21’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Behaviors occurred on 4-6 days of seven days observed;
-Required extensive assistance from staff for most activities of daily living;
-[DIAGNOSES REDACTED].
Review of the resident’s medical records showed the following:
-No DA-124 Level I screening;
-No PASARR Level II screening.

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Based on observation, interview and record review, the facility failed to change an
ordered peripherally inserted central catheter (PICC, used for extended intravenous (IV)
therapy) dressing (Resident #75), failed to ensure diagnoses had been provided for ordered
antibiotic use and antibiotics were administered as ordered (Residents #75, #3 and #63),
failed to ensure the discontinuation of ordered compression stockings (TED hose, aide in
blood circulation in the legs) (Resident #44), failed to ensure oxygen orders were entered
onto the physician order [REDACTED].#33 and #17), and failed to document the placement of
an electronic monitoring device (Resident #36). This affected eight out of 19 sampled
residents. The census was 73.
1. Review of Resident #75’s admission Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 3/21/19, showed the following:
-No cognitive impairment;
-Extensive assistance required for mobility and personal care;
-Received IV medications;
-Received antibiotics seven of seven days;
-Diagnoses included heart failure, diabetes, [MEDICAL CONDITION] and right above the knee
amputation.
Review of the physician’s orders [REDACTED].
-Diagnoses included osteo[DIAGNOSES REDACTED] (bone infection) of the vertebrae, sacral
(bony structure at the base of the vertebrae) and sacrococcygeal (tailbone) region;
-An order, dated 3/7/19, to administer [MEDICATION NAME] (antibiotic) 2 grams (gm) IV in
50 milliliters (ml) of saline every twelve hours. Staff had not documented a [DIAGNOSES
REDACTED].
-An order, dated 3/7/19, to flush the PICC line with 10 cubic centimeters (cc)s of normal
saline (NS) every 12 hours before and after the IV antibiotic;
-An order, dated 3/7/19, to change the PICC line dressing every three days and as needed
(PRN).
Observations on 4/1/19 at 2:00 P.M., 4/2/19 at 10:00 A.M. and 4/3/19 at 7:34 A.M., showed
the resident lay in bed and the PICC line dressing showed a date of 3/29/19.
During an interview on 4/3/19 at 9:00 A.M., the Director of Nursing (DON) said the PICC
line dressing should be changed as ordered, and if the date showed 3/29/19, then that
showed staff had not changed the dressing as ordered.
2. Review of Resident #3’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Diagnoses included heart failure, dementia, stroke and urinary tract infection [MEDICAL

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Based on interview and record review, the facility failed to ensure one resident received
treatment and care in accordance with professional standards of practice by delaying

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to follow physician
orders [REDACTED]. This affected three of 19 sampled residents (Resident #21, #30 and
#26). The census was 73.
1. Review of Resident #21’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/15/19, showed the following:
-Severe cognitive impairment;
-Rejected care between 4-6 days observed;
-Required extensive assistance from staff for bed mobility, transfers, dressing, personal
hygiene and toilet use;
-Impaired range of motion on both sides, upper and lower extremities;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised on 1/19/19 and in use during the survey,
showed the following:
-Problem: Resident is at risk for pain related to contractures with limited mobility and
due to impaired ability to make needs known;
-Goal: Resident will verbalize relief of pain;
-Approaches included the use of non-medicated pain relief measurers such as physical
therapy, stretching and strengthening exercises.
Review of the resident’s medical record, showed the following:
-An (MONTH) 2019 physician order [REDACTED].
-No documentation to show the resident was evaluated by OT or PT or received treatment.
During an interview on 4/2/19 at approximately 11:30 A.M., the regional therapy manager
said they did not receive the order to evaluate and treat the resident. When a physician
gives the order, the nursing department will contact the therapy department to make them
aware. They did not evaluate or treat the resident.
During an interview on 4/03/19 at 9:53 A.M., the Director of Nursing (DON) said therapy is
made aware of orders at morning clinical meeting. This was discussed and therapy declined
to evaluate the resident because he/she had recently been screened. This should have been
documented by therapy and nursing should have discontinued the order.
2. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Extensive assistance of staff required for most activities of daily living (ADLs);
-Lower extremity (LE) impairment on both sides;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of a certificate of medical necessity, dated 8/9/18, showed the following:
-Prognosis: excellent;
-Function level: ambulatory with assistive device;
-Justification: to improve gait and continue ambulation for normal activity;
-Ankle-foot orthosis (AFO), single upright, articula (To help support the repair &
regeneration of articulations & joints);
-Additional notes, date of service 8/9/18, signed by the physician on 9/9/18: Patient

3. Review of Resident #26’s quarterly MDS dated [DATE], showed:
-Severe cognitive impairment;
-Extensive staff assistance needed for toileting, mobility, transfers and hygiene;
-[DIAGNOSES REDACTED].
-Received no physical or restorative therapy (RT).

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Based on observation, interview and record review, the facility failed provide immediate
safety interventions to a voiced suicidal resident (Resident #36) during the crisis and
after readmission from the hospital, failed to obtain a self administration order for
medications and left medications at the bedside unattended (Resident #61) and failed to
clarify transfer orders and techniques before a fall that resulted in an arm fracture
(Resident #26). This affected three of 19 sampled residents. The census was 73.
1. Review of Resident #36’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/6/19, showed the following:
-Moderate cognitive impairment;
-Behaviors included delusions and wandering;
-Required limited assistance from staff for transfers, walking, dressing, toileting and
personal hygiene;
-Used a wheelchair for mobility;
-[DIAGNOSES REDACTED].
-Daily use of wander/elopement alarm.
Review of the resident’s medical record, showed the following:
-A physician’s orders [REDACTED].
-A nurse’s note, dated 11/11/18 at 6:00 P.M., showed the nurse observed the resident to be
agitated and remembered the resident wandered the previous night without sleeping. When
the nurse returned, the resident continued to have lack of sleep. Around 6:00 P.M., the
resident propelled angrily down the hall. When asked what was wrong, the resident said
he/she was really mad because his/her spouse was fooling around with his/her best friend.
The resident became more agitated and requested to go to the hospital before he/she jumped
out of the window. The nurse documented he/she was doing a task and told the resident an
ambulance would be called. The resident said he/she wanted to go to the hospital now and
became loud and more agitated. The resident went to his/her room and tried to throw
himself/herself out of the window. Two certified nurse aides (CNAs) stopped the resident
and the nurse called 911. Staff were able to distract the resident until first responders
arrived;
-On 11/11/18 at 6:10 P.M., the police arrived, and the resident calmed down but still
wanted to be seen at the hospital. The resident stated he/she would throw him/herself out

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Based on observation, interview and record review, the facility failed to ensure staff
used proper urinary drainage bags and privacy bags for residents in bed, obtain
physician’s orders [REDACTED].#45, #75 and #34). The sample size was 19. The census was
73.
1. Review of Resident #45’s admission Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/18/19, showed the following:
-No cognitive impairment;
-Required limited assistance with all care;
-Suprapubic catheter (SP, a small rubber tube inserted through the abdomen in to the
bladder to drain urine);
-Special procedures included [MEDICAL TREATMENT] (a procedure that filters the blood to
rid the body of harmful waste);
-[DIAGNOSES REDACTED].
Review of the care plan, dated 2/19/19, showed the following:
-Problem: Required a SP catheter related to [MEDICAL CONDITION];
-Goal: SP catheter care will be managed appropriately as evidenced by not exhibiting signs
of obstruction, signs of infection, dislodgment of catheter, bowel perforation or trauma;
-Approaches: Assess drainage every shift and observe for signs/symptoms of infection,
avoid obstruction in the drainage, keep the system a closed system as much as possible,
position the bag below the level of the bladder.
Review of the physician’s orders [REDACTED]. The orders showed a check mark next to
catheter care.
During an observation and interview on 3/28/19 at 11:33 A.M., the resident lay flat in bed
with a urinary drainage bag strapped around his/her calf. He/she said he/she received
[MEDICAL TREATMENT] three times a week and had very little urine output.
Observation on 3/29/19 at 1:39 P.M., showed he/she lay flat in bed with no visible urinary
drainage bag.
During an observation and interview on 4/1/19 at 12:09 P.M., the resident said the
catheter was inserted three months ago and had never been changed. He/she emptied the bag
every day but there was usually only a few drops of urine in the bag. He/she added that
staff had not put a dressing on the insertion site.
Observations on 4/1/19 at 4:16 P.M. and 4/2/19 at 7:22 A.M. and 10:11 A.M., showed he/she
lay flat in bed with no visible urinary drainage bag.
2. Review of Resident #75’s admission MDS, dated [DATE], showed the following:
-No cognitive impairment;

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Based on observation, interview and record review, the facility failed to provide a
contract with the [MEDICAL TREATMENT] company and orders for and pertaining to [MEDICAL
TREATMENT] (the clinical purification of blood to rid the body of harmful waste as a
substitute for the normal function of the kidney). In addition, the facility failed to
perform thorough assessments, monitoring and ongoing communication with the [MEDICAL
TREATMENT] center for one of one resident who received [MEDICAL TREATMENT] (Resident #45).
The sample size was 19. The census was 73.
Review of Resident #45’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/18/19, showed the following:
-No cognitive impairment;
-Required limited assistance with all care;
-Special procedures included [MEDICAL TREATMENT];
-[DIAGNOSES REDACTED].
Review of the care plan, dated 2/19/19, showed the following:
-Problem: Requires [MEDICAL TREATMENT];
-Goal: Resident will not exhibit signs of fluid volume excess;
-Approaches: Assess for fluid excess (weight gain, [MEDICAL CONDITION] (swelling),
increased urinary output, shortness of breath, increased blood pressure and/or bounding
pulse and notify the physician. Monitor lab work and administer medications as prescribed.
Review of the resident’s physician order [REDACTED].

Based on interview and record review, the facility failed to establish a system of records
of receipt and disposition of all controlled drugs in sufficient detail to enable an
accurate reconciliation. The facility failed to properly document narcotic counts for the
controlled substances on two of the four facility medication carts. The facility census

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Based on interview and record review, the facility failed to ensure as needed (PRN) orders
for [MEDICAL CONDITION] drugs were limited to 14 days unless the attending physician or
prescribing practitioner believed that it was appropriate for the PRN order to be extended
beyond 14 days, document their rationale in the resident’s medical record and indicate the
duration for the PRN order, for two residents (Resident #54 and Resident #28). The
facility failed to ensure orders regarding PRN medications were clear. Furthermore, the
facility failed to ensure residents who use [MEDICAL CONDITION] drugs received gradual
dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue
these drugs by failing to ensure a resident’s monthly pharmacy drug regimen recommendation
was reviewed and acted upon by the physician for one sampled resident (Resident #28). This
resulted in a delay of four months to complete a GDR on a resident as recommended by the
pharmacist. The facility also failed to ensure all antipsychotic PRN medications had
appropriate diagnoses to show the necessity for the medication for one resident (Resident
#74). The sample size was 19 and the census was 73.
1. Review of Resident #54’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/23/19, showed the following:
-No cognitive impairment;
-Extensive assistance required for all care;
-Diagnoses included [MEDICAL CONDITION] (partial or total loss of movement to all four
limbs and torso), depression, anxiety and [MEDICAL CONDITIONS];
-Received antianxiety medication seven out of seven days.
Review of the physician’s orders [REDACTED].
Review of the Medication Administration Record [REDACTED].
Review of the MAR, dated 2/1 through 2/28/19, showed [MEDICATION NAME] 0.5 mg administered
26 times.
Further Review of the POS [REDACTED]. Start [MEDICATION NAME] after the supply of
[MEDICATION NAME] runs out.
Review of the MAR, dated 3/1 through 3/31/19, showed the following:
-[MEDICATION NAME] 0.5 mg administered 15 times;
-[MEDICATION NAME] 1 mg. administered 5 times;
-Both [MEDICATION NAME] and [MEDICATION NAME] administered on 3/30/19.
Review of the care plan, dated 2/25/19, showed the following:
-Problem: Receives antianxiety medication related to anxiety;
-Goal: Will not exhibit drowsiness, over sedation, delayed reactions or other adverse side
effects;
-Approaches: Assess behavior and mood, attempt non-pharmacological interventions, monitor
for the medication’s effectiveness and document the resident’s behaviors and moods.
During an interview on 4/3/19 at 9:00 A.M., the administrator said all psychoactive
medications have to be renewed every 14 days, and the Director of Nursing (DON) said the
medications should be reviewed monthly by the participating pharmacy. The DON said he
would have expected the pharmacy to pick up on the fact that the PRN medication had gone
beyond the 14 days. He added that the order for [MEDICATION NAME] should have never been
written the way it was. The [MEDICATION NAME] should have just been discontinued and then
start the [MEDICATION NAME]. He said the nurse should have obtained clarification of the
order, and actually the medication should be changed to routine since the resident used it

Based on observation, interview and record review, the facility failed to store, prepare,
distribute and serve food in accordance with professional standards for food service

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Based on observation, interview and record review, the facility failed to follow the
infection control policy and procedure to prevent potential spread of confirmed [MEDICAL
CONDITION] ([MEDICAL CONDITION], a bacteria that causes diarrhea and colon inflammation)
infection for one resident with [MEDICAL CONDITION] infection (Resident #63). This
practice placed current facility residents at risk for infection. The sample size was 19.
The census was 73.
Review of the facility’s Infection Prevention and Control policy and procedure for
[MEDICAL CONDITION] showed the following:
-Policy: The facility qualified staff will deliver care to the resident with [MEDICAL
CONDITION];
-General Information: [MEDICAL CONDITION] is a gram positive rod, spore forming organism
which produces toxin that damages the intestinal cells which may cause diarrhea and
[MEDICAL CONDITION];
-Transmission occurs when the organism or its spores get into a person’s mouth by direct
contact. It may transferred to residents if good hand hygiene/handwashing and appropriate
use of gloves are not practiced. The [MEDICAL CONDITION] spores can survive in the
environment for long periods of time;
-Precautions: Contact precautions will be implemented with known or suspected [MEDICAL
CONDITION]
*Full barrier precautions
-Gowns and gloves worn when staff are in contact with patients with [MEDICAL CONDITION]
infection and for contact with body fluids and environment;
-Gloves should be changed if visibly soiled and after touching or handling surfaces or
materials contaminated with feces;
-Gowns and gloves should be removed before exiting room.
Review of Resident #63’s medical record, showed the following:
-An order, dated 2/19/19, to obtain a [MEDICAL CONDITION] test sample;
-On 2/25/19, a positive [MEDICAL CONDITION] test;
-An order, dated 2/26/19, to begin [MEDICATION NAME] (antibiotic) 250 milligrams (mg) tab
four times a day for 30 days immediately.
During an observation and interview on 3/29/19 at 9:25 A.M., Certified Medication
Technician (CMT) H entered the resident’s room and did not wash his/her hands, gown, glove
or apply a mask. The resident’s door showed a red isolation precautions sign and
instructed staff must apply gloves, gown, mask and wash hands. CMT H placed the bottle of