Original Inspection report

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interview, and record review, the facility failed to ensure staff
treated residents in a manner to maintain their dignity when staff left Resident #25’s
catheter tubing visible to the public and allowed Resident #18 and #101’s brief and
abdomen skin to remain exposed in public areas. The facility census was 52.
1. Review of Resident #25’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 12/21/18, showed:
– Long and short term memory problems;
– Required extensive assistance of two staff for bed mobility, transfers, dressing, toilet
use and personal hygiene;
– Frequently incontinent of urine;
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 2/19/19, showed:
– The resident was at risk for a urinary tract infection [MEDICAL CONDITION], due to the
presence of an indwelling catheter (sterile tube inserted into the bladder to drain the
urine);;
– Keep the drainage bag off the floor at all times.
Observation on 2/19/19, at 8:15 A.M., showed:
– The resident sat at the nurse’s station in his/her tilt back wheelchair and it was
tilted all the way back;
– The catheter tubing was visible to the public and rested on the floor.
Observation on 2/19/19, at 9:15 A.M., showed:
– The resident sat at the nurse’s station and was tilted all the way back in his/her tilt
back wheelchair;
– The resident’s catheter tubing was visible to the public.
Observation on 2/20/19, at 8:49 A.M., showed:
– The resident sat at the nurse’s station and was tilted all the way back in his/her
wheelchair;
– The resident’s catheter tubing, with urine in the tubing, was visible to the visitors,
staff and other residents.
Observation on 2/20/19, at 4:00 P.M., showed:
– At various times during the day, the resident was tilted all the way back in his/her
tilt back wheelchair at the nurse’s station;
– The resident’s catheter tubing, with urine in the tubing, was visible to the public.
Observation on 2/21/19, at 5:53 A.M., showed:
– The resident sat at the nurse’s station and was tilted all the way back in his/her
wheelchair;
– The resident’s catheter tubing, with urine in the tubing, was visible to the public.
During an interview on 2/22/19, at 5:22 P.M., the Director of Nursing (DON) said:
– If there was urine in the catheter tubing or the catheter tubing was visible to anyone
who came to the facility, it would be a dignity issue.
2. Review of Resident #18’s MDS, dated [DATE], showed:
– Some difficulty with decision making skills;
– Extensive assist for dressing and locomotion from place to place in the facility;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, reviewed 12/4/18, directed staff to assist the

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
resident with dressing.
Observation on 2/19/19 at 11:49 A.M., showed the resident sat in a high back wheelchair in
the dining room at the assist table. The resident’s shirt did not reach the waist of
his/her pants. At least two inches of the resident’s sides and front of his/her abdomen
was visible to other residents and staff in the dining room. The resident wore a clothing
protector which did reach past the waist of the pants so that portion of the abdomen was
covered by the clothing protector. Nursing staff administered medication, served the noon
meal and assisted residents at the table, but no staff readjusted the resident’s clothing.
3. Review of Resident #101’s MDS, dated [DATE], showed:
– Some difficulty with decision making skills;
– Required assistance with dressing and moving from place to place in the facility;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 11/6/18, directed staff to assist the resident
with dressing.
Observation on 2/21/19 at 11:38 A.M., showed CNA C moved a chair in the dining room and
assisted the resident in his/her wheelchair move up to the assist table. On the resident’s
left side a six to eight inch triangle of skin and brief was visible to other residents
and staff in the dining room. Staff sat at the table to assist the residents eat but did
not re adjust the resident’s clothes. At 1:35 P.M., the resident sat in his/her wheelchair
in the front lobby, his/her shirt still did not reach the waist of the pants and the
triangle of skin and brief were still visible.
During an interview on 2/22/19, at 5:22 P.M., the Director of Nursing (DON) said:
– Staff should assist the residents with dressing if needed;
– Staff should make sure appropriate skin and briefs were covered, especially when in
public areas.

F 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Reasonably accommodate the needs and preferences of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to provide
acceptable accommodation of needs when they did not provide foot pedals for Resident #25’s
tilt back wheelchair (allows the whole wheelchair to tilt). The facility census was 52.
1. Review of Resident #25’s care plan, revised, 10/5/18, showed;
– The resident required assistance with activities of daily living (ADL’s) due to
cognitive deficit and disease progression;
– Use wheelchair for mobility;
– The resident is at risk for falls due to unsteadiness and increased weakness;
– Keep the resident’s wheelchair in the in reclined position when he/she is sitting out in
the lobby.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated, 12/21/18, showed:
– Long and short term memory problems;
– Required extensive assistance of two staff for bed mobility, transfers, dressing, toilet
use and personal hygiene;
– Frequently incontinent of urine;
– Always incontinent of bowel;

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
– [DIAGNOSES REDACTED].
Observation on 2/19/19, at 8:15 A.M., showed:
– The resident sat at the nurse’s station in his/her tilt back wheelchair and it was
tilted all the way back;
– The tilt back wheelchair did not have any foot pedals on it and the resident’s feet were
just dangling.
Observation on 2/19/19, at 9:15 A.M., showed:
– The resident was tilted all the way back in his/her tilt back wheelchair;
– The tilt back wheelchair did not have any foot pedals on it and the resident’s feet were
just dangling.
Observation on 2/20/19, at 8:49 A.M., showed:
– The resident was tilted all the way back in his/her wheelchair and did not have any foot
pedals on the wheelchair and his/her feet were just dangling.
Observation on 2/20/19, at 4:00 P.M., showed:
– At various times during the day, the resident was tilted all the way back in his/her
tilt back wheelchair;
– The resident did not have any foot pedals on the wheelchair and his/her feet were just
dangling.
Observation on 2/21/19, at 5:53 A.M., showed:
– The resident was tilted all the way back in his/her wheelchair;
– The resident did not have any foot pedals on the wheelchair and his/her feet were just
dangling.
Observation on 2/22/19, at 11:58 A.M., showed:
– The resident was tilted all the way back in his/her wheelchair;
– The resident did not have any foot pedals on the wheelchair and his/her feet were just
dangling.
During an interview on 2/21/19, at 1:45 P.M., Certified Nurse Aide (CNA) B said:
– He/she did not know why the resident did not have any foot pedals on his/her wheelchair;
– He/she thought the were foot pedals for it.
During an interview on 2/22/19, 2:09 P.M., CNA A said:
– The foot pedals did not fit on the resident’s wheelchair because the resident was so
tall;
– The staff tilted the resident all the way back because they did not want the resident to
stand up without assistance;
– The resident did not propel him/herself in the tilt back wheelchair;
– He/she did not think it was a restraint.
During an interview on 2/22/19, at 5:22 P.M., the Director of Nursing (DON) said:
– The foot pedals did not fit on the resident’s tilt back wheelchair;
– It is not the resident’s wheelchair and one of the foot pedals were broken and the
resident’s spouse would not let the facility get the resident a different chair;
– The resident had not been able to get up and walk since he/she had been there.

F 0572

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Give residents a notice of rights, rules, services and charges.

Based on interview and record review the facility failed to annually inform residents 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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0572

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
their rights; failed to orient newly admitted residents residing on the locked Geri-Psych
Unit (GPU) on how to communicate needs or inform them on GPU rules, services and
schedules. This affected two newly admitted residents (Resident #202 and #102). The
facility census was 52.
1. Review of the facility policy on Resident Rights revised 4/1/11, showed:
– Copies of survey reports and notices were to be available to residents. Any notice of
noncompliance will be posted along with survey inspections reports.
– Residents were to be fully informed of resident rights and responsibilities, and
reviewed with resident by the facility staff each year. Copies of such rights along with
governing rules are given upon admission to the facility. Documentation is made verifying
the receipt of resident rights by the resident.
– Each resident shall be encouraged and assisted throughout his/her stay to exercise their
rights as resident and citizen.
– Telephones appropriate to the residents needs shall be accessible at all times.
2. Review of Resident Council minutes for the past year showed staff did discuss or inform
residents of their rights.
Interview on 2/20/19 at 2:17 P.M., of the GPU resident group meeting showed:
– 6 of 12 residents in attendance, stated staff had not informed them of their rights.
Resident’s rights were not discussed at Resident Council meetings. Residents did not know
where to locate state survey results.
– Resident #202 said he/she was a new resident and had only resided in the facility for
six days. Since admit to the facility, Staff have not provided information to him/her
about the rules, schedule or where to go for services. He/she did not know any of the
staff. He/she did not know where a phone was or how to use it. He/she wanted to call
his/her family to let them know where he/she is living.
In an interview on 2/21/19 at 8:03 A.M., the Activities Director (AD) said he/she began
his/her position four months ago. He/she assisted residents with resident council. He/she
had not and did not know to review resident rights with residents. He/she reviewed
information provided to him/her on how to assist resident council. The information did not
include reviewing resident’s rights with the council. He/she has never informed residents
where to find state survey results and did not know where the results were located on the
GPU. Results were kept on the other side of the facility where GPU residents did not have
access. GPU residents should also have access to the results.
In an interview on 2/21/19 at 8:13 A.M., the Social Services Director (SSD) said:
– He/she attended three resident council meetings a year. He/she has never reviewed
resident rights with the council.
– He/she met with resident #202 at time of admit. He/she may not have informed the
resident about how to use the resident use phone. He/she should have informed the resident
as soon as he/she was admitted on how to access and use the phone.
– Resident #102 was admitted to the facility two weeks ago. He/she did not know if he/she
reviewed all the facility rules with the resident.
– Most GPU residents have guardians (GDN) who complete admission paperwork. The paperwork
includes a section on resident’s rights. He/she could not rely on GDN’s to pass on all
facility information to the residents.
– He/she met with residents upon facility admission and attempted to provide basic
knowledge of the facility. He/she did not use a guide or other information to assure all
areas including meal service schedule, smoking schedule, how to access money, where to
locate staff or how to access and use the resident use phone were covered. All areas of
care and services should be covered with residents upon admission. He/she did not have and
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0572

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
should have a system to assure residents knew all the rules. He/she should have a list as
a guide to assure he/she covered all areas.
3. In an interview on 2/22/19 at 6:41 P.M., the Administrator said newly admitted
residents should be oriented to the facility in order to know schedules for meals,
activities and smoking along with phone access, provided services and the environment of
the facility. She was not aware of residents not being informed of their rights.

F 0575

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Post a list of names, addresses, and telephone numbers of all pertinent State agencies
and advocacy groups and a statement that the resident may file a complaint with the State
Survey Agency.

Based on observations and interviews, the facility failed to ensure they posted in a
conspicuous location and available for residents and visitors on the facility locked
Geri-Psych Unit (GPU) a list of names, addresses (mailing and email), and telephone
numbers of all pertinent State agencies, such as the State Survey Agency, the State
licensure office, adult protective services, Medicaid and Medicare program information.
This had the potential to affect all of the 34 residents who resided on the GPU. The
facility census was 52.
1. Review of the facility policy on Resident Rights revised 4/1/11, showed postings were
to be in a conspicuous place.
A GPU group meeting on 2/20/19 at 2:17 P.M., showed 6 of 12 residents in attendance, who
actively participated in the meeting, agreed they did not know where information was
posted to access the state hotline number or Medicaid and Medicare information.
During an interview on 2/21/19 at 8:13 A.M., the Social Services Director (SSD) said
he/she did not know if state hotline phone number was posted. A year ago, the facility put
up a new residents rights poster on the GPU that did not include the state agency hotline
number. Medicaid and Medicare information was not posted.
Observation on of the GPU on 2/21/19 at 8:40 A.M., showed no list of names, addresses
(mailing and email), and telephone numbers of all pertinent State agencies, such as the
State Survey Agency, the State licensure office, adult protective services, Medicaid and
Medicare program information was posted.
In an interview on 2/22/19 at 6:41 P.M., the Administrator said required postings
information should be available and posted for the residents. They had problems with
residents who tore down the postings. They did not know of a way to secure the postings to
keep them available for all residents. They do not have a postings policy.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain resident rooms and
resident use areas in a clean homelike manner when tile floors were stained, dirty, had

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
debris or was broken; doors, door frames, drawers, wall unit registers and walls were
marred, scratched chipped or damaged; odor was persistent, bathroom ceiling lights had no
covers; painted surfaces were chipped; resident medical equipment was stored in resident
use area and black tape shown around wall unit air conditioners. This had the potential to
affect all of the facility residents. The facility census was 52.
1. Observations and interviews starting on 2/19/19 at 10:00 A.M., and all days of the
survey, 2/19/19 through 2/22/19, showed the following:
– No bathroom ceiling light covers in resident room restrooms for rooms 207, 209, 2B, 212
and 214.
– A persistent foul odor at the end of the 100 hall corridor.
– Dull floors with dirt, debris and food particles throughout the floors and room coves
for resident room [ROOM NUMBER] and 214.
– Resident room [ROOM NUMBER] had chipped paint on the bottom one-half portion of the
resident’s closet doors, bathroom door and interior corridor doors.
– The corridor door across from room [ROOM NUMBER] and room [ROOM NUMBER] restroom door
had scratched door finish covering half the door surfaces.
– Resident room [ROOM NUMBER] tile floor was chipped near the corridor door and was dusty.
– Resident room [ROOM NUMBER] floor had dull, cracked broken and separated tile with a
dark surface underneath.
– Resident room [ROOM NUMBER] had scuffed and marred walls.
– Resident room [ROOM NUMBER] floor corners were covered with dark dirt colored particles.
– Resident room [ROOM NUMBER] floor was dirty and stained. The wall unit register paint
was chipped, marred and scuffed. The restroom light was not working. The bathroom floor
was stained.
– Resident rooms 114, 116 and 118 had black tape around air conditioners mounted in the
wall. Wall unit registers were scratched.
– Resident room [ROOM NUMBER] wall unit register was chipped and marred. The drawer paint
was chipped. The floor was dirty and dull.
– Staff stored a Hoyer lift in front of the private phone use room of the locked
Geri-Psych Unit (GPU).
– The GPU weight room floor was stained, dull and dirty.
Observation and interview on 2/20/19 at 3:31 P.M., showed:
– Resident room [ROOM NUMBER] closet doors had chipped paint extending throughout half the
door surface. The floor surface and molding was dirty, dull and stained.
– Resident #40 said staff should repaint the doors. The floor molding was dirty and needs
to be cleaned up. The floor was dull and stained. Staff needed to clean and shine the
floor.
Observation and interview on 2/21/19 at 12:26 P.M., showed resident room [ROOM NUMBER]
wall unit had chipped paint across the surface. Door frames were scratched. Floor tile
near bed 2 had a section torn off. Corners of the floor was dirty. Resident #49 said the
room had been that way for a while.
During observation and interview on 2/21/19 12:48 P.M., Resident room [ROOM NUMBER] had
stained bathroom flooring. The drawer cabinet in the room had scuffed paint. Resident #102
said he/she was locked in the facility and wanted his/her room to look like a home with
the drawers painted.
Observations and interviews of Resident #13’s room, showed:
– On 2/19/19 at 10:59 A.M., the resident was lying in bed. Underneath and around the bed
was a rotten apple core, food wrapper, food crumbs and debris. The room floor was dull.
The room floor and cove edging around the room had a dark dirty appearing substance. The
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
resident said staff were in his/her room for cleaning one time daily. He had not eaten an
apple in the room for a few days.
– On 2/22/19 at 8:31 A.M., food crumbs and debris were around room cove edging and room
floor. The room floor appeared dull and dirty. The resident said staff should clean floors
better as it could attract pest.
2. During a group meeting in the facility locked GPU on 2/20/19 at 2:17 P.M., showed:
– 6 of 12 residents in attendance, who actively participated in the meeting, agreed that
the environment needed improvement.
– Resident #48 said the end of the facility South Hall corridor smelled like a dirty
toilet. He/she thought the cause could be a plumbing issue. He/she did not have the right
amount of light in his/her room.
– Resident #202 said resident room floors did not have a wax finish. He/she thought
facility floors would look better to anyone if they had a wax finish. He/she would want a
wax finish on the floor if he/she had visitors. He/she thought resident rooms needed
brighter bulbs to provide more light.
– Resident #40 said the back side of the dining room floor has never been cleaned like it
should be. The floors looked terrible.
3. In an interview on 2/21/19 at 12:55 P.M., Housekeeper (HSK) A said some floors need
replaced or refinished. Chipped paint surfaces needed to be repainted.
In an interview on 2/22/19 at 4:08 P.M., the Maintenance Supervisor (MS) said the
environmental problems in the facility were his responsibility. He was behind in painting.
Staff should keep floors clean and shiny. Lights should have covers. He did not have a
schedule to check room conditions. He checked rooms when he had a reason to access the
rooms. He was aware of concerns regarding an odor at the end of the 100 hall corridor.
Staff told him the end of the 100 corridor had a strong odor of vomit. He relied on his
housekeeping and laundry staff to inform him of room issues. He was responsible for staff
actions and needed to monitor the staff closer.
In an interview on 2/22/19 at 5:22 P.M., the Director of Nursing said she has instructed
and reminded staff not to store the Hoyer in front of the GPU private phone use room. The
GPU needed to be repainted and have a more homelike atmosphere.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interviews, the facility failed to assure they
provided care and treatment in accordance with professional standards of practice when
staff failed to follow guidelines for nasal spray, nebulizer treatment, inhalers and
medicated eye drops for Resident #8, #34, #45 and #50. Facility staff did not check
[DEVICE] placement before they administered medications for Resident #1. Staff did not
thoroughly complete an admission assessment and obtain physician’s orders
[REDACTED].#102’s pressure wound. Staff did not use a clean field for eye drop medication.
The facility’s census was 52.
1. Review of the facility’s policy for Installation of Eye Medication, dated 3/15, showed:
– Instruct resident to close eye. Gently press tissue against the lacrimal duct (inner
corner of the eye lid for approximately three minutes after the administration.

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
2. Review of Resident #45’s POS, dated 2/19, showed the physician ordered [MEDICATION
NAME] 0.3%
(medicated eye drop) one drop into each eye three times a day for 5-10 days until clear.
Observation on 2/21/19 at 7:51 A.M., showed CMT A, removed the cap of the eye drops and
sat it on the counter by the handwashing sink without using a clean field, and
administered one drop of [MEDICATION NAME] 0.3% in to each eye. He/she gave no instruction
to the resident to gently close his/her eyes for one to two minutes and did not apply
pressure to the inner corner of the eyelid.
During an interview on 2/21/19 at 1:53 P.M., CMT A said:
– He/she only new the resident had an order for [REDACTED].>- He/she should have
applied pressure to the inner corner of the eye for about a minute.
During an interview on 2/22/19 at 5:23 P.M., the DON said:
– Staff should apply pressure to the inner corner of the eye for five seconds after they
administered the eye drop;
– Staff should use a clean field.
4. Review of the facility’s Wound Care and Treatment policy, dated 7/15, showed:
– It is the purpose of this facility to prevent and treat all wounds;
– The physician will specifically order the treatment to be provided. (Includes cleansing,
ointments gauze dressing type and frequency of treatment).
5. Review of Resident #102’s medical record showed the following:
– admitted to the facility on [DATE];
– Admission Observation Detail List Report completed by the admitting charge nurse showed
at risk for skin break down and a wound vac. Monitor condition and report changes to the
Director of Nurses (DON)/Physician as applicable, Follow skin/wound treatment orders.
– The resident’s physician’s orders [REDACTED].
– CNAs documented on a Skin Monitoring Shower Sheet that the resident had two [DEVICE],
one on each hip.
Observation on 2/21/19 at 8:46 A.M. showed Certified Nurse Aide (CNA) C and D provided
incontinent care for the resident. The resident had [DEVICE] on the right and left hips.
The resident had a frayed duoderm, dated 2/11/19, attached to his/her left buttock.
Observation and interview on 2/22/19 at 8:44 A.M., showed Registered Nurse (RN) A
completed a dressing change to the resident’s left buttock. RN A said he/she obtained a
treatment order for the resident’s left buttock earlier on 2/22/19. Facility staff were
unaware the area on the left buttocks existed and had never treated the pressure ulcer on
the resident’s buttocks. There was no order to clean the wound vac areas on the right and
left hips, they just had an order to apply Santyl to the wound vac areas.
6. During an interview on 2/22/19 at 5:23 P.M., the DON said:
– The admitting charge nurse should have completed a head to toe assessment, identified
the wound on the resident’s left buttock and obtained orders to both cleanse and treat the
wound on the left buttock.
7. Review of the facility’s administration of gastrostomy tube medications, dated, March,
(YEAR), showed, in part:
– Check for tube placement.
8. Review of Resident #1’s physician order [REDACTED].
– an order for [REDACTED].>- an order for [REDACTED]. per peg tube daily;
– an order for [REDACTED].
– Aspirin 81 mg. chewable per peg tube daily;
– Flush peg tube with 30 ml. of water before medications and 60 ml. of water after
medications;
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
– Flush peg tube with 100 ml. every four hours;
– [MEDICATION NAME] 1.5 via peg tube continuously at 40 ml./hr.
Observation on 2/21/19, at 8:38 A.M., showed:
– Licensed Practical Nurse (LPN) B prepared the medications in separate medication cups;
– LPN B stopped the continuous tube feeding, disconnected the tube feeding and held it in
his/her gloved hand;
– LPN B attached the syringe and pulled back on the plunger and checked the residual;
– LPN B did not check for tube placement;
– LPN B flushed the peg tube and administered the medications, flushed the peg tube again
and restarted the continuous feeding.
During an interview on 2/22/19, at 5:22 P.M., the DON said:
– Staff should check for placement.
During an interview on 2/22/19, at 7:11 P.M., LPN B said:
– He/she thought he/she should have checked for placement but he/she had never done it
before and no one had shown him/her how to do it.
9. Review of the facility’s medication administration guidelines policy, dated, March,
(YEAR), showed, in part:
– It is the purpose of this facility that residents receive their medications on a timely
basis and in accordance with established policies. Drug administration shall be defined as
an act in which an authorized person, in accordance with all laws and regulations
governing such acts, gives a single dose of a prescribed drug or biological to a resident.
The complete act of administration entails removing an individual dose from a previously
dispensed properly labeled container (including a unit dose container), verifying it with
the physician’s orders [REDACTED].
– If there is doubt concerning the administering of medications, the physician’s orders
[REDACTED].
Review of the insert for [MEDICATION NAME] nasal solution, showed, in part:
– Before using, blow your nose gently;
– Close one nostril by gently placing your finger against the side of your nose, tilt your
head slightly forward and , keeping the bottle upright, insert the nasal tip into the
other nostril;
– Point the tip toward the back and outer side of he nose;
– Following each spray, sniff deeply and breathe out through your mouth;
– After spraying the nostril and removing the unit, tilt your head backwards for a few
seconds to let the spray spread over the back of the nose.
10. Review of Resident #50’s POS, dated, 2/19/19 through 2/28/19, showed:
– an order for [REDACTED].>- Did not specify if it was one or both nares.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] solution, 0.06%, two sprays nasally two times a day.
Observation on 2/21/19, at 8:13 A.M., showed:
– LPN B gloved, held one side of the resident’s nostril and gave one spray and repeated on
the other side with one spray;
– LPN B did not give the resident any instructions and did not have the resident blow
his/her nose before administering the nasal spray.
During an interview on 2/22/19, at 5:22 P.M., the DON said:
– Staff should follow the guidelines for the nasal spray;
– Staff should clarify if it is one nostril or both;
– If the order said for two sprays, staff should administer two sprays, staff should
follow the physician’s orders [REDACTED].>During an interview on 2/22/19, at 7:11 P.M.,
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
LPN B said:
– He/she should have administered two sprays;
– He/she should have followed the guidelines for administering the nasal spray.
11. Review of Resident #34’s POS, dated, February, 2019, showed:
– an order for [REDACTED].
Review of the package said to rinse mouth thoroughly after each use.
Observation on 2/21/19, at 8:03 A.M., showed:
– LPN B placed the medication in the chamber, handed the pipe to the resident, turned the
machine on and left the room.
Observation and interview on 2/21/19, at 8:20 A.M., showed:
– The resident had completed his/her nebulizer treatment and shut the machine off;
– The resident did not rinse his/her mouth out afterwards.
During an interview on 2/22/19, at 5:22 P.M., the DON said:
– Staff should make sure the resident rinsed their mouth after using the nebulizer and
also with steroid inhalers.
During an interview on 2/22/19, at 7:11 P.M., LPN B said:
– He/she should have had the resident rinse his/her mouth after the nebulizer.
Review of the website, www.webmd.com., for [MEDICATION NAME] eye drops, showed:
– To avoid contamination, do not touch the dropper tip or let it touch your eye or any
there surface;
– Tilt your head back, look upward, and pull down the lower eyelid to make a pouch;
– Hold the dropper directly over your eye and place one drop into the pouch;
– Look downward, gently close your eyes, and place one finger at the corner of your eye
(near the nose);
– Apply gently pressure for 1 to 2 minutes before opening your eyes. This will prevent the
the medication from draining out;
– Try not to blink or rub your eye;
– Repeat for the other eye.
12. Review of Resident #8’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] solution 0.03%, one spray in each nostril twice daily for allergies
[REDACTED].>- [MEDICATION NAME] solution 0.5%, instill one drop in both eyes twice
daily for [MEDICAL CONDITION].
Observation 2/21/19, at 9:51 A.M., showed:
– LPN B handed the [MEDICATION NAME] (atrovent) nasal spray to the resident and did not
give him/her any instructions on how to administer it;
– The resident sprayed one spray in each nostril;
– The resident did not blow his/her nose and did not close one side of his/her nostril;
– LPN B administered one drop of [MEDICATION NAME] to each eye of the resident and did not
apply lacrimal pressure.
During an interview on 2/22/19, at 5:22 P.M., the DON said:
– Staff should follow the guidelines for administering nasal spray, the resident should
blow their nose, and close one side of their nostril;
– Staff should apply pressure to the inner corner of the eye for five seconds after they
administered the eye drop.
During an interview on 2/22/19, at 7:11 P.M., LPN B said:
– The MAR indicated [REDACTED]
– He/she should have followed the guidelines for administering the nasal spray.

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0675

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor each resident’s preferences, choices, values and beliefs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review the facility failed to ensure one
resident (Resident #25) received care which would allow the resident to achieve his/her
highest practicable well being. The facility census was 52.
1. Review of Resident #25’s care plan, revised, 10/5/18, showed;
– The resident required assistance with activities of daily living (ADL’s) due to
cognitive deficit and disease progression;
– Use wheelchair for mobility;
– The resident is at risk for falls due to unsteadiness and increased weakness;
– Keep the resident’s wheelchair in the in reclined position when he/she is sitting out in
the lobby;
– The care plan did not address the resident’s activities.
Review of the resident’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 12/21/19, showed;
– The resident had long and short term memory problems;
– Required extensive assistance of two staff for bed mobility, transfers, dressing, toilet
use and personal hygiene;
– Required extensive assistance of one staff with meals;
– Dependent on one staff for bathing;
– Frequently incontinent of bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s progress notes, dated, 12/27/18, showed:
– Activities: the resident is unable to participate in activities;
– The resident’s spouse visits nearly every day and does take him/her to bingo;
– The resident sits in the lobby in his/her tilt wheelchair;
– He/she said hello to the resident but not for sure if the resident understood.
Observation on 2/19/19, at 8:15 A.M., showed:
– The resident sat at the nurse’s station in his/her tilt back wheelchair and it was
tilted all the way back;
– The resident’s eyes were closed.
Observation on 2/19/19, at 9:15 A.M., showed:
– The resident sat at the nurse’s station and was tilted all the way back in his/her tilt
back wheelchair;
– The resident was awake and staring at the ceiling
Observation on 2/20/19, at 8:49 A.M., showed:
– The resident sat at the nurse’s station and was tilted all the way back in his/her
wheelchair;
– The resident was awake and staring at the ceiling.
– The resident’s catheter tubing, with urine in the tubing, was visible to the visitors,
staff and other residents.
Observation on 2/20/19, at 4:00 P.M., showed:
– At various times during the day, the resident was tilted all the way back in his/her
tilt back wheelchair at the nurse’s station.
Observation on 2/21/19, at 5:53 A.M., showed:
– The resident sat at the nurse’s station and was tilted all the way back in his/her
wheelchair;

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0675

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
– The resident is awake and staring at the ceiling.
Observation on 2/22/19, at 9:12 A.M., showed:
– The resident sat at the nurse’s station and was tilted all the way back in his/her
wheelchair;
– The resident was awake and staring at the ceiling.
During an interview on 2/22/19, at 2:40 P.M., the resident’s spouse said:
– The staff do not take the resident to any activities;
– The resident just sits at the nurse’s station in his/her tilt back wheelchair;
– Sometimes if he/she is there, he/she will take the resident to play bingo;
– He/she would rather have the resident with his/her feet on the floor, but if staff did
not stay and monitor the resident, he/she would try to get up without assistance and would
fall and the spouse did not want the resident to fall.
Observations from 2/19/19 through 2/22/19, at various times showed:
– When the resident was awake, he/she could only stare at the ceiling due to being tilted
back in his/her wheelchair;
– When someone would walk past, the resident would look out of corner of his/her eye to
see who it was or what was happening.
During an interview on 2/22/19, at 5:22 P.M., the Director of Nursing (DON) said:
– The resident has not been able to walk since he/she had been admitted ;
– The tilt back wheelchair would probably be a restraint since the resident could not move
him/herself;
– The resident’s spouse took the resident to bingo if he/she was here;
– The resident should have a care plan for activities.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure
dependent residents received complete perineal care, which affected Resident #1 and #39,
and failed to provide A.M.,or morning cares, which affected Resident #37 and #50. The
facility census was 52.
1. Review of the facility’s perineal care policy, dated, March, (YEAR), showed, in part:
– The purposed is to cleanse the perineum and to prevent infection and odor;
– Use one gloved hand to stabilize the and separate the skin folds, with the other hand,
wash from front to back;
– Wash the perineal folds and separate the skin folds.
2. Review of Resident #1’s care plan, revised, 11/9/18, showed:
– The resident required assistance with activities of daily living (ADL’s) due to advanced
age and cognitive deficit.
Review of the resident’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 2/5/19, showed:
– Cognitive skills for daily decision making moderately impaired:
– Limited assistance of one staff for bed mobility, transfers, and toilet use;
– Supervision of one staff for dressing and personal hygiene;
– Always continent of bowel and bladder.

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
Observation on 2/21/19, at 7:08 A.M., showed:
– Certified Nurse Aide (CNA) A and CNA B used a gait belt and transferred the resident
from his/her recliner to the bedside commode;
– CNA A removed the resident’s wet incontinent brief;
– After the resident urinated and had a bowel movement, CNA A and CNA B stood the resident
up;
– CNA A wiped the rectal area with toilet paper;
– CNA A used a wet wash cloth and wiped from front to back with fecal material;
– CNA A used a new wash cloth and wiped from front to back;
– CNA A did not clean the front perineal folds or the buttocks;
– CNA A and CNA B sat the resident back down on the bedside commode;
– CNA B put a clean incontinent brief on the resident;
– CNA A and CNA B used the gait belt and stood the resident up and transferred him/her
into the recliner.
During an interview on 2/21/19, at 1:45 P.M., CNA A said:
– He/she should have cleaned all the areas of the skin where urine or fecal material had
touched.
3. Review of the facility’s early morning A.M., care, dated, March, (YEAR), showed:
– Allow the resident to brush teeth, or brush teeth or dentures for the resident if he/she
is not able;
– Wash resident’s face and hands and dry well;
– Did not address brushing or combing the resident’s hair.
Review of Resident #37’s care plan, revised, 11/5/18, showed:
– The resident required assistance with activities of daily living (ADL’s) due to
increased weakness and advanced age.
Review of the resident’s quarterly MDS, dated , 1/11/19, showed:
– Cognitive skills intact;
– Required extensive assistance of one staff with dressing and personal hygiene;.
Observation on 2/21/19, at 6:36 A.M., showed:
– The resident was in bed and pre-dressed;
– CNA A emptied the resident’s drainage bag;
– CNA A and CNA B used the gait belt and stood the resident up;
– CNA A and CNA B did not comb the resident’s hair, offer oral care or wash his/her face
and hands;
– The resident ambulated to the dining room with his/her rolling walker.
4. Review of Resident #50’s care plan, revised, 11/3/17, showed:
– Potential for decline in ADL’s and required supervision due to general weakness and
advanced age.
Review of the resident’s quarterly MDS, dated , 1/30/19, showed:
– Cognitive skills intact;
– Supervision of one staff with personal hygiene.
Observation on 2/21/19, at 6:46 A.M., showed:
– The resident was in his/her chair and was pre-dressed;
– The resident asked for a wet wash cloth to wash his/her face and hands;
– The resident transferred him/herself into the wheelchair;
– CNA A and CNA B did not offer oral care or brush the resident’s hair.
During an interview on 2/21/19, at 1:45 P.M., CNA B said:
– When the resident had been pre-dressed in the morning, he/she should have checked to see
if the resident was clean and dry;
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
– Should have made sure we offered the resident a wash cloth to wash his/her face and
hands, offered oral care and brushed or combed the resident’s hair.
During an interview on 2/21/19, at 2:09 P.M., CNA A said:
– He/she should have offered oral care, washed the resident’s face and hands and brushed
their hair.
During an interview on 2/22/19, at 5:22 P.m., the DON said:
– Staff should not pre-dress the resident unless the resident wants to be pre-dressed;
– In the morning, the staff should make sure the resident’s are clean, have clean clothes
different from what they slept in, hair combed, teeth brushed, deodorant applied, and wash
the resident’s face and hands.
5. Review of Resident #39’s care plan, last reviewed 5/18, showed:
– The resident is at risk for skin breakdown due to decreased bed mobility and urinary
incontinence;
– Take to the toilet before and after meals, at bedtime as needed to decrease incontinence
episodes;
– The resident wears adult briefs for dignity.
The care plan did not direct staff to provide peri care.
Review of the resident’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– Required extensive assist of staff with toilet use and personal hygiene;
– Occasionally incontinent of urine.
Observation and interview on 2/19/19 at 9:05 A.M., showed the resident sat in his/her
wheelchair in is/her room. The resident said his/her main problem was not all of the staff
would help him/her to the bathroom and do peri care for him/her. He/she said sometimes
he/she had to sit in a wet brief for hours and then he/ she got red and got a rash. He/she
had a rash that hurt in the groin area.
Observation and interview on 2/21/19 at 12:52 P.M., showed CNA C and CNA D removed the
residents pants and brief to provide peri care for the resident. Both groin areas were an
angry looking red. CNA C provided peri care in the following way:
– CNA C used pre-moistened wipes for each swipe and wiped once under the abdominal fold,
once down each groin and around the outer aspect of the genitalia;
– CNA C did not move and thoroughly cleanse all the perineal folds;
– CNA C wiped once from the rectum to the coccyx and one hand width on each buttock;
– CNA C said he/she did not think the resident’s groin area had been broken out or very
long;
– The resident usually told them when he/she needed to use the bathroom.
– CNA C did not clean the inner legs next to the perineal floor or the complete buttocks.
6. During an interview on 2/22/19, at 5:22 P.M., the Director of Nursing (DON) said:
– Staff should cleanse the front, back, the legs and the buttocks;
– Clean from front to back and the perineal folds;
– Staff should separate and clean all areas of the skin where urine or fecal material had
touched.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
Based on observation, interview, and record review, the facility failed to assure staff
completed a nursing admission assessment, identify a pressure ulcer and assure a physician
ordered treatment was in place for Resident #102’s pressure ulcer on the left buttock. The
facility census was 52.
Review of the facility’s Wound Care and Treatment policy, dated 7/15, showed:
– It is the purpose of this facility to prevent and treat all wounds;
– The physician will specifically order the treatment to be provided. (Includes cleansing,
ointments gauze dressing type and frequency of treatment).
Review of Resident #102’s medical record showed the following:
– admitted to the facility on [DATE];
– The admitting nurse’s Admission Observation Detail List Report assessment showed at risk
for skin break down and a wound vac (Vacuum assisted closure of a wound to his/her right
and left hips). The report did not show the nurse identified a pressure ulcer on the
resident’s left buttock.
– The resident’s 2/19 physician’s orders [REDACTED].
– Skin Monitoring Shower Sheets dated 2/15/18 and 2/18/19 showed staff did not identify a
pressure ulcer on the resident’s left buttock.
Observation on 2/21/19 at 8:46 A.M. showed Certified Nurse Aide (CNA) C and D provided
incontinent care for the resident. The resident had [DEVICE] on the right and left hips.
The resident had a frayed duoderm (dressing that aides in wound healing), dated 2/11/19,
attached to his/her left buttock.
Observation and interview on 2/22/19 at 8:44 A.M., showed Registered Nurse (RN) A
completed a dressing change to the resident’s left buttock. RN A said:
– He/she was not aware the resident had a pressure area on his/her left buttock;
– Facility staff were unaware the area on the left buttocks existed and had never treated
the pressure ulcer on the resident’s buttocks;
– He/she removed a duoderm from the left buttock dated 2/11/19 and obtained a treatment
order for the resident’s left buttock earlier in the morning on 2/22/19.
RN A cleaned the pressure ulcer and said it was a Stage II pressure ulcer (a partial
thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow
crater) that measured 1 centimeter (cm) by 1.5 cm by 1.5 cm depth.
During an interview on 2/22/19 at 5:23 P.M., the DON said:
– The staff had not treated the resident’s wound on the left buttocks because they did not
know it was there;
– The admitting charge nurse should have completed a head to toe assessment, identified
the wound on the resident’s left buttock and obtained orders to both cleanse and treat the
wound on the left buttock;
– Staff completing the Shower Skin Assessments should have identified the area and
reported it to their charge nurse.
During an interview on 2/22/19 at 7:11 P.M., Licensed Practical Nurse (LPN)B said:
– He/she admitted the resident to the facility;
– He/she only looked at the [DEVICE] on the resident’s hips;
– He/she did not look at the resident’s buttocks;
– He/she should have assessed and documented the area on the resident’s left buttock.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interview and record review, the facility failed to assure staff
assured residents remained free of accident hazards when they did not use proper
techniques to reduce the possibility of accidents and injuries during the use of a gait
belt (a safety device and mobility aid used to provide assistance during transfers,
ambulation or repositioning) transfer for Resident #102. The facility did not assure staff
performed a full length side rail assessment for Resident #39. Staff left a small oxygen
canister set on Resident #34’s floor unsecured within a few feet of another oxygen
canister in a portable holder. The facility census was 52.
The facility did not provide a gait belt policy.
1. Review of Resident #102’s medical record showed the following:
– admitted to the facility on [DATE];
– Staff had not completed a Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff.
– The admitting nurse’s Admission Observation Detail List Report assessment showed assist
of one staff with transfer.
Observation on 2/22/19 at 8:44 A.M., showed Certified Nurse Aide (CNA ) E placed a gait
belt around the resident then placed his/her right arm under the resident’s armpit,
grabbed the residents upper arm and held on to the gait belt with his/her left hand. When
he/she lifted the resident from the wheelchair the gait belt rose and the resident’s
shoulder rose. After staff completed a wound treatment on the resident, staff transferred
the resident back to the wheelchair. Once in the wheelchair the resident asked to lay back
down in bed. CNA E placed both of his/her arms under the resident’s upper arms, lifted the
resident under the arms and transferred him/her from the wheelchair back to the bed. CNA E
did not use the gait belt which was still on the resident.
During an interview on 2/22/19 at 9:40 A.M., CNA E said:
– He/she puts the gait belt on the resident at the mid section, tight but loose enough to
get his/her hand up under it;
– He/she always grabs the resident’s arm with one hand during the transfer because he/she
feels doing so is a supportive way to help the residents stand and it helps him/her
compensate for the need of a knee brace;
– He/she had noticed the residents felt more comfortable when he/she held under their arm
verses when he/she held the gait belt;
– The closer his/her body was to the resident the better they liked the transfer.
During an interview on 2/22/19 at 5:23 P.M., the Director of Nurses (DON) said:
– Staff should never hold the resident’s arm and lift a resident;
– Staff should use a gait belt to transfer the resident, one hand in front and one hand in
back.
2. Review of Resident # 39’s care plan, dated 2/1/18, showed the resident at risk for
falls due to [MEDICAL CONDITION] drug use and a history of falls and unsteadiness. The
care plan did not address the use of any side rails for the resident
Review of the resident’s Side Rail Assessment, dated 11/2/18, showed staff assessed the
resident needed quarter length side rails to assist the resident with bed mobility and to
assist with transfers.
Review of the resident’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– Required extensive assistance of two staff for transfers;

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
– [DIAGNOSES REDACTED].
Observation on 2/19/19 at 8:55 A.M., showed the resident sat in his/her wheelchair beside
the bed which was equipped with full length side rails. The full length side rails
remained on the resident’s bed on 2/20/19, 2/21/19 and 2/22/19.
Observation and interview on 2/22/19 at 3:04 P.M., the Administrator said the resident
only had quarter side rails that he/she used to help turn in the bed. When the
Administrator and Maintenance Man entered the residents room they looked at saw full
length side rails on the resident’s bed. Both said they did not know full length side
rails were used for any residents in the facility. The Administrator said they had
recently moved the resident to the special care unit and had not moved his/her bed. She
did not know the new bed had full length side rails, she would have them removed.
During an interview on 2/22/19 at 5:23 P.M., the DON said:
– Side rail assessments were completed by the charge nurse on admission to the facility
and then each quarter by the MDS coordinator.
3. Review of Resident #34’s admission MDS, dated , 11/21/18, showed:
– Cognitive skills intact;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated, February, 2019, showed:
– The resident did not have an order for [REDACTED].>Observation on 2/19/19, at 9:14
A.M., showed:
– The resident had a mini bottle of oxygen which sat directly on the floor in the
resident’s room and was not contained.
Observation on 2/21/19, at 8:00 A.M., showed:
– Mini bottle of oxygen sat directly on the floor in the resident’s room and was not
contained.
During an interview on 2/22/19, at 5:22 P.M., the DON said:
– Oxygen containers should not be left in a resident’s room unsecured.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record review, the facility failed to ensure staff
provided proper catheter (a sterile tube inserted into he bladder to drain urine) care in
a manner to prevent a urinary tract infection [MEDICAL CONDITION] or the possibility of a
UTI, which affected four residents, (Resident #5, #37, #50 and #102). The facility census
was 52.
1. Review of the facility’s indwelling catheter care policy, dated, March, (YEAR), showed,
in part:
– The purpose is to prevent infection and reduce irritation;
– Separate the outer skin folds and cleanse inside the skin folds using one area of a wash
cloth;
– Use a downward (front to back) cleansing stroke;
– Change position of the wash cloth with each downward stroke;
– Change the position of the wash cloth and wash around the urinary meatus (opening from

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
which urine flows from the bladder);
– Use a clean wash cloth to cleanse the from the insertion site to approximately four
inches outward (towards the point of attachment to the drainage bag tubing);
– Secure catheter utilizing a leg band;
– Did not address cleansing of the drainage port or keeping the drainage bag below the
level of the bladder to prevent backflow of urine into the urinary bladder.
2. Review of Resident #5’s care plan, revised, 10/5/18, showed:
– The resident had an indwelling catheter;
– Catheter care every shift;
– Keep drainage bag below bladder level at all times.
Review of the resident’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 2/8/19, showed:
– Cognitive skills severely impaired;
– Dependent on the assistance of two staff for transfers and toilet use;
– Had a Foley catheter;
– Frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 2/19/19, at 6:58 A.M., showed;
– Certified Nurse Aide (CNA) A and CNA B used the mechanical lift to transfer the resident
from his/her bed to the wheelchair;
– CNA A held the drainage bag above the resident’s bladder during the transfer;
– CNA B lowered the resident into his/her wheelchair and CNA A handed the drainage bag to
CNA B while CNA A unhooked the resident from the lift;
– CNA B placed the drainage bag and tubing on the floor;
– CNA A reached under the resident’s wheelchair and picked the drainage bag up and placed
it in the dignity bag under the resident’s wheelchair.
During an interview on 2/21/19, at 1:45 P.M., CNA B said:
– The drainage bag or tubing should not rest on the floor.
During an interview on 2/21/19, at 2:09 P.M., CNA A said:
– The drainage bag or tubing should not be on the floor;
– The drainage bag should not be held above the resident’s bladder.
Observation on 2/19/19, at 10:44 A.M., showed:
– The resident lay in bed and the drainage bag hung on the side of the bed and was not in
a dignity bag;
– The resident did not have a leg strap to secure the catheter tubing;
– CNA C used a wash cloth and wiped down one side of the resident’s groin, used a new wash
cloth and wiped down the other side of the resident’s groin;
– CNA C did not separate and clean all the front perineal folds;
– CNA C did not anchor the tubing and wiped down it;
– CNA C and CNA D dressed the resident and used the mechanical lift to transfer the
resident from his/her bed to the wheelchair;
– During the transfer CNA D held the drainage bag above the resident’s bladder;
– CNA D placed the drainage bag in the dignity bag under the resident’s wheelchair.
During an interview on 2/22/19, at 8:44 A.M., CNA C said:
– He/she should have anchored the catheter tubing at the insertion site where it enters
the body;
– The drainage bag should not bed held above the resident’s bladder;
– The resident should have a leg strap to secure the catheter tubing;
– He/she should have separated and cleaned all the perineal folds.
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
During an interview on 2/22/19, at 8:46 A.M., CNA D said:
– The resident should have had a leg strap to secure the catheter tubing;
– The drainage bag should not be held above the resident’s bladder.
3. Review of Resident #37’s care plan, revised, 11/5/18, showed:
– The resident was at risk for UTI’s due to the presence of an indwelling catheter;
– Catheter care every shift.
Review of the resident’s quarterly MDS, dated , 1/11/19, showed:
– Cognitive skills intact;
– Supervision with bed mobility and transfers;
– Limited assistance of one staff for toilet use;
– Had a Foley catheter;
– Occasionally incontinent of bowel.
Review of the resident’s physician order [REDACTED].
– The POS did not have an order to change the Foley catheter or for catheter care.
Observation on 2/21/19, at 6:36 A.M., showed:
– The resident was dressed and lay on the bed and the resident’s drainage bag was hung on
the side of the bed inside the dignity bag;
– CNA B wet wash cloths and placed them inside a plastic bag;
– CNA A hung the drainage bag on the side of the resident’s walker;
– CNA A placed a paper towel on the floor and placed the graduate on it;
– CNA A removed the spout from the sleeve, unclamped it and emptied the urine in the
graduate (a clear plastic container with markings which is used to collect and measure
urine);
– CNA A used a wet wash cloth and cleaned the spout and replaced it in the sleeve.
During an interview on 2/21/19, at 1:45 P.M., CNA B said:
– Should clean the drainage spout with an alcohol wipe.
During an interview on 2/21/19, at 2:09 P.M., CNA A said:
– He/she should have cleaned the drainage spout with an alcohol wipe;
– He/she should have emptied the drainage bag first, cleaned the spout and cleaned the
tubing at the insertion site.
4. Review of Resident #50’s quarterly MDS, dated , 1/30/19, showed:
– Cognitive skills intact;
– Supervision of one staff for bed mobility;
– Limited assistance of one staff for transfers and toilet use;
– Had a Foley catheter;
– Occasionally incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 2/19/19, showed:
– The resident had a Foley catheter;
– The resident was at risk for UTI’s due to the presence of an indwelling catheter;
– Catheter care every shift.
Observation on 2/21/19, at 6:46 A.M., showed:
– The resident sat in his/her chair;
– CNA B placed a paper towel on the floor and placed the graduate on it;
– CNA B removed the spout from the sleeve, unclamped it and emptied the urine in the
graduate;
– CNA B cleaned the spout with a wash cloth and replaced it in the sleeve;
– CNA B did not provide complete catheter care.
During an interview on 2/21/19, at 1:45 P.M., CNA B said:
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
– Should clean the drainage spout with an alcohol wipe;
– He/she should have provided complete catheter care.
5. Review of Resident #102’s medical record showed the following:
– admitted to the facility on [DATE];
– The admitting nurse’s Admission Observation Detail List Report assessment showed the
resident sometimes incontinent of bowel and bladder
Review of the resident’s 2/19 physician order [REDACTED].>Observation on all days of
the survey 2/19/19, 2/20/19, 2/21/19 and 2/22/19 at varying times throughout the day
showed the resident had an indwelling catheter.
Observation and interview on 2/21/19 at 8:46 A.M., showed the resident sat in his/her
wheelchair. CNA C and CNA D transferred the resident from his/her wheelchair to the bed
and provided peri care and catheter care in the following way:
– The urinary drainage bag dragged the floor as CNA C passed the drainage bag under the
wheelchair to CNA D;
– CNA D used pre-moistened wipes and wiped one time down each groin and once down the
front middle peri area;
– CNA D did not open and thoroughly cleanse all perineal folds;
– Staff assisted the resident roll to his/her side, CNA D wiped twice from rectum to
coccyx and removed smearing of fecal material. The resident said staff did not wipe
him/her good;
– With a clean wipe CNA D grasped the catheter tubing about four inches from the insertion
site and wiped from the insertion site down to where he/she held the tubing. The resident
hollered out, Don’t take it out, it’s hurting, it feels like you are pulling it out.
During an interview on 2/21/19 at 1:58 P.M.,, CNA D said when he/she provided peri care
and catheter care, he/she:
– Wiped once down the left side, once down the right side and once down the center;
– Rolled the resident to their side and wiped twice from the rectum to the coccyx;
– Should hold the tubing away from where it entered the body and the wipe down the tubing;
– He/she tried to not pull on the tubing.
6. During an interview on 2/22/19, at 5:22 P.M., the Director of Nursing (DON) said:
– Staff should not let the catheter tubing rest on the floor;
– Staff should use an alcohol pad to clean the drainage spout, not a wet wash cloth;
– When staff clean the catheter tubing, staff should anchor just a little ways down from
the insertion site and should clean the length of the tubing;
– Staff should not anchor the catheter tubing where it connects to the drainage tubing;
– Staff should provide peri care before they provide catheter care;
– Staff should not hold the drainage bag above the resident’s bladder;
– Staff should clean all areas of the skin;
– Catheter care is cleaning all areas of the skin, not just emptying the drainage bag
– Staff should make sure the resident had an order for [REDACTED].>

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to assure staff
provided proper respiratory care when staff failed to properly clean oxygen concentrator
filters, failed to ensure the oxygen tubing and nebulizer tubing had been changed and

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
dated, which affected four residents, (Resident #1, #5, #45 and #50). The facility census
was 52.
1. Review of the facility’s oxygen equipment cleaning guidelines policy, dated, March,
(YEAR), showed, in part:
– Purpose: oxygen equipment will be cleaned to ensure safety in handling and administering
oxygen;
– Humidifiers must be emptied and refilled every 24 hours with distilled water;
– Humidifiers are to be dated, initialed, and replaced monthly and PRN (as needed);
– Tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and PRN,
and marked with dated and initials;
– All concentrator outside surfaces are to be cleaned weekly by nursing personnel, and
marked with date and initials.
2. Review of Resident #1’s physician order [REDACTED].
– Change oxygen cannula every Sunday;
– Change nebulizer every Sunday;
– Check water in concentrator humidifier every shift and refill PRN;
– Clean concentrator, change water canister and clean filter weekly on Mondays.
Observation on 2/19/19, at 8:32 A.M., showed:
– The oxygen concentrator filter was covered in gray lint;
– The oxygen and nebulizer tubing was not dated;
– The sterile humidified water bottle attached to the oxygen concentrator was not dated
and almost out of water.
3. Review of Resident #5’s POS, dated, 2/1/19 through 2/18/19, showed:
– Change oxygen cannula every Sunday;
– Change nebulizer every Sunday;
– Check water in concentrator humidifier every shift and refill PRN;
– Clean concentrator, change water canister and clean filter weekly on Mondays;
– [MEDICATION NAME]/[MEDICATION NAME] inhalation solution, one vial per nebulizer four
times a day as needed for shortness of air.
Observation on 2/19/19, at 8:43 A.M., showed:
– The oxygen tubing and the nebulizer tubing did not have a date on it;
– The oxygen concentrator filter had gray lint on it;
– The humidified water bottle did not have a date on it.
4. Review of Resident #50’s POS, dated, 2/18/19 through 2/28/19, showed:
– Change oxygen cannula every Sunday;
– Change nebulizer every Sunday;
– Check water in concentrator humidifier every shift and refill PRN;
– Clean concentrator, change water canister and clean filter weekly on Mondays.
Observation on 2/19/19, at 8:57 A.M., showed:
– The oxygen tubing was not dated;
– The humidified water bottle did not have a date on it.
5. Review of Resident #45’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– [DIAGNOSES REDACTED].
Staff did not include oxygen therapy or a respiratory disease on the quarterly MDS.
Review of the resident’s care plan, dated 2/19/19, showed:
– Resident receiving antibiotic therapy for upper respiratory infection;
– Monitor for shortness of air.
Review of the resident’s 2/19 physician order [REDACTED].>- If on oxygen, check oxygen
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
saturation levels every shift and maintain greater than 90 %;
– [MEDICATION NAME] one vial per nebulizer four times a day times five days then four
times a day as needed;
– Change oxygen cannula every Sunday
– Change nebulizer every Sunday;
– Check water in concentrator humidifier every shift and refill as needed;
– Clean concentrator, change water canister and clean filter weekly on Monday.
Observation on 2/21/19 at 7:51 A.M., showed the resident sat in his/her room with
visitors. Neither the nebulizer or oxygen tubing were dated. The top of the oxygen
concentrator was dusty.
6. During an interview on 2/22/19, at 5:22 P.M., the Director of Nursing (DON) said:
– The night nurse changes out the oxygen and nebulizer tubing monthly on the 15th;
– The night nurse cleans the oxygen filters monthly;
– The oxygen and nebulizer tubing should be dated with tape;
– If the POS said for the nebulizer and oxygen tubing to be changed weekly, then it should
be done weekly.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assure staff
followed their policy for accountability and reconciliation of a Schedule IV
(narcotics/medications with a potential for abusive use and dependence upon the
medication) controlled substance for a medication stored in the facility’s locked
medication cart which affected Resident #5. The facility census was 52.
1. Review of the facility’s scheduled II – V medications policy, dated, March, (YEAR),
showed, in part:
– All Schedule II, III, IV, and V medications must be counted (comparing number of pills
to disposition record) at every change of shift by two Certified Medication Technician
(CMT) or one CMT and one licensed nursing staff;
– Both personnel must sign verification of correct count for Schedule II, III, IV, and V;
– If, at any time, the count is incorrect, CMT must notify licensed nursing staff, who
will call the Director of Nursing (DON) or designee.
2. Review of the facility’s medication administration guidelines, dated, March, (YEAR),
showed:
– It is the purpose of this facility that residents receive their medications on a timely
basis and in accordance with established policies. Drug administration shall be defined as
an act in which an authorized person, in accordance with all laws and regulations
governing such acts, gives a single dose of a prescribed drug or biological to a resident.
The complete act of administration entails removing an individual dose from a previously
dispensed properly labeled container (including a unit dose container), verifying it with
the physician’s orders [REDACTED].
– The person administering the drugs must chart medications immediately following the
administration;
– The date, time administered, dosage, etc. must be entered in the medical record and

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
signed by the person entering the data;
– If there is doubt concerning the administering of medications, the physician’s orders
[REDACTED].
– Each facility should institute and follow a policy and procedure for regular counting of
Class III and IV drugs.
3. Review of Resident #5’s physician order [REDACTED].
– 1/31/19- order clarification: [MEDICATION NAME] 5/325 mg., one tab every four hours PRN
(as needed) for pain.
Review of the resident’s individual controlled substance record, showed:
– 1/31/19: [MEDICATION NAME] 5/325 mg. one tab every four hours as needed (generic for
[MEDICATION NAME]), 30 tabs received.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated, 2/8/19, showed:
– Cognitive skills severely impaired;
– Occasionally had moderate pain;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated, February, 2019, showed:
– Start date: 9/19/18 – [MEDICATION NAME] 5/325 mg., one every four hours.
Review of the resident’s medication administration record (MAR), dated, February, 2019,
showed:
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
2/1/19: staff documented on the front of the MAR and documented on the back of the MAR the
medication administered, the reason and initialed.
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/1/19: Staff did not sign any [MEDICATION NAME] out for the resident.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
– 2/2/19: staff documented on the front of the MAR it was administered twice and
documented on the back of the MAR it was administered twice.
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/2/19: Staff did not sign any [MEDICATION NAME] out for the resident.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
– 2/3/19: staff documented on the front of the MAR it was administered twice and
documented on the back of the MAR it was administered twice.
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/3/19: Staff signed the [MEDICATION NAME] out, remaining count 29.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
– 2/7/19: staff documented on the front of MAR it was administered three times and
documented on the back of the MAR it was administered three times.
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/7/19: Staff signed the [MEDICATION NAME] out three times, remaining count 26;
– 2/8/19: staff signed the [MEDICATION NAME] out twice, remaining count 24;
Review of the resident’s MAR, dated, February, 2019, showed:
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
– 2/8/19: staff did not document on the front or the back of the MAR the medication had
been administered twice;
– 2/9/19: staff documented on the front of MAR it was administered once and documented on
the back of the MAR it was administered once.
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/9/19: staff signed the [MEDICATION NAME] out once, remaining count 23;
– 2/12/19: staff signed the [MEDICATION NAME] out twice, remaining count 21;
– 2/14/19: staff signed the [MEDICATION NAME] out once, remaining count 20;
– 2/16/19: staff signed the Hydorocodone out once, remaining count 19.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
– 2/12/19: staff did not sign the medication out on the front of the MAR and did not
document on the back of the MAR;
– 2/14/19: staff did not sign the medication out on the front of the MAR and did not
document on the back of the MAR;
– 2/16/19: staff did not sign the medication out on the front of the MAR and did not
document on the back of the MAR;
– 2/17/19: staff documented on the front of the MAR it was administered, did not document
on the back of the MAR.
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/17/19: staff did not sign any [MEDICATION NAME] out for the resident.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
– 2/18/19: staff documented on the front of the MAR it was administered, and documented on
the back of the MAR.
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/18/19: Staff signed the [MEDICATION NAME] out once, remaining count 18.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
– 2/19/19: staff documented on the front of the MAR it was administered, and documented on
the back of the MAR.
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/19/19: Staff signed the [MEDICATION NAME] out once, remaining count 17.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
– 2/20/19: staff documented on the front of the MAR it was administered, and documented on
the back of the MAR.
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/20/19: Staff signed the [MEDICATION NAME] out three times, remaining count 14.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] 5/325 mg., one tab every four hours PRN;
– 2/21/19: staff documented on the front of the MAR it was administered, and documented on
the back of the MAR.
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
Review of the resident’s controlled substance record showed:
– [MEDICATION NAME] 5/325 mg. one tab every fours hours PRN;
– 2/21/19: Staff signed the [MEDICATION NAME] out once, remaining count 13.
During an interview on 2/22/19, at 5:22 P.M., the DON said:
– If a resident wanted a pain pill, staff should document it on the front of the MAR and
on the back of the MAR why it was given and if it was effective;
– The narcotic pain medication has to be signed out on the narcotic count sheet;
– The narcotic count sheet, the MAR, front and back, should match and be correct;
– She thought staff were signing out the medication and administering it without
documenting they gave it, but it could easily be something else.
During an interview on 2/22/19, at 7:11 P.M., Licensed Practical Nurse (LPN) B said:
– When a resident requested a narcotic pain pill, should sign it out on the narcotic count
sheet, document it on the front of the resident’s MAR and on the back of the MAR with the
reason why it was administered.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure as
needed (PRN) orders for psychotic and [MEDICAL CONDITION] and drugs were limited to 14
days for Residents #17 and #39. The facility census was 52.
1. Review of Resident #17’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/6/18, showed:
– Unable to make daily decisions;
– Takes antipsychotic medication;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last reviewed 12/6/18, showed:
– Resident at risk for falls due to [MEDICAL CONDITION] drug use;
– Monitor for side effects of [MEDICAL CONDITION] drug use and report to charge nurse.
Review of the resident’s 2/19, physician order [REDACTED].
– [MEDICATION NAME] tablet 0/5 milligram (mg) one every six hours as needed (PRN) for
anxiety dated 11/5/18.
2. Review of Resident # 39’s MDS, dated ,[DATE], showed:
– Able to make daily decisions;
– Takes antipsychotic medication;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last reviewed 1/31/19, showed:
– Resident at risk for falls due to [MEDICAL CONDITION] drug use:
– Monitor for side effects of [MEDICAL CONDITION] drug use and report to charge nurse.
Review of the resident’s 2/19 POS, showed:
– [MEDICATION NAME] tablet 0.5 mg. Take one tablet four times a day as needed (PRN) dated
2/12/18.
During an interview on 2/22/19 at 5:23 P.M., the Director of Nurses (DON) said:

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
– She tried to catch the PRN [MEDICAL CONDITION] orders and speak with the physician when
he was in the building to have him update the orders for every 14 days.
– She had difficulty getting the physician’s response to drug regimen reviews and for
assessing residents every 14 days for PRNs order updates;
– The same physician had most of the residents in the facility and was also the facility’s
medical director.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff
administered medications with a medication error rate of less than 5%. Facility staff made
four medication errors out of 31 opportunities which resulted in a medication error rate
of 12.9%, which affected four residents, (Resident #1, #50 and #202). The facility census
was 52.
1. Review of the facility’s administration of gastrostomy tube medications, dated, March,
(YEAR), showed, in part:
– When possible order medications in liquid form to avoid clogging the tube;
– Medications should not be crushed for medications that will alter its effectiveness or
safety (i.e., [MEDICATION NAME] coated and time released);
– Check for tube placement;
– Check for residual and return to stomach if greater than 100 ml. of residual. If less
than 100 ml., of residual, return to stomach and flush with amount of water as ordered.
Review of the facility’s crushing medications policy, dated, March, (YEAR), showed, in
part;
– Medications shall be crushed only when it is appropriate to do so, consistent with
physician orders;
– The nursing staff and/or consultant pharmacist shall notify any attending physician who
gives an order to crush a drug when the manufacturer has stated that it should not be
crushed (for example, long-acting or [MEDICATION NAME] coated medications).
– The attending physician or consultant pharmacist must identify an alternative or the
attending physician must document (or provide the nurses with a clinically pertinent
reason to document ) why crushing the medication will not adversely affect the resident;
– Crushed medications should be administered with liquids or soft foods to ensure that the
resident receives the entire does ordered.
2. Review of Resident #1’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 2/5/19, showed:
– Cognitive skills moderately impaired;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED].
Review of the resident’s Medication Administration Record [REDACTED]
– [MEDICATION NAME] 1.5 via peg tube continuously at 40 ml./hr.;
– Flush peg tube with 100 ml. of water every four hours;
– Flush peg tube with 30 ml. of water before medications and 60 ml. of water after
medications.

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
Observation on 2/21/19, at 8:38 A.M., showed:
– Licensed Practical Nurse (LPN) B popped the [MEDICATION NAME] in a plastic medication
cup then placed it in a plastic pouch and crushed the medication and placed it in the
plastic medication cup and mixed it with 5 ml. of water;
– LPN B stopped the continuous tube feeding, disconnected the tube feeding and held it in
his/her gloved hand;
– LPN B attached the syringe and pulled back on the plunger and checked the residual;
– LPN B did not check for tube placement;
– LPN B flushed with 30 ml., of water then administered the [MEDICATION NAME] and did not
get all the residual of the medication from the medication cup;
– LPN B flushed the 60 ml., of water and had chunks of the [MEDICATION NAME] in the bottom
of the syringe and flushed with another 40 ml. of water with chunks of the [MEDICATION
NAME] still in the syringe;
– LPN B reattached the feeding tube and turned it back on;
– LPN B rinsed out the syringe with the chunks of [MEDICATION NAME] and placed it back in
the graduate container.
During an interview on 2/22/19, at 5:22 P.M., the Director of Nursing (DON) said:
– [MEDICATION NAME] should not be crushed;
– There should not be any medication left in the medication cup or the syringe.
During an interview on 2/22/19, at 7:11 P.M., LPN B said:
– The [MEDICATION NAME] had to be crushed because the resident had a peg tube;
– He/she should have made sure all the medication was out of the medication cup and the
syringe.
3. Review of the facility’s medication administration guidelines policy, dated, March,
(YEAR), showed, in part:
– It is the purpose of this facility that residents receive their medications on a timely
basis and in accordance with established policies. Drug administration shall be defined as
an act in which an authorized person, in accordance with all laws and regulations
governing such acts, gives a single dose of a prescribed drug or biological to a resident.
The complete act of administration entails removing an individual dose from a previously
dispensed properly labeled container (including a unit dose container), verifying it with
the physician’s orders [REDACTED].
– If there is doubt concerning the administering of medications, the physician’s orders
[REDACTED].
Review of the insert for [MEDICATION NAME] nasal solution, showed, in part:
– Before using, blow your nose gently;
– Close one nostril by gently placing your finger against the side of your nose, tilt your
head slightly forward and , keeping the bottle upright, insert the nasal tip into the
other nostril;
– Point the tip toward the back and outer side of he nose;
– Following each spray, sniff deeply and breathe out through your mouth;
– After spraying the nostril and removing the unit, tilt your head backwards for a few
seconds to let the spray spread over the back of the nose.
4. Review of Resident #50’s POS, dated, 2/19/19 through 2/28/19, showed:
– an order for [REDACTED].>- Did not specify if it was one or both nares.
Review of the resident’s MAR, dated, February, 2019, showed:
– [MEDICATION NAME] solution, 0.06%, two sprays nasally two times a day.
Observation on 2/21/19, at 8:13 A.M., showed:
– LPN B gloved, held one side of the resident’s nostril and gave one spray and repeated on
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
the other side with one spray;
– LPN B did not give the resident any instructions.
During an interview on 2/22/19, at 5:22 P.M., the DON said:
– Staff should follow the guidelines for the nasal spray;
– Staff should clarify if it is one nostril or both;
– If the order said for two sprays, staff should administer two sprays, staff should
follow the physician’s orders [REDACTED].>During an interview on 2/22/19, at 7:11 P.M.,
LPN B said:
– He/she should have administered two sprays.
5. Review of the insert for Humalog (fast acting insulin) provided by the Director of
Operations who stated Humalog was the same as [MEDICATION NAME] insulin, did not indicate
administration time in relation to the time of meal service,
Review of the current [MEDICATION NAME] Web MD guideline showed:
– [MEDICATION NAME] is a fast acting insulin. Eat a meal within five to ten minutes after
taking it.
6. Review of Resident #202’s physician order [REDACTED].
– [MEDICATION NAME] (fast acting insulin) 8 units three times a day with meals and at
bedtime;
– [MEDICATION NAME] sliding scale (SS) with meals and at bedtime: 151-200 1 unit.
Observation and interview on 2/21/19 at 7:16 A.M. showed the Director of Nurses (DON) did
the following:
– Completed a finger stick with a 187 result;
– Drew up eight units of [MEDICATION NAME] and administered the injection to the resident;
– The resident said it should be nine units with the sliding scale insulin added;
– The DON told Resident #202, staff got a new order that read SS at bedtime only, and the
resident went back and sat at the table to wait for breakfast;
– Staff served the resident’s breakfast at 7:41 A.M. (25 minutes after the injection).
When the DON clarified the new order with LPN A who took off the new order, LPN A said the
order SS at bedtime only meant the physician did not want staff to administer the
scheduled eight units of [MEDICATION NAME] at bedtime. Staff should continue to administer
SS [MEDICATION NAME] with meals. The DON said she would re-write the new order because it
was confusing. She should have added another unit of insulin.
7. During an interview on 2/22/19 at 5:23 P.M., the DON said:
– 15 minutes is the longest time that should lapse between administration of fast acting
insulin and meal service;
– Currently there was no system in place between nursing and dietary to alert dietary
staff that a resident had received their fast acting insulin;
– She should have clarified the new insulin order before she gave the resident his/her
insulin.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
properly stored and discarded resident medications, stock medications and treatment
supplies. Staff failed to date medications when opened and failed to ensure the emergency
kits (E kits) were locked. The facility census was 52.
1. Review of the facility’s storage of medications policy, dated, March, (YEAR), showed,
in part:
– No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use;
– All such drugs must be returned to the issuing pharmacy or destroyed in accordance with
established guidelines.
2. Observation and interview on 2/22/19, at 9:40 A.M., of the North medication room,
showed:
– One opened bottle of [MEDICATION NAME] (used to treat anxiety), 2 mg./ml., had a sticker
on the bottle which said do not use after 2/6/19;
– One opened vial of [MEDICATION NAME] purified protein derivative (Manitou) [MEDICATION
NAME], did not have a date when it was opened;
– One opened vial of influenza vaccine did not have a date when it was opened;
– The Director of Nursing (DON) said any multi dose vials should have a date when it was
opened;
– 14 2.7 ml vacutainers for blood, expired 7/31/18. The DON said they should not be used
since they are expired;
– Eight unopened bottles of sterile water, expired 9/2018;
– 30 packages of sure prep skin protective barrier wipe, expired 11/2018;
– Two unopened tubes of [MEDICATION NAME] hydrogel, expired 8/16;
– One unopened Shiley ([MEDICAL CONDITION]), expired 4/15;
– One unopened bottle of hydrogen peroxide, expired 7/2018;
– Two emergency intravenous (IV) kits did not have locks on them. The DON said they should
have locks on them;
– The DON said staff should not use expired medications or use anything which is expired.
Observation on 2/22/19, at 10:19 A.M., of the North treatment cart, showed:
– 18 Curad triple antibiotic ointment packets, expired 3/2018;
– A box of six silver antimicrobial wound dressing plus one one opened package, expired
2/2017;
– One opened tube of [MEDICATION NAME] skin protectant paste, expired 11/18;
– Five unopened bottles of sterile water, expired 9/2018.
Observation and interview on 2/22/19, at 10:33 A.M., of the North medication cart showed:
– Two packages of thera tears (used to treat dry eyes), did not have a label to indicate
which resident they belonged to;
– Nine loose pills were found in the medication cart. The DON did not know who they
belonged to;
– One unopened bottle of [MEDICATION NAME]d, (used to treat pain), expired 10/2018.
Observation and interview on 2/21/19, at 8:32 A.M., of the South nurse’s medication cart
and medication room, showed:
Medication Cart
– One undated opened multi-dose bottle of sterile water;
– One undated opened multi-dose bottle of Humalog insulin;
– An expired, 12/18/18, bottle of [MEDICATION NAME] Solution 10 gram /15 milliliters (ml).
South medication store room:
– Multi-dose vial of influenza vaccine opened 10/20/18;
– Two bottles of Magnesium [MEDICATION NAME] with no expiration date;
– Four hemocult stool sample kits expired 7/2017;
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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
– Ten one ml [MEDICATION NAME] syringes expired 11/2016.
Registered Nurse (RN) A said:
– Staff should date all bottles of medication, insulins and inhalers when they were
opened;
– He/she checked the medication cart and the medication storage rooms once a month, but
lately had checked it more frequently.
During an interview on 2/22/19, at 10:33 A.M., the DON said:
– The day charge nurse on Sundays should check the medication cart, the treatment cart and
the medication room. If he/she does not get it done, it should be passed on to the next
nurse;
– She destroyed the expired medications on Friday.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on interview and record review, the facility failed to obtain a Registered
Dietitian’s (RD) approved alternate menu. The facility census was 52.
1. Review of the facility Menus policy dated 4/2006 showed the menus should be approved by
the consultant dietitian and signed by the consultant. An alternate meat or entrée, an
alternate vegetable and alternate starch will be provided at each meal according to the
menu.
Interview and record review on 2/21/19 at 9:04 A.M., showed the alternate menu was not
approved by the Registered Dietician (RD). The Dietary Manager (DM) said the alternate
choice menu was not preplanned or signed off on by the RD. She was not aware that an
alternate menu had to be approved by the RD.
In an interview on 2/21/19 at 9:36 A.M., the Administrator said she did not know the
alternate menu required RD approval.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and record review dietary staff failed to wash their hands according
to the facility policy. This had a potential to affect all residents who were served foods
from the kitchen. The facility census was 52.
1. Review of the dietary services Glove use policy dated 8/2005, showed hand washing
should occur between each task. Hands should be washed after handling dirty dishes and
when changing task.
Observations, during the kitchen breakfast meal service, starting on 2/21/19 at 6:58 A.M.
showed:
– Dietary Aide (DA) A and Cook A washed dirty dishes and pulled out clean dishes from the
dish washer numerous times without washing their hands between dirty dish and clean dish

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:

265745

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNSET HOME

STREET ADDRESS, CITY, STATE, ZIP

1201 S. POLK
MAYSVILLE, MO 64469

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
contacts.
– DA A went into the dining room, gathered residents food protectors, returned to the
kitchen, washed dirty dishes and pulled dishes out of the dishwasher without washing
his/her hands between tasks.
– The Dietary Manager left the kitchen, returned without washing her hands, touched clean
cups, went back out of the kitchen, poured drinks and served them to the residents.
Latter, the DM served resident’s food in the dining room then came back into the kitchen,
pulled a cake out of oven and then began serving residents food with no hand washing
between tasks. While serving the locked unit dining room, the DM pushed a resident in a
wheelchair, then returned to the steam table and served food with no hand washing between
the tasks.
During an interview on 2/21/19 at 9:20 A.M., the DM said that she needed to work with
staff on their hand washing policy to assure staff wash hands between tasks.