Sun View Estates Home Care.

“Based on documentation review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of two residents reviewed. The deficient practice posed a health and safety risk.   Findings include:   1. A review of department documentation revealed an intake report dated January 13, 2026, which revealed that R1 was in the emergency department at St. Joseph’s Hospital.   2. A review of R1's record revealed no documentation showing the date and time of the incident; the names of the individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future.   3. In an interview, E1 reported that the police reached out to E1 and let E1 know that R1 called and requested EMS to come and transport R1 due to his infection and that R1 needed to go to the hospital. 4.  In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager retained a resident without meeting the requirements in R9-10-814.B.2, at least once every six months throughout the duration of the resident's condition, for a resident confined to a bed or chair because of an inability to ambulate even with assistance, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R2's medical record revealed a document titled "Determination and Authorization for Continued Residency" stating R2 was "confined to a chair." R2's record contained a determination letter dated July 14, 2023- March 26, 2024 and March 13, 2025; however, R2's record did not contain a determination letter every six months as required. 3. In an interview, E1 reported E1 thought the determination could be done every year. E1 acknowledged R1's medical record did not contain evidence of compliance with R9-10-814.B.2.b.i, at least once every six months.”