Sunset Vista First LLC.

“Based on observation, record review, documentation review, and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that was reviewed and updated no later than 14 calendar days after a significant change in the resident’s physical, cognitive, or functional condition. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. During the environmental inspection, the Compliance Officer observed R1 in the resident's room. The resident was laying down in the bed. 2. A record review of R1's Initial physician statement revealed, the resident was ambulatory and used a walker. 3. A record review of R1's service plan revealed, was ambulatory with a walker and required one person assist for mobility. 4. A review of the facility's document titled "APS Allegation Form" dated November 13, 2025 stated, "Due to the resident's health problem that's why the resident can't walk." 5. A record review of R1's progress note dated June 10, 2025 stated, "After [the resident's] lunch R1 go to the bathroom, [R1] do that an after a few minute [R1] called [the caregiver] and asking for help so [the caregiver] go to the bathroom and saw [R1] laying on the floor. [R1] said [R1] was out balance and fell down. [The caregiver] look at [R1] head and arm and there is no injury in any part of [R1's] body." 6. A record review of R1's progress note dated November 13, 2025 stated, "[R1] can walk using his walker. After a month [R1] fell down can not able to get up. [R1] declined [the caregivers] never let [R1] use [the] walker and [the caregiver] always put [R1] in the wheelchair. But after several week it very hard for [R1] to transfer on to a wheelchair [R1] legs are very (unknown word) to bend and [R1] complaining about that. [The caregivers] let [R1] stay in the bed." 7. A review of R1's service plan revealed it had not been updated after R1's change in condition on June 10th. 6. In an interview, E2 acknowledged the manager failed to ensure that R1 had a service plan that was established, documented, and implemented that was reviewed and updated no later than 14 calendar days after a significant change in the resident’s physical, cognitive, or functional condition.”

“Based on record review, documentation review and interview, the manager retained a resident confined to a bed or chair without meeting the requirements in R9-10-814.B.2.a.b.i-iii., including documentation of the resident's or the resident's representative's request the resident remain in the facility; documentation to demonstrate the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. During the environmental inspection, the Compliance Officer observed R1 in the resident's room. The resident was laying down in the bed. 2. A record review of R1's record revealed the resident was non-ambulatory. 3. Review of R1’s medical records revealed no documentation of a determination from a medical practitioner at the onset of the condition, which stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to residents. Findings include: 1. During the environmental inspection, the Compliance Officer observed the backyard of the facility where bedframes, mattresses, wheelchairs, Hoyer lifts, portable toilets, and other items were being stored against the walls of the facility. 2. In an interview, E2 acknowledged the manager did not ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury.”

“Based on observation and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed potential egress dangers to residents. Findings include: 1. The Compliance Officer observed a laundry room door on the south side of the facility which had a key in the lock that allowed residents to open the door to the backyard of the facility. 2. The Compliance Officer observed that the laundry room door led to a backyard with a six foot high by four foot wide hole in the backyard fence which led directly to a residential street. 3. In an interview, E1 confirmed that the door in the laundry room had a key in the lock which allowed residents direct access to the backyard. E1 also confirmed that there was a six foot high by four foot wide hole in the backyard fence which led directly to a residential street.”

“Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practiced posed a potential risk to the health and safety of residents. Findings include: 1. The Compliance Officer observed a bottle of Levothyroxine and Hydrocodone stored in a cabinet which was not secure and was accessible to residents. 2. The Compliance Officer observed all of R1's and R2's medications, were stored in a cabinet that was not secure and was accessible to residents. 3. In an interview, E1 reported that the bottle of Levothyroxine, the bottle of Hydrocodone and all of R1's and R2's medications were stored in a cabinet which was not secure and was accessible to residents.”