Sunset Manor Conv Hosp

Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) received mail and other packages within 24 hours of delivery.This deficient practice violated Resident 1's right to receive mail promptly (delivery of mail or other materials to the resident within 24 hours of delivery) and had the potential to impact Resident 1's well-being.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 4/25/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), acute pulmonary edema (rapid accumulation of fluid in the lungs) and anxiety disorder (a mental health condition characterized by excessive worry and fear that interferes with daily life).

During a review of Resident 1's History and Physical (H&P) dated 8/13/2025, the H&P indicated Resident 1 had the capacity to make medical decisions.

During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 10/31/2025, the MDS indicated Resident 1 had intact cognition (ability to make daily decisions).

The MDS indicated Resident 1 was independent of dressing, shower/bathe self, toileting hygiene and personal hygiene.

During an interview on 11/25/2025 at 9:10 AM with Resident 1, Resident 1 stated the facility's Social Service gave the mail to Resident 1 from Supplemental Security Income (SSI) dated 9/1/2025 in November 2025.

During a concurrent interview and record review on 11/25/2025 at 3:55 PM with the facility's Social Service Director (SSD), Resident 1's mail from SSI dated 9/1/2025 on the first page of the letter, was reviewed.

The SSD stated the SSD did not know what date the mail was delivered to the facility, and the SSD delivered the letter to Resident 1 in October 2025 after receiving the letter for a couple weeks already.

The SSD stated the facility did not have any documentation to trace and record the date of receiving and delivering mail to the residents.

During a concurrent interview and record review on 11/26/2025 at 10:01 AM with the facility's Social Service Assistant (SSA), Resident 1's mail from SSI dated 9/1/2025 was reviewed.

The SSA stated the SSA and the SSD gave the mail to Resident 1 in October 2025.

The SSA stated the facility's Social Service Department was responsible for delivering mail to the residents but there was no documentation to trace and record the date of receiving and delivering mail to the residents.

During an interview on 11/26/2025 at 10:39 AM with the facility's Business Office Assistant (BOA), the BOA stated, the Social Service Department was responsible for delivering the letters and packages to residents after receiving them.

The BOA stated the facility does not deliver mail or packages to residents on weekends (Saturdays and Sundays) because there was no Social Service staff during the weekends.

During a concurrent interview and record review on 11/26/2025 at 12:01 PM with the facility's Director of Nursing (DON), the DON stated the facility did not have a policy and procedure on tracing received mails and packages and delivering them to the residents.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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