Sunset Rehabilitation And Health Care

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident R1's incident. On 10/31/25 at 3:10 pm, V7 (Assistant Director of Nursing/ADON) stated V7 was standing in

the front foyer by the reception desk when Resident R1 wheeled his wheelchair by her and started heading up the ramped hallway toward his room, when she heard Resident R1 yell out an explicit word. V7 immediately went to him to see what was going on and noted he had spilled his coffee into his lap. V7 (ADON) immediately assisted Resident R1 to his room where his pants were removed, and it was noted he had reddened area to his thighs and groin area. V7 (ADON) did not recall seeing Resident R1 with coffee as he went by her. On 11/4/25 at 10:32 am, V1 (Administrator) confirmed she sees Resident R1 with coffee frequently. V1 also confirmed Resident R1 has impaired cognition and safety awareness. On 11/4/25, V14 (Certified Nursing Assistant/CNA) stated, I do not feel he is safe to have coffee without a lid and staff should have carried it for him. V14 (CNA) also verified Resident R1 has poor safety awareness. On 11/4/25 at 10:50 am, V6 (Licensed Practical Nurse/LPN) stated she feels Resident R1 is not safe with coffee. He tilts his cup in his lap when he is wheeling the halls in his wheelchair. On 11/4/25 at 11:00 am, V2 (Director of Nursing/DON) stated, I don't think anyone is safe with an open cup of coffee. The following corrective actions were implemented to correct the noncompliance for those residents found to have been affected by the alleged deficient practice.The facility Administrator made notification to the department per

the regulations on 10/20/25.The facility adopted Hot Beverage Policy.Resident R1 resides at the facility, and the facility QA Team reviewed/revised the care plan on 10/20/25.The Facility Administrator and Divisional VP of Clinical implemented an Ad Hoc QAPI tool on 10/20/25 to ensure Plan of Correction is effective and deficiency remains corrected.The facility Administrator and DON In-Serviced staff regarding the facility's Hot Beverage Policy & Procedure. All beverages rechecked using food-safe thermometers to ensure serving at 130 degrees before being served to the residents. Dietary is responsible for ensuring coffee and hot water are not leaving the kitchen until the temperature is 130 degrees, this includes hot beverages for activities. All residents have the potential to be affected by the alleged deficient practice. However, due to

the implementation of the above corrective action, alleged deficient practice will not recur.A systemic review of the facility systems, including Hot Beverage Policy & Procedure. This review found that all procedure(s) are in compliance with State and Federal guidelines. No further changes are required.The following Quality Assurance programs have been implemented to ensure continued compliance.The Quality Assurance Committee will ensure compliance through the internal Quality Assurance Process. The facility dietary manager is to record daily temperature checks for beverages and maintain logs for review in addition to daily checklist. The facility DON is to complete weekly observation audits for 4 weeks and then monthly for 3 months to ensure compliance with beverage temperature policy. Noncompliance findings to be discussed

in QAPI meetings monthly until sustained compliance for 90 days. Concerns about the progress of the implementation of the Hot Beverage Policy & Procedure will be discussed in the QA Morning meetings for immediate resolution. The ongoing progress will be reviewed quarterly during the QA meetings. The DON or Designee will educate newly hired dietary staff on Hot Beverage Policy & Procedures.

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