| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | At the time of the virtual walkthrough on 10/22/21, there was no tape available in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Tape was added to the first aid kit. Staff are to complete weekly form titled "First Aid Checklist" which will ensure that all contents are located in the first aid kit. |
11/02/2021
| Accepted |
| 6400.111(c) | At the time of the virtual walkthrough on 10/22/21, there was no fire extinguisher available in the kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Sunset's maintenance department returned fire extinguisher back to the kitchen. |
11/02/2021
| Accepted |
| 6400.143(a) | Individual #1 refused to take their medications 96 times in June 2021, 143 times in July 2021, 150 times, in August 2021, 147 times in September 2021, and 108 times through 10/21/21. The refusals are documented, but there is no documentation the individual was educated on the importance of following doctor's recommendations. Individual #1 refused to go to the dentist on 12/2/20, 6/17/21, and 9/16/21. Individual #1 also refused to go to a follow-up Ear, Nose, and Throat Appointment on 5/12/21 and 7/2/21. The refusals were documented. There is no documentation that Individual #1 was educated on the importance of attending medical appointments and following doctor's recommendations. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Sunset has sent out a company-wide training to all staff that ABC's (documentation) must be completed by staff after every refusal. On these ABCs, staff will write what they have done to educate the individual on the importance of taking medications, attending medical appointments and following doctor¿s recommendations. |
11/02/2021
| Accepted |
| 6400.144 | Individual #1 is prescribed the following PRN medications: Glucagon Kit 1mg, Glucose Chew 4mg, Keto-diastix, and Polyethylene Glycol. At the time of the virtual walkthrough on 10/22/21, none of these items were available in the home. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| All medications are located in the medication cabinet. An additional section of a shelve was predesignated for diabetes medications (Glucagon Kit 1mg, Glucose Chew 4mg and Keto-diastix). Polyethylene Glycol was placed in its proper bin. |
11/02/2021
| Accepted |