Sun Harbor Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility policy and procedures, resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 4 (Resident #8, #17, #95, and #47) of 4 sampled residents who required assistance with activities of daily living (ADL's). The findings included: The facility policy Activities of Daily Living documented, The facility shall ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living . A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . 1. Review of the clinical record revealed Resident #8 had an admission date of 6/7/24 with diagnoses including anxiety, depression, hypothyroidism and adult failure to thrive. Review of the admission Minimum Data Set (MDS) (standardized assessment tool…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of the facility policy and procedure and resident and staff interviews, the facility failed to ensure appropriate treatment, equipment and services to maintain mobility for 2 (Resident #17 and #95) of 5 residents reviewed with contractures and splinting devices. The findings included: Review of the facility policy Assistive Devices and Equipment documented, Our facility provides, maintains, and supervises the use of assistive devices and equipment for residents. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. 1. Review of the clinical record revealed Resident #17 had an admission date of 6/25/10 with diagnoses including type 2 diabetes, anxiety, left breast neoplasm and dementia. The Quarterly Minimum Data Set (MDS) dated [DATE] documented, Resident #17…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff and resident interview and record review the facility failed to safely store medication to prevent unauthorized access for 3 (Resident #6, #24, and #94) of 3 residents observed with unsecured medications at bedside. The findings included: Review of the facility's policy titled, Administering medications with a revision date of 2/21/24 revealed Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of facility policy titled: 5.0 Medication Storage noted, Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida Department of Health guidelines. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. 1. On 9/16/24 at 9:22 a.m., a bottle of Flonase…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident representative and staff interviews, the facility failed to act on the designated Health Care Surrogate request for a change of treatment for 1 (Resident #118) of 2 residents reviewed for choices and representative involvement in care plan and decision making. The findings included: Review of the clinical record revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included Dementia with psychotic disturbance, Alzheimer's disease, Atrial Fibrillation (irregular heartbeat), and cardiac pacemaker (implanted device that regulated the heart's rhythm). The Advance Health Care Directive in the clinical record revealed on November 20, 1995, Resident #118 designated her husband to be her healthcare surrogate. If her husband was unable or unwilling to serve in this capacity, the resident designated her daughter to serve as her healthcare surrogate. Review of the admission Minimum Data Set (MDS) assessment with a target date of 8/29/24 noted Resident #118…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and Interview, the facility failed to ensure the resident's right to include representative in care planning for 1 (Resident #47) of 2 cognitively impaired residents reviewed for choices and care planning. The findings included: Review of the clinical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included Malnutrition and Dementia. Review of the Notification & Consent for Medical Services & Medications form dated 7/26/24 showed Resident #47 signed the form authorizing medical services and medications. The admission Minimum Data Set (MDS) Assessment with a target date of 8/2/24 noted Resident #47 scored a 06 on the Brief Interview for Mental Status, indicating severe cognitive impairment. On 8/2/24 Resident #47 signed a consent for wound care. The resident's signature was witnessed by a facility staff. On 8/7/24 the Medical Director documented Resident #47 was alert and oriented to 1-2 (Person and place). On 9/16/24 at 10:44 a.m., and 9/18/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident representative and staff interviews, the facility failed to make prompt efforts to resolve a grievance related to missing personal property for 1 (Resident #118) of 3 residents reviewed for resolution of grievances. The findings included: Review of the clinical record revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included Dementia. On 9/16/24 at 9:50 a.m., Resident #118 was observed wandering in her bedroom. Resident #118 was not able to answer interview questions. An empty eyeglass case was observed in a drawer in the resident's dresser. Resident #118 was not able to say where her glasses were. Review of the personal items inventory list signed by Resident #118, and dated 8/25/24 showed an X next to glasses, indicating Resident #118 was admitted to the facility with a pair of glasses. Review of Resident #118's Inventory of Personal Effects dated 8/25/24, there is an X mark next to glasses indicating the resident was admitted with a pair of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 1 (Resident #86) of 4 residents with diagnoses of mental illness, and failed to refer the resident to the appropriate state designated authority for a comprehensive evaluation within the specified time frame. The findings included: Review of the facility policy for PASSR (Preadmission Screening and Resident Review) reviewed April 2022 revealed, It is the policy of the center to follow the Federal and State regulations with regards to pre-screening residents with a mental disorder and individuals with intellectual disability for individuals requiring more than 30 days in the Center. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/20/21 revealed Resident #86 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, and depression. The list of diagnoses noted Bipolar Disorder and Major Depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, the facility failed to appropriately address the consultant pharmacist's recommendations for 1 (Resident #48) of 5 residents reviewed for unnecessary medications. The findings included: Review of Resident #48's medical record revealed an order for Acetaminophen Tablet 325 milligrams (mg), give 2 tablets by mouth every 6 hours for chronic pain. Do not exceed 3000 mg in 24 hours, start date 1/18/2023 at 2:00 p.m. Review of the record revealed a separate order for Percocet Oral Tablet 7.5-325 mg (Oxycodone 7.5 mg with Acetaminophen 325 mg), give 1 tablet by mouth every 6 hours as needed for moderate to severe pain, hold for sedation and altered mental status (AMS), start date 3/21/2023 at 5:15 p.m. Review of the medical record revealed on 5/8/23 the consultant pharmacist documented Resident #48 was currently receiving Oxycodone/Acetaminophen as needed which was used daily along with standing order for Acetaminophen 650 mg every 6 hours. Please evaluate current pain management and consider switching to Oxycodone twice daily and PRN (as needed) to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff and resident interview, the facility failed to provide documented evidence resident and/or representative, if applicable, were provided with a copy of a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions for 8 (Resident #54, #100, #112, #160, #261, #262, #266, and #267) of 8 residents reviewed for baseline care plans. The findings included: On 10/27/21, review of facility policy Plan of Care, revised 9/25/17, revealed Develop and implement an individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, Preadmission Screening and Resident Review (PASARR) recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. 1. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment in the area of documentation of the number and stage of pressure ulcers on a required admission assessment for 1 (Resident # 261) of 2 residents reviewed with pressure ulcers. In addition, the facility failed to have accurate MDS assessments for 2 (Resident #110 and #2) of 5 residents reviewed for discharge. Inaccurate encoding of the MDS can adversely affect the care provided to the resident. The findings included: 1. Review of the Resident Assessment Instrument (RAI) dated October 2019 showed the steps for assessment include: Examine the resident and determine whether any ulcers, injuries, scars, or non-removable dressings/devices are present. Assess key areas for pressure ulcer/injury development (e.g., sacrum, coccyx, trochanters, ischial tuberosities, and heels). Also assess bony prominences (e.g., elbows and ankles) and skin that is under braces or subjected to pressure (e.g., ears…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to maintain complete and accurate records in the area of wound assessments for 1 (Resident #261) of 2 sampled residents reviewed for pressure ulcers. Accurate and complete records are necessary to document the course of a resident's care provided by the facility. The findings included: The facility's Clinical/Medical Records policy- MR195, revised on 8/25/17; stated Clinical records are maintained in accordance with professional practice standards to provide complete and accurate information on each resident for continuity of care. The purpose of the clinical record is to document the course of the resident's plan of care and to provide a medium of communication among health care professionals involved in this care. On 10/27/21, review of Resident #261's clinical record revealed a facility Admission/readmission Data Collection form which indicated the resident was admitted on [DATE] at 3:15 p.m. Under the section M. skin, Licensed Practical Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.