Sunrise Point Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report an allegation of abuse made by a resident within the required timeframe and failed to report and investigate an allegation of abuse made by a resident to the state agency (SA) for 2 of 6 residents reviewed for abuse, of a total sample of 15 residents, (#4, and #10). Findings: 1. Review of resident #4's medical record revealed he was readmitted to the facility on [DATE] with diagnoses of encephalopathy, hemiplegia and hemiparesis (muscle weakness and paralysis to one side of the body) following a stroke, type 2 diabetes and chronic pain. Encephalopathy is a change in how the brain functions. It may cause confusion or agitation or temporary disturbance or it could permanently damage the brain, (retrieved from www.clevelandclinic.org on 1/26/25). Review of resident #4's Minimum Data Set (MDS) annual assessment with Assessment Reference Date (ARD) 11/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated he…

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, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 38 residents, (#47). Findings: Resident # 47 was admitted on [DATE] to the facility and then readmitted on [DATE] with diagnoses including cerebral infarction (stroke), unspecified glaucoma, asthma, and shortness of breath. Review of the Minimum Data Set (MDS) admission assessment with an assessment reference date of 4/30/24 revealed resident #47 had a Brief Interview for Mental Status score of 00 out of 15, which indicated she was severely cognitively impaired. On 8/06/24 at 11:20 AM, resident #47 was observed lying back in bed watching television. Her bedside table was over her lap, with personal items, including a 15 milliliter (ml) Afrin nasal spray. The resident said she used the nose spray because her nose got stuffy sometimes. On 8/06/24 at 11:30 AM, the resident's bedside…

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, interview, and record review, the facility failed to honor resident's rights to choose their preferred bathing preferences for 1 of 3 residents reviewed for choices, of a total sample of 38 residents, (#81). Findings: Review of the medical record revealed resident #81 was admitted to the facility on [DATE] from the hospital. Her diagnosis included end stage renal disease, type II diabetes, heart failure, and dependence on renal dialysis. Resident #81's admission Minimum Data Set (MDS) with an assessment reference date of 6/27/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status indicating she did not have any cognitive impairment. The MDS assessment also indicated resident #81 required substantial/maximal assistance with bathing, it was very important to her to choose between a shower and bed bath, and she participated in the assessment and goal setting. It also revealed the resident did not exhibit behavior symptoms or rejection of care that was necessary…

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 interview and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level 1 evaluation for 3 of 5 residents reviewed for PASARR, of a total sample of 38 residents, (#15, #46 & #55). Findings: 1. Resident #46 was admitted to the facility on [DATE]. His diagnoses included anxiety, hypertension and schizophrenia. Review of resident #46 Minimum Data Set (MDS) dated [DATE] revealed a diagnosis of schizophrenia. The MDS assessment also revealed the resident was on antipsychotic medications listed under the section for high-risk drug class medications. Review of the resident's orders revealed an order for Quetiapine Fumarate 50 milligrams (mg) twice daily and 150 mg at bedtime. The care plan for resident #46 listed him as being at a risk for complications related to the use of psychotropic drugs; the antipsychotic which was initiated 12/17/20. The care plan indicated the resident has a tendency to distort and confabulate information/statements related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow accepted standards of practice to prevent cross-contamination during wound care for 1 of 2 residents reviewed for pressure ulcers, of a total sample of 38 residents, (#350). Findings: Resident #350 was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included dementia, seizures, hypertension, heart failure, acute kidney failure, unstageable pressure ulcer sacral wound and urinary tract infection. Review of the wound care physician orders dated 8/03/24 included daily treatment of the resident's sacrum. The order directed the nurses to cleanse with wound cleanser, pat dry, apply Santyl, super absorbency and cover with border foam. As defined by Centers for Medicare and Medicaid Services (CMS), Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar…

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 interview, and record review, the facility failed to notify the physician of an acute (requires immediate care), significant change of condition for 1 of 3 residents reviewed for Quality of Care and Treatment, of a total sample of 3 residents, (#1). Finding: Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from an acute care hospital on 4/16/24. The resident had diagnoses that included metabolic encephalopathy (brain dysfunction), sepsis (blood infection), myocardial infarction (heart attack), hypertension, dysphagia (difficulty swallowing), Urinary Tract Infection (UTI), muscle weakness, bipolar disorder, and cognitive communication deficit. On 4/21/24, the resident was transferred back to an acute care hospital via 911 Emergency Medical Services. The Minimum Data Set 5-day Assessment with Assessment Reference Date 4/21/24 noted the resident was unable to complete the Brief Interview for Mental Status, and she had severely impaired cognitive…

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, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care for 1 of 4 dependent residents of a total sample of 35 residents, (#28). Findings: Resident #28 was re-admitted to the facility from an acute care hospital on [DATE]. Her diagnoses included tracheostomy status (artificial opening in the neck), hemiplegia post stroke, muscle weakness and traumatic brain injury. The resident's quarterly Minimum Data Set (MDS) assessment with assessment reference date 2/4/21 revealed no history of rejection of care. Her Brief Interview for Mental Status (BIMS) score was 15/15 which indicated she was cognitively intact. The resident required extensive assistance of 1- 2 staff with her personal hygiene and was totally dependent on staff for bathing. The resident's care plan for ADL self-care performance deficit revised on 7/6/20 noted interventions that included, Bathing/showering: The resident is totally dependent on 1 staff for personal hygiene . 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.

Based on observation and interview, the facility failed to follow proper thawing procedures to prevent the potential of food borne illness when preparing frozen chicken. Findings: On 4/05/21 at 7:05 AM, the production sink noted a pan with wrapped chicken packages thawing under cold running water. The Certified Dietary Manager (CDM) had placed the chicken in the pan and had water flowing over the chicken. The water temperature was checked by the CDM with a calibrated thermometer and read 72.8 °F (Fahrenheit). She said she was not aware that water temperature for thawing under cold water had to be 70°F or below in accordance with the Food and Drug Administration 2017 Food code Chapter 3-501.1.

Based on observation, interview and record review, the facility failed to ensure the safe functioning of resident beds for 1 of 35 total sampled residents, (#4). Findings: On 4/05/21 02:17 PM, Licensed Practical Nurse (LPN) B reached for resident #4's hand to check her pulse oxygen saturation. As she leaned forward, the bed slid away from her. The base of the bed foot wheels was in lock position. Resident #4 said, the bed had slipped before and it scared me. I thought they fixed it. On 4/07/21 at 10:15 AM, the Director of Maintenance (DOM) said he did not have a routine program in place to ensure beds were safe. He said an outside service company inspected beds annually for electrical functioning and safety. He stated the process was that when staff identified a problem with a bed, they contacted him, and he replaced the bed. He said he had new beds available and he changed the beds when staff identified a problem with the bed. On 4/07/21 at 12:06 PM, resident #4 said that was not the first time the bed rolled away. She said when staff leaned against the bed it would slide away. She…

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.