Sun Terrace Health Care Center

Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen, walk-in cooler, walk-in freezer, reach-in freezer, and stock room (Photographic evidence obtained). Findings include: During an observation while conducting a walk-through tour of the kitchen with the Dietary Manager (DM) on 6/3/2024 starting at 8:40 AM, there were one large, perforated pan with raw chicken pieces thawing that was not in running water or covered; one sheet pan with 20 packages containing meat products with no identifying label or date on the pan or packages; three cases of health shakes, each containing 72 individual cartons, that were completely thawed and were in a case that read, Keep Frozen; and three containers containing pesto with no date or identifying label in the walk-in cooler. There was one opened large clear bag of a breaded food product with no label or date on the product in the walk-in freezer. There was French fries left opened and exposed to the elements in the reach-in freezer. During…

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, record review, and interview, the facility failed to ensure residents received care and services for PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 of 3 reviewed residents with a PICC access device, Resident #104 (Photographic evidence obtained). Findings include: During an observation on 6/3/2024 at 9:52 AM, Resident #104's PICC line was visible in right upper arm. The transparent dressing over the gauze securing PICC and insertion site was not visible. The transparent dressing was peeling off on one side. The dressing was dated 5/28/2024. During an observation on 6/4/2024 at 10:22 AM, Resident #104's PICC line was visible in right upper arm. The transparent dressing over the gauze securing PICC and insertion site was not visible. The transparent dressing was peeling off on one side. The dressing was dated 5/28/2024. During an interview on 6/4/2024 at 10:22 AM, Resident #104 stated, I don't remember exactly when the dressing was changed, but they change the dressing about once a week.…

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 ensure medical records were complete and accurate for 1 of 3 reviewed residents with PICC (Peripherally Inserted Central Catheter) line, Resident #104. Findings include: Review of Resident #104's physician order dated 5/14/2024 read, Dressing change every week and PRN [as needed]. RUA [Right Upper Arm] Measure length of line and circumference of arm upon admission/insertion then weekly. To measure length start from hub of PICC line to insertion site on forearm, to measure arm circumference measure at the insertion site around the forearm. Continue weekly until line discontinued. Document the length of line & circumference of arm upon admission/insertion below. PICC Line Length [blank] cm [centimeter]. Arm Circumference: [blank] cm, every day shift every 7 day(s) for IV [Intravenous] maintenance, Report s/s [sign and symptom] of infections/infiltration/dislodgement to MD [Medical Doctor]. Change dressing weekly and document measurement of line. Review of Resident #104's Medication Administration Record (MAR) for May 2024…

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, interview, and record review, the facility failed to ensure staff used proper PPE (Personal Protective Equipment) while providing high-contact care for 1 of 3 residents reviewed for transmission-based precautions, Resident #341, and failed to ensure staff performed hand hygiene between residents during meal tray delivery to help prevent the possible development and transmission of communicable disease and infections. Findings include: Review of Resident #341's physician order dated 6/4/2024 showed that it read, Enhanced Barrier Precautions for Dx [diagnosis] Wound every shift nurse to verify correct door signage and equipment present. During an observation on 6/5/2024 at 8:01 AM, Resident #341's door had a sign posted for Enhanced Barrier Precaution (EBP) use. Staff D, Certified Nursing Assistant (CNA), wore gloves, but no gown, opened Resident #341's shared bathroom door from inside the bathroom and pushed Resident #341 in her wheelchair into the resident's room. After exiting Resident #341's bathroom with the resident, Staff D doffed her gloves and threw them…

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 observations and interviews, the facility failed to maintain an environment that promotes dignity and privacy for one (Resident #87) of thirty five sampled residents. Findings included: A review of Resident #87's Medical Record revealed that Resident #87 was admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder and chronic obstructive pulmonary disease. A review of Resident #87's Minimum Data Set (MDS) Assessment revealed, under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14, which indicated that Resident #87 was cognitively intact. An observation of medication administration for Resident #87 was conducted on 03/16/2022 at 09:10 AM with Staff G, Registered Nurse (RN). After pulling Resident #87's medications from the medication cart, Staff G, RN knocked on Resident #87's door and asked permission to enter the room. Resident #87 granted Staff G, RN to enter her room and administer the medications. During the observation, Resident #87…

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 ensure the care plan was implemented related to preventing skin impairment for one (Resident #25) of three in-house acquired pressure injury residents, and 2. facility did not ensure to implement the plan of care for Resident # 37 regarding placement of an ankle brace and podus boots. Findings included: 1. Medical record review for Resident #37 revealed that the resident was admitted to the facility on [DATE] with a re-admission date of 1/7/22. Resident #37 had multiple diagnoses not limited to paraplegia, spinal stenosis lumbar region, difficulty walking and generalized weakness. Resident #37 is alert and oriented with a BIMS (Brief Interview for Mental Status) of 14 indicating cognitively intact. A review of Resident #37's plan of care revealed that (Effective date 3/04/22) the resident was care planned for ADL (activities of daily living) self-care performance deficit related to chronic back pain, post laminectomy, impaired ROM (range…

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 implement pressure injury prevention measures for one (Resident #25) of three residents sampled for in-house acquired pressure ulcers. Findings included: Resident #25's admission record revealed medical diagnoses of Parkinson's disease, unspecified dementia without behavioral disturbance, muscle weakness, and congestive heart failure. The resident's minimum data set (MDS), dated [DATE], revealed the resident has impaired cognition and requires extensive assistance with two staff members for assistance in bed mobility, and has total dependence on staff for transfers. Further review of the resident's MDS revealed the resident is at risk for developing pressure ulcers/injuries. The resident has one or more unhealed pressure ulcers/injuries. Resident #25's care plan revealed a focus area for The resident has potential for impaired skin integrity, initiated on 2/07/2022, with interventions of encouraging patient to float heels whenever in the…

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 observations, staff interviews, and medical record review the facility failed to ensure care plan interventions were implemented for one (#98) of 54 sampled residents as evidenced by Resident #98 not wearing an abductor wedge pillow between her legs as ordered and care planned. Findings Included: A record review for Resident #98 revealed admission diagnoses to include fracture of unspecified part of neck of Left Femur, subsequent encounter for closed fracture with routine healing, weakness, and difficulty walking. A review of active physician orders dated 12/05/2020 revealed an order to apply abductor wedge between legs when in wheelchair for LE (lower extremity) positioning every shift and dated 12/02/2020 Hip Range of Motion (ROM) precautions every shift. Record review of the admission Minimum data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 14, indicating the resident was cognitively intact. Review of the Care Plan for Resident #98 initiated on 12/4/20 revealed…

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, observation, and interviews the facility did not ensure appropriate physician's orders were obtained and implemented for nephrostomy tubes for one (#226) of 54 sampled residents. Findings included: A review of Resident #226's clinical record revealed she was admitted to the facility on [DATE] with a diagnosis of iron deficiency anemia secondary to blood loss, according to the face sheet in the admission record. Review of the admission summary dated [DATE] reflected a left iliac crest (rear) nephrostomy tube site and right iliac crest (rear) nephrostomy tube site. The 12/19/20 skin check indicated 2. other nephrostomy. Review of the care plan dated 12/22/20 and revised on 12/30/20 showed a Focus area of nephrostomy tubes. The interventions included change tubes as ordered and monitor tubes as ordered. A review of the Minimum Data Set (MDS) assessment, section H, bladder and bowel, dated 1/8/21 reflected an indwelling catheter (including Suprapubic catheter and nephrostomy tube). A review…

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, interview and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure an indwelling urinary catheter bag and tubing was maintained off the floor to prevent potential infection for one resident #(243) during two of two observations, of 5 residents with catheters. Findings included: On 1/05/21 at 4:30 PM, an observation of Resident #243 revealed he was lying in bed with the urinary catheter bag and tubing on the left side of the bed hanging from the bed frame and resting on the floor. The catheter bag was completely on the floor. On 1/07/21 at 8:44 AM, another observation was conducted. Resident #243 was in his bed watching TV. The bed was in the low position near the floor. The catheter bag was sitting completely on the floor near the head of the bed on the resident's left side facing the door. The tubing was also on the floor. On 1/07/21 at 8:46 AM, an interview and observation was conducted with Staff I, LPN UM. Staff I, LPN UM confirmed the catheter bag and tubing were on the floor. A review of Resident #243's clinical…

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 interviews and record review the facility failed to ensure laboratory services were provided in a timely manner in accordance with physician orders for one (#112) of 54 sampled residents related to a lipid panel. Findings included: A medical record review was conducted for Resident #112 to ensure that the Medication Regimen Review recommendations were being followed. A review of Resident #112's admission record revealed a diagnosis of hyperlipidemia. A review of the Pharmacist Medication Regimen Review for the last three months revealed that on 11/22/2020 a recommendation was made for a lipid panel now and every 12 months to monitor the medication of Atorvastain. There was a physician signature on the form acknowledging the pharmacist recommendation and a signature by Staff C, Registered Nurse (RN) Unit Manager (UM) that documented noted and the date of 11/30/20. Further medical record review revealed a physician's order was written in the computerized system on 11/30/2020 for a lipid panel in the a.m. and then yearly per pharmacy recommendation. A review of the lab…

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.