Sunrise Manor Nursing Home

Based on observation, interview, and review of facility policy the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 127 of the facility's 127 residents who consumed food from the kitchen.The findings include:Review of the facility policy titled, Food Storage: Dry Goods and Cold Foods, revised 09/2017, stated all foods will be appropriately stored in accordance with guidelines of the FDA Food Code. FDA Food Code states, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; (2) At 5 C (41 F) or…

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 review of the facility's policy, it was determined the facility failed to store, handle, prepare, distribute, serve food, maintain safe temperatures of food in storage, in order to ensure food safety. Observation, on 03/20/2022 during the initial kitchen tour at 2:00 PM, revealed dirty floors, staff members with their masks positioned below the nose, open food not labeled or dated, a dirty stove, pitchers of tea and coffee uncovered and not labeled, a trash can with its lid open, the dishwasher was broken, the sanitizing solution in the three (3) compartment sink and the sanitizing bucket were not maintained at the correct concentration. Additionally, observation, on 03/20/2022, revealed inconsistencies with documentation logs for the standing refrigerator and dry storage, and the dishwasher was not in use/broken. Further observation, on 03/21/2022 at 11:35 AM, during lunch meal service, revealed two (2) male staff with hair on their face and neck with no beard restraint, and another staff person was observed with the mask below the nose. 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 observation, interview, record review, review of the facility's policies, review of the Centers' for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS) guidelines; and the CDC's website, HTTPS://www/Coronavirus, it was determined the facility failed to implement the CDC's and CMS's interventions to establish and maintain an infection prevention and control program designed to provide a safe, and sanitary environment to help prevent and control the development and transmission of communicable diseases including COVID-19. Total census was 97. Observations on 03/20/2022, revealed staff did not use Personal Protective Equipment (PPE) in residents' rooms, who were under Droplet Precautions and Contact Precautions. Resident #299 and Resident #12 had Physician's Orders to be in isolation. However, observations revealed the facility's staff entered Resident #299's and Resident #12's room without donning (putting on) PPE required in order to enter the room. An additional…

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, record review, and review of the facility's Baseline Care Plan policy, it was determined the facility failed to ensure the Baseline Care Plan was developed and implemented to provide effective person-centered care for one (1) of seventy-one (71) sampled residents (Resident #299). Resident #299's Baseline Care Plan, initiated on 03/17/2022, revealed the resident required isolation as warranted per the resident's condition. However, the facility failed to further implement the Baseline Care Plan to include interventions related to Resident #299's Droplet Precaution isolation. Observations on 03/20/2022, revealed staff entered the resident's room to provide care without appropriate Personal Protective Equipment (PPE). Further observations on 03/20/2022 revealed staff exited the resident's room without following proper infection control guidelines. The findings include: Review of the facility's policy, Baseline Care Plan Process, dated 07/18/2018, revealed the charge nurse who…

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, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident was treated with respect and dignity for four (4) of eighteen (18) sampled residents, Residents #19, #74, #88, and #91. Interviews revealed the facility failed to meet the personal care needs of the residents in a timely manner. The findings include: Review of the facility's policy, Resident Rights, revised 08/16/18, revealed all residents had the right to be treated with respect and dignity. The residents' rights were protected and promoted by the facility in a manner that maintained or enhanced the residents' quality of life. When staff provided care and services, they respected the residents' individuality and valued their input by providing a dignified existence, through self-determination and communication, and with access to persons and services inside and outside the facility. Observation of the first floor north hall, on 01/23/19 at 9:39 AM, revealed the call…

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, record review, and review of the facility's policy and resident rights, it was determined the facility failed to invite one (1) of two (2) sampled residents, Resident #91, to participate in his/her care plan conference. The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/19/18, revealed the resident and the representative participated in the interdisciplinary team meeting as much as practicable for the resident and the representative. Each resident had the right to participate in choosing his/her treatment options, and was able to participate in the development, review, and revision of their care plan and was considered part of the interdisciplinary team. When a resident refused to participate in the development of the care plan, the facility staff entered the appropriate documentation into the resident's medical record. Review of the facility's Resident Rights, revised on 08/16/18, revealed the resident had a right to participate in decisions and care…

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, record review, and review of the facility's Census and Conditions, it was determined the facility failed to ensure there was a sufficient amount of nursing staff to meet resident needs for eight (8) of eighteen (18) sampled residents, Resident #16, #19, #28, #64 #74, #88, #91, and #102. Nursing staff failed to answer resident call lights in a timely manner to address the residents' needs. The findings include: Review of the facility's Census and Conditions of Residents, dated 01/21/19, revealed the facility had one hundred and twenty-three (123) residents. One hundred and eight (108) residents required the assist of one (1) or two (2) staff for transferring and toilet use. Review of the facility's Weekly Schedule, dated 01/11/19 to 01/17/19, revealed on 01/11/19, the facility scheduled sixteen (16) Certified Nursing Assistants (CNA); however, review of the facility's Punch Variances Report (time staff clocked in/out) revealed only nine (9) CNAs worked. Continued review of 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure records were maintained to account for controlled drugs for five (5) of eight (8) medication carts. Record review revealed missing staff signatures on the controlled drug accountability forms, which were used to count and reconcile controlled drugs at shift change. The findings include: The facility did not provide a policy for controlled medication accountability. Review of the facility's Controlled Substance Accountability Count form, dated January 2013, revealed the form was used to verify controlled drugs on hand had been counted, and each medication count was in agreement with the quantity stated on Controlled Drug Record(s). The form was to be dated, the shift identified, and signed by the on-coming nurse and the off-going nurse. Review of the Controlled Substance Accountability Count form, dated January 2019, for the Rehab Unit, revealed missing staff signatures on 01/02/19 at 7:00 AM, 01/03/19 at 7:00 PM, 01/04/19 at 7:00 PM, 01/05/19 at 7:00 PM, 01/07/19 at 7:00 PM, 01/08/19…

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, it was determined the facility failed to ensure refrigerated narcotics were stored in a permanent affixed compartment in the medication refrigerators in two (2) of four (4) medication rooms. In addition, the medication refrigerators were small and not secured and could be removed from the medication rooms. The findings include: The facility did not provide a policy for the security of refrigerated scheduled medications or medication refrigerators. Observation of the second floor south hall medication room, on 01/24/19 at 10:50 AM, revealed a small locked medication refrigerator not affixed to the wall or to a counter. The refrigerator contained Dronabinol (scheduled III medication) 2.5 milligrams (mg) tablets, not secured in a separate affixed box in the refrigerator. Further observation revealed Licensed Practical Nurse (LPN) #8 picked up the small refrigerator and moved off the cart toward the door. Observation of the second floor north hall medication room, on 01/24/19 at 11:34 AM, revealed a small locked medication refrigerator not affixed 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 observation, interview, record review, and facility policy review, it was determined the facility failed to provide a safe, clean, and comfortable homelike environment for two (2) of thirty-one (31) sampled residents, Resident #55 and #102. Observation and interview revealed Resident #55's mattress was deteriorated, and the soap holder in Resident #102's shower was broken with sharp, protruding edges. The findings include: The facility did not provide a policy pertaining to resident mattresses. Review of the facility's policy, Maintenance Service, dated January 2005, revealed the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The maintenance department would maintain the building in good repair and free from hazards. 1. Interview with Resident #55, on 01/21/19 at 3:00 PM, revealed his/her mattress was broken down and hurt his/her back. Observation, on 01/21/19 at 3:12 PM, with Registered Nurse (RN) #4 revealed Resident #55's mattress's outer waterproof cover was worn off, exposing 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 observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for four (4) of thirty-one (31) sampled residents, Resident #19, #88, #91, and #168. The facility care planned for staff to assist with Activities of Daily Living needs; however, interviews revealed staff failed to meet the needs of the residents timely. The findings include: Review of the facility's policy, Comprehensive Care Plans, dated 07/19/18, revealed the care plan included objectives and timetables to meet residents' medical, nursing, mental, and psychological needs. In addition, the care plan included how the facility would assist the resident to meet their needs, goals, and preferences and aided the resident in reducing declines in functional status and/or functional levels. 1. Review of Resident #168's clinical record revealed the facility admitted the resident on 01/10/19, with diagnoses of Chronic Obstructive Pulmonary Disease, Muscle Weakness, and Difficulty…

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 interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of thirty-one (31) sampled residents, Resident #316. Resident #316 sustained a non-injury fall on 01/20/19, and the facility failed to revise the care plan after the fall with interventions to prevent further falls. The findings include: Review of the facility's policy, Comprehensive Care Plans dated 09/21/16, revealed a person-centered comprehensive care plan that included measureable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. The care plan included how the facility would assist the resident to meet their needs, goals, and preference. The care plans were ongoing and revised as information about the resident and the resident's condition changed. The nurse/Interdisciplinary Team was responsible for the review and updating of care plans. The care plan should reflect the status of the resident and updated with changes in the resident status and when residents were…

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, it was determined the facility failed to assist residents to toilet for one (1) of four (4) sampled residents, Resident #168, who was unable to toilet himself/herself. The findings include: The facility did not provide a policy for provision of Activities of Daily Living. Record review for Resident #168 revealed the facility admitted the resident on 01/10/19, with diagnoses of Chronic Obstructive Pulmonary Disease, Muscle Weakness, and Difficulty Walking. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident required the assistance of one (1) staff for transfers, toileting, personal hygiene, and bathing, and the resident was occasionally incontinent of urine. The facility assessed the resident with Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) and determined the resident was not interviewable. Review of the facility's Certified Nursing Assistant (CNA) Care Record, dated January 2019, revealed staff…

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, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received appropriate treatment and services related to enteral feeding (directly into the stomach) for one (1) of four (4) sampled residents, Resident #110. Observation of the resident's tube feeding bags revealed there was no label to include the resident's name, date, time, or initials of staff that hung the tube-feeding. The findings include: Review of the facility's policy, Gastrostomy Feeding, reviewed 06/05/18, revealed feeding administration systems were to be changed every twenty-four (24) hours. The piston syringe was to be replaced every twenty-four (24) hours. Review of the facility's policy, Infection Prevention and Control Program, revised October 2018, revealed an element of the infection control program was the prevention of infections, which included instituting measures to prevent complications, education, and ensuring staff adhered to proper techniques…

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.