Sundale Nursing Home

Inspectors wroteBased on observation, staff interview and and record review, the facility failed to implement a resident's care plan by failing to use both floor mats for Resident #79 with a a history of falls. Resident identifier: #79. Facility Census: 91.

Inspectors wroteBased on Observations and Staff interviews, the facility failed to store food in accordance with professional standards for food safety. The first floor south nutrition room had five (5) Glucerna drinks that were expired. This was a random opportunity for discovery during the normal Long Term Survey Process, that had the potential to effect more then a limited number of residents. Facility Census: 91. a) During the facility walkthrough and inspection of the nutrition areas on 05/27/26 at approximately 10:45 AM, five (5) expired Glucerna supplements were found in the first-floor south wing resident nutrition room. They expired on 01/03/26 and remained in the cabinet accessible to residents. During a interview with Social Worker #148 on 05/27/26 at approximately 11:15 AM, they confirmed the supplements were expired and then discarded them.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Quality assessment and assurance (QAA) meetings were completed at minimum quarterly. This failed practice has the potential to affect more than a minimal number of residents residing in the long term care facility. Facility Census: 91Findings included: a) Record review completed on 06/03/26 revealed the QAA meeting for Quarter Two (2) was held on 10/29/25 along with the Quarter Three (3) meeting. During an interview on 06/03/26 at approximately 11:30 AM the Administrator stated they normally hold meetings the month following the end of the quarter to discuss all items for that quarter. However, the Doctor was unable to attend the scheduled meeting for Quarter Two (2) so they combined both the Quarter Two (2) and Quarter Three (3) meetings. This confirms there was no meeting during the second quarter.

Inspectors wroteBased on interview and record review, the facility failed to document voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and maintain evidence of the result of all grievances for no less than 3 years from the date the grievance decision was issued. This has the potential to affect, more than a limited number of Residents. Facility census: 85. Findings Included: Record review of the facility's policy titled, Resident and Family Grievances, showed: --The grievance official is responsible for overseeing the grievance process: receiving and tracking grievances through their conclusion. --Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. A grievance log will be maintained for each calendar year. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure accurate weights were obtained for three (3) out of three (3) residents sampled for weight loss. Failure to monitor and investigate significant changes in resident's weight status places the residents at risk for an incorrect assessment or diagnosis of impaired nutrition or hydration status. Further, this failed practice potentially prevented the interdisciplinary team from accurately developing and implementing interventions to stabilize or improve the resident's nutritional status before complications arose. Resident Identifiers: Residents #24, #53 and #78. Facility Census:85.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a resident's significant change in weight, and failed to ensure that the physician conducted a medical evaluation of a resident with a sudden significant change in weight. As a result, the residents were not evaluated to determine the cause for the sudden change in body weight. This placed the resident at risk for serious harm or death. Resident Identifiers: Resident #24, #53, and #78. Facility Census: 85. Findings Included: a) Resident #24 During a review of Resident #24's weights on 01/09/25 at approximately 9:18 AM, the following values were revealed: [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to store food in a safe sanitary manner in regard to storing medical ice packs in the freezer in the residents pantry. This has the potential to affect a limited number of residents. Facility census: 85. Findings Included: a) Two South Resident Pantry During the tour on 01/08/25 at 9:20 AM to the Resident pantry, two (2) medical Ice packs were observed stored in resident freezer. An interview, on 01/08/25 at 9:20 AM, with the Dietary Manager confirmed the medical ice packs should not be stored with resident food.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that the long-term care Ombudsman was sent a copy of the written Notice of Transfer for acute hospital transfers. This was true for two (2) out of two (2) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #28 and #4. Facility census: 85.

Inspectors wroteBased on record review and staff interviews, the facility failed to identify Major Depressive disorder on Preadmission Screening and Resident Review (PASARR). This was found true for one (1) of three (3) residents reviewed during the long-term care survey process. Resident identifier: Resident #53. Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that the Resident had a person-centered, comprehensive care plan, developed and implemented to meet his / her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of nine (9) residents' care plans reviewed during the Long-Term Care Survey Process (LTCSP). This failure to ensure that the comprehensive care plan was developed to ensure the residents' highest practicable well-being placed the resident at risk of not receiving services that would meet their desires or needs. Resident Identifier: Resident #53. Facility Census: 85.

Inspectors wroteBased on record review, and staff interview, the facility failed to follow physician orders related to administration of pain medication. This was true for one (1) of three (3) residents reviewed for pain during the annual long-term care survey process. Resident identifier: #2. Facility census: 85.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a comprehensive social services assessment in its entirety for Resident #35. This was a random opportunity for discovery. Resident identifier: #35. Facility census: 85.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to develop and/or implement a care plan regarding fall prevention interventions for Resident #38 and #9. Resident Identifiers: #38 and #9. Facility Census: 85. Findings Included: a) Resident #38 On 01/03/24 at 10:07 AM, a record review was completed for Resident #38. The review found the fall prevention interventions on the care plan had not been implemented. An observation of Resident #38's wheelchair found no anti-roll backs were in place. Nurse Aide (NA) #104 confirmed the anti-roll backs were not in place. The resident was found to have multiple falls throughout the stay at the facility. On 01/03/24 at 10:15 AM, the record review found an additional fall prevention intervention of check q (every) 30 minute checks to ensure toileting and ADL (activities of daily living) needs were met. [...]

Inspectors wroteBased on record review and staff interview the facility failed to revise a careplan related to a significant weight loss and to include supplements. This was a random opportunity for discovery. Resident identifier # 81. Facility census 85.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to follow the physician's orders regarding fall prevention interventions for Resident #38 and #9. Resident Identifiers: #38 and #9. Facility Census: 85. Findings Included: a) Resident #38 On 01/03/24 at 10:07 AM, a record review was completed for Resident #38. The review found the physician's orders for the fall prevention interventions were not being followed . An observation of Resident #38's wheelchair found no anti-roll backs were in place. Nurse Aide (NA) #104 confirmed the anti-roll backs were not in place. The resident was found to have multiple falls throughout the stay at the facility. [...]

Inspectors wroteBased on observation, staff interview, and facility policy the facility failed to serve house snacks in a sanitary manor, by serving snacks off of a cart which included dirty dishes. This was a random opportunity for discovery. This failed practice was true for two (2) of two (2) residents. Resident identifiers #9 and #16. Facility census 85.

Inspectors wroteBased on observation and record review, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A medication cart and a treatment cart were unlocked with no one in attendance. These were random opportunities for discovery that had the potential to affect residents who were able to access the carts. Resident identifiers: #34, #73, #60, #21, #54, #78, #38, #135, #8, #81, #72, #76, #9. Facility census: 84.

Inspectors wroteBased on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. During the kitchen tour it was discovered dry food bins had not been dated when filled. This had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Resident hand hygiene was not performed before the noon meal. This was a random opportunity for discovery. Resident identifiers: #38, #284, #45, #73. Facility census: 84.

Inspectors wroteBased on record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident. This deficient practice was found for one (1) of 20 resident MDS assessments reviewed during the Long Term Care Survey Process. Resident identifier: #60. Facility census: 84.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a comprehensive person- centered care plan for Resident #27. This was discovered for one (1) of three (3) residents reviewed for the care area of nutrition during the Long Term Care Survey Process. Resident identifier: #27. Facility census: 84.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The deficient practice was true for one (1) of four (4) residents reviewed for the care area of falls during the Long Term Care Survey Process. Resident identifier: #60. Facility census: 84.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. A multi-use tuberculin purified protein derivative (PPD) vial was not dated when opened to determine when the vial should be discarded. This was a random opportunity for discovery that had the potential to affect residents receiving tuberculin PPD injections. Facility census: 84.