Sunharbor Manor

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for one (Resident #246) of three residents reviewed for pain management. Specifically, Resident # 246 had a physician's order for a Lidocaine (a medication used to treat pain) patch to be applied to the resident's lumbar area (lower back). On 3/15/2024 during the medication pass observation, the medication nurse applied a Menthol patch to the resident's lower back instead of the Lidocaine patch. The finding is: [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated Survey (Complaint # NY 00320409) initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that they developed and implemented an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition the resident to post-discharge care. This was identified for one (Resident #466) of one resident reviewed for Discharge. Specifically, Resident #466 was discharged from the facility on 7/17/2023 with no confirmation of acceptance from a Home Care Agency. On 7/18/2023 the referred Home Care Agency denied Home Healthcare Services for Resident #466. [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024 the facility did not ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. This was identified for one (Resident #155) of four residents reviewed for communication. Specifically, Resident #155 required hearing aid devices for both ears. Resident #155 lost the left ear hearing aid. The resident had multiple physician orders on 1/18/2024, 1/23/2024, 2/03/2024, 2/20/2024, 3/11/2024, and 3/19/2024 for an Audiology Consult. The Audiology appointment was not confirmed until 3/19/2024, two months after the first physician's order was written. The finding is: Resident #155 was admitted with diagnoses that included Type 2 Diabetes, Hypertension, and Congestive Heart Failure. [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024 the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for two (Resident #240 and Resident #101) of seven residents reviewed for Accidents. Specifically, 1) on 3/15/2024 Resident #240 was observed unsupervised outside of the building on the front sidewalk in the facility's designated smoking area. The resident was smoking but was not one of the residents that had been assessed and determined to be a safe smoker. The facility was not aware the resident had exited the building; and 2) Resident #101 was observed with multiple medication tablets in a medication cup and an inhaler on their overbed table on 3/14/2024 and 3/20/2024. There were no staff members in the vicinity. [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024 the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment, care, and services to prevent complications of enteral feeding. This was identified for one (Resident #161) of one resident reviewed for Tube Feeding. Specifically, on 3/15/2024 at 12:03 PM, Resident #161's tube feeding and hydration (water) bags were observed hanging without labels including the resident's name, and the time the tube feeding was initiated. The finding is: The facility's Gastrostomy Tube Feeding policy dated 5/2023 documented that the facility will provide gastrostomy tube feedings to residents according to Physician's orders. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey initiated on 03/14/2024 and completed on 03/21/2024, the facility did not ensure that each resident received care and services for the provision of parenteral fluids consistent with professional standards of practice and in accordance with physician orders and the comprehensive person-centered care plan. This was identified for one (Resident #216) of one resident reviewed for Hydration. Specifically, on three separate occasions, 03/14/2024 at 10:02 AM, 03/15/2024 at 10:30 AM, and 03/18/2024 at 09:12 AM, Resident #216 was observed with a Peripheral Intravenous Catheter in their left hand; however, there was no Physician's order for the placement and the care of the Intravenous Catheter. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that for each resident, as-needed orders for psychotropic drugs were limited to 14 days, and there was a rationale and indication for the duration of the medication. This was identified for one (Resident #68) of one resident reviewed for Choices. Specifically, on 2/9/2024 Resident #68 was prescribed Ambien (a sedative medication to help people sleep) 10 milligrams to be taken as needed. The order was not limited to 14 days and there was no rationale and indication for the continued use of the medication documented in the physician's notes. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024 the facility did not ensure that all drugs used were labeled in accordance with professional standards including expiration dates, and that the medications were stored at proper temperatures. This was identified for three of twelve medication carts reviewed during the Medication Storage task. Specifically, 1a) an open Lantus Solostar insulin pen for Resident #194 was observed on 3/19/2024 in the medication cart with an open date of 2/23/2024, more than 28 days. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that residents were assisted in obtaining routine dental care. This was identified for one (Resident #2) of one resident reviewed for Dental. Specifically, Resident #2 had a Physician's Order for a dental consult dated 7/6/2023; however, the resident was not seen by the Dentist until 2/4/2024. Additionally, during a subsequent dental visit on 2/16/2024, the Dentist made a recommendation for the resident to have six tooth extractions so that a full upper and lower denture could be made. These recommendations were never addressed by the facility until it was brought to the facility's attention on 3/19/2024 by the Surveyor. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #252) of four residents reviewed for Infection Control. Specifically, Resident #252 had a physician's order for Contact Precautions for an infection of Clostridium Difficile(C-Diff). During an observation on 3/14/2024 of the resident's room, the Contact Precaution signage that included instructions for the use of specific Personal Protective Equipment was not posted in a conspicuous location outside of the resident's room. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident as determined by resident assessment and individual plans of care. This was identified through staff interviews, resident council task, review of Facility Assessment and staffing assignments. Specifically, 1) The facility nursing staffing assignments did not reflect the staffing needs as indicated in the Facility Assessment for the Certified Nursing Assistants (CNA), the Licensed Practical Nurses (LPN), and the Registered Nurses (RN); 2) Resident #94 did not receive floor ambulation twice a day as ordered; [...]

Inspectors wroteBased on record reviews and staff interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility failed to have 100% vaccination compliance rate. Specifically, the staff matrix for staff vaccination documented that out of the 341 staff members employed by the facility, one staff member, a Licensed Practical Nurse (LPN) #1 was not fully vaccinated and provided resident care. The finding is: The Center for Medicaid and Medicare Services (CMS) QSO-22-07-ALL, dated 12/28/2021, CMS expects all providers' and suppliers' staff to have received the appropriate number of doses by the timeframes specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by CDC. Facility staff vaccination rates under 100% constitute noncompliance under the rule. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00288885) initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that all injuries of unknown origin are thoroughly investigated. This was identified for one (Resident # 228) of four residents reviewed for Accidents. Specifically, Resident #228 sustained an unwitnessed displaced fracture of the distal femur (leg bone). The Accident/Incident (A/I) report lacked documented evidence that all statements were obtained from staff that cared for Resident #228 prior to the identification of the injury. The statements that were obtained were not complete to rule out abuse, neglect, and mistreatment. Additionally, there was no statement obtained from Resident #228, who was cognitively intact, to ascertain the cause of the fracture. The finding is: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was identified for 1 (Resident #66) of 4 residents reviewed during the medication administration task. Specifically, Registered Nurse (RN) #2 crushed and mixed 11 medications and supplements together and administered them simultaneously to Resident #66 with applesauce, including an extended-release heart medication (Metoprolol Succinate). The finding is: The facility's undated policy, titled Crushing Medications, documented long-acting or enteric-coated medications may not be crushed without a physician's order. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice and that interventions were implemented in accordance with the resident's Comprehensive Care Plan (CCP). This was identified for 1 (Resident #10) of 4 residents reviewed for Pressure Ulcers. Specifically, Resident #10 had a Stage 4 Pressure Ulcer to the sacral region and was utilizing an air mattress to offload the bony prominences and the sacral area. The physician ordered the air mattress setting to be set at 210 pounds. Upon two separate observations, the air mattress was observed at the firm setting. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that its medication error rates were not 5 percent or greater. This was identified for 11 of 26 opportunities during a medication pass observation resulting in a 42.3 % medication error rate. Specifically, during the medication administration observation for Resident #66, the Registered Nurse (RN) #2 crushed and mixed 11 medications and supplements together and administered them simultaneously to the resident with apple sauce. The finding is: The facility's undated policy, titled Crushing Medications, documented long-acting or enteric-coated medications may not be crushed without a physician's order. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that each resident remained free of significant medication errors. This was identified for 1 (Resident #66) of 4 residents reviewed during the medication administration task. Specifically, during the medication administration observation for Resident #66, the Registered Nurse (RN) #2, the medication administration nurse, crushed and mixed seven medications and four supplements (total of 11 items) together, including Metoprolol Succinate (heart medication) 25 milligram (mg) extended-release tablet. RN #2 then administered the medications simultaneously to the resident with apple sauce. The finding is: [...]

Inspectors wroteBased on observations and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that the nurse staffing data was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. Specifically, during a tour on 5/18/2022 and 5/19/2022, there was no posting of the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) observed in a prominent area such as the lobby, near the elevator, or on the individual nursing units. The finding is: A tour was made on 5/18/2022 between 9:30 AM and 11:00 AM of the lobby and the five nursing units. There was no staffing data posting visible that contained the number of staff providing care for each nursing shift: 7AM-3 PM, 3 PM-11PM, and 11 PM-7 AM. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident. This was identified for one (Resident #114) of three residents reviewed for Activities of Daily Living (ADLs). Specifically, Resident #114 had a physician's order for a nursing rehabilitation (rehab) standing program to be done twice a day; however, the resident consistently refused the standing program during the evening shift and there was no documented evidence that the Certified Nursing Assistant (CNA) reported the resident's refusals to the nurse. The finding is: [...]

Inspectors wroteBased on observation, record review and staff interviews during the recertification survey, the facility did not ensure that each resident's Comprehensive Care Plan (CCP) was reviewed and revised to reflect the resident's current status. This was identified for one (Resident #62) of two residents reviewed for Communication-Sensory Care. Specifically, Resident #62 experienced double vision, had an Ophthalmology Consultation outside the facility, and wore an eye patch for three weeks without the resident's Vision Comprehensive Care Plan (CCP) being updated. The finding is: Resident #62 was admitted to the facility on [DATE] and has diagnoses which include Psychotic Disorder with Delusions and Hypertension. [...]

Inspectors wroteBased on record review and staff interviews during the recertification survey, the facility did not provide care and services to maintain acceptable parameters of nutritional status for one (Resident #157) of five residents reviewed for Nutrition. Specifically, Resident #157 had a significant weight loss of over 7.5% in a three month time period with no updates to the resident's plan of care to address this weight loss. The finding is: The undated Documentation of Weight Loss policy documented Nursing will report significant weight change upon discovery to the Physician and Dietitian. The Dietitian will review weights timely within one week of notification. The Dietitian must evaluate the resident with significant weight change, initiate the weight loss protocol if not already ordered by the Physician and change the resident's treatment plan. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did ensure that each resident's total program of care, including medications and treatments was reviewed at each visit. This was identified for one (Resident # 157) of five residents reviewed for Nutrition. Specifically, Resident #157 had a significant weight loss of over 7.5% in a three month time period which was not addressed by the Attending Physician and Physician's Assistant. There was no a physician's evaluation when a change in a resident's nutritional status was identified to address the medical and nutritional issues related to the significant weight loss. The finding is: The undated Documentation of Weight Loss policy documented that Nursing will report significant weight change upon discovery to the Physician and Dietitian. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did not ensure that the Attending Physician documented review of an identified irregularity as identified by the Pharmacist for one (Resident #62) of five residents reviewed for Unnecessary Medications. Specifically, the Pharmacist documented on 9/30/19 a recommendation for the Primary Physician to address. The Physician agreed to the recommendation on 10/4/19; however, never documented or addressed it in the resident's medical record. The finding is: The facility's undated Monthly Drug Regimen Review policy documented that the Prescriber/Licensed Designee (Physician) shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation and provide a brief clinical rationale if no change is to be made. [...]

Inspectors wroteBased on observation and interviews during Recertification survey the facility did not ensure that medications were stored in accordance with currently accepted professional principles and under proper temperature controls on 1 of 5 nursing units. Specifically, the 2 North nursing unit refrigerator thermometer was observed at 50 degrees Fahrenheit (F). Insulin pens and Insulin vials, as well as a vial of Procrit, were observed in a plastic tray which contained a 1/2 inch of water that had collected from defrosting ice. In addition, there was one flu vaccine in the refrigerator. The finding is: The facility's undated policy, titled Refrigerator Policy-Nourishment and Medication, documented that refrigerator temperatures should be within the range of 36-46 degrees F. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey the facility did not ensure that practices were in place to help prevent the development and transmission of communicable diseases and infections for one (Resident #142) of two residents reviewed for Pressure Ulcers. Specifically, during the wound care observation for Resident # 142, the Registered Nurse (RN) treatment nurse did not not wash his hands or change his gloves after cleansing the wound. The finding is: The facility's policy titled Aseptic Dressing, dated 4/4/18, documented that the nurse will remove gloves and wash hands after cleansing the wound. Resident #142 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Diabetes Mellitus, Peripheral Vascular Disease, and Stage 4 Pressure Ulcer to the Sacral Region. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did not ensure that their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption specifically included how facility staff would ensure that a resident is assisted in accessing and consuming the food, if the resident is not able to do so on his or her own. The finding is: The facility's Handling of Food from Outside Sources dated 3/12/18 was reviewed on 11/4/19 at 9:30 AM. The policy did not specifically include how the facility would ensure that a resident was assisted in accessing and consuming food brought in by family and other visitors, if the resident was not able to do so on his or her own. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not meet the electronic transmittal requirements for a Minimum Data Set (MDS) Discharge Assessment to the Centers for Medicare and Medicaid Services (CMS) system within fourteen days after the completion of the assessment. This was evident for one of two residents reviewed in the Resident Assessment Facility Task. Specifically, Resident #1 was discharged to home on 6/6/19. The MDS Discharge Assessment with a completion date of 6/17/19, had not been transmitted within 14 days of the completion of the assessment, the MDS was transmitted to CMS on 11/5/19. The finding is: Resident #1, with diagnoses including Hypertension and Diabetes Mellitus, was admitted to the facility on [DATE] for short term rehabilitation. [...]