Sunrise Manor Center for Nursing and Rehabilitatio

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure that medications were administered in accordance with physician orders and in accordance with the facility's medication administration policy for one (1) of three (3) residents reviewed for a medication error (Resident #1). Specifically, the facility administered Vimpat (lacosamide), a controlled anti-seizure medication, at a dose of 200 milligram by mouth for four (4) doses when the medication administration record reflected an order for 50 mg by mouth twice daily. Findings Include:Resident #1 was admitted on [DATE] with diagnosis that include Cerebellar stroke syndrome, Conversion disorder with seizures or convulsions, and depression. On 12/23/2025 a Minimum Data Set Brief Interview of Mental Status was completed for Resident #1 and documented a score of 00 indicating severe cognitive impairment. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification and Abbreviated (NY 00363437) Survey initiated on 3/26/2025 and completed on 4/1/2025, the facility did not develop a comprehensive person-centered care plan for each resident that includes measurable objective and time frames to meet a residents medical, nursing, mental and psychosocial need that are identified in the comprehensive assessment. This was identified for one (Resident #50) of three residents reviewed for Skin Conditions. Specifically, Resident #50 was incontinent of bowel and bladder and there was no care plan developed to address the resident's incontinence care. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #3) of three residents reviewed for Accidents. Specifically, Resident #3 was assessed to require a mechanical lift with two staff members for transfer from one surface to another. On 3/26/2025, Certified Nursing Assistant #4 was observed transferring Resident #3 with a mechanical lift by themselves. The finding is: The facility's policy titled Mechanical Lifts, last reviewed on 10/2024, documented at least two nursing assistants are needed to safely move a resident with a mechanical lift. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure the Physician documented in the resident's medical record that the irregularity identified by the Pharmacist had been reviewed and what action had been taken to address the recommendations. This was identified for one (Resident #64) of five residents reviewed for Unnecessary Medications. Specifically, the Physician disagreed with a recommendation provided by the Consultant Pharmacist on the Medication Regimen Review form for Resident #64 and did not document the rationale for the disagreement. The finding is: The facility's policy, titled Medication Regimen Review, last reviewed on 10/2024, documented the facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, the ham sandwich temperatures were not maintained at a safe temperature of 41 degrees Fahrenheit (F) or below. The finding is: The facility policy titled Food Preparation, Service and Distribution, revised on 10/2024 documented that the facility will ensure safe and sanitary food preparation, holding, transport, and distribution to prevent food-borne illness. The facility will avoid the following potential risks to reduce food-borne illness: will not hold foods in the danger zone (temperatures above 41 degrees and less than 135 degrees Fahrenheit). [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure call systems were accessible to each resident while residents were in their rooms. This was identified for one (Resident #274) of one resident reviewed for call systems. Specifically, Resident #274 was observed in bed on 3/26/2025 at 9:36 AM and again on 3/26/2025 at 11:20 AM with no call bell within reach. The finding is: The facility's policy and procedure titled Call Bells, reviewed in 9/2024, documented to ensure accessibility and timely response to the activated call bells. Call bells are to be attached near the resident's bed appropriately and be within reach at all times. Resident #274 was admitted with diagnoses including Cardiac Arrest, Gout, and Major Depressive Disorder. [...]

Inspectors wroteBased on observations, interviews, and record review during an abbreviated (NY00360500) survey conducted on 12/04/2024 through 12/09/2024, the facility failed to protect each resident's right to be free from sexual abuse. This was identified for one (Resident #1) of four residents reviewed for sexual abuse. Specifically, Resident #1, with a diagnosis of Dementia and severely impaired cognition, was observed in Resident #2's room by Licensed Practical Nurse #1 performing oral sex. Resident #2 was cognitively intact. Resident #1's family member was interviewed and stated that if Resident #1 was cognitively intact, they would have been upset, embarrassed, and humiliated. This resulted in actual psychosocial harm to Resident #1 and the potential for harm to 9 of 72 cognitively impaired residents reviewed for sexual abuse, which was Immediate Jeopardy and Substandard Quality of Care. [...]

Inspectors wroteBased on observations, record review and interviews during the abbreviated Survey initiated on 8/4/2024 and completed on 8/09/2024 (NY00360500) the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for one (1) (Resident #1) of four (4) residents with the potential to affect 9 of 72 cognitively impaired residents reviewed for sexual abuse. Specifically, Resident #1 who had severely impaired cognition and was found in Resident #2's room by Licensed Practical Nurse #1 performing oral sex on Resident #2 (with intact cognition.). [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 11/08/2023 and completed on 11/14/2023, the facility did not ensure that a Comprehensive person-centered care plan was developed and implemented for each resident. This was identified for two (Resident #18, and Resident # 69) of two residents reviewed for Respiratory care. Specifically, 1) Resident #18 had Physician's order to receive 2 liters (L) of Oxygen (O2) per minute (min). On 11/08/2023 and 11/10/2023, Resident # 18 was observed receiving Oxygen at a flow rate of 6 liters/per minute; and 2) Resident # 69 had Physician's orders to receive Oxygen at a flow rate of 3 L/min. On 11/08/2023 and 11/10/2023, Resident # 69 was observed receiving Oxygen at a flow rate of 6L/min.

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification Survey initiated on 11/08/2023 and completed on 11/14/2023, the facility did not ensure that each resident's medical record was maintained in accordance with accepted professional standards and practices. The facility did not maintain medical records for each resident that were complete and accurately documented. This was identified for one (Resident #51) of five residents reviewed for unnecessary medications. Specifically, during an observation of Resident #51 on 11/09/2023 at 4:17 PM, Resident #51 was observed with redness to the inner corner of their left eye. During a second observation on 11/10/2023 at 3:15 PM Resident #51's left eye inner corner remained red. During a third observation of Resident #51 on 11/13/2023 at 1:52 PM the left eye was completely reddened. [...]

Inspectors wroteBased on observations, record review and interview during the Recertification Survey and Complaint Survey NY00281499, the facility did not ensure that all residents had a clean and homelike environment. This was identified from the Resident Council meeting conducted on 10/05/2021 and observations made in 15 of 40 rooms in the facility (#101, #102, #103, #109, #113, #119, #120, #203, #204, #205, #206, #212, #216, #217, and #218). Specifically, 1) residents from the resident council voiced concerns about dirty shower drains during four resident council meetings (5/19/2021, 7/6/2021, 8/3/2021, and 9/14/2021) and observations revealed that the shower drains continued to be clogged with hair and dirt; and 2) observations revealed debris including wrappers, straws, and surgical masks, dust, and food residue in 15 of 40 rooms. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey completed on 10/12/2021, the facility did not ensure that all medication irregularities identified by the Licensed Pharmacist on the monthly Medication Regimen Review (MRR) were addressed by the Physician for one (Resident #33) of five residents reviewed for Unnecessary Medications. Specifically, a recommendation was made by the Pharmacist consultant on 10/5/2021 to change Resident #33's Synthroid (thyroid medication) medication administration time from 6 AM to 2 PM. The attending Physician agreed with the recommendation on 10/6/2021; however, a Physician's order was not written to reflect the recommended change. The finding is: [...]