Sunrise Manor Nursing Home

Inspectors wroteBased 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.

Inspectors wroteBased on interview, record review, review of the facility's policy, and review of the facility's Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's administration failed to ensure thorough actions were taken after the 02/25/2021 misappropriate/drug diversion involving eight (8) residents. In addition, the facility failed to ensure the safety of residents to prevent falls for a resident assessed as a high risk for falls. Additionally, the facility's administration failed to maintain substantial compliance, after the 01/24/2019, Recertification Survey, in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656, F657); [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility. The Governing Body failed to ensure compliance in the areas of 42 CFR 482.12 Freedom from Abuse, F600, F602, and F610; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F655, F656, F657; 42 CFR 483.25 Quality of Care, F689; 42 CFR 483.45 Pharmacy Services, F755; CRF 42 483.60 Food and Nutrition Services, F812; 42 CFR 483.70 Administration, F835 and F837; 42 CFR 483.75 Quality Assurance and Performance, F867; and 42 CFR 483.80 Infection Prevention and Control, F880 during the Recertification Survey 03/20/2022 through 04/14/2022. Continued non-compliance was cited during this Survey at 42 CFR 482.12 Freedom from Abuse, F610; 42 CFR 483.20; [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's policy, and review of the facility's Plans of Correction (POC) submitted for the 01/24/2019 and 11/05/2019 surveys, it was determined the facility failed to have effective processes in place to address system failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) meetings. As a result, the facility failed to identify quality of care deficiencies; failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. This was evidenced by deficient practice cited at F656, F657, F689, and F755, on the 01/24/2019 survey; and F610, and F656, which were cited on the 11/05/2019 survey. [...]

Inspectors wroteBased on observation, interview, record review, policy review, and Centers for Medicare and Medicaid Services, Resident Assessment Instrument Manual 3.0, it was determined the facility failed to develop and/or implement a person-centered Comprehensive Care Plan (CCP) which included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for two (2) of seventy-one (71) sampled residents (Residents #12 and #49) 1. Review of Resident #49's Comprehensive Care Plan (CCP) revealed an intervention to place the resident near the nurses' station when out of bed on 09/08/2020. On 05/28/2021, the facility added the intervention to keep the resident near the nurses' station when up in the wheelchair (w/c). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of the facility's fall investigation, it was determined the facility failed to ensure routine maintenance of assistive devices to prevent an avoidable accident for one (1) of thirty-one (31) sampled residents, Resident #82. On 12/06/18, Certified Nursing Assistant (CNA) #13 was pulling the resident backwards in a shower chair, over a lip in the floor, and the chair broke causing the resident to fall and sustain a broken hip. Interview and record review revealed a thorough investigation had not been completed because the shower chair was not fully examined in order to determine how it had malfunctioned. Interview and record review also revealed the shower chair had not been routinely checked by maintenance per the facility's policy and procedures. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.