Sunrise Nursing & Rehabilitation

Inspectors wroteBased on interview, and record review, the facility failed to ensure the rights of the one sampled resident's (Resident # 3) Durable Power of Attorney (DPOA) was exercised to maintain the resident safety when the facility allowed a family member who was not the POA to take the resident out of the facility out of 15 sampled residents. The facility census was 139 residents. Review of the facility's policy, Decision Making Capacity, dated 8/2020 showed:-Identifying a Surrogate Decision-maker: A person with legal authority to make medical treatment decisions on behalf of a resident was a person designated under a valid POA, a guardian, a conservator or a next of kin. The facility did not have a policy about an incapacitated resident leaving the facility. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate storage and labeling of medications throughout the facility's medication carts and medication rooms which had the potential to affect all residents within the facility; and failed to ensure medications were stored in the medication cart/medication room for one resident (Resident #58) observed during the medication pass. The facility census was 134 residents. Review of the facility's policy titled Storage of Medications dated August 2020 showed: -Medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. -All medications dispensed by the pharmacy were stored in the pharmacy container with the pharmacy label. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain plastic cutting boards and plate covers in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs; and failed to store foodstuffs within their recommended acceptable temperature parameters, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 134 residents with a licensed capacity for 156 residents at the time of the survey. 1. Observation on 6/23/25 between 9:51 A.M. and 11:39 A.M. during a kitchen sanitation inspection showed the following: [...]

Inspectors wrote2. Review of Resident #12's admission record showed he/she admitted to the facility with the following diagnoses: -Low Back Pain. -Chronic Pain Syndrome (a condition characterized by persistent pain lasting longer than three months, significantly impacting physical, emotional, and social well-being). Review of the resident's Medication Administration Record (MAR) dated June 2025 showed a physician order for Lidocaine Patch 4%, apply to lower back topically in the morning for pain related to Chronic Pain Syndrome. Observation on 6/24/25 at 7:54 A.M. of the resident's Lidocaine 4% patch administration completed by Certified Medication Technician (CMT) B showed: -He/She had put on gloves and unlocked the medication cart without washing or sanitizing his/her hands before putting on the gloves. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Family Care Safety Registry (FCSR) screening was completed per facility policy for three newly hired employees (Employee #1, #2, and #4) out of 10 newly hired employees. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 134 residents. Review of the facility Background Check Policy dated 2/2025 showed: -Candidates for all staffing positions are subject to background checks. -The Department of Human Resources is responsible for the general administration and implementation of this policy. 1. Review of Employee #1's Employee File showed: -His/Her hire date was 8/28/24. -A FCSR was completed on 9/24/24, one month after the employee was hired. 2. Review of Employee #2's Employee File showed: -His/Her hire date was 7/24/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that professional standards were met when Certified Medication Technician (CMT) B pre-popped and signed as given prior to administration the medications for three supplemental residents (Resident #6, #56, and #400) out of four supplemental residents. This practice had the potential to affect all residents in the 700 hall. The facility census was 134 residents. Review of the facility's undated policy titled Medication-Administration showed: -The purpose of the policy was to provide practice standards for safe administration of medications for residents in the facility. -The time and dose of the drug or treatment administered to the resident would be recorded in the resident's individual medication record by the person who administered the drug or treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store nebulizers (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) and a nasal cannula (a device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through your nose) in a bag for three sampled residents (Resident #48, #41, and #105); and failed to complete a periodic assessment for one sampled resident's (Resident #63) ability to self-administer his/her respiratory care, including tracheostomy (trach - an opening surgically created through the neck into the windpipe; a tube is usually placed through this opening to provide an airway and to remove secretions) out of 27 sampled residents. The facility census was 134 residents. Review of facility policy titled Respiratory Care Policy revised January 2025 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Federal, State, and Local Laws to ensure the facility van was licensed to ensure legal transport of residents to and from the facility. This failure had the potential to affect all residents who required transportation to and from the facility for appointments. The facility census was 134 residents. A policy related to vehicle maintenance and licensure was requested and not received during survey. 1. During an interview on [DATE] at 12:41 P.M., the Director of Nursing (DON) said: -The facility had two vans in the parking lot. -One van had a sister facility's name on the side that the facility had not used due to the van having mechanical issues. That van had expired tags. -The second van had the facility's name on the side of the van. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's responsible party when changes to his/her medication orders were changed for one sampled resident (Resident #80) out of 27 sampled residents. The facility census was 134 residents. Review of the facility's Change of Condition Notification policy dated June 2020 showed: -Purpose was to ensure residents and resident representatives are notified of changes in condition in a timely manner. -A change of condition included changes in treatment. -Staff were to document the notification in the resident's medical records. 1. Review of Resident #80's admission Record showed he/she: -Was admitted to the facility on [DATE]. -Had a medical Power of Attorney (POA- a person previously identified to make decisions for an individual in the event of inability to make wishes known). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly smoking assessments were completed per facility policy for one sampled resident (Resident #24) out of 27 sampled residents. The facility census was 134 residents. Review of the facility's policy titled Smoking by Residents dated November 2023 showed: -Residents who wanted to smoke would be assessed for their ability to smoke safely prior to being allowed to smoke independently in the designated smoking areas. -Residents who were not able to smoke independently and safely would be accompanied by facility staff while smoking. -All residents who smoked were to be assessed related to smoking safety at the time of admission and then at least quarterly thereafter. 1. Review of Resident #24's admission Record showed that he/she admitted to the facility with the following diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hand hygiene during catheter (a hollow, partially flexible tube inserted into the bladder to drain urine) care; and failed to ensure the catheter bag was maintained below the level of the bladder for one sampled resident (Resident #37) out of 27 sampled residents. The facility census was 134 residents. Review of the facility undated Catheter Care policy showed: -A resident with a catheter receives care and services to prevent infections to the extent possible. -Wash hands and put on gloves prior to handling the catheter, drainage system or bag. -Position the catheter drainage system and bag utilizing gravity to facilitate drainage. -Always keep the urine collection bag below the level of the bladder. Review of the facility Handwashing/Hand Hygiene policy dated August 2019 showed: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure as needed controlled mediation (drug or other substance that was tightly controlled by the government because it may be abused or cause addiction) were signed out on the Controlled Drug Administration Record and in the Nurse's Medication Administration Record (MAR) for two sampled residents (Resident #48 and #113) out of 27 sampled residents. The facility census was 134 residents. Review of facility policy titled Administration Procedures for all Medications revised 8/2020 showed: -After administration, return to the cart, document administration in the MAR or Treatment Administration Record (TAR) and if the mediation was a controlled substance sign out the record. Review of the undated facility policy titled Medication Administration showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication rate under five percent for three sampled residents (Resident #130, #58, and #21) with a medication error rate of 22.58%. The facility census was 134 residents. A policy on insulin pens was requested and not received by the time of exit. Review of the facility Medication Administration policy undated showed: -Medications will be administered per the order of an attending physician or licensed practitioner. -Medications will not be left at the bedside. -The time and dose of the drug or treatment administered to the resident will be recorded in the resident's medication record by the person who administers the medication. A policy for self-administration of medications was requested and not received. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to transfer one sampled resident (Resident #2) safely by failing to use a full body mechanical lift or a gait belt to transfer the resident safely from the shower chair to his/her bed, resulting in a hospitalization, left knee swelling,use of a knee brace and increased pain with movement out of five sampled residents. The facility census was 127 residents. A policy was requested and no policy was received by the facility. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident rights of one sampled resident (Resident #1) for self determination by inappropriately placing the resident on a locked unit without his/her consent and without evidence, rationale or documentation showing the resident was at risk for elopement, was exit seeking or had wandering behaviors or was a danger to self and needed a more secured placement out of 5 sampled residents. The facility census was 127 residents. Review of the facility's undated Transfer of Resident from Non-Secure Unit to Secure Unit showed this policy outlines the process for transferring a resident within our facility from a non-secured, non-locked unit to a secure, locked unit. The transfer criteria include specific assessments, documentation, and approval to ensure resident safety and well-being. The policy showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Residents #3) remained free from abuse, out of seven sampled residents. The facility census was 122 residents. On 10/17/23, the Administrator was notified of the past noncompliance which occurred on 10/15/23. The facility administration was notified on the same day the incident occurred and investigations were started. Facility staff were educated on the facility's abuse and neglect policy, resident interventions, and behaviors before the start of next shift. Resident care plans were updated. The deficiency was corrected on 10/16/23. Review of the facility Abuse Prevention and Prohibition Program, dated 10/24/22, showed: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. [...]

Inspectors wroteBased on observation, interview and record review, the facility dietary staff failed to observe and adhere to the sanitary and hygienic food practices as outlined in the professional standards of the U.S. Food and Drug Administration's (FDA) Food Code, when they prepared residents' meals by not wearing the required hair restraints. The facility had census of 112 residents. 1. Observation on 8/3/23 between 5:03 A.M. and 6:45 A.M. in the kitchen, showed: -At 6:10 A.M. a Dietary Aide (DA) was in the kitchen and prepared cold cereal on a food preparation table. -The DA did not have a total covering of his beard, mustache and sideburns. -At 6:35 A.M. the Dietary Manager (DMgr) entered the kitchen, had a full beard with a mustache, and was not wearing a beard/hair restraint. -At 6:38 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to complete a background screening through the Certified Nurse Assistant (CNA) Registry prior to hire to determine if there was a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) for seven out of ten new employees whose files were sampled. This had the potential to affect any facility resident who received services from or whose medical records or belongings could have been accessed by one or more of the seven new employees. The facility census was 112 residents. On 8/7/23, the Administrator was notified of the past noncompliance which took place over a period of time to include 1/19/23 through 7/22/23. [...]

Inspectors wroteBased on interview and record review, the facility, failed to ensure residents' monthly Drug Regimen Review (DRR-thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) were completed by the pharmacy to ensure irregularities were identified so they could be acted upon for four sampled residents (Resident #23, #41, #90, and #84) out of 24 sampled residents. The facility census was 112 residents. Review of the facility's policy titled DRR revised 6/20/20 showed: -A pharmacist must review each resident's medication regimen at least once per month and document this in the resident's medical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection control program that included tracking and trending of facility resident infections. The facility census was 112 residents. Review of the facility policy titled Infection Prevention and Control Program revised October 24, 2022 showed: -The facility must establish an Infection Prevention and Control Program under which it identifies, investigates, controls, and prevents infections in the facility and maintains a record of incidents and corrective actions related to infections. -The Infection Preventionist (IP) collects, analyzes, and provides infection data and trends to nursing staff, physicians. -The IP will determine specific sites and pathogen trends. -The IP will at least on a monthly basis conduct an infection control audit to identify trends. -Infection data is analyzed to identify trends. [...]

Inspectors wroteBased interview and record review, the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 112 residents. Review of the facility policy titled Antibiotic Stewardship Program revised 6/20 showed: -The Infection Preventionist (IP) would be responsible for infection surveillance tracking. -The IP would utilize the Antibiotic Tracking Sheet. -The IP would measure and report outcomes at monthly/quarterly Infection Control Committee meetings. -The Antibiotic Stewardship Program (ASP) was designed to promote the appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #83) out of 24 sampled residents was free from physical abuse from another sampled resident (Resident #84), who had a history of previous resident to resident altercations, when Resident #84 placed his/her hand on Resident #83's neck and pushed him/her backwards causing Resident #83 to fall and sustain injuries, mainly bruising. The facility census was 112 residents. Review of the facility's Abuse Prevention and Prohibition Program policy, dated October 24, 2022 showed: -The facility had zero tolerance for abuse. -The facility was committed to protecting residents from abuse by anyone, including, but not limited to other residents. 1. Review of Resident #83's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to place a date on items to indicate when they were placed in the walk in refrigerator; failed to maintain the fan that was used, free of dust on the metal grate and on the blades; failed to maintain the floors under the preparation steam table and the serving steam table free of food debris; failed to maintain the upper nozzles of the automated dishwasher free of debris within the nozzles; and failed to ensure dietary staff checked the temperature of the ground meat when he/she pulled it from the steamer. This practice potentially affected at least 90 residents who ate food from the kitchen. The facility census was 96 residents. 1. Observations on 7/29/21 from 9:32 A.M. through 12:56 P.M., showed: - At 9:37 A.M. and 10:09 A.M., a heavy buildup of food debris under serving steam table. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control protocol and procedures were followed for the use of Personal Protective Equipment (PPE) during nasal testing for coronavirus disease 2019; SARS-CoV-2, (COVID-19 a new disease caused by a novel (new) coronavirus). The facility census was 96 residents. Reference review by Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-38-NH DATE: August 26, 2020 and revised on 4/27/2021 showed: -Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests. -During specimen collection, facilities must maintain proper infection control and use recommended PPE, which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's rights for visitation were not limited, in a private area and not restricted for five sampled residents (Resident #1001, #1003, #1011, #1012, and #1017) out of 33 sampled residents. The facility census of 107 residents. Record review of the Centers for Medicare and Medicaid revised visitation recommendations dated 4/27/21 showed: -Facilities shall not restrict visitation without a reasonable clinical or safety cause, consistent with 42 CFR § 483.10(f) (4) (v). -A nursing home must facilitate in-person visitation consistent with the applicable CMS regulations, which can be done by applying the guidance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: maintain a shower chair commode in the 600 Hall shower room free of debris; maintain a stand up lift on the 600 Hall free of a used adult brief in the open hallway; to maintain the beds of Resident's #76 and #72 in a clean and/or easily cleanable condition; to maintain oscillating fans in the room of Resident # 52 and Resident #34, free of a heavy buildup of dust; to maintain the mouthpiece for a breath operated call light system free of debris inside the mouthpiece for Resident #40; to maintain the shower stall of the 100 Hall shower room free of soap scum for two different days, and to ensure a pillow without cracks was available to Resident #58. This practice potentially affected at least 25 residents who resided in or used those areas. The facility census was 96 residents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the shift change narcotic count sheet was filled out completely and was signed by both the on-coming and off-going nursing staff. The facility census was 96 residents. Record review of Storage of Controlled Substances policy effective 9/2018 and revised 8/2020 showed: -At each shift change, or when keys were transferred, a physical inventory of all controlled substances, including refrigerated items, was conducted by two licensed personnel and was documented. 1. Record review of the facility's Narcotic Shift Count Sheet for the 500 hall medication cart dated 6/27/21 thru 7/8/21 showed: -16 out of 30 opportunities the number of cards was not listed on the count sheet. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the removal of debris from under the ice machine in the 700 Hall clean storage room and failed to ensure the box fan used in the laundry, was free of a heavy buildup of dust which blew dust on the clean clothing side of the laundry. This practice affected two non-resident use areas. The facility census was 96 residents. 1. Observation with the Maintenance Director on 8/11/21 at 9:44 A.M., showed the presence of debris including a glass container with black rocks, a cup, a spoon, and water under the ice machine located in the 700 Hall Clean storage room. During an interview in conjunction with an observation on 8/17/21 at 2:04 P.M., the Housekeeping Supervisor said it is the responsibility of the housekeeping department to clean under the ice machine. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor and develop a care plan for one sampled resident (Resident #1001) who kept medications at his/her bedside and self administered these medications out of 33 sampled residents. The facility census was 107 residents. Record review of Certified Medication Technician (CMT) manual dated 2008 showed self administration of medication shall mean the act of actually taking or applying medication to oneself. Record review of the facility Pharmacy script self-Administration of Medication Policy revised 8/20 showed: -The resident who desire to self-administer medication were permitted to do so if the facility interdisciplinary team (IDT) has determined that the practice would be safe for the resident and other residents of the facility and there was a prescribed physician order to self-administer medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one sampled resident (Resident #1006) from possible abuse when Licensed Practical Nurse (LPN) A wrapped his/her arms around the resident's shoulders during a verbal altercation; escorted him/her to his/her room unwillingly while other staff were present in area out of 33 sampled residents. The facility census was 107 residents. Record review of the facility's policy titled Abuse Prevention and Prohibition Program, dated 8/2020 showed: -The facility had zero tolerance for abuse and each resident had the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. -The facility was committed to protecting residents from abuse by anyone including facility staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's medication was available for administration and failed to notify the physician of medications not being given as ordered for one sampled resident (Resident #23) out of 27 sampled residents. Six residents were sampled for medication review. The facility census was 96 residents. Record review of the facility's controlled substance (medications that have the potential for abuse and dependence) prescriptions policy dated as revised August 2020 showed: -A written prescription may be faxed to the pharmacy or a valid electronic prescription may be transmitted by the prescriber to the pharmacy. -The facility staff should contact the prescriber when the medication is not or will not be available for administration. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring to prevent resident falls was provided, failed to ensure fall interventions were followed to prevent falls and failed to document a comprehensive fall investigation for two sampled residents who were at risk for falls and had prior falls (Resident #36 and #72) out of 27 sampled residents. The facility census was 96 residents. Record review of the facility's Fall Evaluation and Prevention policy and procedure dated 8/2020, showed the purpose was to ensure the resident's environment remained free from accident hazards as is possible, and that each resident received adequate supervision and assistance to prevent accidents. The procedure showed: -Staff should evaluate the resident promptly in order to identify and treat injuries. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physician orders for oxygen for three sampled residents (Resident #44, #80, and #30) out 27 sampled residents. The facility census was 96 residents. 1. Record review of Resident #44's face sheet showed he/she last admitted to the facility on [DATE] with the following diagnoses: -Chronic Respiratory Failure with Hypoxia (a condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels). -Moderate Persistent Asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing. It usually results from an allergic reaction or other forms of hypersensitivity). -Dependence on supplemental oxygen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a cover on the trash container within the kitchen and failed to close either the top lid or the sliding lid to the outside dumpster. The facility census was 96 residents. 1. Observations of the open trash container on on 7/29/21 from 9:32 A.M. through 12:56 P.M., showed: - At 9:34 A.M. a trash container open without a lid next to center steam table. - At 10:04 A.M. DA A placed a napkin in the open trash container. - At 10:13 A.M. the Dietary Manager (DM) placed a glove in the open trash container. - At 10:29 A.M. Dietary [NAME] (DC) A placed onion peels into the open trash container. - At 10:55 A.M., a new trash bag was placed inside the trash container - At 11:01 A.M. DC A placed a straw in the open trash container. - At 11:04 A.M. DM placed gloves in the open trash container. [...]