Sunrise Skilled Nur & Rehab

Inspectors wroteBased on interview and record review, the Facility failed to follow its abuse policy by reporting and investigating all allegations of abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4.

Inspectors wroteBased on interview and record review, the Facility failed to report allegations of abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4.

Inspectors wroteBased on interview and record review, the Facility failed to investigate allegations of abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4.

Inspectors wroteBased on Interview, and Record Review, the facility failed to properly transfer 1 of 4 residents (R2), reviewed for appropriate safe transfers in the sample of 4. This failure resulted in R2 having a fall, sustaining a right hip fracture and ultimately passing away. The Findings Include: R2's admission Record, dated [DATE], documents R2 was originally admitted to the facility on [DATE] and was discharged on [DATE] with diagnosis of Cerebral Atherosclerosis, Dementia, Anemia, Hypertension, Atherosclerosis of Aorta, Generalized Anxiety Disorder, Major Depressive Disorder, Abdominal Aortic Aneurysm, Osteoporosis, Disorders of bone density and structure, Personal history of (healed) traumatic fracture left humerus. R2's Care Plan, dated as complete on [DATE], documents R2 has a Self-Care Deficit as Evidenced by: [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure residents were supervised to prevent accidents for 1 of 3 residents (R2) reviewed for falls in the sample of 5. This failure resulted in R2 being left unsupervised in bed in the high position on a low airloss mattress causing R2 to fall from the bed sustaining multiple fractures to both legs.

Inspectors wroteBased on interview and record review, the facility failed to obtain physician ordered laboratory testing in 1 of 3 residents (R2), reviewed for medication monitoring in the sample of 9. This failure resulted in R2 being admitted to the hospital on [DATE], where he remains. R2 was diagnosed in the hospital with Supratherapeutic INR (Initial Normalized Ratio) with a level greater than 10 (target range is between 2-3) and had to receive medication to reverse the effects from the anticoagulant, Warfarin, that R2 was receiving in the facility for a diagnosis of Pulmonary Embolism. This failure resulted in an immediate jeopardy when the facility failed to obtain laboratory testing to monitor R2's anticoagulant levels to ensure a therapeutic level was obtained. [...]

Inspectors wroteBased on interview and record review, the facility failed to insure a preventative fall alarm was working to prevent a fall for 1 of 3 residents (R5) reviewed for falls.

Inspectors wroteBased on interview, observation, and record review, the facility failed to store medications at an appropriate temperature and dispose of expired multi-dose/stock medications. This failure has the potential to affect all 83 residents in the facility.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to provide timely and complete incontinent care including improper glove changes and hand hygiene for 3 out of 6 residents, (R7, R8, R9) reviewed for incontinence care in a sample of 41.

Inspectors wroteBased on interview, observation, and record review, the facility failed to change gloves and perform hand hygiene during resident care and to wear appropriate Personal Protectant Equipment (PPE) for a resident on isolation for 5 of 24 residents (R7, R9, R17, R18, R179) reviewed for infection control in the sample of 41.

Inspectors wroteBased on observation, interview and record review, the Facility failed to prevent pressure ulcer development, implement preventative measures and follow physicians orders for 1 of 2 residents (R8) reviewed for skin integrity, in the sample of 41.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plan interventions were followed, assess resident smoking risk to prevent injury and provide appropriate supervision to prevent falls for 3 of 6 residents (R17, R46, R64) reviewed for safety and supervision in the sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to prevent the use of an unnecessary antibiotic for 1 of 3 residents (R3) reviewed for unnecessary medication in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic was appropriate for the organism of a urinary tract infection for 1 of 3 residents (R3) reviewed for antibiotic stewardship in the sample of 4.

Inspectors wroteBased on observation, interview and record review the facility failed to properly store medications, discard expired medication, and label tuberculin multi dose vial. This has the potential to effect all 78 residents living in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide dining assistance and assistance with hygiene for 6 of 18 residents (R5, R8, R45, R46, R59, R64) reviewed for assistance with a activities of daily living (ADLs) in the sample of 45.

Inspectors wroteBased on interview, observation and record review, the facility failed to identify a restraint and have written risks versus benefits for 2 of 2 residents (R69, R73) reviewed for restraints in the sample of the sample of 45.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe transfers for 2 of 7 residents (R59, R31) reviewed for falls in the sample 45.

Inspectors wroteBased on interview, observation and record review, the facility failed to perform hand hygiene before donning gloves, in between glove changes and after removing gloves for 3 of 14 residents (R17, R21, R69) in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the Facility to serve food at palatable temperatures 4 of 4 residents (R27, R32, R69 and R70) reviewed for palatable food temperatures in the sample of 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to inform resident/representative of change in treatment for 1 of 7 residents (R40) reviewed for right to be informed/make treatment decisions in the sample of 40. Findings Include: R40's Face Sheet dated 11/15/2021 documents diagnosis of unspecified dementia with behavioral disturbances. On 5/4/2022 at 1:00 PM, R40's Physician's Order Sheet, dated 3/29/2022 at 11:55 AM documents R40 was to receive Risperidone 0.5 milligrams (mg) three times daily. R40's Progress Notes dated 3/29/2022 at 11:57 AM document physician's order to increase Risperidone to three times daily and have psych evaluate (R40). R40's Facility Verification Informed Consent for Psychotherapeutic Drugs, dated 5/4/2022, was signed by Power of Attorney (POA) for Risperidone which was initially ordered on 3/29/2022. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to identify, provide timely treatment and pressure relief to prevent pressure ulcers for 1 of 6 residents (R43) reviewed for pressure ulcers in the sample of 40.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinent care for 1 of 4 residents (R43) reviewed for incontinent care in the sample of 40.