Sundale Nursing Home

In the surveyor’s words

From the most serious findings on record at Sundale Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF585Jan 14, 2025

  Based on interview and record review, the facility failed to document voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and maintain evidence of the result of all grievances for no less than 3 years from the date the grievance decision was issued. This has the potential to affect, more than a limited number of Residents. Facility census: 85. Findings Included: Record review of the facility's policy titled, Resident and Family Grievances, showed: --The grievance official is responsible for overseeing the grievance process: receiving and tracking grievances through their conclusion. […]

• No harm, potential for more than minimal, patternF692Jan 14, 2025

  Based on observation, record review, and staff interview, the facility failed to ensure accurate weights were obtained for three (3) out of three (3) residents sampled for weight loss. Failure to monitor and investigate significant changes in resident's weight status places the residents at risk for an incorrect assessment or diagnosis of impaired nutrition or hydration status. Further, this failed practice potentially prevented the interdisciplinary team from accurately developing and implementing interventions to stabilize or improve the resident's nutritional status before complications arose. Resident Identifiers: Residents #24, #53 and #78. […]

• No harm, potential for more than minimal, patternF710Jan 14, 2025

  Based on record review and interview, the facility failed to notify the physician of a resident's significant change in weight, and failed to ensure that the physician conducted a medical evaluation of a resident with a sudden significant change in weight. As a result, the residents were not evaluated to determine the cause for the sudden change in body weight. This placed the resident at risk for serious harm or death. Resident Identifiers: Resident #24, #53, and #78. Facility Census: 85. […]

• No harm, potential for more than minimal, patternF812Jan 14, 2025

  Based on observation and staff interviews, the facility failed to store food in a safe sanitary manner in regard to storing medical ice packs in the freezer in the residents pantry. This has the potential to affect a limited number of residents. Facility census: 85. Findings Included: a) Two South Resident Pantry During the tour on 01/08/25 at 9:20 AM to the Resident pantry, two (2) medical Ice packs were observed stored in resident freezer. An interview, on 01/08/25 at 9:20 AM, with the Dietary Manager confirmed the medical ice packs should not be stored with resident food.

• No harm, potential for more than minimal, patternF689Feb 22, 2023

  Based on observation and record review, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A medication cart and a treatment cart were unlocked with no one in attendance. These were random opportunities for discovery that had the potential to affect residents who were able to access the carts. Resident identifiers: #34, #73, #60, #21, #54, #78, #38, #135, #8, #81, #72, #76, #9. Facility census: 84. Findings included: a) Medication cart On 02/21/23 at 8:28 AM, the medication cart in the 100 hallway was noted to be unlocked. No staff member was present. Licensed Practical Nurse (LPN) #13, who was administering medications, came out of a resident room and verified the medication cart was unlocked. […]