Sunharbor Manor

In the surveyor’s words

From the most serious findings on record at Sunharbor Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF725May 25, 2022

  Based on record review and interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident as determined by resident assessment and individual plans of care. This was identified through staff interviews, resident council task, review of Facility Assessment and staffing assignments. […]

• No harm, potential for more than minimal, patternF888May 25, 2022

  Based on record reviews and staff interviews during the Recertification Survey initiated on 5/18/2022 and completed on 5/25/2022, the facility failed to have 100% vaccination compliance rate. Specifically, the staff matrix for staff vaccination documented that out of the 341 staff members employed by the facility, one staff member, a Licensed Practical Nurse (LPN) #1 was not fully vaccinated and provided resident care. The finding is: The Center for Medicaid and Medicare Services (CMS) QSO-22-07-ALL, dated 12/28/2021, CMS expects all providers' and suppliers' staff to have received the appropriate number of doses by the timeframes specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by CDC. […]

• No harm, potential for more than minimal, isolatedF656Mar 21, 2024

  Based on observation, record review, and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for one (Resident #246) of three residents reviewed for pain management. Specifically, Resident # 246 had a physician's order for a Lidocaine (a medication used to treat pain) patch to be applied to the resident's lumbar area (lower back). On 3/15/2024 during the medication pass observation, the medication nurse applied a Menthol patch to the resident's lower back instead of the Lidocaine patch. […]

• No harm, potential for more than minimal, isolatedF660Mar 21, 2024

  Based on record review and interviews conducted during the Recertification and Abbreviated Survey (Complaint # NY 00320409) initiated on 3/14/2024 and completed on 3/21/2024, the facility did not ensure that they developed and implemented an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition the resident to post-discharge care. This was identified for one (Resident #466) of one resident reviewed for Discharge. Specifically, Resident #466 was discharged from the facility on 7/17/2023 with no confirmation of acceptance from a Home Care Agency. On 7/18/2023 the referred Home Care Agency denied Home Healthcare Services for Resident #466. […]

• No harm, potential for more than minimal, isolatedF685Mar 21, 2024

  Based on observation, record review and interviews during the Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024 the facility did not ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. This was identified for one (Resident #155) of four residents reviewed for communication. Specifically, Resident #155 required hearing aid devices for both ears. Resident #155 lost the left ear hearing aid. The resident had multiple physician orders on 1/18/2024, 1/23/2024, 2/03/2024, 2/20/2024, 3/11/2024, and 3/19/2024 for an Audiology Consult. The Audiology appointment was not confirmed until 3/19/2024, two months after the first physician's order was written. […]