Sunrise Manor Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, patternF602Apr 14, 2022

  Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to ensure residents were free from misappropriation of property (medication) for eight (8) of seventy-one (71) sampled residents (Residents #19, #30, #63, #77, #150, #151, #161, and #162). On 02/25/2021, State Registered Nurse Assistant (SRNA) #8 reported to the facility's previous Administrator, that Licensed Practical Nurse (LPN) #7 had taken medication from a resident at the facility. SRNA #8 provided to the previous Administrator a photograph of Resident #151's prescribed medication at LPN #7's home. The facility initiated an investigation and LPN #7 and SRNA #8 were suspended pending the investigation. […]

• Immediate jeopardy, patternF755Apr 14, 2022

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an effective system was in place for pharmaceutical services to meet the needs of each resident. The facility failed to develop a system to ensure medications received from the pharmacy were accounted for. In addition, the facility failed to collaborate with their contracted pharmacy to develop safeguards and put systems in place to control, account for, and periodically reconcile medications to prevent diversion, and there was no documentation that the causes of the discrepancies were thoroughly investigated. These failures affected eight (8) of seventy-one (71) sampled residents (Residents #19, #30, #63, #77, #150, #151, #161 and #162). […]

• Immediate jeopardy, patternF835Apr 14, 2022

  Based 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. […]

• Immediate jeopardy, patternF837Apr 14, 2022

  Based 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. […]

• Immediate jeopardy, patternF867Apr 14, 2022

  Based 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. […]