A list of the most recent deficiencies for Sunrise Country Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-16 | 2023-06-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-16 | 2023-06-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-15 | 2023-06-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-04 | 2023-02-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-04 | 2023-02-17 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-23 | 2022-06-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-23 | 2022-06-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-23 | 2022-06-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-06-03 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-23 | 2022-06-03 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-23 | 2022-06-03 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-02-23 | 2022-04-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-23 | 2022-04-08 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-02-23 | 2022-04-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-23 | 2022-04-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-23 | 2022-04-08 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-23 | 2022-04-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-23 | 2022-04-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-02-23 | 2022-04-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-23 | 2022-04-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-23 | 2022-04-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-23 | 2022-04-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-23 | 2022-04-08 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-02-23 | 2022-04-08 | Y |
| Dispose of garbage and refuse properly. | Health | 2022-02-23 | 2022-04-08 | Y |
| Meet other general requirements. | Fire Safety | 2022-02-15 | 2022-04-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-15 | 2022-04-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-15 | 2022-04-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-15 | 2022-04-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-15 | 2022-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-07 | 2020-02-24 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2020-01-07 | 2020-02-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-21 | 2020-02-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-21 | 2020-02-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-21 | 2020-02-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-21 | 2020-02-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-21 | 2020-02-21 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-01-21 | 2020-02-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-21 | 2020-02-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-21 | 2020-02-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-21 | 2020-02-21 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2020-01-21 | 2020-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-21 | 2020-02-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-21 | 2020-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-21 | 2020-02-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-21 | 2020-02-21 | N |
