A list of the most recent deficiencies for Sunshine Health and Rehab. 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 pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-26 | 2024-03-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-08 | 2023-07-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-08 | 2023-07-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-08 | 2023-07-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-08 | 2023-07-13 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-06-08 | 2023-07-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-08 | 2023-07-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-08 | 2023-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-08 | 2023-07-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-08 | 2023-07-13 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-06-08 | 2023-07-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-01 | 2023-03-06 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-14 | 2021-06-30 | 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 | 2021-05-14 | 2021-06-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-14 | 2021-06-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-14 | 2021-06-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-14 | 2021-06-30 | 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 | 2021-05-14 | 2021-06-30 | 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 | 2021-05-14 | 2021-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-14 | 2021-06-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-05-06 | 2021-05-26 | 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 | 2021-05-06 | 2021-05-26 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-05-06 | 2021-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-06 | 2021-05-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-06 | 2021-05-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-06 | 2021-05-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-06 | 2021-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-06 | 2021-05-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-06 | 2021-05-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-06 | 2021-05-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-07 | 2019-07-31 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-06-07 | 2019-07-31 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-06-07 | 2019-07-31 | 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 | 2019-06-07 | 2019-07-31 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-06-07 | 2019-07-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-07 | 2019-07-31 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-06-07 | 2019-07-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-07 | 2019-07-31 | 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 | 2019-06-07 | 2019-07-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-07 | 2019-07-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-07 | 2019-07-31 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-07 | 2019-07-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-07 | 2019-07-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-07 | 2019-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-07 | 2019-07-31 | 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 | 2019-06-07 | 2019-07-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-07 | 2019-07-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-07 | 2019-07-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-07 | 2019-07-31 | 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 | 2019-06-07 | 2019-07-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-06-07 | 2019-07-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-07 | 2019-07-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-06-07 | 2019-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-07 | 2019-07-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-06-07 | 2019-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-30 | 2019-06-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-30 | 2019-06-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-30 | 2019-06-23 | N |
