Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Deficiencies: 0
Feb 11, 2025
Visit Reason
The inspection was conducted to review facility documentation and staff interviews to assess compliance with Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements based on documentation review and staff interviews.
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 11
Jan 14, 2025
Visit Reason
An unannounced annual recertification and relicensure survey was conducted to assess compliance with federal regulations for Sundale Nursing Home.
Findings
The survey identified multiple deficiencies including failure to follow physician orders for pain medication, failure to notify physicians of significant weight changes, incomplete care plans, failure to update PASARR for new diagnoses, failure to notify Ombudsman of hospital transfers, incomplete social services assessments, failure to provide rationale for not performing gradual dose reduction of medications, failure to document grievances, and improper food storage.
Severity Breakdown
SS=D: 9
SS=E: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to follow physician orders related to administration of pain medication for Resident #2. | SS=D |
| Failure to notify physician of significant weight changes and failure to ensure medical evaluation for Residents #24, #53, and #78. | SS=D |
| Failure to develop and implement a comprehensive person-centered care plan addressing Major Depressive Disorder for Resident #53. | SS=D |
| Failure to ensure accurate weights and proper monitoring of nutritional status for Residents #24, #53, and #78. | SS=E |
| Failure to document and maintain grievance records and evidence of grievance resolution. | SS=E |
| Failure to update PASARR to reflect new diagnosis of Major Depressive Disorder for Resident #53. | SS=D |
| Failure to provide written notice of transfer to the State Long-Term Care Ombudsman for hospital transfers of Residents #28 and #4. | SS=D |
| Failure to provide resident/resident representative written notice of bed hold policy at time of hospital transfer for Residents #4 and #28. | SS=D |
| Failure to complete a comprehensive social services assessment in its entirety for Resident #35. | SS=D |
| Failure of attending physician to provide rationale for not performing gradual dose reduction of psychotropic medications for Resident #36. | SS=D |
| Failure to store medical ice packs in a safe sanitary manner; medical ice packs were stored in resident freezer. | SS=E |
Report Facts
Facility census: 85
Weight loss Resident #24: 16.8
Weight loss Resident #53: 5.5
Weight gain Resident #53: 14.7
Weight gain Resident #78: 13.6
Weight loss Resident #78: 11.8
Psychotropic medications review date: 2024
Number of grievances logged: 0
Number of residents with new MDD diagnosis without PASARR update: 15
Number of residents reviewed for pain medication: 3
Number of residents reviewed for weight loss: 3
Number of residents reviewed for hospital transfers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged medication administration error and failure to notify physician of weight changes |
| Director of Social Services | Director of Social Services | Acknowledged failure to update PASARR, grievance log, and bed hold notices |
| Quality Assurance Trainer #104 | Quality Assurance Trainer | Provided staff training protocols and acknowledged weighing technique issues |
| Certified Dietary Manager | Dietary Manager | Confirmed improper storage of medical ice packs and implemented corrective actions |
| Social Services Director | Social Services Director | Responsible for transfer/discharge logs and social services assessments |
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 14, 2025
Visit Reason
The visit was conducted as an annual recertification and annual relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility, Sundale Nursing Home, was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.
Inspection Report
Routine
Census: 85
Capacity: 100
Deficiencies: 4
Jan 8, 2025
Visit Reason
The inspection was a routine survey to assess compliance with fire safety codes and emergency preparedness regulations, including fire alarm system maintenance, fire drills, and electrical system testing.
Findings
The facility failed to document semiannual visual inspections and sensitivity testing of smoke detectors, conduct fire drills at varying times as required, and perform weekly battery voltage testing on emergency generators. These deficiencies had the potential to affect all residents but no adverse consequences were reported.
Severity Breakdown
SS=F: 3
SS=C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide documentation of semiannual visual inspections of all smoke detectors as required by NFPA 72 Fire Alarm Signaling Code. | SS=F |
| Lack of documentation by contracted vendor of detailed printout of each smoke detector's sensitivity results during annual testing. | SS=F |
| Failure to conduct fire drills at unexpected times under varying conditions, specifically no afternoon shift fire drill conducted in the first quarter. | SS=C |
| Failure to test and document weekly battery voltage levels for emergency generator batteries as required by NFPA 110. | SS=F |
Report Facts
Facility capacity: 100
Census: 85
Fire drills frequency: 4
Generator battery voltage testing frequency: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Environmental Services Director (ESD) | Responsible for ensuring compliance with fire alarm inspections, fire drills, and emergency generator testing |
| Plant Operations Director | Discussed deficiencies related to fire alarm and generator testing | |
| Administrator | Discussed deficiencies at exit interview |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 4, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Sundale Nursing Home.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 3, 2024
Visit Reason
The inspection was conducted as an investigation survey triggered by a complaint, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Findings
Sundale Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with the facility in substantial compliance with previously cited deficient practices.
Complaint Details
Investigation survey concluding on 01/03/24 with plans of correction accepted in lieu of onsite revisit; facility found in substantial compliance with previously cited deficiencies.
Report Facts
Event ID: Event ID E1V412 referenced in report
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 4
Jan 2, 2024
Visit Reason
An unannounced complaint survey was conducted at Sundale Nursing Home from 01/02/24 to 01/03/24 based on observations, resident clinical records, interviews, and other facility documentation.
Findings
The facility was found deficient in multiple areas including failure to revise a care plan related to significant weight loss and supplements for Resident #81, failure to serve house snacks in a sanitary manner affecting Residents #9 and #16, failure to develop and implement fall prevention care plans and interventions for Residents #38 and #9, and failure to follow physician orders regarding fall prevention interventions for these residents.
Complaint Details
The complaint survey was substantiated for WV29681 and unsubstantiated for WV29559. The survey identified deficiencies related to care plan revisions, sanitary food service, and fall prevention interventions.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to revise care plan related to significant weight loss and supplements for Resident #81. | SS=D |
| Failure to serve house snacks in a sanitary manner, serving snacks off a cart with dirty dishes affecting Residents #9 and #16. | SS=D |
| Failure to develop and implement fall prevention care plans for Residents #38 and #9. | SS=D |
| Failure to follow physician orders regarding fall prevention interventions for Residents #38 and #9. | SS=D |
Report Facts
Facility census: 85
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #52 | Dietary Aide | Named in finding related to serving snacks in an unsanitary manner. |
| Director of Nursing | Interviewed regarding care plan revisions and fall prevention documentation. | |
| Dietary Manager | Interviewed regarding dietary care plan and snack service. | |
| Nurse Aide #104 | Confirmed anti-roll backs were not in place for Resident #38. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 6, 2023
Visit Reason
An unannounced complaint investigation survey was conducted at Sundale Nursing Home on June 6, 2023.
Findings
The facility was found to be in substantial compliance with applicable regulations. Complaint 28525 was unsubstantiated with no related or unrelated deficiencies cited.
Complaint Details
Complaint 28525 was unsubstantiated with no related or unrelated deficiencies cited.
Inspection Report
Deficiencies: 0
Apr 3, 2023
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 22, 2023
Visit Reason
The visit was conducted as an annual recertification and annual relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the regulatory requirements, with the review of plans of correction and credible evidence accepted in lieu of an onsite revisit. The facility maintained compliance with previously cited deficient practices.
Inspection Report
Life Safety
Census: 84
Deficiencies: 3
Feb 22, 2023
Visit Reason
The inspection was conducted to assess compliance with life safety codes, including sprinkler system maintenance, HVAC system compliance, and fire drills, as part of regulatory oversight.
Findings
The facility failed to provide evidence of the third quarter sprinkler system inspection as required by NFPA 25, failed to schedule required smoke damper testing every four years per NFPA 90A, and failed to conduct fire drills at unexpected times under varying conditions in accordance with NFPA standards. Corrective actions and staff training plans were outlined.
Severity Breakdown
SS=C: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide evidence of third quarter sprinkler system inspection as required by NFPA 25. | SS=C |
| Failed to schedule testing of smoke dampers every four years as required by NFPA 90A. | SS=F |
| Failed to conduct fire drills at unexpected times under varying conditions as required by NFPA. | SS=C |
Report Facts
Facility census: 84
Deficiency count: 3
Fire drill timing: 1
Fire drill corrective action timeframe: 5
Smoke damper testing frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Responsible for addressing sprinkler system inspection deficiencies, scheduling smoke damper testing, revising fire drill policies, and preparing compliance reports | |
| Plant Operations Director | Discussed deficiencies related to sprinkler system and HVAC with surveyors | |
| Administrator | Discussed deficiencies with surveyors at exit |
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 8
Feb 22, 2023
Visit Reason
An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Sundale Nursing Home from February 20-22, 2023.
Findings
The survey identified multiple deficiencies including inaccurate resident assessments, unlocked medication and treatment carts, failure to perform resident hand hygiene before meals, incomplete care plans, unsafe kitchen equipment, failure to ensure resident safety devices were used, improper food storage labeling, and unlabeled medications.
Complaint Details
Complaint #27601 was unsubstantiated with no related or unrelated deficiencies cited.
Severity Breakdown
SS=D: 4
SS=E: 3
SS=A: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to complete an accurate Minimum Data Set (MDS) assessment for Resident #60, specifically not coding a fall correctly. | SS=D |
| Medication and treatment carts were found unlocked and unattended, posing accident hazards. | SS=E |
| Resident hand hygiene was not performed prior to lunch meal for several residents. | SS=E |
| Failed to develop a comprehensive person-centered care plan for Resident #27 related to nutrition. | SS=D |
| Walk-in cooler kitchen equipment had rusted shelves needing replacement. | SS=A |
| Resident #60 was observed not wearing hip pads and lacked a non-skid pad on wheelchair as ordered. | SS=D |
| Dry food bins in kitchen were not dated when filled. | SS=E |
| Multi-use tuberculin purified protein derivative (PPD) vial was not dated when opened. | SS=D |
Report Facts
Facility census: 84
Residents reviewed for MDS assessments: 20
Residents reviewed for nutrition care plans: 3
Residents reviewed for falls care: 4
Random audits frequency: 5
Audit duration: 3
Random nutrition care plan audits: 1
Random nutrition care plan audit duration: 8
Random kitchen audits duration: 8
Medication storage audits duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN Supervisor | Provided immediate education to LPN and CNA regarding resident #60 safety devices | |
| Dietary Manager | Certified Dietary Manager | Reviewed and updated resident care plans, conducted kitchen audits, and provided staff education |
| Assistant Dietary Manager | Assisted in reviewing care plans, kitchen audits, and staff education | |
| LPN #13 | Licensed Practical Nurse | Verified medication cart was unlocked |
| RN #126 | Registered Nurse | Confirmed treatment cart was left unlocked |
| MDS Coordinator #25 | Verified fall was not coded correctly in MDS | |
| RA #72 | Restorative Aide | Observed not offering hand hygiene to residents before meals |
| RN #120 | Registered Nurse | Present during medication room inspection |
| RN #84 | Registered Nurse | Confirmed undated PPD vial in medication room |
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 27, 2021
Visit Reason
The visit was conducted as an annual recertification survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.
Findings
Sundale Nursing Home was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.
Inspection Report
Census: 86
Capacity: 100
Deficiencies: 0
Dec 15, 2021
Visit Reason
A Life Safety Code Comparative Federal Monitoring Survey and an Emergency Preparedness Comparative Federal Monitoring Survey were conducted following a West Virginia Department of Health survey to assess compliance with Medicare/Medicaid participation requirements.
Findings
Sundale Nursing Home was found to be in compliance with the Life Safety Code requirements at 42 CFR 483.90(a) and the Emergency Preparedness requirements at 42 CFR 483.73. The facility is a two-story, fully sprinklered building with supervised smoke detection and a generator tied to fire safety systems. The survey process was modified due to COVID-19 Public Health Emergency waivers.
Report Facts
Certified beds: 100
Census: 86
Inspection Report
Routine
Census: 83
Deficiencies: 1
Nov 9, 2021
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal regulations, specifically focusing on the testing and maintenance of portable patient-care related electrical equipment (PCREE) such as oxygen concentrators.
Findings
The facility failed to maintain required annual testing and maintenance documentation for 30 oxygen concentrators, which are classified as portable patient-care related electrical equipment. This deficiency could potentially affect all residents, staff, and visitors. The facility acknowledged the deficiency and agreed it needed correction.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain testing and maintenance requirements for fixed and portable patient-care related electrical equipment, specifically oxygen concentrators, in accordance with NFPA 101. | SS=C |
Report Facts
Oxygen concentrators without annual testing documentation: 30
Census: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Director | Discussed the deficiency regarding oxygen concentrators at the time of discovery. | |
| Administrator | Discussed and agreed on the deficiency needing correction at the time of exit. | |
| Facilities Management Coordinator | Facilities Management Coordinator (FMC) | Identified all oxygen concentrators requiring testing, coordinated testing with certified biomedical services vendor, and responsible for ongoing compliance and reporting. |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 9
Nov 8, 2021
Visit Reason
An unannounced annual recertification and annual relicensure survey was conducted at Sundale Nursing Home from November 8-10, 2021.
Findings
The survey identified multiple deficiencies including failure to display the most recent State inspection survey results in an accessible area, failure to provide safe and comfortable medical equipment, failure to implement abuse and neglect policies and reporting, inaccurate assessments, failure to follow physician orders, incorrect pressure ulcer staging, pharmaceutical service deficiencies, food safety violations, and infection control lapses.
Severity Breakdown
C: 1
D: 5
E: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to display the most recent State inspection survey results in a readily accessible area for residents and family. | C |
| Failure to provide a safe and comfortable medical recliner chair for Resident #71. | D |
| Failure to implement abuse and neglect policies for Resident #37, including failure to investigate and report bruises of unknown origin. | D |
| Failure to ensure accurate Minimum Data Set (MDS) assessment for hospice services for Resident #12. | D |
| Failure to follow physician's order for applying a compression glove for Resident #11. | D |
| Failure to correctly stage a pressure ulcer for Resident #51; down staging from stage IV to stage III. | D |
| Failure to establish pharmaceutical procedures to promptly identify loss or diversion of controlled medications. | E |
| Failure to label and date food items in kitchen and pantry refrigerators and failure to remove expired food items. | E |
| Failure to ensure appropriate infection control standards including improper handling of soiled linens, hand hygiene lapses during wound care, and incomplete visitor screening. | E |
Report Facts
Facility census: 83
Deficiencies cited: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #60 | Nurse Aide | Confirmed medical recliner chair was in poor repair for Resident #71 |
| Social Worker #144 | Social Worker | Did not report or investigate bruises of unknown origin for Resident #37 |
| Director of Nursing Services | Director of Nursing | Conducted investigations and provided education related to abuse and neglect policies |
| Assistant Dietary Manager | Assistant Dietary Manager | Removed expired and unlabeled food items from kitchen and pantry refrigerators |
| LPN #141 | Licensed Practical Nurse | Verified soiled linens and improper linen handling in Room #213 |
| Employee #44 | Performed wound care using same wipe on multiple wounds without hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 6, 2021
Visit Reason
An unannounced complaint investigation was conducted at Sundale Nursing Home on October 4-6, 2021, to investigate allegations related to the facility.
Findings
The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was found in substantial compliance with applicable federal and state regulations, including infection control and emergency preparedness related to COVID-19.
Complaint Details
Complaint #25343 was unsubstantiated with no related or unrelated deficiencies cited.
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Mar 3, 2021
Visit Reason
An unannounced complaint investigation survey was conducted at Sundale Nursing Home from March 2, 2021 to March 3, 2021.
Findings
The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rule. Complaint 25094 was unsubstantiated with no related or unrelated deficiencies cited.
Complaint Details
Complaint 25094 was unsubstantiated with no related or unrelated deficiencies cited.
Inspection Report
Abbreviated Survey
Census: 89
Deficiencies: 0
Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on June 22, 2020.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Dec 19, 2019
Visit Reason
An unannounced complaint investigation was conducted at Sundale Nursing Home on 12/18/19 to 12/19/19.
Findings
The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.
Complaint Details
Complaint #23553 was unsubstantiated with no related or unrelated deficiencies cited.
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 26, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.
Findings
Sundale Nursing Home was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 97
Deficiencies: 10
Jul 17, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Sundale Nursing Home from 07/15/19 through 07/17/19.
Findings
The survey identified multiple deficiencies including failure to maintain resident dignity during feeding, failure to ensure call lights were within reach, failure to protect personal medical records, inaccurate resident assessments, incomplete care plans, unsecured hazardous materials and equipment, improper oxygen tubing storage, unlabeled medications, and inadequate infection control practices.
Severity Breakdown
SS=D: 5
SS=E: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure care was provided in a dignified manner during feeding assistance. | SS=D |
| Failure to ensure call light was within reach of a resident. | SS=D |
| Failure to protect residents' personal medical records; pill medication administration punch cards were not discarded properly. | SS=E |
| Failure to accurately assess residents' medical information related to Alzheimer's disease and anticoagulant use. | SS=E |
| Failure to develop and implement a comprehensive care plan for residents related to pacemaker and feeding assistance. | SS=D |
| Failure to revise care plan after wound healing was documented. | SS=D |
| Failure to provide an environment free of accident hazards; unsecured chemicals, oxygen tank, razors, heated electrical devices, and hot liquids were accessible to residents. | SS=E |
| Failure to ensure oxygen tubing was stored properly according to professional standards. | SS=E |
| Failure to ensure medication labeling met professional standards; mouthwash bottles lacked expiration dates. | SS=D |
| Failure to follow infection control practices during medication administration. | SS=E |
Report Facts
Facility census: 97
Deficiency count: 10
Temperature of curling iron: 190
Temperature of hot liquid: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #136 | Certified Nursing Assistant | Named in dignity during meal times deficiency for feeding resident while standing. |
| LPN #77 | Licensed Practical Nurse | Named in medication administration punch card confidentiality deficiency and infection control deficiency. |
| RN #24 | Registered Nurse | Named in inaccurate assessment deficiency related to Alzheimer's and anticoagulant use. |
| LPN #44 | Licensed Practical Nurse | Named in care plan revision deficiency related to wound care. |
| RN #120 | Registered Nurse | Named in oxygen tubing storage deficiency. |
| LPN #116 | Licensed Practical Nurse | Named in medication labeling deficiency. |
| LPN #77 | Licensed Practical Nurse | Named in infection control deficiency during medication pass. |
Inspection Report
Deficiencies: 0
Jul 16, 2019
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing related to compliance with NFPA 101, Life Safety Code, 2012, and Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 17, 2018
Visit Reason
The visit was conducted as an annual recertification and relicensure survey for Sundale Nursing Home, including a review of plans of correction and credible evidence in lieu of an onsite revisit.
Findings
Sundale Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules, with no new deficiencies cited during this survey.
Report Facts
Survey completion date: Sep 17, 2018
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 5
Aug 1, 2018
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Sundale Nursing Home from July 30, 2018 through August 1, 2018.
Findings
The survey identified multiple deficiencies including failure to accommodate resident food preferences and dietary needs, unsafe storage of chemicals and personal care items, failure to follow menus for therapeutic diets, unsanitary food handling practices, and improper storage of nasal cannula tubing and resident basins.
Severity Breakdown
SS=D: 1
SS=E: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure resident autonomy regarding meal preferences, specifically Resident #27 was served foods not accommodating his weight loss diet and preferences. | SS=D |
| Failure to provide an environment free from accident hazards; unsecured chemical cleaners and personal care items accessible to residents in shower room. | SS=E |
| Failure to follow menus and prepare meals to meet residents' dietary needs; low fat/low sodium gravy not prepared for therapeutic diets. | SS=E |
| Failure to serve food in a sanitary manner; nursing assistants failed to wash hands between serving residents and touched resident food with bare hands. | SS=E |
| Failure to provide a safe, functional, sanitary environment; improper storage of nasal cannula tubing and resident basins without labeling or protective measures. | SS=E |
Report Facts
Facility census: 93
Survey dates: 2018-07-30 to 2018-08-01
Survey sample size: 20
Inspection Report
Routine
Census: 93
Deficiencies: 3
Jul 31, 2018
Visit Reason
Routine inspection of Sundale Nursing Home to assess compliance with NFPA 101 and NFPA 25 standards related to life safety, sprinkler system installation, maintenance, and testing.
Findings
The facility failed to maintain proper illumination of means of egress with six exit lights lacking redundancy, had 59 rooms with light fixtures obstructing sprinkler coverage, and had not scheduled the required five-year internal sprinkler system inspection per NFPA 25. No negative outcomes were reported.
Severity Breakdown
SS=C: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Exit way lighting not equipped with redundancy in lighting in the event of bulb failure. | SS=C |
| 59 rooms had bowl shaped light fixtures installed in close proximity to sprinkler heads obstructing spray pattern. | SS=C |
| Facility failed to provide evidence of a five-year internal inspection of the sprinkler system piping as required by NFPA 25. | SS=C |
Report Facts
Facility census: 93
Number of exit lights lacking redundancy: 6
Number of rooms with obstructive light fixtures: 59
Scheduled date for NFPA 25 sprinkler testing: Aug 16, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Verified findings related to lighting and sprinkler deficiencies | |
| Administrator | Acknowledged findings at exit interview | |
| Facilities Management Coordinator (FMC) | Responsible for supervising corrective actions, inspections, and compliance reporting |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Jun 19, 2018
Visit Reason
An unannounced complaint investigation was conducted June 18, 2018 to June 19, 2018 at Sundale Nursing Home for Complaint Reference #20456.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 and West Virginia Nursing Home Licensure Rules.
Complaint Details
Complaint Reference #20456 was unsubstantiated with no deficient practices identified.
Report Facts
Sample size: 20
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Apr 18, 2018
Visit Reason
An unannounced complaint investigation was conducted from April 16, 2018 to April 18, 2018 at Sundale Nursing Home for Complaint Reference #20067.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with applicable federal and state nursing home regulations.
Complaint Details
Complaint Reference #20067 was investigated and found to be unsubstantiated with no deficiencies identified.
Report Facts
Sample size: 6
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 21, 2017
Visit Reason
The document is a plan of correction related to a Quality Indicator and Licensure Survey for Sundale Nursing Home, accepted in lieu of an onsite revisit.
Findings
Sundale Nursing Home is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 3
Jul 26, 2017
Visit Reason
Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Sundale Nursing Home from July 24, 2017 through July 26, 2017 to assess compliance with regulatory requirements.
Findings
The survey identified deficiencies related to failure to revise a resident's care plan for a hemodialysis access device, failure to ensure food was stored and served in a sanitary manner, and failure to store drugs and biologicals in accordance with accepted professional principles. Corrective actions and staff education plans were outlined for each deficiency.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to revise care plan interventions for a resident's current hemodialysis access device. | SS=D |
| Failure to ensure food was stored and served in a sanitary manner, including undated opened food items in the kitchen. | SS=D |
| Failure to store drugs and biologicals in accordance with professional principles; expired medications and biologicals found in medication storage rooms. | SS=E |
Report Facts
Facility census: 98
Survey dates: 3
Sample size: 31
Expired Heparin IV flushes: 50
Expired IV Start Kits: 21
Expired specimen collection containers: 1
Inspection Report
Routine
Census: 98
Deficiencies: 7
Jul 25, 2017
Visit Reason
Routine inspection of Sundale Nursing Home to assess compliance with NFPA standards and other regulatory requirements related to fire safety, electrical systems, and resident rights.
Findings
The facility failed to maintain sprinkler piping free from loading, failed to exercise the disaster plan annually, failed to conduct fire drills at unexpected times, failed to maintain electrical wiring properly, failed to maintain emergency generator and battery operated lighting, failed to complete electrical testing for portable patient-care related equipment, and failed to provide training on medical gas and cylinder safety.
Severity Breakdown
SS=C: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to maintain sprinkler piping free from loading with low voltage wiring tied to sprinkler hangers and lack of documentation for sprinkler gauge calibration. | SS=C |
| Failed to exercise the disaster plan on an annual basis; last disaster rehearsal was over a year prior. | SS=C |
| Failed to perform fire drills at unexpected times and under varying conditions; drills were conducted at predictable times. | SS=C |
| Failed to maintain electrical wiring according to NFPA standards; issues included unprotected wiring, missing junction boxes, and cut wires without termination boxes. | SS=C |
| Failed to maintain emergency generator in accordance with NFPA 110; incomplete electrolyte testing and lack of battery operated lighting at generator locations. | SS=C |
| Failed to complete electrical testing for portable patient-care related electrical equipment; no evidence of testing was found. | SS=C |
| Failed to provide safety and usage training for staff involved with medical gas cylinders. | SS=C |
Report Facts
Facility census: 98
Deficiency completion date: 2017
Number of sprinkler gauges to be replaced: 4
Fire drill frequency: 12
Generator inspection interval: 7
Fire sprinkler maintenance program duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facilities Management Coordinator | Facilities Management Coordinator (FMC) | Named in multiple findings related to sprinkler system, fire drills, electrical systems, generator maintenance, and training |
| Staff Development Coordinator | Staff Development Coordinator | Responsible for re-educating nursing staff and environmental services on oxygen safety and training |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 25, 2016
Visit Reason
The document is a plan of correction related to a Quality Indicator and Licensure Survey for Sundale Nursing Home, accepted in lieu of an onsite revisit.
Findings
Sundale Nursing Home is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility must inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information. | Level C |
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 5
Jun 20, 2016
Visit Reason
An unannounced Annual Quality Indicator and State Licensure surveys were conducted at Sundale Nursing Home from June 13, 2016 through June 20, 2016.
Findings
The survey identified multiple deficiencies including failure to maintain sanitary and comfortable environment in resident common shower rooms, failure to develop and revise comprehensive care plans based on residents' current conditions, failure to store and maintain food under sanitary conditions, and failure to ensure an effective infection control program during medication administration.
Severity Breakdown
E: 2
D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior in two resident common shower rooms with poorly repaired wall plaster board and loose tile baseboards. | E |
| Facility failed to develop a comprehensive care plan for a resident with behaviors that included measurable objectives and timetables. | D |
| Facility failed to review and revise the care plan for range of motion services for a resident whose condition and expressed wishes changed, risking pain due to contractures. | D |
| Facility failed to store, maintain and/or distribute food under safe sanitary conditions, including storing hamburger and hot dog buns past acceptable use by or expired dates or with no visible expiration dates. | E |
| Facility failed to ensure an infection control program designed to provide a safe, sanitary and comfortable environment, including failure to properly clean reusable medication containers during medication administration. | D |
Report Facts
Facility census: 93
Survey sample: 25
Packages of hot dog buns expired: 3
Packages of hamburger buns without expiration date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #24 | Confirmed assignment and care details for Resident #29 regarding range of motion care | |
| Licensed Practical Nurse #57 | LPN | Observed during medication administration failing to use barrier and clean medication container, acknowledged infection control issue |
| Director of Nursing Registered Nurse #76 | Director of Nursing | Interviewed regarding care plan and range of motion instructions for Resident #29 |
| Assistant Director of Nursing Registered Nurse #111 | Assistant Director of Nursing | Interviewed regarding care plan and range of motion instructions for Resident #29 |
| Maintenance Supervisor #74 | Accompanied tour identifying maintenance issues in shower rooms | |
| Housekeeping Supervisor #136 | Accompanied tour identifying housekeeping issues in shower rooms | |
| Assistant Dietary Manager | Interviewed regarding expired and unlabeled food packages | |
| Dietary Manager | Interviewed regarding food storage and vendor issues | |
| MDS Nurse #50 | Interviewed regarding care plan for Resident #82 | |
| Nurse Aide #53 | Interviewed regarding care instructions for Resident #29 |
Inspection Report
Census: 93
Deficiencies: 3
Jun 14, 2016
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to resident rights and facility safety.
Findings
The facility was found deficient in protecting corridor openings with doors capable of resisting smoke passage, maintaining required placards on fire extinguishers, and properly maintaining emergency generator logs and testing. Specific deficiencies included gaps in resident room doors, missing placards on a kitchen fire extinguisher, and failure to perform weekly electrolyte testing on generator batteries.
Severity Breakdown
SS=B: 1
SS=C: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to protect corridor openings with doors capable of resisting the passage of smoke; two resident room doors had gaps exceeding allowed limits. | SS=B |
| Portable K Guard fire extinguisher in the kitchen lacked the required placard stating fire protection system activation prior to extinguisher use. | SS=C |
| Facility failed to maintain emergency generator in accordance with NFPA 110; weekly electrolyte testing of generator batteries was not performed or recorded. | SS=C |
Report Facts
Facility census: 93
Number of smoke compartments affected: 2
Number of resident room doors with gaps: 2
Generator logs reviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Acknowledged gaps in resident room doors and failure to perform weekly electrolyte testing on generators | |
| Maintenance Director | Acknowledged lack of required placard on portable K Guard fire extinguisher |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 8, 2016
Visit Reason
The inspection was conducted as a complaint investigation to review the facility's compliance with previously cited deficient practices and to verify correction of issues.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 and state nursing home licensure rules based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
Complaint investigation concluded on 04/28/16 with facility found in substantial compliance and previously cited deficiencies corrected.
Report Facts
Complaint Reference Number: 15506
Inspection Report
Re-Inspection
Census: 88
Deficiencies: 0
Aug 5, 2015
Visit Reason
An unannounced revisit was conducted at Sundale Nursing Home on 08/04/15 to 08/05/15 for the Quality Indicator Survey concluding on 06/08/15.
Findings
The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.
Report Facts
Revisit survey sample size: 3
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 5
Jun 8, 2015
Visit Reason
Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Sundale Nursing Home from June 1, 2015 through June 8, 2015.
Findings
The survey identified multiple deficiencies including failure to conduct proper fingerprint-based criminal background checks for employees, failure to maintain resident dignity related to uncovered Foley catheter bags, malfunctioning call light system in semi-private rooms, improper disposal of expired medication, and failure to maintain infection control with a Foley catheter bag found on the floor.
Severity Breakdown
SS=F: 1
SS=E: 1
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure fingerprint-based criminal background checks were completed for employees who had lived out of state within the past five years. | F225 SS=F |
| Failure to maintain resident dignity by not covering a resident's Foley catheter bag. | F241 SS=D |
| Resident call light system malfunction where bedside call light canceled bathroom call light in semi-private rooms. | F323 SS=E |
| Failure to properly dispose of an open vial of out-of-date Purified Protein Derivative (PPD) medication. | F425 SS=D |
| Failure to maintain infection control; resident's Foley catheter bag was observed on the floor. | F441 SS=D |
Report Facts
Survey sample size: 17
Facility census: 85
Number of semi-private rooms affected: 15
Number of deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #112 | Nurse Aide | Named in finding related to uncovered Foley catheter bag and infection control |
| Registered Nurse #11 | Registered Nurse | Named in finding related to incomplete fingerprint-based criminal background check |
| Registered Nurse #24 | Registered Nurse | Named in finding related to incomplete fingerprint-based criminal background check |
| Licensed Practical Nurse #80 | Licensed Practical Nurse | Named in finding related to expired medication not properly discarded |
Inspection Report
Life Safety
Census: 84
Capacity: 100
Deficiencies: 11
Jun 4, 2015
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including fire safety, sprinkler system maintenance, means of egress, medical gas storage, generator inspection, and electrical safety.
Findings
The facility was found deficient in multiple life safety code areas including lack of 'No Exit' signage on a glass door leading to a non-exit patio, failure to conduct fire drills at varied times, sprinkler system maintenance issues such as wires lying on sprinkler pipes and debris on sprinkler heads, obstructions in means of egress due to patient lifts charging in hallways, improper segregation and marking of oxygen cylinders, inadequate generator inspection documentation and fuel source reliability, and electrical hazards including open junction boxes and improper use of power strips.
Severity Breakdown
SS=A: 1
SS=B: 2
SS=C: 3
SS=E: 5
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| No 'No Exit' sign posted on a glass door leading to an enclosed patio area that is not an exit. | SS=A |
| Fire drills on night shift were conducted at the same time repeatedly, failing to vary times as required. | SS=C |
| Sprinkler pipes had external loads such as wires and metal tubing lying on them. | SS=E |
| Sprinkler heads had debris or foreign material on them. | SS=E |
| Sprinkler escutcheons missing or not fitting properly, leaving gaps that could impede sprinkler operation. | SS=E |
| Ceiling tiles missing or with openings around sprinkler escutcheons, preventing smoke tightness. | SS=E |
| Means of egress obstructed by unattended patient lift charging in hallway exit corridor. | SS=E |
| Empty and full oxygen cylinders stored together without marking to distinguish them. | SS=C |
| Natural gas generators lacked documented weekly inspections and fuel source reliability letter. | SS=F |
| Open electrical junction boxes without covers found in multiple locations. | SS=B |
| Power strips improperly daisy chained and appliances plugged into power strips instead of dedicated outlets. | SS=B |
Report Facts
Facility census: 84
Total capacity: 100
Fire drills: 4
Oxygen cylinders: 6
Empty oxygen cylinders: 1
Generator KW: 80
Generator KW: 85
Open junction boxes: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged multiple deficiencies including sprinkler piping issues, fire drill times, oxygen cylinder storage, generator logs, and electrical hazards. | |
| Maintenance Supervisor | Acknowledged patient lift was plugged in and charging in hallway obstructing means of egress. | |
| LPN A | Provided information about patient lift charging location. | |
| LPN B | Unable to specify patient lift charging location. | |
| CNA A | Described patient lift charging practices contributing to egress obstruction. |
Inspection Report
Deficiencies: 0
Mar 5, 2014
Visit Reason
The visit was conducted as a review of plans of correction and credible evidence in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 2014-01-16.
Findings
Sundale Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and with previously cited deficient practices.
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 6
Jan 16, 2014
Visit Reason
An unannounced annual Quality Indicator and State Licensure Survey was conducted at Sundale Nursing Home from January 13, 2014 through January 16, 2014.
Findings
The facility was found deficient in multiple areas including failure to maintain confidentiality of medical records, inadequate housekeeping and maintenance, failure to allow residents to make choices regarding bathing, failure to provide care to ensure highest well-being related to orthostatic hypotension and falls, failure to safeguard medications by keeping medication carts locked, and failure to maintain call lights in good working order.
Severity Breakdown
SS=F: 1
SS=E: 2
SS=D: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide confidentiality of medical records; medication administration records were exposed on unattended medication carts in hallways. | F 164 SS=F |
| Failed to ensure effective maintenance services; wallpaper had multiple holes and carpets were stained in hallways across all units. | F 253 SS=E |
| Failed to allow residents to make choices regarding bathing; residents were not given opportunity to choose tub bath instead of shower or bed bath. | F 242 SS=D |
| Failed to provide care and services to ensure highest practicable well-being; no follow-up assessment for orthostatic hypotension after medication discontinuation despite additional falls. | F 309 SS=D |
| Failed to safeguard medications; medication carts were found unlocked and unattended on two occasions. | F 431 SS=E |
| Failed to ensure call lights were in good working order; call light in Room 111 West would not turn off. | F 463 SS=D |
Report Facts
Residents in census: 87
Survey sample size: 25
Falls: 8
Time unattended: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #76 | Licensed Practical Nurse (LPN) | Named in medication administration record confidentiality and medication cart unlocked findings |
| Employee #100 | Licensed Practical Nurse (LPN) | Named in medication administration record confidentiality and medication cart unlocked findings |
| Employee #130 | Administrator | Interviewed regarding facility maintenance and carpet replacement plan |
| Employee #92 | Maintenance Staff Member | Interviewed about whirlpool bathtub use and call light repair |
| Employee #128 | Nursing Assistant (NA) | Interviewed about call light malfunction in Room 111 West |
| Employee #93 | Housekeeper | Assessed and repaired call light in Room 111 West |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding follow-up of orthostatic hypotension for Resident #105 |
Inspection Report
Life Safety
Deficiencies: 0
Jan 14, 2014
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Plan of Correction
Deficiencies: 1
May 14, 2013
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Sundale Nursing Home.
Findings
The document includes a summary statement of deficiencies, specifically citing a violation related to the facility's obligation to inform residents of their rights and services in writing and orally, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to inform residents both orally and in writing of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Report Facts
Deficiency ID: 156
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Apr 10, 2013
Visit Reason
The inspection was conducted as a complaint investigation related to a substantiated complaint record with related citation.
Findings
The facility failed to maintain a safe environment free from accident hazards by not locking housekeeping closets on the first and second floors, which contained hazardous chemicals accessible to cognitively impaired residents.
Complaint Details
Complaint Reference: 13080 / 7933. The complaint was substantiated with related citation.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Housekeeping closets on the first and second floors were not locked, allowing access to hazardous chemicals such as bleach and floor cleaner by residents. | SS=E |
Report Facts
Facility census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #39 | Housekeeper | Interviewed regarding unlocked first floor housekeeping closet |
| Employee #66 | Housekeeper | Interviewed regarding unlocked second floor housekeeping closet |
| Employee #97 | Environmental Services Director | Interviewed regarding housekeeping closet locking policy and staff training |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 9, 2012
Visit Reason
Onsite revisit for the annual survey to assess compliance with previously cited issues.
Findings
All previously cited issues were found to be in substantial compliance during the revisit.
Inspection Report
Annual Inspection
Deficiencies: 13
Jun 8, 2012
Visit Reason
Traditional recertification survey conducted from 06/03/12 to 06/08/12 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to develop effective grievance follow-up, improper use of helmets on cognitively impaired residents, failure to develop individualized care plans especially related to dental care and fall prevention, inadequate timely treatment for injuries, failure to provide appropriate feeding tube care, unsafe food preparation and sanitation practices, failure to provide palatable and properly prepared pureed diets, infection control lapses, and inadequate nurse aide in-service training.
Severity Breakdown
SS=D: 4
SS=E: 4
SS=F: 3
SS=G: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to develop an effective grievance program with follow-up visits to ensure resolution for residents #84, #18, and #74. | SS=D |
| Facility required three cognitively impaired residents (#34, #57, #78) to wear helmets that a reasonable person would not choose to wear. | SS=D |
| Failure to develop individualized dental care plan for resident #34, including proper denture care and removal at night. | SS=D |
| Failure to revise comprehensive care plans as needed for residents #9, #10, #14, and #34, especially related to fall prevention and injury treatment. | SS=E |
| Failure to provide timely care and services for residents #10 and #14, including delayed treatment for fracture and improper wound care. | SS=G |
| Failure to provide appropriate treatment and services to prevent complications for resident #43 with feeding tube, including failure to administer tube feeding as ordered. | SS=D |
| Failure to ensure a safe environment free of accident hazards and adequate supervision for residents #9, #10, #33, #34, #78, and #85, including failure to analyze root causes of falls and revise care plans accordingly. | SS=E |
| Failure to prepare and serve palatable, properly textured pureed diets for residents requiring mechanically altered diets, with foods served cold and floating in milk. | SS=F |
| Failure to prepare and serve food in a form designed to meet individual needs for residents on pureed diets, including presence of chunks in pureed turkey salad. | SS=F |
| Failure to maintain sanitary food procurement, storage, preparation, and serving practices, including failure to sanitize thermometer probe, unclean blender, unsafe dish machine temperatures, and potential cross contamination of foods. | SS=F |
| Failure to maintain essential kitchen equipment in safe operating condition; specifically, chipped and damaged blades on the Robot Coupe blender used for mechanically altered diets. | SS=E |
| Failure to provide required nurse aide in-service education of at least 12 hours per year and failure to develop education based on performance reviews. | SS=F |
| Failure to implement infection control policies, including administering eye drops without changing gloves, tasting medication with bare finger, handling residents' food with unwashed or bare hands. | SS=E |
Report Facts
Number of falls: 12
Number of falls: 7
Number of falls: 4
Number of falls: 3
Dish machine unsafe rinse temperature days: 17
Dish machine unsafe rinse temperature days: 14
Pureed diet residents affected: 19
Pureed diet residents affected: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 66 | Licensed Practical Nurse | Administered eye drops without changing gloves |
| LPN 68 | Licensed Practical Nurse | Tasted medication with bare finger |
| CNA 12 | Certified Nursing Assistant | Handled resident's food with bare hands without washing |
| AA 11 | Activity Assistant | Handled ready to eat food with bare hands |
| Assistant Dietary Manager | Confirmed poor food preparation and unclean blender | |
| Director of Nursing | Director of Nursing | Acknowledged deficiencies in grievance follow-up and education tracking |
| Charge Nurse LPN 55 | Licensed Practical Nurse | Reported denture care concerns |
| Certified Nursing Assistant 19 | Certified Nursing Assistant | Reported denture care concerns |
| Wound Nurse LPN 54 | Licensed Practical Nurse | Noted wound care order discrepancy |
Inspection Report
Life Safety
Deficiencies: 1
Jun 8, 2012
Visit Reason
The inspection was conducted to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically to verify that the fire alarm system is installed, tested, and maintained according to applicable codes and standards.
Findings
The facility failed to ensure that the fire alarm system was fully inspected annually, as inspection reports did not include testing of magnetic locks or smoke dampers. This deficiency was confirmed by an interview with the Environmental Services Director.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that the fire alarm system is fully inspected annually; inspection reports did not include testing of magnetic locks (x12) or smoke dampers (x9). | SS=C |
Report Facts
Magnetic locks: 12
Smoke dampers: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Interview confirmed findings regarding fire alarm system inspection deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 16, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint Reference ID: State 12087 / ACTS 7069.
Findings
The complaint was unsubstantiated and no deficiencies were found during the investigation.
Complaint Details
Complaint Reference ID: State 12087 / ACTS 7069. The complaint was unsubstantiated with no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 10, 2012
Visit Reason
The inspection was conducted in response to two complaint references: State #12050 / ACTS #6997 and State #12053 / ACTS #7000.
Findings
Both complaints were found to be unsubstantiated with no citations issued during the inspection.
Complaint Details
Complaint Reference ID: State #12050 / ACTS #6997 and State #12053 / ACTS #7000 were both unsubstantiated with no citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 17, 2011
Visit Reason
The inspection was conducted as a complaint investigation in response to complaint reference #11219.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #11219 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 20, 2010
Visit Reason
The inspection was conducted in response to complaint reference #10183.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #10183 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Complaint reference number: 10183
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 5, 2010
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Sundale Nursing Home.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Mar 8, 2010
Visit Reason
The inspection was conducted as a complaint investigation (reference #10038) regarding the facility's failure to provide adequate supervision and/or assistive devices to prevent accidents, specifically related to Resident #98 who sustained multiple falls during a short-term hospice stay.
Findings
The facility failed to assess the need for full side rails for Resident #98, who had a history of falls and was admitted for hospice respite care. Despite multiple falls and attempts at various interventions, the facility did not develop an appropriate care plan or complete a pre-restraint assessment. The resident was discharged after sustaining twelve reported falls during the stay.
Complaint Details
Complaint reference #10038 was substantiated with no deficiencies cited initially, but the investigation revealed failure to assess and implement appropriate safety measures for Resident #98, resulting in multiple falls during her stay.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide adequate supervision and/or assistive devices to prevent accidents by not assessing the need for full side rails for Resident #98. | SS=D |
Report Facts
Resident falls: 12
Facility census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Verified information regarding resident safety needs and interventions during interview on 03/08/10. | |
| Nurse (Employee #1) | Provided explanation about pre-restraint assessment form and its use. | |
| Nurse (Employee #2) | Acknowledged that full side rails were not used despite requests and explained communication with MPOA. |
Inspection Report
Life Safety
Deficiencies: 0
Jan 14, 2010
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 11
Jan 7, 2010
Visit Reason
The inspection was conducted as part of the annual survey of Sundale Nursing Home to assess compliance with federal regulations related to resident rights, facility management, housekeeping, assessments, care planning, medication management, laboratory services, and record keeping.
Findings
The facility was found deficient in multiple areas including failure to obtain written authorization for managing resident funds, inadequate employee screening for abuse registry, failure to eliminate urine odor in resident rooms, inaccurate resident assessments and care plans, failure to monitor and revise care plans after resident falls, unsecured hazardous areas accessible to residents, expired medication not discarded, failure to obtain ordered lab tests, and incomplete or inaccurate medical records.
Severity Breakdown
SS=A: 1
SS=C: 1
SS=D: 7
SS=E: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to obtain written authorization to manage a resident's personal fund account. | SS=A |
| Failed to assure employees were screened through the nurse aide registry for abuse or neglect findings. | SS=E |
| Housekeeping staff failed to eliminate lingering urine odor in resident rooms. | SS=D |
| Failed to ensure accuracy of minimum data set assessments for cognition and pressure ulcers. | SS=D |
| Failed to complete comprehensive assessment after significant change in resident's health status. | SS=D |
| Failed to develop comprehensive care plans with measurable objectives appropriate to residents' needs. | SS=D |
| Failed to review and revise care plan to address changes in healthcare needs after repeated falls. | SS=D |
| Failed to ensure resident environment was free of accident hazards by not securing hazardous areas. | SS=C |
| Failed to discard expired multidose vial of influenza vaccine within recommended timeframe. | SS=E |
| Failed to obtain laboratory testing as ordered by physician. | SS=D |
| Failed to maintain accurate and complete medical records including documentation of oral intake, medication allergies, and dated physician orders. | SS=D |
Report Facts
Facility census: 93
Resident falls: 18
Resident falls: 12
Resident falls: 9
Resident falls: 2
Expired medication days: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Accountant (Employee #115) | Unable to provide evidence of written authorization to manage resident's personal fund account | |
| Human Resources Representative (Employee #128) | Acknowledged only checking nurse aide registry for nursing assistants | |
| Nurse in charge (Employee #97) | Identified source of urine odor as wheelchair cushion | |
| MDS Nurses (Employees #82 and #85) | Acknowledged errors in resident assessments and care planning | |
| Social Worker (Employee #130) | Verified cognitive decline and lack of care plan revision | |
| Director of Nursing (Employee #138) | Acknowledged inaccurate allergy listing and undated physician statement | |
| Registered Nurse (Employee #119) | Confirmed expired flu vaccine vial not discarded | |
| Licensed Practical Nurse (Employee #125) | Administered medication despite allergy listing | |
| Registered Nurse (Employee #82) | Acknowledged incomplete documentation of resident intake and lab test follow-up | |
| Director of Environmental Services (Employee #105) | Confirmed non-functional door locks on hazardous rooms |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 24, 2009
Visit Reason
The inspection was conducted in response to complaint references #9291 and #9296.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited during the investigation.
Complaint Details
Complaint references #9291 and #9296 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 3, 2009
Visit Reason
The inspection was conducted in response to complaint reference #9209 to investigate allegations made against the facility.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #9209 was unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 31, 2008
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of Sundale Nursing Home.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights, rules, services, and charges as required by regulation 483.10(b). | Level C |
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 19, 2008
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Sundale Nursing Home.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b). | Level C |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Oct 2, 2008
Visit Reason
The inspection was conducted due to allegations of neglect involving two residents (#5 and #19) that were not reported to appropriate state agencies as required by law.
Findings
The facility failed to report allegations of neglect for two residents to the appropriate state agencies, failed to follow its oxygen utilization policy by not changing and labeling oxygen tubing weekly for seven residents, and failed to properly investigate and report neglect allegations as required.
Complaint Details
The complaint investigation revealed that neglect allegations for Residents #5 and #19 were investigated internally but not reported to adult protective services, the regional ombudsman, or the state survey and certification agency as required by facility policy and West Virginia State law.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to report allegations of neglect to appropriate state agencies for two residents (#5 and #19). | SS=D |
| Failed to follow oxygen utilization policy by not changing and labeling oxygen tubing weekly for seven residents (#69, #7, #49, #17, #14, #58, and #19). | SS=E |
Report Facts
Facility census: 86
Number of residents with unreported neglect allegations: 2
Number of residents with unlabeled oxygen tubing: 7
Inspection Report
Life Safety
Deficiencies: 1
Oct 2, 2008
Visit Reason
The inspection was conducted to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically focusing on the fire alarm system's installation, testing, and maintenance in accordance with NFPA 70 and NFPA 72.
Findings
The facility's fire alarm system is required to be installed, tested, and maintained per NFPA standards. However, the quarterly fire alarm inspection and testing reports for the prior 12 months were incomplete, failing to identify or confirm the existence and functional status of magnetic locking devices on designated exit doors.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility's quarterly fire alarm inspection and testing reports do not identify, acknowledge, or confirm the existence or functional status of magnetic locking devices on designated exit doors. | SS=C |
Report Facts
Inspection dates: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 29, 2008
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-8195.
Findings
The complaint was substantiated; however, no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8195 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 10, 2008
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-8044.
Findings
The complaint was substantiated, but no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8044 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 22, 2008
Visit Reason
Complaint investigation referenced as #2-8005 to address concerns raised about the facility.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8005 was unsubstantiated with no deficiencies cited.
Inspection Report
Census: 99
Deficiencies: 1
Jul 26, 2007
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the maintenance and sensitivity testing of smoke detectors in the facility.
Findings
The facility failed to maintain the fire alarm system in accordance with NFPA 72 standards, as there was no documentation of current or complete sensitivity testing of the smoke detectors, and the facility had no record that such testing had been conducted.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the fire alarm system in accordance with NFPA 72 due to lack of documentation of current or complete sensitivity testing of smoke detectors. |
Report Facts
Facility census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services | Interviewed regarding the lack of records for sensitivity testing of smoke detectors |
Inspection Report
Annual Inspection
Census: 103
Deficiencies: 6
Jul 19, 2007
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing facilities, including preadmission screening, quality of care, accident prevention, hydration, sanitary conditions, infection control, and resident rights.
Findings
The facility was found deficient in multiple areas including failure to ensure preadmission screening forms were reviewed prior to admission, inadequate pain assessment and management for a resident with multiple myeloma, unsecured medication storage posing accident hazards, insufficient hydration for a resident leading to recurrent urinary tract infections, unsanitary food handling practices, and failure to maintain proper infection control during dressing changes and ice pass.
Severity Breakdown
SS=D: 4
SS=G: 1
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure preadmission screening forms were reviewed prior to admission for one resident. | SS=D |
| Inadequate assessment and treatment of pain for a resident with multiple myeloma who refused opiates and was only treated with ineffective Tylenol. | SS=G |
| Unsecured clean utility room with accessible topical medications and nail polish remover posing accident hazards. | SS=D |
| Failed to provide sufficient fluids to maintain hydration for a resident, resulting in dehydration and urinary tract infections. | SS=D |
| Food served under unsanitary conditions including failure to wash hands after handling tray carts and telephone. | SS=F |
| Failure to maintain clean and sanitary infection control practices during dressing changes and ice pass, including not washing hands between glove changes and contamination of ice with scoop touching pitchers. | SS=D |
Report Facts
Facility census: 103
Resident sample size: 18
Fluid intake average: 308
Fluid intake per kg: 6.64
Deficiency completion dates: 2007
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Acknowledged preadmission screening form was not completed prior to admission for Resident #84 (Employee #163) | |
| Nurse | Observed during dressing changes for Resident #53, failed to wash hands between glove changes (Employee #152) | |
| Nurse | Assigned to unit during unsecured medication storage observation (Employee #87) | |
| Nursing Assistant | Observed contaminating ice during ice pass (Employee #52) | |
| Director of Nursing | Interviewed regarding pain management and infection control practices | |
| Medical Director | Interviewed regarding prognosis and pain management of Resident #53 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 26, 2006
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #2-6248.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-6248 was unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 14, 2006
Visit Reason
Paper revisit to review the facility's plan of correction following previous deficiencies.
Findings
The document contains a statement of deficiencies related to resident rights notification and a plan of correction. No new inspection findings are detailed beyond the paper revisit.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to inform residents of their rights and services in writing and orally as required. | Level C |
Inspection Report
Annual Inspection
Census: 103
Deficiencies: 4
Apr 20, 2006
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, comprehensive assessments, restorative nursing services, menus and nutritional adequacy, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to properly document the cause and nature of resident incapacity, incomplete documentation of resident assessment protocols, ineffective restorative nursing services with inadequate documentation and staffing issues, and failure to prepare and serve therapeutic diets according to prescribed sodium restrictions.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to document the cause and nature of resident incapacity as required by state law for a resident adjudged incompetent. | SS=D |
| Failure to indicate location of supporting documentation for resident assessment protocols in comprehensive assessments for sampled residents. | SS=D |
| Failure to maintain an effective restorative nursing system ensuring appropriate treatment and documentation of range of motion and ambulation services. | SS=E |
| Failure to prepare and serve foods in accordance with the planned 2-gram sodium therapeutic diet menu. | SS=E |
Report Facts
Facility census: 103
Residents sampled: 21
Residents sampled: 18
Residents affected: 16
Residents with 2-gram sodium diet orders: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #147 | Confirmed incomplete capacity statements | |
| Employee #67 and #60 | MDS coordinators who confirmed lack of documentation for RAP assessment location | |
| Employee #123 | Indicated restorative nursing staff were pulled to floor duties | |
| Physical Therapy Assistant (PTA) | Entered restorative nursing data without access to complete records | |
| Restorative nurse | Provided information on restorative nursing documentation and staffing | |
| Director of Nursing | Interviewed regarding restorative nursing documentation | |
| Certified Dietary Manager (CDM), Employee #151 | Admitted to serving non-low salt dressing against policy |
Inspection Report
Life Safety
Deficiencies: 0
Apr 19, 2006
Visit Reason
The inspection was conducted to determine the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was found to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 7, 2005
Visit Reason
This document is a plan of correction related to a paper revisit survey conducted at Sundale Nursing Home.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights and services, but no detailed findings or severity levels are provided.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
Sep 28, 2005
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-5258, which was substantiated with deficiencies cited.
Findings
The facility failed to ensure that residents unable to carry out activities of daily living received adequate oral hygiene care, and failed to provide adequate supervision and assistive devices to prevent accidents for a resident with a history of falls and side rail entrapment. Deficiencies were noted in care for residents #20, #80, and #72.
Complaint Details
Complaint reference #2-5258 was substantiated with deficiencies cited related to inadequate oral hygiene care and failure to prevent accidents for residents.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to assure that two residents unable to carry out activities of daily living received care to maintain good oral hygiene. | Level D |
| Failure to ensure that a resident with a history of falls and side rail entrapment received adequate supervision or assistive devices to prevent additional accidents. | Level D |
Report Facts
Facility census: 102
Deficiencies cited: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 18, 2005
Visit Reason
The inspection was conducted in response to a complaint referenced as #2-5170.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-5170 was unsubstantiated with no deficiencies cited.
Report Facts
Complaint reference number: 25170
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 14, 2005
Visit Reason
The document is a plan of correction related to a paper revisit survey conducted at Sundale Nursing Home.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights and services, but no detailed findings or severity levels are provided.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Report Facts
Provider/Supplier Identification Number: 515083
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Mar 30, 2005
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-5082, which was ultimately unsubstantiated with no deficiencies cited in that regard.
Findings
The facility failed to ensure that one of three sampled residents with pressure ulcers received necessary assessments, care, and services to prevent the development of pressure ulcers. Resident #57 developed pressure ulcers after admission despite known risk factors including immobility, poor nutrition, and incontinence. Weekly skin assessments failed to identify the breakdown timely, and protective measures were delayed.
Complaint Details
Complaint reference #2-5082 was unsubstantiated with no deficiencies cited related to the complaint itself.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that a resident with pressure ulcers received necessary assessments, care, and services to prevent development of pressure ulcers. | SS=G |
Report Facts
Facility census: 104
Resident admission date: Sep 2, 2004
Dates of skin assessments: 7
Date protective boot ordered: Nov 22, 2004
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 1
Mar 16, 2005
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of inadequate care for residents, specifically regarding incontinence care on the night shift of 10/23/04 to 10/24/04.
Findings
The facility failed to provide adequate incontinence care to nine residents on a unit of twenty-six residents during the night shift, resulting in residents being found in urine-soaked beds and with dried bowel movements on their hands and buttocks. Staffing shortages and inexperienced, non-certified aides contributed to the deficiencies.
Complaint Details
Complaint reference #2-5081 was substantiated with deficiencies cited related to inadequate incontinence care for nine residents during the 11-7 shift on 10/23/04 to 10/24/04.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure nine residents received adequate incontinence care, resulting in residents lying in urine-soaked beds and one resident with dried bowel movement on hands and buttocks. | SS=E |
Report Facts
Residents affected: 9
Residents on unit: 26
Aides assigned: 1
Aides assigned: 3
Residents on west wing: 26
Residents on other wing: 25
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 13
Mar 4, 2005
Visit Reason
Complaint investigation related to resident rights, care, and facility compliance with regulations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights, inadequate notice of bed hold policy, neglect resulting in harm, improper staff qualifications, incomplete resident assessments and care plans, failure to follow dietary menus and substitutions, inaccurate medical records, and failure to notify employees of the Central Abuse Registry.
Complaint Details
Complaint reference #2-5036. Complaint was unsubstantiated with no related deficiencies cited.
Severity Breakdown
B: 2
C: 1
D: 2
E: 7
G: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure rights of six residents determined to lack capacity to make medical decisions, with incomplete documentation and failure to inform residents. | E |
| Failed to provide written notice of bed hold policy to resident and family upon hospital transfer. | D |
| Failed to ensure necessary care and services to prevent harm; resident left on bedpan resulting in open areas and lack of investigation/reporting. | G |
| Failed to employ only qualified staff; unlicensed nurse contributed to care plans and assessments after license revocation. | E |
| Failed to maintain resident dignity during meal times; delayed incontinence care and negative staff behavior observed. | E |
| Failed to make comprehensive assessments using RAI and document reasons for care planning decisions for six residents. | E |
| Failed to develop and implement comprehensive care plan with measurable goals and resident-specific interventions for dialysis resident. | D |
| Failed to provide care by qualified persons; unlicensed employee performing assessments and care planning decisions. | E |
| Failed to provide necessary care and services to maintain highest practicable well-being; missed restorative treatments and failure to apply protective devices. | E |
| Failed to assure menus were followed for residents on pureed diets; substitution of pureed greens for cucumber and onion salad. | B |
| Failed to notify employees of Central Abuse Registry as required by state law. | C |
| Failed to provide food substitutions of similar nutritive value; fruit substituted for vegetable. | B |
| Failed to maintain clinical records that are complete and accurate; discrepancies in documentation of intake, elimination, baths/showers, and unclear DNR orders. | E |
Report Facts
Facility census: 110
Residents sample size: 22
Residents affected by pureed diet deficiency: 22
Residents with rights deficiency: 6
Residents with restorative care deficiency: 4
Residents with care plan deficiency: 1
Personnel records reviewed: 10
Professional employees reviewed: 9
Missed restorative treatments: 15
Weight loss percentage: 6.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Performed resident assessments and care plan decisions beyond scope of practice | |
| Registered Nurse (RN) | Employee with revoked license continued to contribute to care plans and assessments | |
| Assistant Director of Nursing (ADON) | Interviewed regarding documentation and care plan deficiencies | |
| Dietary Manager | Confirmed substitution error of pureed diet menu |
Inspection Report
Life Safety
Deficiencies: 0
Mar 2, 2005
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101 Life Safety Code, 2000 Existing Edition.
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 28, 2005
Visit Reason
Paper revisit to review previously identified deficiencies and the facility's plan of correction.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on informing residents of their rights and services. No new deficiencies or severity levels are explicitly stated.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents orally and in writing of their rights, rules, services, and charges as required. | Level C |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 3, 2005
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Sundale Nursing Home.
Findings
The report includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges in accordance with regulatory requirements.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to inform residents both orally and in writing of their rights, rules, services, and charges as required. | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 21, 2005
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of neglect involving eight residents who allegedly did not receive incontinence care.
Findings
The facility failed to submit an allegation of neglect to the State Nurse Aide Registry for one certified nursing assistant involved in the neglect of eight residents, despite evidence from the facility's investigation indicating their involvement.
Complaint Details
Complaint reference #2-5018 was substantiated with deficiencies cited related to staff treatment of residents and failure to report neglect allegations appropriately.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility did not ensure that one allegation of neglect by a certified nursing assistant was submitted to the appropriate State agencies involving eight residents who allegedly did not receive incontinence care. | SS=E |
Report Facts
Residents involved: 8
Date of neglect incident: Oct 24, 2004
Date of inspection: Jan 21, 2005
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 8, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4385, to evaluate allegations of neglect and improper care related to the application of an unordered skin care product to a resident.
Findings
The facility was found to have neglected to apply a skin care treatment in accordance with physician orders, resulting in skin breakdown for Resident #74. Additionally, the facility failed to report the incident of neglect involving nursing assistants applying an unordered ointment/cream. Hazardous substances were also found accessible to cognitively impaired residents, posing accident risks.
Complaint Details
Complaint reference #2-4385 was substantiated with findings of neglect related to the application of an unordered skin care product causing skin breakdown and failure to report the incident as required.
Severity Breakdown
Level G: 1
Level E: 1
Level D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility staff neglected to assure that a skin care treatment was applied in accordance with physician orders, resulting in skin breakdown for Resident #74. | Level G |
| Facility failed to report a documented incident of neglect involving nursing assistants applying an unordered ointment/cream causing harm to a resident. | Level E |
| Facility left harmful substances such as aerosol sprays at the bedside of residents accessible to cognitively impaired residents, creating accident hazards. | Level D |
Report Facts
Resident sample size: 3
Wings affected: 2
Wings potentially affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Provided care to Resident #74 and confirmed no physician order for ointment application | |
| Facility Social Worker | Confirmed application of unordered ointment and stated facility's understanding of reporting requirements | |
| Director of Nurses (DON) | Interviewed regarding hazardous substances found at bedside and facility policies |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 2
Sep 16, 2004
Visit Reason
The inspection was conducted in response to complaint references #2-4311 and 2-4304. The complaints were unsubstantiated but unrelated deficiencies were cited during the investigation.
Findings
The facility was found to have deficiencies related to medication carts being left unlocked and the presence of food and drink items in resident care areas, which compromised safety and sanitation. Specifically, one medication cart was unlocked with medications unattended, and food and beverages were found on medication and linen carts and chart racks in hallways.
Complaint Details
Complaint references #2-4311 and 2-4304 were investigated and found to be unsubstantiated, with unrelated deficiencies cited.
Severity Breakdown
SS=D: 1
SS=B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication carts were not locked when left unattended, posing a safety hazard. | SS=D |
| Facility did not maintain a sanitary environment; food and drink items were found on medication carts, linen carts, and chart racks in resident care areas. | SS=B |
Report Facts
Medication carts observed: 4
Facility census: 108
Hallways observed: 4
Hallways with deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding presence of popcorn, coffee mug, and soda products in resident care areas | |
| Medication nurse | Observed leaving medication cart unlocked with medications unattended |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 22, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced by complaint #2-4185, which was substantiated with deficiencies cited.
Findings
The facility failed to ensure that care plans for three sampled residents were updated to reflect their current needs and were accessible to staff. Deficiencies included inadequate care planning for residents with cognitive impairments, improper management of pressure ulcers, and failure to address residents' unique skin care needs and safety concerns. Additionally, there were issues with documentation and communication regarding resident care and safety.
Complaint Details
Complaint reference #2-4185 was substantiated with deficiencies cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Care plans for three residents were not updated to address present capabilities or needs and were not readily accessible to staff. | SS=D |
| Failure to provide necessary treatment and services to promote healing and prevent pressure sores for one resident. | SS=D |
Report Facts
Sampled residents: 5
Residents with deficient care plans: 3
Pressure ulcer size: 1
Dressing change frequency: 3
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 16
Apr 30, 2004
Visit Reason
Complaint investigation related to allegations of neglect, failure to notify Medicaid residents about account balances, improper admission agreements, and other regulatory compliance issues.
Findings
The facility was found deficient in multiple areas including failure to notify a Medicaid resident about account balance limits, improper third party guarantee in admission agreements, neglect in medication administration, failure to report allegations of neglect, inadequate abuse prevention training, failure to promote resident dignity, failure to act on resident council grievances, incomplete resident assessments and care plans, inadequate pain assessment, failure to restore continence, insufficient staffing on the 11-7 shift, failure to maintain accurate staff postings, food safety violations, and incomplete medical record documentation.
Complaint Details
Complaint reference #2-4095 was unsubstantiated with no related deficiencies cited. Multiple allegations of neglect were investigated, including failure to provide medications, failure to report neglect, and failure to provide adequate supervision. Several allegations were found valid with deficiencies cited.
Severity Breakdown
B: 1
C: 3
D: 6
E: 5
F: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to notify one Medicaid resident about account balance reaching $200 less than SSI resource limit. | C |
| Admission agreement contained a third party guarantee of payment as a condition of admission or continued stay. | C |
| Failed to assure one resident was free from neglect; ordered medications not provided timely upon readmission. | D |
| Failed to report five allegations of neglect to appropriate authorities and failed to provide investigation results within required timeframe. | E |
| Failed to provide abuse prevention training during orientation for two employees. | B |
| Failed to promote resident dignity; resident observed undressed and unkempt in public area; call lights not answered timely; dirty dining ware observed. | C |
| Failed to act upon grievances and recommendations made by residents during resident council meetings. | E |
| Failed to utilize resident assessment protocols (RAPs) to further assess triggered problem areas for five residents. | E |
| Failed to complete significant change reassessment for one resident with multiple changes in condition. | D |
| Care plans for four residents were not implemented as written, lacked specific directives, and did not reflect resident needs. | E |
| Failed to provide adequate monitoring and documentation for antipsychotic medication use for three residents. | D |
| Failed to implement interventions to restore bowel and bladder functions for two residents who had declined continence. | D |
| Insufficient nursing staff on 11-7 shift to provide adequate supervision and assistance to prevent accidents related to toileting. | E |
| Failed to update posting of staff in accordance with Federal law requirements. | D |
| Failed to assure food preparation and service under sanitary conditions; multiple sanitation infractions observed. | F |
| Failed to maintain complete and accurate clinical records; psychiatric consults lacked resident identifiers; no nursing note for resident discharge. | D |
Report Facts
Incident reports reviewed: 146
Falls related to toileting: 29
Bathroom-related falls on 11-7 shift: 14
Bathroom-related falls on 3-11 shift: 8
Bathroom-related falls on 7-3 shift: 7
Facility census: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Nursing Staff | Failed to receive abuse prevention training during orientation |
| Employee D | Nursing Staff | Failed to receive abuse prevention training during orientation |
| Director of Nursing | Director of Nursing | Interviewed regarding medication delays and reporting failures |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed regarding abuse prevention training |
| Behavior Management Specialist | Behavior Management Specialist | Interviewed regarding antipsychotic medication use and behavior management |
Inspection Report
Deficiencies: 3
Apr 28, 2004
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including sprinkler system coverage, means of egress, and proper storage within exit enclosures.
Findings
The facility was found deficient in providing complete sprinkler coverage, with no sprinkler heads at the bottom of two hydraulic elevators. Storage within exit enclosures interfered with egress, and soiled linen carts exceeding allowed capacity were located within designated means of egress.
Severity Breakdown
SS=D: 1
SS=C: 1
SS=B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| No sprinkler head is located at, or serves, the bottom of either of the two hydraulic elevators. | SS=D |
| Storage within facility exit enclosures interferes with its use as an exit, including two clean linen carts staged in resident room corridors. | SS=C |
| Facility has in use soiled linen carts exceeding thirty-two gallons located within the designated Means of Egress. | SS=B |
Report Facts
Number of hydraulic elevators without sprinkler coverage: 2
Number of clean linen carts stored in corridors: 2
Capacity of each soiled linen bag: 32
Total area occupied by soiled linen carts: 8
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 1
Feb 4, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4021, substantiated with deficiencies cited related to resident care and response times.
Findings
The facility failed to ensure timely response to call lights for assistance to the bathroom for residents #20, #59, and #62, negatively impacting their dignity and well-being. Observations and interviews confirmed delays of up to 15-20 minutes in answering call lights, despite staff presence nearby.
Complaint Details
Complaint reference #2-4021 was substantiated with deficiencies cited related to delayed response to call lights and inadequate assistance to residents.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure call lights were answered in a timely manner for residents needing assistance to the bathroom. | Level D |
Report Facts
Facility census: 113
Call light response delay: 15
Call light response delay: 20
Resident #20 care plan dates: Care plan dated 11/27/03 to 02/25/04
Resident #59 care plan dates: Care plan dated 09/25/03 to 03/11/04
Resident #62 care plan dates: Care plan dated 12/04/03 to 03/04/04
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 9, 2003
Visit Reason
Complaint investigation referenced as #2-3249.
Findings
The complaint was substantiated but no deficiencies were cited.
Complaint Details
Complaint reference #2-3249 was substantiated with no deficiencies cited.
Inspection Report
Census: 117
Deficiencies: 3
Aug 20, 2003
Visit Reason
The inspection was conducted to evaluate staff development and training programs, as well as the physical environment and safety of the facility, including housekeeping and maintenance.
Findings
The facility failed to ensure that new employees were properly trained and evaluated on operational procedures, specifically for certified nursing assistants. Additionally, the environment was found to be unsafe and inadequately maintained, with issues such as unsecured doors, damaged carpets, and lack of proper bathroom fixtures.
Deficiencies (3)
| Description |
|---|
| New employees, specifically four midnight shift CNAs, were not evaluated on orientation checklists and lacked specific job duty training. |
| The adolescent girls' bedrooms had outside doors without alarms or locking mechanisms, and staff were not awake on weekend nights to monitor safety. |
| The facility failed to maintain adequate housekeeping and maintenance, including personal belongings left behind furniture, carpet damage, torn furniture, and missing bathroom fixtures. |
Report Facts
Facility census: 117
Number of CNAs not evaluated: 4
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Provided information about CNA orientation and training deficiencies |
| Operations Supervisor | Conducted tour of residence and identified safety and maintenance issues | |
| Treatment Coordinator | Participated in tour of residence identifying maintenance deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 1
May 13, 2003
Visit Reason
The document is a Plan of Correction related to deficiencies identified during a survey of Sundale Nursing Home.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Report Facts
Survey completion date: May 13, 2003
Inspection Report
Life Safety
Deficiencies: 0
Apr 17, 2003
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 1967 New Edition.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was determined to be in compliance with the Life Safety Code.
Inspection Report
Annual Inspection
Deficiencies: 3
Apr 10, 2003
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident rights, quality of care, and laboratory services.
Findings
The facility was found deficient in informing residents of their rights, ensuring residents were free from unnecessary drugs, and providing timely laboratory services as ordered by physicians. Specifically, two residents received hypnotic medication without adequate indications, and one resident did not receive a required laboratory test every six months.
Severity Breakdown
Level C: 1
Level D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and services in a language they understand. | Level C |
| Two residents received hypnotic medication without adequate indications for use. | Level D |
| Failure to obtain a laboratory test (BUN) every six months as ordered for one resident. | Level D |
Report Facts
Residents sampled: 20
Times hypnotic administered to Resident #44: 6
Times hypnotic administered to Resident #78: 2
Months between last BUN test and missed test: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding lack of assessment before hypnotic administration |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 21, 2003
Visit Reason
The document is a plan of correction related to a previously identified deficiency regarding the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally.
Findings
The facility was found deficient in informing residents of their rights and services as required by regulation 483.10(b)(5)-(10). The deficiency is cited as F 156 with a severity level of C.
Severity Breakdown
C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents both orally and in writing of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | C |
Inspection Report
Life Safety
Deficiencies: 0
Aug 6, 2002
Visit Reason
The inspection was conducted to assess the facility's compliance with the Life Safety Code based on observation, performance testing, and record review from 08/05/02 to 08/06/02.
Findings
The facility was determined to be in compliance with the Life Safety Code (short form) during the inspection period.
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 10, 2002
Visit Reason
The inspection was conducted as a health survey to assess compliance with regulatory requirements.
Findings
No deficiencies were found as a result of the health survey conducted on July 10, 2002.
Inspection Report
Annual Inspection
Census: 95
Deficiencies: 2
Jan 18, 2002
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and quality of care standards at Sundale Nursing Home.
Findings
The facility failed to ensure adequate supervision and assistance to prevent accidents for one resident who experienced multiple falls due to ill-fitting footwear and non-compliance with safety measures. The resident had not yet been fitted for diabetic shoes despite a physician's order.
Severity Breakdown
Level C: 1
Level D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and facility rules in an understandable language. | Level C |
| Failure to ensure adequate supervision and assistance to prevent accidents, resulting in multiple falls for one resident. | Level D |
Report Facts
Resident falls: 6
Facility census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding resident supervision and care | |
| Facility RN | Interviewed regarding resident supervision and care | |
| Physical Therapist | Interviewed regarding resident's diabetic shoe order and compliance | |
| Facility Medical Director | Reviewed resident's medical record |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 1
Jan 18, 2002
Visit Reason
The inspection was conducted due to a complaint alleging staff mistreatment of a resident.
Findings
The facility failed to follow written abuse policies and procedures for one resident, including delayed body assessment after an alleged abuse incident. The allegation was ultimately found to be unsubstantiated.
Complaint Details
The complaint involved an allegation that a male activities aide physically restrained and pinched a resident (#79) on 01/15/02. The facility's investigation found the allegation unsubstantiated. However, the facility failed to conduct a timely body assessment, which was delayed until the next morning at 9:30 a.m. on 01/16/02, contrary to their abuse reporting procedure.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow written abuse policies and procedures related to mistreatment of a resident. | SS=D |
Report Facts
Resident count: 117
Date of alleged incident: Jan 15, 2002
Date of body assessment: Jan 16, 2002
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 3
Aug 25, 2001
Visit Reason
The inspection was conducted as a complaint investigation (Complaint 2-1191) regarding resident rights and care issues at Sundale Nursing Home.
Findings
The facility failed to notify residents or responsible parties that students would be providing care, failed to report two skin tears of unknown origin on a resident to the state survey agency, and did not ensure residents receiving thickened liquids had cold thickened water at bedside or that residents were not gotten up earlier than they wished.
Complaint Details
Complaint 2-1191 involved issues with resident notification about student caregivers, failure to report skin tears, and quality of life concerns including early rising and improper handling of thickened liquids.
Severity Breakdown
Level C: 1
Level D: 1
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify residents or responsible parties that students would be providing care during training. | Level C |
| Failure to report two skin tears of unknown origin on Resident #101 to the state survey and certification agency. | Level D |
| Failure to ensure residents receiving thickened liquids had cold thickened water at bedside and residents were not gotten up earlier than they wished. | Level E |
Report Facts
Resident census: 100
Skin tears: 2
Residents gotten up early: 14
Time residents gotten up: 5.5
Inspection Report
Life Safety
Deficiencies: 0
Aug 8, 2001
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of the NFPA 101 Life Safety Code, 1967 New Edition.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was determined to be in compliance with the NFPA 101 Life Safety Code.
Inspection Report
Routine
Deficiencies: 7
Aug 1, 2001
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal regulations governing nursing home operations, including resident rights, quality of care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to respond to resident grievances regarding missing clothing, failure to maintain resident dignity and privacy, failure to accommodate resident needs and preferences, failure to provide necessary care to maintain physical well-being, failure to maintain a safe environment by leaving medication carts unlocked, failure to store food under sanitary conditions, and failure to establish an effective infection control program.
Severity Breakdown
SS=D: 6
SS=A: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to respond to resident complaints of missing clothing items. | SS=D |
| Facility failed to ensure residents were free from exposure and afforded privacy during interviews. | SS=D |
| Facility failed to provide services with reasonable accommodation of individual needs and preferences for one resident. | SS=D |
| Facility failed to ensure two residents received care and services to attain or maintain the highest practicable physical well-being. | SS=D |
| Facility failed to ensure resident environment remains as free of accident hazards as possible; medication carts were left unlocked and unattended. | SS=D |
| Facility failed to store and prepare food under sanitary conditions; staff personal beverages stored in resident food refrigerator. | SS=A |
| Facility failed to establish an infection control program; nurse administered insulin injection without gloves. | SS=D |
Report Facts
Deficiencies cited: 7
Resident sample size: 21
Units of insulin administered: 21
Dates of missing clothing reported: 4
Dates weights not done: 3
Date of air mattress order: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Admissions Coordinator | Confirmed resident #72 reported missing skirts but could not locate report. | |
| Certified Nursing Assistant (CNA) | Entered resident #51's room during interview without permission and took temperature without asking. | |
| Nurse | Explained need for full side rails for air mattress for Resident #96. | |
| Director of Nursing | Reported new bed was lower and trapeze bar wheels would not fit under bed for Resident #96. | |
| RN Supervisor | Confirmed Resident #98's legs were to be elevated in geri chair. | |
| Medication Nurse | Observed administering insulin without gloves and confirmed facility did not require gloves. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 30, 2001
Visit Reason
The inspection was conducted in response to a complaint (Complaint 2-1068) regarding grievances filed by a resident's legal representative about poor care received at the facility.
Findings
The facility failed to keep the resident's legal representative appropriately informed about the progress and final resolution of the grievance filed. This was confirmed through review of the complaint file and interviews with the legal representative and facility staff.
Complaint Details
The complaint was filed by the legal representative of Resident #107 on 1/18/01 regarding poor care. The facility did not document any communication to the legal representative about the investigation progress or results. Interviews confirmed no contact was made to update the legal representative.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to keep the resident's legal representative apprised of the progress and final resolution of a grievance regarding poor care. | SS=D |
Report Facts
Complaint number: 2
Number of grievances reviewed: 2
Date of grievance filing: Jan 18, 2001
Date of complaint file review: Mar 29, 2001
Date of legal representative interview: Mar 29, 2001
Date of staff interview: Apr 2, 2001
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding failure to notify legal representative about grievance investigation |
| Administrator | Administrator | Interviewed regarding failure to notify legal representative about grievance investigation |
| Social Worker | Social Worker | Interviewed regarding failure to notify legal representative about grievance investigation |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 31, 2001
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify family of an injury, inadequate wheelchair fitting, failure to update care plans after falls and injuries, and failure to properly assess and document a resident's fall.
Findings
The facility failed to notify the family timely about an injury of unknown origin to Resident #11, failed to provide a properly fitted wheelchair, did not update the care plan after a hip fracture and subsequent falls, and failed to document and assess a fall on 01/02/01 according to policy. These failures placed the resident at risk for further injury.
Complaint Details
The complaint investigation revealed that Resident #11 experienced a fall on 01/02/01 which was not documented or reported timely, was found with abrasions of unknown origin on 01/04/01, sustained a fractured hip on 01/05/01, and had no changes made to the care plan to prevent further injury. The resident fell again after hip repair with no updated interventions.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to inform the family of an injury of unknown origin to Resident #11 within 24 hours. | SS=D |
| Failure to provide a properly fitted wheelchair for Resident #11, creating risk of sliding off the seat. | SS=D |
| Failure to adequately supervise, assess, and update the care plan for Resident #11 after falls and a hip fracture. | SS=D |
| Failure to provide necessary care and services to Resident #11 to maintain highest practicable physical well-being after a fall on 01/02/01. | SS=D |
Report Facts
Length of injury scratch: 24
Length of injury scratch: 6
Fall risk assessment score: 16
Fall risk assessment score: 19
Resident height: 72
Resident weight: 202
Wheelchair seat depth deficit: 2.5
Days fall not documented: 6
Days nursing documentation missing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| B. M. | Medical Power of Attorney | Notified of Resident #11's injury on 01/05/01 |
| Director of Nursing | Director of Nursing | Confirmed failure to report injury timely and failure to follow up on fall |
| Physical Therapist | Physical Therapist | Interviewed regarding wheelchair fitting for Resident #11 |
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 23, 2001
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, quality of care, and administration of services at Sundale Nursing Home.
Findings
The facility was found deficient in informing residents of their rights and services, failed to act on a psychologist's recommendation to restart an antidepressant for a resident with depression, and lacked a formal contract with an outside dialysis center providing treatments to a resident.
Severity Breakdown
Level C: 1
Level E: 1
Level A: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and services in writing and orally in a language they understand. | Level C |
| Failure to provide appropriate care by not forwarding psychologist's recommendation to restart antidepressant medication for a resident with depression. | Level E |
| Failure to establish a formal contract with a local dialysis center providing weekly treatments to a resident. | Level A |
Report Facts
Number of sampled residents with deficiencies: 2
Psychologist visits per month: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding psychologist's recommendations and communication system failure | |
| Behavior Management Specialist | Interviewed regarding psychologist's recommendations and communication system failure | |
| Administrator | Interviewed regarding lack of formal contract with dialysis center |
Inspection Report
Annual Inspection
Deficiencies: 11
Oct 6, 2000
Visit Reason
The inspection was conducted as an annual survey of Sundale Nursing Home to assess compliance with federal regulations regarding resident rights, quality of care, staff treatment, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to report abuse allegations timely, inadequate staff training on abuse reporting, failure to verify nurse licensing, failure to promote resident dignity and quality of life, inadequate social services for depression, incomplete and outdated care plans, improper wound care, failure to apply ordered treatments and devices, and failure to act on pharmacist recommendations for depression treatment.
Severity Breakdown
SS=D: 8
SS=E: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to report an allegation of verbal abuse immediately and educate unit supervisors on reporting requirements. | SS=D |
| Failure to verify nurse license prior to employment. | SS=D |
| Failure to promote resident dignity by ensuring clean faces after feeding and appropriate clothing. | SS=E |
| Failure to provide accommodations regarding meal timing and water temperature. | SS=E |
| Failure to provide social service interventions for treatment of depression. | SS=D |
| Failure to develop comprehensive care plans for residents receiving dialysis, seizure disorder, and hospice care. | SS=E |
| Failure to revise care plan to reflect new diet order for low potassium diet. | SS=D |
| Failure to ensure decubitus ulcer care was provided by qualified persons; CNAs applied ointment instead of nurses. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable well-being including failure to apply heel protectors, gel socks, and bowel protocol. | SS=E |
| Failure to provide appropriate treatment and services to prevent further decrease in range of motion for residents with contractures. | SS=D |
| Failure to act on consultant pharmacist's recommendation to treat resident with signs and symptoms of depression. | SS=D |
Report Facts
Sampled residents: 21
Residents affected by dignity failure: 7
Weight loss: 11
Days without bowel movement: 6
Date of survey completion: Oct 6, 2000
Inspection Report
Deficiencies: 0
Oct 5, 2000
Visit Reason
The inspection was conducted based on a review of facility documentation, staff interview, and observation to assess compliance with the provisions of 483.70 Physical Environment.
Findings
The facility was determined to be in compliance with the provisions of 483.70 Physical Environment.
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 3, 2000
Visit Reason
The document is a plan of correction related to deficiencies found during a life safety code inspection conducted on October 3 and 4, 2000, at Sundale Nursing Home.
Findings
The facility's Soiled Utility Rooms were found not to be provided with one hour fire rated construction as required by NFPA 101 Life Safety Code standards. Specifically, sprinkler coverage and fire rated construction were lacking in these hazardous areas.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Soiled Utility Rooms are not provided one hour fire rated construction; sprinkler coverage and fire rated construction are required. | SS=C |
Report Facts
Deficiency date: Oct 3, 2000
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