Inspection Reports for
Sunrise Nursing & Rehabilitation

The facility had multiple deficiencies including failure to notify responsible parties of medication changes, incomplete background checks for new employees, improper medication administration practices including pre-popping medications and insulin pen priming errors, expired medical supplies and improper medication storage, failure to maintain infection control practices during medication and wound care, inaccurate tuberculosis testing procedures, and unlicensed facility van use. The facility also lacked a comprehensive Legionella control plan.

Complaint investigation focused on Resident #1's inappropriate placement on a locked unit without consent or documented risk, and Resident #2's unsafe transfer causing injury. Resident #1 was moved to a locked unit without documented wandering or elopement risk and became aggressive when smoking restrictions were enforced. Resident #2 was transferred without mechanical lift or gait belt, causing knee injury and hospitalization.

The facility failed to ensure resident self-determination by placing a resident on a locked unit without proper documentation or consent and failed to safely transfer a resident resulting in knee injury requiring hospitalization. The resident on the locked unit became agitated and physically aggressive toward staff. The resident with transfer issues was moved without a mechanical lift or gait belt, causing injury.

The complaint investigation was substantiated as Resident #4 hit Resident #3 on the head causing minor scratches. The incident was witnessed by a Certified Nursing Assistant and reported promptly. The facility administration was notified on the day of the incident and corrective actions were taken.

The facility failed to ensure one sampled resident (Resident #3) remained free from abuse when Resident #4 hit Resident #3 causing minor injuries. The facility staff intervened immediately, provided first aid, and conducted staff education on abuse prevention. The deficiency was corrected promptly.

The investigation was triggered by a complaint alleging physical abuse when Resident #84 pushed Resident #83, causing injury. The abuse was substantiated, and Resident #84 was issued a summons for assault. The facility and police conducted interviews and investigations confirming the incident.

The facility failed to ensure Resident #83 was free from physical abuse by Resident #84, who had a history of resident-to-resident altercations. Resident #84 pushed Resident #83 by the neck, causing Resident #83 to fall, sustain bruising, a skin tear, and an abrasion. Resident #84 was placed on 1:1 supervision and issued a summons for assault. The facility investigated and concluded the incident was reactionary, but physical abuse was confirmed.

The complaint investigation was triggered by an incident where Resident #84 pushed Resident #83, causing Resident #83 to fall and sustain injuries including bruising, skin tear, and abrasion. Police were involved, and Resident #84 was issued a summons for assault. The facility conducted an investigation and placed Resident #84 on 1:1 supervision.

The facility failed to protect Resident #83 from physical abuse by Resident #84, resulting in injuries including bruising, skin tear, and abrasion. Resident #84 was placed on 1:1 supervision and issued a summons for assault. The facility also failed to complete background screenings prior to hire for seven employees, failed to ensure monthly pharmacy drug regimen reviews for multiple residents, failed to maintain proper hair restraints in dietary staff, and failed to maintain infection control and antibiotic stewardship programs with proper data tracking.

The complaint investigation was substantiated with findings of immediate jeopardy beginning on 2023-04-25 due to resident-to-resident abuse. Resident #1 assaulted Resident #2 on 4/20/23 and again on 4/25/23, causing injuries including a laceration requiring staples. Police were involved and Resident #1 was issued a summons for assault. The immediate jeopardy was removed on 2023-04-28 after facility corrective actions.

The facility failed to protect Resident #2 from resident-to-resident abuse by Resident #1, who struck Resident #2 with a trophy and later with a rock inside a sock, causing injuries requiring medical attention. The facility was found to have immediate jeopardy which was removed after corrective actions. Multiple witness statements, progress notes, and police reports confirmed the incidents and the facility's response.

The complaint involved failure to assess and monitor a resident self-administering medications without proper orders or assessments, and included concerns about visitation rights, abuse, medication administration, fall prevention, oxygen orders, narcotic counts, infection control during COVID-19 testing, and environmental cleanliness.

The facility failed to ensure proper assessment and monitoring of a resident self-administering medications without physician orders or nursing assessments. Additionally, the facility failed to ensure residents' visitation rights were respected, maintain a safe and clean environment, protect a resident from possible abuse, ensure medication availability and administration, prevent falls with adequate supervision and investigation, provide physician orders for oxygen therapy, maintain pharmaceutical services with proper narcotic counts, follow infection control protocols during COVID-19 testing, and maintain cleanliness in non-resident areas.