Sunrise Nursing Healthcare LLC

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on observation, staff interviews and policy review, the facility failed to ensure staff smoked only in designated areas of the facility in accordance with the facilities smoking policy. This affected one (Resident #58) of three reviewed for oxygen usage. The facility census was 62.

Findings include:

Review of the medical record for Resident #58 revealed an admission date of 09/22/23 with diagnoses of traumatic subarachnoid hemorrhage, anoxic brain damage, metabolic encephalopathy and tracheostomy.

Review of the Quarterly Minimum Data Set (MDS) assessment dated 05/17/24 revealed Resident #58 had severe cognitive impairment and had range of motion impairment of bilateral upper and lower extremities. Resident #58 was non-communicative and dependent on staff for all Activities of Daily Living (ADLs).

Review of the physician orders for July 2024 revealed Resident #58 had a tracheostomy with continuous oxygen and received nutrition through an enteral feeding tube.

Observation of the video with date and time that was blurred and unable to be visualized provided by the family through a camera located in the room of Resident #58 revealed Registered Nurse (RN) #222 visibly lighting an unidentified smoking paraphernalia on two occasions in the room of Resident #58.

Observation of Resident #58 on 07/09/24 throughout the survey in her room revealed continuous oxygen was in use and administered through a tracheostomy. Further observations of Resident #58's room door on 07/09/24 revealed signage in place stating, Oxygen in use / No-Smoking Permitted.

Interview on 07/09/24 at 3:10 P.M. The Administrator and Vice President of Clinical Operations (VPCO) #333 confirmed smoking is not permitted inside any part of the facility and in any area where oxygen is being used or stored. The Administrator and VPCO #333 confirmed RN #222 was observed on video camera smoking in Resident #58's room on 06/25/24. The Administrator and VPCO #333 confirmed the facility became aware of RN #222 smoking in Resident #58's room on 06/25/24 and the police were called and RN #222 was immediately removed from duty. The Administrator and VPCO #333 stated they were unable to determine what RN #222 was smoking in Resident #58's room.

Review of the Smoking Policy-Employees revised 05/2019 revealed employee smoking is permitted only in places where it is designated and this includes use of cigarettes, e-cigarettes, chewing tobacco, pipes, cigars and vaping. Smoking is prohibited in all other areas. Smoking is prohibited in any area where oxygen is being used or stored, in any area that bears a No-Smoking sign, or in any area that would create a hazardous or unsafe condition.

The deficiency was corrected on 06/26/24 when the facility implemented the following corrective actions:

On 06/25/24 at 10:40 P.M. the RN #222 was immediately relieved of duty and placed under the supervision of Licensed Practical Nurse (LPN) # 401 until law enforcement arrived at the facility.

On 06/25/24 the RN #222 exited the facility with law enforcement and never returned.

On 06/25/24 the RN #222 was replaced as the RN on duty by the Director of Nursing (DON).

On 06/26/24 the DON completed a skin assessment on Resident #58 with no new skin impairments noted.

On 06/26/26 the Administrator, a report with the Ohio Board of Nursing on the RN #222. The report # is 24-003334.

On 06/26/24 the Administrator and/or his designee interviewed all Residents to ensure they felt safe in their environment and had no concerns. No concerns were noted.

On 06/26/26 the Administrator interviewed staff working the evening/night of 06/25/24 to 06/26/24.

On 06/26/24 the Administrator and/or his designee educated facility staff on the policies of Substance Abuse, Smoking, and Oxygen.

On 06/26/24 the Administrator implemented an audit plan to audit five residents three times a week to ensure they feel safe in their environment and have no concerns. Audits will occur weekly for four weeks and then monthly for two months. Corrective action will be initiated for any noted non-compliance.

On 06/26/24 the Administrator presented the results of the investigation to the Quality Assurance and Performance Improvement (QAPI) committee.

Audit plan findings will be presented to Quality Assurance and Performance Improvement (QAPI) committee monthly for review and recommendations.

This deficiency represents non-compliance investigated under Complaint Number OH00155153.

Based on observations, staff interview interview, and review of the facility policy, the facility failed to ensure there were no expired tube feed formula bottles stored in the medication rooms and central supply room. The facility identified one resident (#26) who received Glucerna 1.5 (a specialized tube feed formula) and no residents currently who received Nephro 1.8 (a specialized tube feed formula). The facility identified 11 residents who receive tube feed formula. The facility census was 63.

Findings include:

Observation of medication room B with Registered Nurse (RN) #206 on 06/06/24 at 11:15 A.M. verified there were eight bottles of expired Glucerna 1.5 in the medication room. The eight bottles had expiration date of 06/01/24. Subsequent observations of the central supply room with RN #206 verified there were eight bottles Glucerna 1.5 with the expiration date of 06/01/24. RN #206 verified there were a total of 16 bottles of Glucerna 1.5 bottles with expired date 06/01/24 in medication room B and central supply room.

Observation of medication room A with Licensed Practical Nurse (LPN) #709 on 06/05/24 at 11:58 A.M. verified there was one bottle of Nephro 1.8 and one bottle of Glucerna 1.5 with an expiration date of 06/01/24 in medication room A.

Interview on 06/05/24 at 1:38 P.M. with Central Supply (CS) #215 stated she was educated recently on checking in central supply the expiration dates on the gastric tube feeds. CS #215 stated she recently got rid of many expired gastric tube feeds bottles with expired dates already.

Review of the facility policy titled Storage of Medication

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, staff interview and contracted entity provider representative interview, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This affected four (#01, #09, #11, and #12) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected two additional current Residents (#03 and #19) and 16 discharged Residents (#02, #04, #05, #06, #07, #08, #10, #13, #14, #15, #16, #17, #18, #20, #21, and #22) for total of 22 residents. The census was 46.

Findings include:

1) Review of the medical record for Resident #01 revealed an admission date of 11/18/19. Diagnoses included Parkinsonism, dementia, and protein calorie malnutrition.

Review of the Minimum Data Set (MDS) assessment dated 10/08/23 for Resident #01, revealed the resident had moderate cognitive impairment.

Review of the Care Plan for Resident #01 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity.

Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #01, revealed the resident was ordered to receive nutrition DRIPT (entity who provides intravenous (IV) hydration and vitamin nutrient therapy) IV one-time monthly 1000 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 1000 mLs an hour (hr.) with total additive volume of 27.4 mLs of the additive formula: Vitamin C (ascorbic acid) 5 grams (gms), Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 200 mgs, Dexpanthenol (Dex) 4 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin [Methyl]) 2 mgs, Magnesium Chloride (MagCl) 1000 mgs, Calcium Chloride (CaCl) 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine (Arg) 500 mgs, Ornithine (Orn)150 mgs, Lysine (lys) 250 mgs, Vitamin D2 (calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic).

2) Review of the medical record for Resident #09 revealed the resident was admitted on 01/13/20. Diagnoses included sequelae of cerebral infarction, protein calorie malnutrition, and vascular dementia.

Review of the MDS assessment dated 10/10/23 for Resident #09, revealed the resident had moderate cognitive impairment.

Review of the care plan for Resident #09 revealed areas of focus for risk for nutrition and skin integrity.

Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #09, revealed the resident was ordered to receive nutrition DRIPT intravenous (IV) one-time monthly 1000 mLs of 0.9 % NS at rate of 1000 mLs an hr. with total additive volume of 27.4 mLs of the additive formula: Vitamin C (Ascorbic acid) 5 gms, Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 200 mgs, Dexpanthenol 4 mgs, Vitamin B6 Pyridoxine) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin )2 mgs, Magnesium Chloride 1000 mgs, Calcium Chloride 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Vitamin D2 (Calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic).

Review of the MARs for Resident #09 revealed the resident received the ordered infusions on 05/09/23, 06/06/23, and 07/11/23.

3) Review of medical record for Resident #11 revealed the resident was admitted on 04/26/23. Diagnoses included Anemia, hypothyroidism, binge eating disorder, Crohn's disease, Vitamin-D deficiency, and Barrett's esophagus with dysplasia.

Review of the MDS assessment dated 09/07/23 for Resident #11 revealed the resident was cognitively intact.

Review of the Care Plan for Resident #11 revealed areas of focus for risk for nutrition and skin impairment.

Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol - for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additives volume, 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, an amino acid blend (Glutamine 150 mgs, Arginine 500 mg, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic).

Review of the MARs revealed Resident #11 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23.

4) Review of medical records for Resident #12 revealed an admission date of 08/20/22 and a discharge date of 10/22/23 with diagnoses including traumatic brain injury, non-pressure chronic ulcer of left heel and midfoot, non-pressure chronic ulcer of right heel and midfoot, and pressure ulcer of sacral region stage IV.

Review of the MDS assessment dated 10/13/23 revealed Resident #12 was cognitively intact, exhibited verbal behaviors, and refused care.

Review of physician orders revealed orders for Derma Infusion on 03/07/23, 04/10/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/31/23.

Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol - for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additive volume of 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, amino acid blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic).

Review of MARs revealed Resident #12 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23.

Interview with the Administrator and the Director of Nursing (DON) on 11/30/23 at 1:15 P.M. revealed they were unaware if the ancillary provider (DRIPT IV) possessed a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio. The DON verified that the above listed residents received IV infusions provided by the ancillary provider.

Interview with Medical Director (MD) #500 on 11/30/23 at 3:45 P.M. revealed he was told the ancillary provider was a new service vendor brought to the facility to help prevent dehydration, and rehospitalization under the supervision of a physician. MD #500 stated that he was provided information from the facility's corporate management that the outside service was operating under proper local and federal regulations. MD #500 stated no negative reactions were reported to him in connection to the IV infusions.

Interview with the Administrator on 12/06/23 at 10:20 A.M. revealed Vice President of Operations (VPO) #505 from the facility's corporate office notified them to stop administration of IV infusions from the ancillary provider (DRIPT IV) on 09/22/23. They were not made aware of any concerns related to the TDDD Ohio licensure for the ancillary provider.

Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership.

Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance.

The deficiency was corrected on 11/21/23 after the facility implemented the following corrective actions.

On 09/22/23, the contract with DRIPT IV cessation was effective.

On 09/22/23, all 10 (#02, #03, #04, #08, #09, #10, #11, #12, #16, and #19) residents who remained in the facility, who received IV's from DRIPT IV, were assessed and had no signs or symptoms or adverse effects related to the IV medications.

On 11/21/23, all contracts that involve providing medications to the residents were reviewed to ensure the proper TDD licensure is in place and no issues were found.

On 11/21/23, education was provided to the governing body (Vice President of Operations #505, Director of Operations #510, and Director of Clinical Operations #515) to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication.

On 11/21/23, to monitor ongoing compliance, the facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly for three months. The audits will be taken to the Quality Assurance Performance Improvement (QAPI) review.

On 12/06/23 at 10:10 A.M., an interview with the Administrator and the DON, verified education was provided by Vice President of Operations (VPO) #505 and confirmed education about verifying sources of medications were compliant with Ohio regulations regarding pharmacy and medications was providing.

Review of four Residents (#01, #9, #11, and #12) medical records revealed assessments were completed.

This deficiency represents non-compliance investigated under Complaint Number OH00148167.

Based on record review, staff and resident interviews, review of personnel files, and review of facility policy, the facility failed to ensure residents were allowed to have visitors of their choice. This affected two residents (#11 and #16) out of six Residents reviewed for visitation. The facility census was 47.

Findings included:

1) Review of the clinical record for Resident #11 revealed the resident was admitted to the facility on 02/24/21. Diagnoses included, but are not limited to, type II diabetes, cognitive communication deficit, major depressive disorder, hypertension, morbid obesity, and overactive bladder.

Review of the quarterly Minimum Data Set (MDS) assessment dated 04/13/23 for Resident #11, revealed the resident had moderate cognitive impairment.

Review of the care plan for Resident #11, addressed her being dependent on staff for meeting emotional, intellectual, physical, and social needs related to immobility. Interventions included encouraging ongoing family involvement and inviting the resident's family to attend special events, activities, and meals.

Interview on 04/26/23 at 2:45 P.M. with Resident #11, revealed the resident indicated she would like to have one visitor and it was a former Activities Director from the facility. Resident #11 indicated she talked to former Activities Director #60 regularly on the phone. Resident #11 indicated she was told by former Activities Director #60 that she was not allowed to come and visit.

2) Review of the clinical record revealed Resident #16 was admitted to the facility on 08/06/21. Diagnoses included, but are not limited to, schizoaffective disorder, sensorineural hearing loss bilaterally, major depressive disorder, intellectual disabilities,' mild cognitive impairment, type II diabetes, and cognitive communication deficit.

Review of the quarterly MDS assessment dated 03/31/23, revealed Resident #16 had had a BIMS score of 11 indicating she had moderate cognitive impairment. She needed supervision for activities of daily living.

Review of the care plan for Resident #16, revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits.

Interview on 04/26/23 at approximately 2:50 P.M. with Resident #16, revealed the resident indicated she would like to have former Activities Director #60 visit her in the facility.

Interview on 04/26/23 at 10:45 A.M. with Administrator and the Director of Nursing (DON), revealed former Activities Director#60 started in December 2021 and walked off the job in October 2023. The Administrator indicated former Activities Director #60 was aggressive and had emotional outbursts with other staff members prior to leaving. Administrator indicated the Corporate Policy was that when someone quit, they were not to be back in the building. Administrator indicated a friendly reminder was sent to former Activities Director #60 via text message on 03/09/23, after she came to visit residents on a weekend. Administrator displayed his phone to the surveyor, which revealed a text message to former Activities Director #30 stating, I was notified by residents that you were on Sunrise Manor premises visiting and as another reminder, you are not allowed on premises. This is a company policy. Administrator denied having any documented evidence that the Former Activities Director #60 had been verbally or physically abusive to the residents.

Review of the personnel file for former Activities Director #60, revealed no disciplinary action against her prior to a 10/26/22 write up for misconduct when she had outbursts and unprofessional behavior during staff meetings. The personnel file revealed a 90-day evaluation dated 02/25/22, which indicated former Activities Director #60 was rated as working well with others, taking pride in her work, seeking improvement, was always concerned with safety and was always polite and willing to help.

Review of the Employee Handbook effective 12/01/18, revealed the corporate employee policy page 35 and under a section titled Visitors stated personal visits to residents during working hours are prohibited. If you resign or (are) terminated from Sunrise Nursing Healthcare and wish to return to visit a resident, you may do so only after obtaining permission from the Administrator.

Review of the facility's policy titled Visitation revised in September 2022, revealed the facility permitted residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility. The Residents are permitted to have visitors of their choosing at the time of their choosing.

This violation represents non-compliance investigated under Complaint Number OH00141089.

Based on bystander interview, staff interview, review of the facility policy, and medical record review, the facility failed to maintain a safe environment for a resident who had exit seeking behaviors and failed to follow their elopement policy. This affected one (Resident #25) of three residents reviewed for risk of elopement. The facility census was 49.

Findings included:

Review of Resident #25's medical record revealed an admission date of 07/14/22. Diagnoses included encephalopathy, chronic ulcer on the outer part of the left foot, difficulty walking, altered mental status, dementia, seizures, diabetes mellitus, schizophrenia, and Parkinson's disease.

Review of the Minimum Data Set (MDS) assessment dated 11/15/22 revealed Resident #25 had moderate cognitive impairment. Resident #25 required extensive one-person assistance for transfers, bed mobility, and toileting.

Review of Resident #25's plan of care dated 12/12/22 revealed Resident #25 was at risk for elopement and wandering related to impaired safety awareness, dementia, and impaired cognitive function. The plan of care revealed Resident #25 wandered aimlessly and had exit seeking behaviors. Interventions included to distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. Document diversional intervention in the resident's behavior log. Monitor for fatigue or weight loss and to monitor resident for tailgating.

Review of the progress note dated 01/01/23 entered by Agency Registered Nurse (RN) #175 revealed Resident #25 was observed walking down the driveway. RN #175 walked back into the facility and notified State Tested Nursing Assistant (STNA) #113. RN #175 and STNA #113 went to Resident #25. Resident #25 was with a bystander. Resident #25 was confused and not able to be redirected to the facility by either STNA #113 or the nurse. Resident #25 did not want to return to the facility. EMS had been called. The EMS did not want to transport Resident #25 to the hospital because the resident appeared to have no injuries. The police who were also present revealed the EMS could not take Resident #25 to the hospital unless there was a physician order to send the resident to the hospital. A physician order was received from the physician to transport Resident #25 to the hospital. The Director of Nursing (DON) and Resident #25's son were notified. The nurse was not able to complete an assessment, however no visible injuries were noted.

Review of the facility's IDT (Interdisciplinary Team) Post Elopement Investigation Summary