Sunshine Health Place 2

Maintain fire clearance before retaining specified persons

Based on observation and record review, the licensee did not comply with the section cited above as the fire door was observed to have a door stop installed and in use, however fire clearance specifies "door stops prohibited" which poses an immediate safety risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above as Resident #3 (R3), who has a diagnosis of dementia has personal grooming, hygiene items, as well as ointments and creams stored unlocked in their private restroom and R3's physician's report indicates yes, at risk if allowed direct access to personal grooming and hygiene items which poses/posed a potential health and safety risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in as 2 residents (Resident #1 & Resident #2) out of 3 total records reviewed have full bed rails installed on their beds, however neither is on hospice and neither have a valid exception on file which poses a potential personal rights risk to persons in care.

Document behavioral expression and related causes

Based on record review, the licensee did not comply with the section cited above in one out of five residents (Resident #2) had an appraisal older than one year which poses a potential health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

Based on observation and record review, the licensee did not comply with the section cited above in one out of five residents with a half bed rail did not have an order on file (Resident #2) which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in one out of five residents (Resident #1) needed an updated medical assessment which poses a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above as cleaning supplies and disinfectants were accessible to residents in the unlocked garage, unlocked cabinet in the kitchen, and unlocked cabinet in the restroom, which poses an immediate health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained ... attain a temperature of not less than 105 degree F and not more than 120 degree F.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the water temperature measured between 124.3 – 125.7 degrees F, which poses an immediate health and safety risk to residents in care.

Limit operations to licensed capacity

87204(a) Limitations-Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the facility had seven (7) residents between 11/30/22-12/2/2022 when they are licensed for a maximum of six (6) residents, which poses an immediate health and safety risk to residents in care.

87625(b)(1) Managed Incontinence. …The licensee shall be responsible for the following: (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as R1 was double diapered due to their bladder and bowel incontinence, which poses an immediate health and safety risk to residents in care.

Right to sufficient care and qualified staff

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. …Residents … shall have ...the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff failed to follow physician’s orders related to wound care for R1, which poses an immediate health and safety risk to residents in care.

Assistance with self-administered medications shall be limited to the following: Medications usually prescribed for self-administration which have been authorized by the person's physician.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff administered additional medications to one out of six residents (R2) which poses an immediate health and safety risk to residents in care.

Call 9-1-1 for imminent health threats

87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis....This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses an immediate health and safety risk to residents in care.

Limit staff assistance with self-administered drugs

87465(a)(5) Incidential Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on medications review and interview, the licensee did not comply with the section cited above, as the medication count was off for three out of six residents (R1, R2, R3), which poses an immediate health and safety risk to residents in care.