Sunshine Manor

Based on observation and record review, the licensee did not comply with the section cited above, as 1 resident (R3) out of 6 residents observed has full bed rails, but is no longer on hospice care, which poses a potential personal rights risk to persons in care.

Maintain fire clearance before retaining specified persons

Based on observation, interview, and record review, the licensee did not comply with the section cited above as R1 and R2 were observed to be in Bedroom #4, which has an ambulatory only fire clearance, but R1 is non-ambulatory and R2 was observed to be non-ambulatory, but is documented as bedridden, as well as R3 is marked bedridden, but is in a non-ambulatory room which poses an immediate health and safety risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above as the toilet in the shared resident restroom was backing up and there was clutter in the outside walkway of the facility, which poses potential health and safety risk to persons in care.

Assist residents with self-administered medication

Based on observation and record review, the licensee did not comply with the section cited above as R3 has medications that are prescribed as needed (PRN) however, the facility does not have a PRN authorization form and the nurse directed the staff to administer the medication daily without providing a new presciption order, which poses a potential health risk to persons in care.

Give PRN medication by physician order

Based on record review, the licensee did not comply with the section cited above in seven medicatinotons being available for R1, 1 medication without a current physicians order for R1, and 1 medication not logged for R2, which poses an immediate health and safety risk to persons in care.

Limit postural support devices to mobility needs

Based on observation, the licensee did not comply with the section cited above as the LPA observed a caregiver restraining a resident in a wheel chair with a gait belt which poses an immediate health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as out of the five files reviewed, the LPA identified that one resident (R3) is missing a physicians report, two residents (R1 & R2) need an updated physicians report, due to the diagnosis of dementia, and two residents (R1 & R2 ) need an annual Appraisal & Needs and Service Plan report, due to the diagnosis of dementia, which poses a potential health and safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as four out of four staff are misisng 3 out of 8 hours of dementia care which poses a potential health and safety risk to persons in care.

Notify agency before locking doors or gates

Based on observation the licensee did not comply with the section cited above as the following was accesible to residents with dementia: razors, medication, bleach, tools, fertilizer, and other.., which poses an immediate health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as four out four staff files reviewed were missing 3 out of 4 hours of postural supports, restricted conditions or health services, and hospice care training which poses a potential health and safety risk to persons in care.

Maintain fire clearance before retaining specified persons

Based on observation, the licensee did not comply with the section cited above as the two fire extinghishers in the home were last serviced in 2021 which poses an immediate health and safety risk to persons in care.

Use slip-resistant surfaces in bathing areas

Based on observation, the licensee did not comply with the section cited above as one of two bathrooms were observed to not have a slip mat which poses a potential health and safety risk to persons in care.

Include required health screening documents

Based on record review, the licensee did not comply with the section cited above as one out of six staff (S1) did not have TB documented in their health screening, or proof of negative TB which poses an immediate health and safety risk to persons in care.

Safe, healthful, comfortable accommodations

Based on observation, the licensee did not comply with the section cited above, as staff and visitors were not following infection control protocols in wearing masks, which poses an immediate health and safety risk to persons in care.

Supervision near heating and water hazards

Based on observation, the licensee did not comply with the section cited above in 1 out of 1 swimming pool gate was unlocked which poses an immediate health, safety or personal rights risk to persons in care.