Inspection visit
Health inspection
14 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation and interviews, the facility failed to honor a resident's dignity when she was not
provided incontinence care in a timely manner during night shift and she was left sopping wet in her bed.
This affected one (Resident #9) of 16 residents reviewed during the annual survey for dignity issues. The
resident census was 33.
Findings include:
Resident #9 was admitted to the facility on [DATE] with diagnoses of heart failure, hypertension,
hyperlipidemia, hip fracture, stroke, hemiplegia, encephalopathy, history of falling, atherosclerotic heart
disease. A review of Resident #9 quarterly comprehensive assessment dated [DATE] revealed her
cognition was intact. She required extensive assistance of two staff with bed mobility, transfers, toilet use,
the extensive assistance of one staff with dressing and personal hygiene. The resident was always
incontinent of bladder functions and frequently incontinent of bowel functions.
On 04/09/19 at 9:45 A.M. the resident stated she was not changed the night prior and she was wet from her
shoulders to her knees. She said she didn't tell anyone because it would not do any good. The resident said
there was not enough staff last night. Resident #9 did not have a sheet on her bed at this time and she
stated it was wet and staff had removed it.
During interview on 04/09/19 at 2:49 P.M., State Tested Nurse Aide (STNA) #16 stated this morning at 7:00
A.M., she was receiving report from the agency aide and they did walking rounds. The agency STNA stated
everyone was dry; everyone was fine. STNA #16 stated when she went to the resident room around 7:25
A.M. and pulled her covers back, she asked the resident if she was changed last night. The resident stated
no, I wasn't changed all night. STNA #16 stated the resident was sopping wet. She did not report this to the
nurse because it was an agency STNA. STNA #16 stated the resident was in her nightgown and the bottom
half of her gown was wet. The sheet was wet under the resident as she was laying in bed.
During interview on 04/09/19 at 4:00 P.M., Regional Clinical Director (RCD) #50 and the Director of Nursing
(DON) stated the resident received a diuretic and she was a heavy wetter. They said two nurses checked
the patch on her chest and they did not smell nor did they see any incontinence. These nurses also
affirmed Resident #9 did not have a care plan for incontinence in the medical record.
On 04/10/19 at 12:44 P.M. the DON affirmed Resident #9 was cognitively intact at times. The DON said she
had asked staff about Resident #9 and heard the resident had refused care and had stayed up all night.
She affirmed there was no documentation in the medical record pertinent to these staff
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 18
Event ID:
366288
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
statements.
Level of Harm - Minimal harm
or potential for actual harm
On 04/10/19 at 3:17 P.M. an observation was made as STNA #17 transferred the resident from the
wheelchair to the commode in the shower room without any other staff assisting. The resident stood up
from the wheelchair and asked for the walker to assist her as she pivoted from the wheelchair to the
commode. The resident voided in the commode and stood up while using the walker to assist her to pivot
back into the wheelchair. STNA #17 transferred her from the wheelchair and to the commode without any
other staff assistance. Resident #9 stood and used the walker to pivot back to the wheelchair.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 2 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Potential for
minimal harm
Based on record review and interview, the facility failed to provide Skilled Nursing Facility Advanced
Beneficiary Notice (SNF ABN) letters to residents discharged from skilled care to nursing care. This
affected three (Residents #13, #26 and #31) of three residents reviewed for Beneficiary Protection
Notification. The facility census was 33.
Residents Affected - Some
Findings include:
1. Review of the SNF Beneficiary Protection Notification Review for Resident #13 revealed Medicare Part A
skilled services began on 12/12/18 and the last covered day was 02/05/19. Resident #13 remained in the
nursing facility and was not provided a SNF ABN Form.
2. Review of the SNF Beneficiary Protection Notification Review for Resident #26 revealed Medicare Part A
skilled services began on 01/31/19 and the last covered day was 02/10/19. Resident #26 remained in the
nursing facility and was not provided a SNF ABN Form.
3. Review of the SNF Beneficiary Protection Notification Review for Resident #31 revealed Medicare Part A
skilled services began on 02/11/19 and the last covered day was 03/15/19 and Resident #31 remained in
the nursing facility and was not provided a SNF ABN Form.
During interview on 04/10/19 at 3:00 P.M., Social Service Director #6 verified that the SNF ABN letters were
not given to Residents #13, #26, and #31.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 3 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Potential for
minimal harm
Based on record review, interview and policy review, the facility failed to ensure reference checks were
obtained on employees prior to hire. This affected two (Dietary Manager #5 and Registered Nurse #21) of
eight employees hired since 01/01/19. This had the potential to affect all 33 residents in the facility.
Residents Affected - Many
Findings include:
1. Review of the personnel file for Dietary Manager #5 revealed this employee was hired on 04/03/19. There
was no evidence of reference checks prior to hire.
2. Review of the personnel file for Registered Nurse #21 revealed this employee was hired on 01/28/19.
There was no evidence of reference checks prior to hire.
On 04/11/19 at 4:35 P.M. an interview with Human Resources Staff (HR) #51 verified the facility had no
evidence of reference checks in these new employee personnel files. HR #51 was unable to provide an
explanation as to why reference checks were not obtained by the facility.
On 04/11/19 at 5:00 P.M. an interview with the Administrator verified the facility policies indicated
background checks would be conducted within two days of an offer of employment.
A review of the facility policy titled Abuse Prevention Program, revised December 2016, read the residents
had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. As part
of the resident abuse prevention, the administration would conduct employee background checks and will
not knowingly employ or otherwise engage any individual who had been found guilty of abuse, neglect,
exploitation, misappropriation of property or mistreatment by a court of law. Nor, would they employ anyone
who had a disciplinary action in effect against his or her professional license by a state licensure body as a
result of finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident
property.
A review of the facility policy titled Background Screening Investigations, revised November 2015, read the
facility conducted employment background screening checks, reference checks and criminal conviction
investigation checks on direct access employees. The Personnel/Human Resources Director, or other
designee will conduct background checks, reference checks and criminal conviction checks on all potential
employees and contract personnel who meet the criteria for direct access employee, as stated above. Such
investigation will be initiated within two days of an offer of employment or contract agreement.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 4 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record revealed Resident #26 was discharged to the hospital on [DATE] for gastrointestinal
issues and was readmitted on [DATE]. The record contained no documentation the resident, resident's
representative, and/or local ombudsman was provided with notice of transfer when the resident was sent
out of the facility.
During interview on 04/10/19 at 3:56 P.M., Regional Clinical Director (RCD) #50 stated the facility did not
provide ombudsman, residents and/or family notification of transfer when residents were sent out of the
facility. She stated the notices had not been sent since December 2018.
Review of the facility policy titled Transfer or Discharge Notice, undated, revealed the facility would provide
the residents and/or representative notice, in writing, before the resident was transferred out of the facility,
and a copy of the transfer notice would be sent to the Office of the State Long-Term Ombudsman.
Based on record review, staff interview and policy review, the facility failed to provide residents, resident
representatives, and/or the local Ombudsman the required notification of transfer when the residents were
sent out to the hospital. This affected two (Residents #26 and #33) of three residents reviewed for
hospitalization. The facility census was 33.
Findings include:
1. Review of the medical record revealed Resident #33 was admitted on [DATE]. The resident was
transferred from the facility to the hospital on [DATE] for hallucinations resulting in aggressive behaviors
towards peer. The resident returned to the faciltiy on 03/07/19. The record contained no documentation the
resident, resident's representative, and/or local ombudsman was provided with notice of transfer when the
resident was sent out of the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 5 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview and policy review, the facility failed to provide residents and/or resident
representatives the required bed hold notices when residents were transferred to the hospital. This affected
two (Residents #26 and #33) of three residents reviewed for hospitalization. The facility census was 33.
Findings include:
1. Review of the medical record revealed Resident #33 was admitted on [DATE]. The resident was
transferred from the facility to the hospital on [DATE] for hallucinations resulting in aggressive behaviors
towards peer. The resident returned to the facility on [DATE]. The record contained no documentation the
resident, resident's representative, and/or local ombudsman was provided with the facility's bed hold policy
when the resident was sent out of the facility.
2. Review of the medical record revealed Resident #26 was discharged to the hospital on [DATE] for
gastrointestinal issues and was readmitted on [DATE]. The record contained no documentation the resident,
resident's representative, and/or local ombudsman was provided with the facility's bed hold policy when the
resident was sent out of the facility.
During interview on 04/10/19 at 3:56 P.M., Regional Clinical Director (RCD) #50 stated the facility did not
provide the required bed hold notices when residents were sent out to the hospital. She stated the notices
had not been sent since December 2018.
Review of the facility policy titled, Holding Bed Space, dated December 2006, read if a resident is sent out
of the facility for emergency transfer the facility would provide, within 48 hours, the bed-hold policy including
but not limited to any charges that the resident may incur if the resident wishes to hold the bed longer than
the remaining allotted bed hold days.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 6 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to accurately code resident's status on the Minimum Data Set
(MDS) Assessments. This affected two (Residents #36 and #27) of 16 residents sampled. The resident
census was 33.
Residents Affected - Few
Findings include:
1. Resident #36 was admitted to the facility on [DATE] and discharged on 01/26/19 to another nursing
home. Review of the five day MDS assessment documented the resident had been discharged to an acute
care hospital on [DATE].
Review of progress notes dated 01/26/19 at 6:15 P.M. revealed the Licensed Social Worker documented the
resident was discharged to another nursing home at the family's request.
During interview on 04/10/19 at 4:57 P.M., Registered Nurse (RN) #75 verified the MDS was coded in error.
2. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses
including type two diagnoses schizoaffective disorder, dementia with behavioral disturbance and major
depressive disorder.
Review of the MDS dated [DATE] also revealed the resident's functional status required supervision with
setup assistance with bed mobility, dressing, eating, toileting, personal hygiene, bathing, however
documents resident required extensive one-person assistance with locomotion and walking, and limited
one-person assistance with transfer. Review of balance during transition and walking revealed the resident
was steady at all times and had no functional limitations in range of motion, and required no assistive
devices for mobility
Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact with
delusional behaviors. Review of the resident's functional status revealed he required supervision with setup
assistance with bed mobility, dressing, eating, toileting, personal hygiene, bathing, however documented
the resident required extensive one-person assistance with locomotion and walking, and limited one-person
assistance with transfer. Review of balance during transition and walking revealed the resident was steady
at all times and had no functional limitations in range of motion, and required no assistive devices for
mobility.
During observation on 04/10/19 at 1:30 P.M.,. Resident #27 was observed in his room with the door shut.
The resident was observed walking independently throughout his room with a steady gait, dressed
appropriately and well-groomed. Resident #27 refused interview at that time.
During interview conducted on 04/10/19 at 2:55 P.M., RN #20 stated Resident #27 prefers to stay in his
room majority of the time. RN #27 stated the resident is alert and independent, he uses his cell phone,
makes his bed, and even holds the door open for others when going in and out of the locked unit.
During interview on 04/10/19 at 3:03 P.M., State Tested Nursing Assistant (STNA) #15 stated Resident #27
stays in his room a lot and keeps to himself. STNA #15 stated the resident does not really
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 7 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
require assistance with his activities of daily living (ADL) and does everything for himself. STNA #15 stated
the only thing she assists the resident with is bringing him his food trays and getting him set up and in the
tub for his baths, so he doesn't fall.
During interview on 04/11/19 at 1:40 P.M., MDS Registered Nurse (RN) #18 stated the facility uses ADL
Flow Records completed by nursing assistants to review and complete MDS assessments. MDS RN #18
reviewed and verified ADL Flow Records completed for Resident #27 documented the resident as
independent with all reviewed ADL's, and only required setup assistance with eating. MDS RN #18 stated
she was aware of Resident #27, and verified the resident was independent with locomotion, ambulation and
transfer. She verified both MDS assessments were inaccurate.
Event ID:
Facility ID:
366288
If continuation sheet
Page 8 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and policy review, the facility failed to initiate a baseline care plan within 48
hours of admission. This affected one (Resident #33) of 13 residents baseline care plans reviewed. The
facility census was 33.
Findings include:
Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses including
Parkinson's disease, dementia and delusions, psychosis, behavior disorder, and vitamin B 12 and D
deficiency.
Review of Resident #33 admission comprehensive assessment dated [DATE] revealed the resident was
severely cognitively impaired. The resident had physical and verbal behavioral symptoms directed toward
others one to three days during the seven day look back period.
The record contained no baseline care plan initiated within 48 hours of admission that addressed the
resident's mental health diagnoses and behaviors.
During interview on 04/11/19 at 12:27 P.M., MDS Registered Nurse (RN) #18 and Regional Clinical
Director(RCD) #50 stated no baseline care plans were ever created relating to the resident's behaviors
and/or mental health needs during the resident's initial stay from 01/23/19 to 03/02/19 when he was
discharged for a short psychiatric hospitalization.
Review of the facility policy titled, Care Plans-Baseline, dated December 2016, revealed the facility will
develop, within 48 hours, baseline care plans to meet the immediate care needs of all residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 9 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident
#9 was admitted to the facility on [DATE] with diagnoses including heart failure, hypertension,
hyperlipidemia, hip fracture, stroke, hemiplegia, encephalopathy, history of falling, atherosclerotic heart
disease.
The quarterly comprehensive assessment dated [DATE] revealed her cognition was intact and she required
extensive assistance of two staff with bed mobility, transfers, toilet use, the extensive assistance of one staff
with dressing and personal hygiene. The resident was always incontinent of bladder functions and
frequently incontinent of bowel functions. The medical record contained no care plan addressing the
resident's incontinence.
On 04/09/19 at 9:45 A.M. the resident stated she was not changed last night and she was wet from her
shoulders to her knees. She said she didn't tell anyone because it would not do any good. Resident #9 did
not have a sheet on her bed at this time and she stated it was wet and staff had removed it.
During interview on 04/09/19 at 2:49 P.M., State Tested Nurse Aide (STNA) #16 stated this morning at 7:00
A.M., she was receiving report from the agency aide and they did walking rounds. The agency STNA stated
everyone was dry; everyone was fine. STNA #16 stated when she went to the resident room around 7:25
A.M. and pulled her covers back, she asked the resident if she was changed last night. The resident stated
no, I wasn't changed all night. STNA #16 stated the resident was sopping wet. She did not report this to the
nurse because it was an agency STNA. STNA #16 stated the resident was in her nightgown and the bottom
half of her gown was wet. The sheet was wet under the resident as she was laying in bed.
During interview on 04/10/19 at 12:44 P.M. the Director of Nursing stated there was no comprehensive care
plan to address the resident's incontinence.
Review of the facility policy titled Care Plans, Comprehensive Person-Centered, undated, read the facility
would develop and implement comprehensive, person-centered care plans to meet the residents's physical,
psychosocial and functional needs, within seven days of the completion of the required [comprehensive
assessment].
Based on medical record review, staff interview and policy review, the facility failed to complete
comprehensive care plans to address resident needs. This affected two (Residents #9 and #33) of 13
residents reviewed for comprehensive care plans. The facility census was 33.
Findings include:
1. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses including
Parkinson's disease, dementia and delusions, psychosis, behavior disorder, and vitamin B12 and D
deficiency.
Review of the admission comprehensive assessment dated [DATE] revealed Resident #33 was severely
cognitively impaired with physical and verbal behaviors directed towards others noted one to three days
during the seven day look back period. The resident required supervision with walking and locomotion,
supervision and setup with eating, limited one-person assistance with bed mobility, transfer,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 10 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
extensive one-person assistance with dressing, toileting, and personal hygiene.
Level of Harm - Minimal harm
or potential for actual harm
There was no evidence in the record a comprehensive care plan was initiated for the resident from
admission on [DATE] to 03/02/19 when the resident was sent to the hospital for aggressive behaviors.
Residents Affected - Few
During interview on 04/11/19 at 12:27 P.M., MDS Registered Nurse (RN) #18 and Regional Clinical
Director(RCD) #50 stated no baseline care plans were ever created relating to the resident's behaviors
and/or mental health needs during the resident's initial stay from 01/23/19 to 03/02/19 when he was
discharged for a short psychiatric hospitalization.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 11 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0661
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure necessary information is communicated to the resident, and receiving health care provider at the
time of a planned discharge.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident
#36 was admitted to the facility on [DATE] and discharged on 01/26/19 to another nursing home. The
comprehensive assessment dated [DATE] documented the resident had been discharged to an acute care
hospital.
On 01/26/19 at 6:15 P.M., a Licensed Social Worker (LSW) documented the resident was discharged to
another nursing home per the family's request on this date.
During interview on 04/11/19 at 2:03 P.M., LSW #6 said the resident was discharged to another nursing
home, not a hospital. LSW #6 verified there was no recapitulation of the resident's stay.
Based on record review and interview, the facility failed ensure discharge records contained a recapitulation
of the resident's stay, a final summary of resident's status, and a reconciliation of all pre- and postdischarge medications. This affected two (Residents #37 and #36) of four residents reviewed for discharge.
The facility census was 33.
Findings include:
1. A closed record review revealed that Resident #37 was admitted on [DATE] discharged on 01/18/19 to
another facility. The closed record revealed there was no discharge summary.
a
Review of Social Service note dated 01/18/19 that Resident #37 was discharged to another facility of
family's choice.
During interview on 04/11/19 at 4:00 P.M. with Regional Clinical Director #50 verified there was no
discharge summary for Resident #37.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 12 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to provide a resident with incontinence care to maintain
personal hygiene. This affected one (Resident #9) of 16 residents sampled. The resident census was 33.
Residents Affected - Few
Findings include:
Resident #9 was admitted to the facility on [DATE] with diagnoses of heart failure, hypertension,
hyperlipidemia, hip fracture, stroke, hemiplegia, encephalopathy, history of falling, atherosclerotic heart
disease. A review of Resident #9 quarterly comprehensive assessment dated [DATE] revealed her
cognition was intact. She required extensive assistance of two staff with bed mobility, transfers, toilet use,
the extensive assistance of one staff with dressing and personal hygiene. The resident was always
incontinent of bladder functions and frequently incontinent of bowel functions.
On 04/09/19 at 9:45 A.M. the resident stated she was not changed the night prior and she was wet from her
shoulders to her knees. She said she didn't tell anyone because it would not do any good. The resident said
there was not enough staff last night. Resident #9 did not have a sheet on her bed at this time and she
stated it was wet and staff had removed it.
During interview on 04/09/19 at 2:49 P.M., State Tested Nurse Aide (STNA) #16 stated this morning at 7:00
A.M., she was receiving report from the agency aide and they did walking rounds. The agency STNA stated
everyone was dry; everyone was fine. STNA #16 stated when she went to the resident room around 7:25
A.M. and pulled her covers back, she asked the resident if she was changed last night. The resident stated
no, I wasn't changed all night. STNA #16 stated the resident was sopping wet. She did not report this to the
nurse because it was an agency STNA. STNA #16 stated the resident was in her nightgown and the bottom
half of her gown was wet. The sheet was wet under the resident as she was laying in bed.
During interview on 04/09/19 at 4:00 P.M., Regional Clinical Director (RCD) #50 and the Director of Nursing
(DON) stated the resident received a diuretic and she was a heavy wetter. They said two nurses checked
the patch on her chest and they did not smell nor did they see any incontinence. These nurses also
affirmed Resident #9 did not have a care plan for incontinence in the medical record.
On 04/10/19 at 12:44 P.M. the DON affirmed Resident #9 was cognitively intact at times. The DON said she
had asked staff about Resident #9 and heard the resident had refused care and had stayed up all night.
She affirmed there was no documentation in the medical record pertinent to these staff statements.
On 04/10/19 at 3:17 P.M. an observation was made as STNA #17 transferred the resident from the
wheelchair to the commode in the shower room without any other staff assisting. The resident stood up
from the wheelchair and asked for the walker to assist her as she pivoted from the wheelchair to the
commode. The resident voided in the commode and stood up while using the walker to assist her to pivot
back into the wheelchair. STNA #17 transferred her from the wheelchair and to the commode without any
other staff assistance. STNA #17 wet a washcloth with water from the shower head and used Silkened
Body Wash to provide incontinence care. The STNA did not rinse the resident's perineum with water after
cleansing with the body wash. The sink in the shower room was not functioning and STNA #17 was unable
to assist the resident to use the sink for handwashing after using the commode.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 13 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
During interview on 04/10/19 at 3:30 P.M., STNA #17 said she usually used a washcloth to wash the
resident's hands as she was unable to use the sink in the shower room. She also verified the body wash
used for incontinence care required rinsing after using this product and she had not rinsed the resident
after using the body wash.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 14 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to provide laboratory testing to monitor the use of
medications. This affected one (Resident #17) of five residents reviewed for unnecessary medications. The
resident census was 33.
Residents Affected - Few
Findings include:
Resident #17 was admitted to the facility on [DATE] with diagnoses including hypertension, urinary tract
infection, hyperlipidemia, dementia, hypothyroidism, colon polyps and atherosclerosis of chronic ischemic
disease.
A review of physician orders revealed Resident #17 was receiving Atorvastatin ( to lower cholesterol),
Levothyroxine (a thyroid medication) and Isosorbide ( for coronary artery disease) every day. The physician
had ordered laboratory testing of Thyroid Stimulating Hormone, Total Thyroid 4, Complete Metabolic Panel,
Complete Blood Count and Liver Profile to be done in January 2019. A review of the medical record
revealed these laboratory tests were not completed in January 2019 in accordance with physician orders.
During interview on 04/10/19 at 11:57 A.M., the Director of Nursing stated the laboratory testes ordered in
January 2019 were not drawn.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 15 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview and policy review, the facility failed to date foods stored in the
refrigerator and failed to dispose of outdated foods in the kitchen. This had the potential to affect all 33
residents in the facility receiving meals from the kitchen.
Findings include:
Observation and interview of facility kitchen was completed on 04/09/19 at 9:40 A.M. with Food Service
Director(FSD) #5. Observation of the facility walk in refrigerator revealed a box of pork chops thawed and
undated; a box of Danish open and undated; a roll of bologna for use or freeze or use by 03/20/19 undated;
two open boxes of bacon, undated; a tub of cole slaw with a use by date of 03/28/19; a package of ham
open and dated 03/31/19; and a head of lettuce that was brown and soggy with green fuzz growing on it.
In the kitchen area there were two loaves of bread with expiration dates of 04/02/19 and six bags of cheese
puffs with a use by date of 03/25/19. FSD #5 verified all foods listed, stating all foods should be dated when
delivered and when switched from the freezer to the refrigerator. Opened foods are discarded within three
to seven days from opening, depending on the foods, and past dated foods should be discarded
immediately.
Review of the facility policy titled, Food Receiving and Storage, dated October 2017, revealed all foods
stored in the refrigerator will be covered, labeled and dated with a use by date, and foods will be stored in a
manner that complies with safe food handling.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 16 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of monitoring measures, interview and policy review, the facility failed to have any water
monitoring for Legionella; failed to provide a functional sink where staff and residents could wash their
hands in the Main Shower Room. This occurred in one (Main Shower Room) of two shower rooms used by
16 residents (Residents #12, #8, #13, #25, #30, #35, 328, #23, #34, #4, #16, #9, #10, #19, #22 and #17);
and failed to administer Tuberculosis (TB) testing in accordance with facility policy. This involved six
employees (Maintenance Director #2, Registered Nurse (RN) #21, Licensed Social Worker (LSW) #6,
Housekeeper #34, the Director of Nursing (DON) and State Tested Nurse Aide (STNA) #4) of eleven
personnel files reviewed. This had the potential to affect all residents residing in the facility. Facility census
was 33.
Residents Affected - Few
Findings include:
1. Review of the facility's Legionella Program revealed that the last water test was completed on 02/21/18
there was no evidence water temperatures being tested or any other monitoring for Legionella.
During interview on 04/11/19 at 2:28 P.M., the Administrator verified that there was no Legionella
monitoring in the facility and the last testing of the water was 02/21/18.
2. During observation on 04/10/19 at 3:17 P.M., Resident #9 was observed being toileted in the main
shower room. STNA #17 provided incontinent care using water from the shower head in the shower. The
the sink in the shower room was not functioning and STNA #17 was unable to assist the resident to use the
sink for handwashing after using the commode.
During interview on 04/10/19 at 3:30 P.M., STNA #17 said she usually used a washcloth to wash the
resident's hands as she was unable to use the sink in the shower room.
During interview on 04/12/19 at 3:50 P.M., Maintenance Director #2 verified the pipes for the sink in the
main shower room were not attached and residents and staff were unable to use this sink for handwashing.
3. During personnel record review, Maintenance Director #2, hired on 01/31/19; Registered Nurse (RN)
#21, hired on 01/28/19; Licensed Social Worker (LSW) #6, hired on 02/01/19; Housekeeper #34, hired on
02/15/19; Director of Nursing (DON), hired on 03/01/19; and State Tested Nurse Aides (STNA) #4 hired on
10/31/12 had no evidence of tuberculosis (TB) testing.
During interview on 04/11/19 at 4:35 P.M., Human Resources Director (HR) #51 verified these employees
did not have the required testing for TB. HR #51 stated the first step of the TB testing should have been
read before they started work. The second step was to be given seven to 14 days later.
A review of the facility policy titled Screening of Employees for Tuberculosis, revised July 2010, revealed the
policy documented all employees shall be screened for tuberculosis (TB) and disease using a two step
tuberculin skin test of blood assay for Mycobacterium and symptom screening, prior to beginning
employment. The need for annual testing shall be determined by the annual TB risk classification or as per
State regulations. Each newly hired employee will be screened for TB infection and disease after an
employment offer has been made but prior to the employee's duty assignment. The need for annual testing
will be based on TB risk classification or as required by State regulations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 17 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366288
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sunrise Nursing Healthcare LLC
3434 State Route 132
Amelia, OH 45102
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and staff interview, the facility failed maintain the stove and dish washer in safe
operating conditions. This had the potential to affect all 33 resident receiving meals from the kitchen.
Residents Affected - Many
Findings include:
Observation and interview of facility kitchen on 04/09/19 at 9:40 A.M. with Food Service Director(FSD) #5
revealed the front bottom panel of the kitchen stove was missing with exposed wires. The wires were held
together by wire connector caps with food noted down the front and sides of the stove that was dried and
crusted. FSD #5 verified the above findings at the time of the observation.
Observation and interview on 04/09/19 at 10:25 A.M. revealed Dietary Aid (DA) #12 was washing dishes in
the dishwasher. The temperature gauges were not working. DA #12 stated she was unsure of how long the
dish washer was broken. DA #12 said they just got test strips to verify sanitization was going to starting to
use them that day.
During interview on 04/10/19 at 12:11 P.M., FSD #5 stated instead of using the sanitization test strips, staff
are using the three compartment sink for all dishwashing until the dishwasher was fixed or replaced.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366288
If continuation sheet
Page 18 of 18
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Back to topCitations
14 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F661 - Quality of life
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
FAQ · About this visit
Common questions about this visit
What happened during the April 11, 2019 survey of SUNRISE NURSING HEALTHCARE LLC?
This was a inspection survey of SUNRISE NURSING HEALTHCARE LLC on April 11, 2019. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SUNRISE NURSING HEALTHCARE LLC on April 11, 2019?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed i..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.