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Deficiency Records for Sunray Healthcare Center
A list of the most recent deficiencies for Sunray Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sunray Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | Health | 2024-09-19 | 2024-09-30 | Y |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-09-19 | 2024-09-30 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-21 | 2024-08-30 | Y |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-08-21 | 2024-08-30 | Y |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-08-07 | 2024-08-22 | Y |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-07-23 | 2024-08-08 | Y |
Observe each nurse aide's job performance and give regular training. | Health | 2024-07-18 | 2024-08-02 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-09 | 2024-07-24 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-09 | 2024-07-24 | Y |
Post nurse staffing information every day. | Health | 2024-06-24 | 2024-07-19 | Y |
Respond appropriately to all alleged violations. | Health | 2024-06-21 | 2024-07-19 | Y |
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2024-06-25 | 2024-07-18 | Y |
Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-06-25 | 2024-07-11 | Y |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-05-23 | 2024-06-10 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-23 | 2024-06-10 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-16 | 2024-05-14 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-13 | 2024-04-15 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-29 | 2024-04-11 | Y |
Respond appropriately to all alleged violations. | Health | 2024-03-29 | 2024-04-11 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-12 | 2024-03-31 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-02 | 2024-02-08 | Y |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-02-02 | 2024-02-08 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-02-08 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-02-08 | Y |
Ensure that residents are free from significant medication errors. | Health | 2024-01-11 | 2024-02-08 | Y |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-12-02 | 2024-02-08 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-02 | 2024-02-08 | Y |
Provide emergency officials' contact information. | Fire Safety | 2023-12-06 | 2024-01-06 | N |
Establish staff and initial training requirements. | Fire Safety | 2023-12-06 | 2024-01-06 | N |
Conduct testing and exercise requirements. | Fire Safety | 2023-12-06 | 2024-01-06 | N |
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-12-06 | 2024-01-06 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-06 | 2024-01-06 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-06 | 2024-01-06 | N |
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-12-19 | 2024-01-03 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-23 | 2024-01-03 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-02 | 2024-01-03 | N |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-02 | 2024-01-03 | N |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-12-02 | 2024-01-03 | N |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-12-02 | 2024-01-03 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-02 | 2024-01-03 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-12-02 | 2024-01-03 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-02 | 2024-01-03 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-02 | 2024-01-03 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-02 | 2024-01-03 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-02 | 2024-01-03 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-02 | 2024-01-03 | N |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-12-02 | 2024-01-03 | N |
Observe each nurse aide's job performance and give regular training. | Health | 2023-12-02 | 2024-01-03 | N |
Post nurse staffing information every day. | Health | 2023-12-02 | 2024-01-03 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-12-02 | 2024-01-03 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-02 | 2024-01-03 | N |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-12-02 | 2024-01-03 | N |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-12-02 | 2024-01-03 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-02 | 2024-01-03 | N |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-02 | 2024-01-03 | N |
Provide and implement an infection prevention and control program. | Health | 2023-12-02 | 2024-01-03 | N |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-12-02 | 2024-01-03 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-02 | 2024-01-03 | N |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-12-02 | 2024-01-03 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-02 | 2024-01-03 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-22 | 2023-12-07 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-11 | 2023-10-31 | Y |
Ensure that residents are free from significant medication errors. | Health | 2023-10-11 | 2023-10-31 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-10 | 2023-10-31 | Y |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-10-10 | 2023-10-31 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-14 | 2023-09-11 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-14 | 2023-09-11 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-11 | 2023-06-10 | Y |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-19 | 2023-05-18 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-11 | 2023-05-10 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-31 | 2023-04-30 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-31 | 2023-04-30 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-31 | 2023-04-30 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-31 | 2023-04-30 | Y |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-31 | 2023-04-30 | Y |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-03-31 | 2023-04-30 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-31 | 2023-04-30 | Y |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-03-31 | 2023-04-30 | Y |
Keep all essential equipment working safely. | Health | 2023-03-31 | 2023-04-30 | Y |
Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-02-15 | 2023-03-20 | N |
List the names and contact information of those in the facility. | Fire Safety | 2023-02-15 | 2023-03-20 | N |
Provide emergency officials' contact information. | Fire Safety | 2023-02-15 | 2023-03-20 | N |
Conduct testing and exercise requirements. | Fire Safety | 2023-02-15 | 2023-03-20 | N |
Implement emergency and standby power systems. | Fire Safety | 2023-02-15 | 2023-03-20 | N |
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Construct fire resistant interior walls. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Have power receptacles that are properly grounded. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2023-02-15 | 2023-03-17 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-09 | 2023-03-10 | N |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-02-09 | 2023-03-10 | N |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-02-09 | 2023-03-10 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-09 | 2023-03-10 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-09 | 2023-03-10 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-09 | 2023-03-10 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-09 | 2023-03-10 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-09 | 2023-03-10 | N |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-09 | 2023-03-10 | N |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-02-09 | 2023-03-10 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-09 | 2023-03-10 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-09 | 2023-03-10 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-09 | 2023-03-10 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-09 | 2023-03-10 | N |
Ensure that residents are free from significant medication errors. | Health | 2023-02-09 | 2023-03-10 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-09 | 2023-03-10 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-09 | 2023-03-10 | N |
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-02-09 | 2023-03-10 | N |
Keep all essential equipment working safely. | Health | 2023-02-09 | 2023-03-10 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-09 | 2023-03-03 | Y |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-02-09 | 2023-03-03 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-27 | 2023-02-24 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-27 | 2023-02-24 | Y |
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-01-13 | 2023-02-10 | Y |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-13 | 2023-02-10 | Y |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-12-28 | 2023-02-10 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-28 | 2023-02-10 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-28 | 2023-02-10 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-12-28 | 2023-02-10 | Y |
Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-10-27 | 2022-11-25 | Y |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-10-03 | 2022-11-25 | Y |
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-10-03 | 2022-11-25 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-03 | 2022-11-25 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-21 | 2022-10-17 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-14 | 2022-09-09 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-02 | 2022-08-26 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-08-26 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-17 | 2022-07-17 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-17 | 2022-07-17 | Y |
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-06-21 | 2022-06-30 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-21 | 2022-06-30 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-19 | 2022-06-23 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-19 | 2022-06-23 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-12 | 2022-06-07 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-12 | 2022-06-07 | Y |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-05-12 | 2022-06-07 | Y |
Ensure staff are vaccinated for COVID-19 | Health | 2022-05-12 | 2022-06-07 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-02-18 | N |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-07 | 2022-01-21 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-12-29 | 2022-01-11 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-11-12 | 2022-01-10 | Y |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-02 | 2022-01-05 | Y |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-11-18 | 2021-11-29 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2019-12-13 | 2020-01-10 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-13 | 2020-01-10 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-13 | 2020-01-10 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-13 | 2020-01-10 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-13 | 2020-01-10 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-12-13 | 2020-01-10 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-13 | 2020-01-10 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-13 | 2020-01-10 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-13 | 2020-01-10 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-11 | 2020-01-03 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-11 | 2020-01-03 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-11 | 2020-01-03 | N |
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