SUNRISE MANOR CTR FOR NURSING AND REHABILITATION
For profit - Corporation
84 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
26/100
#454 of 594 in NY
Photo by Sunrise Manor Nursing Home
Photo by Benjamin Steinman
Photo by Benjamin Steinman
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Sunrise Manor Center for Nursing and Rehabilitation has received a Trust Grade of F, indicating significant concerns and poor overall performance. With a state rank of #454 out of 594 facilities in New York, they fall in the bottom half, and #37 out of 41 in Suffolk County, meaning there are very few options that are worse. The facility's trend is stable, with 5 issues noted in both 2023 and 2025, suggesting ongoing challenges rather than improvement. Staffing is relatively strong, rated 4 out of 5 stars, with a low turnover rate of 24%, which is below the state average. However, they have incurred $51,565 in fines, which is concerning and higher than 93% of similar facilities, indicating potential compliance issues. There are serious weaknesses highlighted by specific incidents found during inspections. For example, a critical incident involved a staff member being accused of sexual abuse, which was not reported to authorities, putting the resident and others at risk. Additionally, the facility failed to ensure that their Infection Preventionist had the necessary specialized training, which is essential for maintaining health standards. Overall, while there are strengths in staffing, the serious deficiencies and poor trust grade raise significant concerns for families considering this facility for their loved ones.
- Trust Score
- F
- In New York
- #454/594
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ✓ Good
- 24% annual turnover. Excellent stability, 24 points below New York's 48% average. Staff who stay learn residents' needs.
- Penalties ○ Average
- $51,565 in fines. Higher than 61% of New York facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 34 minutes of Registered Nurse (RN) attention daily — about average for New York. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 13 deficiencies on record. Higher than average. Multiple issues found across inspections.
26/100
Bottom 24%
Review needed
5 → 5 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 5 issues
2025: 5 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (24%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (24%)
24 points below New York average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below New York average (3.1)
Below average - review inspection findings carefully
Federal Fines: $51,565
Above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 13 deficiencies on record
2 life-threatening
Apr 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification and Abbreviated (NY 00363437) Survey initiated o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification and Abbreviated (NY 00363437) Survey initiated on 3/26/2025 and completed on 4/1/2025, the facility did not develop a comprehensive person-centered care plan for each resident that includes measurable objective and time frames to meet a residents medical, nursing, mental and psychosocial need that are identified in the comprehensive assessment. This was identified for one (Resident #50) of three residents reviewed for Skin Conditions. Specifically, Resident #50 was incontinent of bowel and bladder and there was no care plan developed to address the resident's incontinence care.
The finding is:
The Policy and Procedure for Urinary/Bowel Continence and Incontinence Assessment and Management, revised on 1/2025, documented that if a resident is incontinent, an incontinent care plan will be initiated, reviewed, and revised as needed.
The Policy and Procedure for Comprehensive Care Plan reviewed on 10/2024, documented that the Comprehensive Person-Centered Care Plan includes measurable objectives and time frames. The care plan describes services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Resident #50 was admitted with diagnoses that include Secondary Malignant Neoplasm of Cerebral Meninges, Paraplegia ( inability to voluntarily move the lower parts of the body), and Retention of Urine. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The Minimum Data Set documented the resident was always incontinent of bowel and bladder and was dependent on the staff for toileting.
The Physician's orders dated 2/28/2025 documented to administer 1 capsule of Flomax (tamsulosin) 0.4 milligrams by oral route once a day at 10:00 PM for Urinary Retention.
A review of the medical record revealed there was no documented evidence of a care plan addressing incontinence care.
During an observation on 3/26/2025 at 11:00 AM, Resident #50 was in their bed watching television. Resident #50 stated sometimes they have to wait hours for their incontinence briefs to be changed.
During an interview on 3/28/2025 at 1:46 PM, Certified Nurse Assistant #5, the regularly assigned 7:00 AM-3:00 PM shift Certified Nursing Assistant for Resident #50, stated the resident was frequently incontinent of bowel and bladder. Certified Nurse Assistant #5 stated they check Resident #50 every two hours to make sure Resident #50 was not soiled. Certified Nurse Assistant #5 stated they documented the incontinence care in the electronic medical record every shift.
During an interview on 4/01/2025 at 11:14 AM, Registered Nurse Supervisor #1 stated Resident #50 was incontinent of bowel and bladder due to Paraplegia. Registered Nurse Supervisor #1 stated they were responsible for initiating the care plan for bowel and bladder incontinence but they forgot to initiate the care plan.
During an interview on 4/01/2025 at 12:18 PM, the Director of Nursing Services stated that residents who are incontinent of bowel and bladder, require a care plan for incontinence care. The care plan should be initiated upon admission and reviewed each quarter. The Director of Nursing Services stated the Registered Nurses were responsible for initiating the care plan.
10 NYCRR 415.11(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #3) of three residents reviewed for Accidents. Specifically, Resident #3 was assessed to require a mechanical lift with two staff members for transfer from one surface to another. On 3/26/2025, Certified Nursing Assistant #4 was observed transferring Resident #3 with a mechanical lift by themselves.
The finding is:
The facility's policy titled Mechanical Lifts, last reviewed on 10/2024, documented at least two nursing assistants are needed to safely move a resident with a mechanical lift.
Resident #3 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, and Type 1 Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 9, indicating the resident had moderate cognitive impairment. The Minimum Data Set indicated the resident was dependent on the assistance of two or more caregivers for transfers from a bed to a chair.
A Comprehensive Care Plan titled Activities of Daily Living, last revised on 11/26/2024, documented interventions that included transferring the resident with a standing lift with the assistance of two staff members.
During an observation on 3/26/2025 at 10:50 AM, Resident #3 was observed awake in bed while Certified Nursing Assistant #4 provided a bed bath and morning care. A mechanical lift (the standing lift) was observed in the room near the bed.
During a second observation on 3/26/2025 at 11:04 AM, Certified Nursing Assistant #4 was observed in the resident's room transferring Resident #3 from their bed to their wheelchair utilizing the mechanical lift by themselves.
During an interview on 3/26/2025 at 11:16 AM, Certified Nursing Assistant #4 stated they provided morning care before using the standing lift to transfer Resident #3 out of bed to the wheelchair. Certified Nursing Assistant #4 stated they regularly provide care to Resident #3 and do not need a second caregiver's assistance to transfer the resident from the bed to the wheelchair. Certified Nursing Assistant #4 stated they are comfortable using the lift to get the resident out of bed without a second person.
During an interview on 3/28/2025 at 10:17 AM, Registered Nurse Supervisor #1 stated there should always be, at a minimum, two staff members when a standing lift is being used. Certified Nursing Assistant #4 should have called for assistance when they used the standing lift.
During an interview on 3/31/2025 at 11:17 AM, the Director of Nursing Services stated that Certified Nursing Assistants should not be transferring a resident with a standing lift without the assistance of two staff members to prevent accidents.
10 NYCRR 415.12(h)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025,...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure the Physician documented in the resident's medical record that the irregularity identified by the Pharmacist had been reviewed and what action had been taken to address the recommendations. This was identified for one (Resident #64) of five residents reviewed for Unnecessary Medications. Specifically, the Physician disagreed with a recommendation provided by the Consultant Pharmacist on the Medication Regimen Review form for Resident #64 and did not document the rationale for the disagreement.
The finding is:
The facility's policy, titled Medication Regimen Review, last reviewed on 10/2024, documented the facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The medical director will review all medication regimen recommendations and will address and document if indicated.
Resident #64 had diagnoses including Left Leg Below Knee Amputation, Type 2 Diabetes Mellitus, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 6, which indicated the resident had severe cognitive impairment.
A Comprehensive Care Plan titled Cardiovascular dated 12/03/2024, documented interventions that included administering medications as ordered. Monitor for effectiveness and adverse effects.
The Physician's Order dated 12/3/2024 documented Metoprolol Tartrate (beta-blocker medication that affects the heart and circulation) 50 milligrams, 1 tablet, twice a day by oral route for Hypertension.
The Drug Regimen Review dated 1/14/2025 documented that the resident was currently receiving Metoprolol Tartrate 50 milligrams twice daily. The Consultant Pharmacist recommended to consider switching to Metoprolol Succinate, which offers once daily dosing and reduces administration time requirements. Consider 100 milligrams once daily as a starting dose, follow up blood pressure daily for three days then weekly thereafter, and adjust dosing as necessary. The Physician checked the Disagree box and the reason for the disagreement was not documented. The Medication Regimen Review form was signed by the physician on 1/20/2025.
During an interview on 3/31/2025 at 2:27 PM, the Medical Director, who was also the resident's Primary Physician, stated the resident had stable blood pressure and therefore disagreed with the Pharmacist's recommendation of changing the resident's current medication. The Medical Director stated there was no documentation in the resident's medical record or on the Drug Regimen Review form with a rationale as to why they disagreed with the Pharmacist's recommendation made on 1/14/2025 and there should have been.
10 NYCRR 415.18(c)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure food was stored in accordance with ...
Read full inspector narrative →
Based on observation, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, the ham sandwich temperatures were not maintained at a safe temperature of 41 degrees Fahrenheit (F) or below.
The finding is:
The facility policy titled Food Preparation, Service and Distribution, revised on 10/2024 documented that the facility will ensure safe and sanitary food preparation, holding, transport, and distribution to prevent food-borne illness. The facility will avoid the following potential risks to reduce food-borne illness: will not hold foods in the danger zone (temperatures above 41 degrees and less than 135 degrees Fahrenheit).
During an observation of the Kitchen tray line service on 3/28/2025 at 12:13 PM, multiple ham sandwiches were stored in a hotel pan. The Food Service Director conducted random temperature checks of ham sandwiches and the temperature measured at 68 degrees Fahrenheit.
During an interview on 3/28/2025 at 12:15 PM, the Food Service Director stated that cold food items should be held at a temperature of 40 degrees Fahrenheit or below. The Food Service Director further stated there is a potential for foodborne illness when food is served outside of the appropriate temperature zone.
During an interview on 3/28/2025 at 1:17 PM, the Administrator stated cold food should be kept at a temperature of 41 degrees Fahrenheit or below to prevent food-borne illness.
10 NYCRR 415.14(h)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure call systems were accessible to ea...
Read full inspector narrative →
Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure call systems were accessible to each resident while residents were in their rooms. This was identified for one (Resident #274) of one resident reviewed for call systems. Specifically, Resident #274 was observed in bed on 3/26/2025 at 9:36 AM and again on 3/26/2025 at 11:20 AM with no call bell within reach.
The finding is:
The facility's policy and procedure titled Call Bells, reviewed in 9/2024, documented to ensure accessibility and timely response to the activated call bells. Call bells are to be attached near the resident's bed appropriately and be within reach at all times.
Resident #274 was admitted with diagnoses including Cardiac Arrest, Gout, and Major Depressive Disorder. The Minimum Data Set was not completed as the resident was recently admitted to the facility. The Brief Interview for Mental Status completed upon admission dated 3/26/2025 documented a score of 15, indicating the resident was cognitively intact.
A Physical Therapy Evaluation dated 3/26/2025 documented that Resident #274 was totally dependent on two staff members for bed mobility and transfers.
A Baseline Care Plan titled Potential for Falls dated 3/25/2025 documented interventions that included keeping the call bell within reach or accessible while (the resident) was in the room.
During an observation on 3/26/2025 at 9:36 AM, Resident #274 was alone in their room, in bed. There was no call bell observed within reach of the resident.
During an interview on 3/26/2025 at 9:36 AM, Resident #274 stated they did not have a call bell and did not know why they were never given a call bell.
During an observation on 3/26/2025 at 11:20 AM, Resident #274 was awake in bed, alone in their room, with no call bell.
During an interview on 3/26/2025 at 11:35 AM, the assigned Certified Nursing Assistant #1 stated Resident #274's call bell was placed by their roommate's bed in error. Certified Nursing Assistant #1 then pulled back the privacy curtain of the resident's roommate area and located two call bells attached to the roommate's bedding. Certified Nursing Assistant #1 stated they should have checked that Resident #274 had their call bell within reach.
During an interview on 3/28/2025 at 10:13 AM, Registered Nurse Supervisor #1 stated a call bell should be within reach of the resident while in their room. All staff members on the unit are responsible for making sure each resident's call bell is within reach.
During an interview on 3/31/2025 at 11:26 AM, the Director of Nursing Services stated the call bell should be placed within reach and accessible to the residents while they are in their rooms.
10 NYCRR 415.29
Nov 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 11/08/2023 and completed on ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 11/08/2023 and completed on 11/14/2023, the facility did not ensure that a Comprehensive person-centered care plan was developed and implemented for each resident. This was identified for two (Resident #18, and Resident # 69) of two residents reviewed for Respiratory care. Specifically, 1) Resident #18 had Physician's order to receive 2 liters (L) of Oxygen (O2) per minute (min). On 11/08/2023 and 11/10/2023, Resident # 18 was observed receiving Oxygen at a flow rate of 6 liters/per minute; and 2) Resident # 69 had Physician's orders to receive Oxygen at a flow rate of 3 L/min. On 11/08/2023 and 11/10/2023, Resident # 69 was observed receiving Oxygen at a flow rate of 6L/min.
The findings are:
:
The facility's oxygen policy and procedure, last revised 6/2023, documented: 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. The policy did not include guidance for staff to follow the physician orders related to oxygen administration.
1) Resident #18 was admitted with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Presence of cardiac pacemaker, and Congestive Heart Failure. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #18 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderately impaired cognition. Resident #18 did not have any behavior concerns. Resident #18 required total assistance of two persons for both transfers and bed mobility; and was non-ambulatory. The MDS indicated Resident #18 was on Oxygen therapy and did not have any Dyspnea (difficult or labored breathing).
The monthly physician's orders, originally dated 3/14/2023 and last dated 11/1/2023, documented to administer Oxygen continuously at 2 liters per minute via a Nasal Cannula (tubing used to provide external oxygen through the nose) to maintain an Oxygen saturation rate greater than (>) 92 percent (%).
The Comprehensive Care Plan (CCP) for Oxygen therapy, dated 4/26/2023 documented interventions including but not limited to: provide supplemental oxygen per Physicians (MD) order; monitor skin integrity for signs of breakdown related to use of oxygen tubing or mask; monitor for signs and symptoms of respiratory distress; and report to the Registered Nurse (RN) or the MD.
Resident #18 was observed on 11/08/2023 at 11:26 AM in bed in their room receiving Oxygen via a concentrator and a Nasal Cannula (N/C) at 6 L/min.
Resident #18 was observed on 11/10/2023 at 10:45 AM in bed in their room receiving Oxygen via a concentrator and a Nasal Cannula (N/C) at 6 L/min.
The observation on 11/10/2023 at 10:45 AM was immediately brought to Licensed Practical Nurse (LPN) # 1's attention. LPN #1 stated Oxygen should not be given at this rate and further stated they were not aware the resident was being given Oxygen at 6L/min. LPN # 1 adjusted Resident # 18's Oxygen flow rate to 2L/min.
Certified Nurse Assistant (CNA) #1, who was assigned to Resident # 18 during the day shift (7 AM - 3PM) was interviewed on 11/14/2023 at 12:11 PM. CNA #1 stated they do not adjust the residents Oxygen.
2) Resident #69 was admitted with diagnoses that include Acute and Chronic Respiratory Failure with Hypoxia, Atherosclerotic Heart Disease and Unspecified Asthma. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #69 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #69 did not have any behavior concerns. Resident # 69 required total assistance of two persons for bed mobility and was non-ambulatory. The MDS indicated Resident #69 was on Oxygen therapy and did not have any Dyspnea (difficult or labored breathing).
The monthly physician orders dated 10-13-2023 to 11-13-2023 documented to administer Oxygen continuously at 3 LPM via nasal cannula.
The Comprehensive Care Plan (CCP) for at risk for Respiratory distress related to Acute Respiratory failure with Hypoxia, and Chronic Obstructive Pulmonary Disease (COPD), dated 9/15/2023 included interventions to provide supplemental oxygen per MD order.
Resident #69 was observed on 11/08/2023 at 11:26 AM in bed in their room receiving Oxygen via a concentrator and a Nasal Cannula (N/C) at 6 L/min.
Resident #69 was observed on 11/10/2023 at 10:30 AM in bed in their room with Oxygen being administered at 6 L/min via a concentrator and a N/C.
The observation on 11/10/2023 at 10:30 AM was immediately brought to Licensed Practical Nurse (LPN) # 1's attention. LPN #1 stated Oxygen should not be given at this rate and further stated they were not aware the resident was being given Oxygen at 6L/min. LPN #1 adjusted Resident # 69's Oxygen flow rate to 2L/min.
Certified Nursing Assistant (CNA) #2, who was assigned to Resident # 69, was interviewed on 11/14/2023 at 12:11 PM and stated they do not adjust the residents Oxygen.
The Director of Nursing Services (DNS) was interviewed on 11/10/2023 at 11 AM regarding the observations made for Resident # 18 and Resident # 69. The DNS stated the residents should be given the prescribed Oxygen levels and should not be given anything above the prescribed Oxygen level without a physician order.
The Medical Director was interviewed on 11/14/2023 at 1:00 PM and stated they (the Medical Director) were not aware that the residents were not receiving oxygen as per their physician's order. The Medical Director further stated the residents should receive the prescribed oxygen as ordered.
NYCRR 415.11(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Recertification Survey initiated on 11/08/2023 and...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Recertification Survey initiated on 11/08/2023 and completed on 11/14/2023, the facility did not ensure that each resident's medical record was maintained in accordance with accepted professional standards and practices. The facility did not maintain medical records for each resident that were complete and accurately documented. This was identified for one (Resident #51) of five residents reviewed for unnecessary medications. Specifically, during an observation of Resident #51 on 11/09/2023 at 4:17 PM, Resident #51 was observed with redness to the inner corner of their left eye. During a second observation on 11/10/2023 at 3:15 PM Resident #51's left eye inner corner remained red. During a third observation of Resident #51 on 11/13/2023 at 1:52 PM the left eye was completely reddened. There was no documented evidence in the resident's medical record indicating the resident's left eye status.
The finding is:
The facility's policy titled, Electronic Medical Records dated 11/2017 and last revised on 6/2023 documented, the official medical record includes but is not limited to daily shift report, therapy screens, consults, comprehensive care plans, lab results, labs/radiology, progress notes, and MD [Physician] orders.
Resident #51 was admitted with diagnoses including Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident was unable to complete a Brief Interview for Mental Status (BIMS) because the resident was rarely/never understood. The MDS documented Resident #51 had short and long-term memory problems. The MDS documented Resident #51 had moderately impaired cognitive skills for daily decision making.
Resident #51 was observed sitting in their wheelchair in their room on 11/09/2023 at 4:17 PM. Resident #51 was observed with a red discoloration to the inner portion of their left sclera (white portion of the eye). Resident #51 reported no pain or discomfort to the eye. Resident #51 reported that they dried their face with a towel and the corner of the towel went into their eye.
On 11/10/2023 at 3:15 PM Resident #51 was observed sitting in their wheelchair in the hallway outside of their room and the discoloration was present in the same area of their left sclera. Resident #51 reported no pain or discomfort.
On 11/13/2023 at 1:52 PM Resident #51 was observed sitting in their wheelchair opposite the nurse's station. The sclera of Resident #51's left eye was completely reddened. Resident #51 reported no pain or discomfort and stated someone took care of it this morning.
Resident #51's progress notes dated 11/08/2023 through 2:00 PM on 11/13/2023 were reviewed and there was no documentation pertaining to the redness in Resident #51's left eye.
Licensed Practical Nurse (LPN) #2, medication nurse, was interviewed on 11/13/2023 at 2:05 PM. LPN #2 stated they observed the redness to Resident #51's left eye on 11/09/2023 sometime in the afternoon. LPN #2 stated Resident #51 reported they rubbed their eye. LPN #2 stated they observed the increased redness to Resident #51's left eye on 11/13/2023 in the morning. LPN #2 stated Resident #51 did not complain of pain, and they (LPN #2) planned to call Resident #51's physician. LPN #2 stated they would not document the occurrence because Resident #51 was able to report why their (Resident #51's) eye was red.
The Medical Director was interviewed on 11/13/2023 at 3:16 PM and stated they were in the facility on 11/10/2023 between the hours of 8:30 AM and 11:30 AM. The Medical Director stated they came in to check on all of the residents. The Medical Director stated they observed the reddened area to Resident #51's left eye. The Medical Director stated they did not document the discoloration in Resident #51's medical record and should have written a progress note in the electronic medical record
LPN #3 was interviewed on 11/13/2023 at 3:27 PM. LPN #3 stated they observed Resident #51 with a reddened left eye on the 3 PM-11 PM shift on 11/09/2023 and documented their (LPN #3) observation on the daily report. LPN #3 stated they do not have time to complete resident medications, resident treatments, and documentation so they document concerns on the daily report. LPN #3 stated they provide the daily report to the Registered Nurse Supervisor on the shift.
The Director of Nursing Services (DNS) was interviewed on 11/14/2023 at 9:18 AM and stated the concern regarding Resident #51's reddened left eye was documented in the 3 PM-11 PM shift report on 11/09/2023. The DNS stated the expectation is that concerns will be documented in the progress note section of the resident's electronic medical record.
10 NYCRR 415.22(a)(1-4)
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Abbreviated Survey initiated on 3/7/2023 and completed on 7/18/2023 the f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Abbreviated Survey initiated on 3/7/2023 and completed on 7/18/2023 the facility did not ensure for influenza vaccine that each resident's medical record indicated either the resident received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. This was identified for two (Resident #1 and Resident #4) of four residents reviewed for influenza vaccine.
The findings are:
The facility's policy titled Influenza Vaccination: Residents revised May 2022 documented to obtain written order from attending physician; to obtain informed consent from resident or their responsible party and provide educational literature; this should be included on admission and annually. Consent may be obtained in writing or verbally and to document vaccination in the Medication Administration Record and in nurse notes.
1) Resident #1 was admitted to the facility on [DATE] with diagnoses including Essential Hypertension (HTN), Alzheimer's Disease and 2019-CoV Acute Respiratory Disease. The Quarterly Minimum Data Set (MDS-an assessment tool) dated 1/9/2023 documented the resident with Brief Interview for Mental Status score of 4 indicating severely impaired cognition. The MDS Assessment documented that the resident had received the influenza vaccine in the facility for this year's (2022-2023) vaccination season with date of influenza vaccine received on 11/1/2021.
The Immunization Comprehensive Care Plan (CCP) dated 7/22/2020 documented the resident is at increased risk for contracting influenza infection during flu season secondary to residing in a skilled nursing facility (SNF). Interventions included administer Influenza vaccine per policy, document vaccination per policy in resident record and educate resident/family regarding the benefits and side effects of taking the flu vaccine.
The New York State Department of Health Bureau of Immunization form titled Influenza/Pneumococcal Immunization Consent Form was reviewed and the form documented Resident #1's personal information. Ten screening questions were completed with all responses checked off as No. Under the Influenza Consent section, it was documented that the resident was not able to sign and the NOK's name and phone number were written. The form was undated. There was no documented evidence that NOK consented or declined the influenza vaccine.
The Physician's orders (PO) were reviewed from 9/1/2022 to 3/7/2023 and there was no documented evidence to administer the influenza vaccine.
Resident #1's Preventive Health Care Report was reviewed. There was no documented evidence that the resident received any vaccine including an Influenza vaccine since November 2021.
Resident #1 was observed on 3/7/2023 at 12:25 PM. Resident #1 was, unable to answer questions related to their (resident #1) vaccination status.
The Director of Nursing Services (DNS)/ Infection Preventionist (IP) was interviewed on 3/9/2023 at 12:53 PM stated that they (DNS) have been working in the facility for less than one month. The DNS/IP was unaware of how and what the influenza and COVID-19 vaccine programs and protocols were in the fall of 2022. The DNS/IP stated that the current facility policy on Influenza vaccination does not indicate who is responsible to obtain informed consent each year from resident/representative regarding Influenza vaccine. The DNS/IP reviewed the residents medical record and stated that resident #1 did not have a contraindication to receive the influenza vaccine and that the resident's consent form on file was incomplete. The DNS/IP stated that there was no written documentation whether the resident/representative were educated, accepted, or refused the Influenza vaccine in 2022. The DNS/IP stated that there was no documented evidence that the Influenza vaccine was administered.
The Former Assistant Director of Nursing Service (ADNS)/ Infection Preventionist (IP) was interviewed on 4/5/2023 at 11:23 AM. The ADNS stated that they were certified as infection Preventionist but were not responsible for the roll out and tracking of influenza/COVID vaccine program in the fall of 2022 and they left in October 2022. The ADNS stated that the Administrator and corporal personnel have been responsible to keep track and monitor for the influenza/covid vaccine campaign. The ADNS stated that every resident should be offered the flu vaccine in the fall, and consent should be obtained, documented, and kept on file. The ADNS stated that the tracking was done by Administration.
The Administrator was interviewed on 7/18/2023 at 12:37 PM. The Administrator stated that they (the Administrator) have been working in the facility 6 months ago and was not involved in the flu/pneumococcal campaign in the fall of 2022. The Administrator stated that they were not aware of how the annual flu campaign was run before they started. The Administrator stated that constant effort must be provided and documented to ensure all residents were offered opportunities to be vaccinated for flu during the flu season.
2.) Resident #4 was admitted to the facility on [DATE] with diagnoses including 2019-nCoV Acute Respiratory Disease, Sepsis and Urinary Tract Infection. The Quarterly Minimum Data Set (MDS-an assessment tool) dated 12/7/2022 documented the resident with Brief Interview for Mental Status score of 10 indicating moderately impaired cognition. The MDS assessment documented that the resident was offered and declined the influenza vaccine in the facility for this year's (2022-2023) vaccination season.
Resident #4's Face Sheet documented a family member of the resident as emergency contact and Healthcare Agent.
The Immunization Comprehensive Care Plan (CCP) dated 10/31/2021 documented the resident is at increased risk for contracting influenza infection during flu season secondary to residing in a skilled nursing facility (SNF). Interventions included administer Influenza vaccine per policy, document vaccination per policy in resident record and educate resident/family regarding the benefits and side effects of taking the influenza vaccine.
The New York State Department of Health Bureau of Immunization form titled Influenza/Pneumococcal Immunization Consent Form was reviewed, and the form documented resident #4's personal information. Ten screening questions were completed with all responses checked off as No. Under the Influenza Consent section, it was documented that the resident was not able to sign and the Healthcare Agent's name and phone number were written. The form was undated. There is no documented evidence that resident #4's Healthcare Agent consented or declined the influenza vaccine.
The Physician's orders (PO) were reviewed from 9/1/2022 to 3/7/2023 and no order for influenza vaccine was found.
Resident #4's Preventive Health Care Report was reviewed. There was no documented evidence that the resident received an influenza vaccine since November 2021.
The Director of Nursing Services (DNS)/ Infection Preventionist (IP) was interviewed on 3/9/2023 at 12:53 PM stated that Resident #4 was not contraindicated to receive the influenza vaccine. The DNS stated that the resident's consent form on file was incomplete and not valid. The DNS stated that there was no written documentation whether the resident/representative were educated, accepted, or refused the flu vaccine in 2022. The DNS stated that there was no documentation that the flu vaccine was administered. The DNS stated that an informed consent can be obtained now, and the flu vaccine can still be administered to the resident.
The Former Assistant Director of Nursing Service (ADNS)/ Infection Preventionist (IP) was interviewed on 4/5/2023 at 11:23 AM. The ADNS stated that they were certified as infection Preventionist but were not responsible for the roll out and tracking of influenza/COVID vaccine program in the fall of 2022 and they left the facility in October 2022. The ADNS stated that the Administrator and corporal personnel have been responsible to keep track and monitor for the influenza/covid vaccine campaign. The ADNS stated that every resident should be offered the Influenza vaccine in the fall, and consent should be obtained, documented, and kept on file. The ADNS stated that the tracking was done by Administration.
The Administrator was interviewed on 7/18/2023 at 12:37 PM. The Administrator stated that they (the Administrator) were not involved in the flu/pneumococcal campaign in the fall of 2022. The Administrator stated that they were not aware of how the annual flu campaign was run before they started. The Administrator stated that constant effort must be provided and documented to ensure all residents were offered opportunities to be vaccinated for flu during the flu season.
10 NYCRR 415.19(a)(3)
Jan 2023
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY00307797) the facility failed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY00307797) the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. This was evident for one (Resident #1) of 7 residents reviewed for sexual abuse. Specifically, on 12/10/2022 Resident #1 reported to their family that Licensed Practical Nurse (LPN) #1 on 12/9/2022 asked them to perform oral sex and then proceeded to touch their breast and vaginal area. The resident's family reported the incident to the Administrator on 12/10/2022. LPN #1 continued to work in the facility and had access to the resident on 12/11/2022. As of 1/6/2023 the facility did not report the allegation to the Department of Health and the law enforcement. This resulted in potential harm to Resident #1 and all other residents in the facility, that is Immediate Jeopardy and Substandard Quality of Care.
The finding is:
The facility's policy titled Abuse revised 5/2022 documented it is the policy of the facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. When any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed, reported or suspected by any employee ensure the resident is no longer being provided care and does not have any contact with the accused employee. The Administrator, Director of Nursing or their designee assumes responsibility for notification of the incident.
The policy revealed no documented evidence that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the event that caused the allegation involve abuse or result in serious bodily injury, to the administrator and to other officials, other officials including to the State Survey Agency and Law enforcement.
Resident #1 was admitted with diagnoses including Traumatic Brain Injury, Encephalopathy (disease of the brain), Mental and behavioral disorders and Opioid Abuse. The Minimum Data Set (MDS assessment tool) dated 10/19/2022 documented the resident with Brief Interview for Mental Status score of 9 indicating moderately impaired cognition.
Review of the progress notes dated 12/10/2022 to 1/6/2023 revealed no documented evidence of a resident assessment or investigation related to the 12/9/2022 or 12/10/2022 sexual abuse allegation.
Review of the care plans revealed no documented evidence that the resident was care planned for abuse as victim. The care plan was updated on 12/18/2022 and included risk for abuse. The care plan notes revealed no documented evidence it was updated related to 12/9/2022 or 12/10/2022 sexual abuse allegation.
A review of staffing sheets dated 12/8/2022 and 12/10/2022 documented LPN #1 was scheduled during 7:00 AM-3:00 PM shift as Unit Manager for the 1st and 2nd floor. LPN #1 was not scheduled to work on 12/9/2022.
During an interview with Resident #1 on 1/4/2023 at 12:38 PM they stated they were touched by a staff member identified as LPN #1. Resident #1 stated they could not recall the date, but it was dark, and it happened in their room. Resident #1 stated, LPN #1 went under my clothes and touched my breast and tried to make me suck their dick. Resident #1 further stated they told LPN #1 they were going to call the Police and LPN #1 stopped and left the room. Resident #1 stated they told their family member #1 the next day. Resident #1 was unsure of the date and time of the incident.
During a telephone interview on 1/4/2023 at 2:23 PM with Resident #1's family member #1 they stated that Resident #1 reported to them on 12/10/2022 during a home visit that on 12/9/2022 LPN #1 touched their breast and vaginal area and asked them to perform oral sex. Family member #1 stated they reported the incident to the Administrator on 12/10/2022 at approximately 9-10 PM. They stated that the Administrator stated they will conduct an investigation and LPN #1 will be suspended. The family member #1 stated that the Administrator stated they will not report the incident to the Department of Health (DOH) because there was no proof. The family member #1 stated they saw LPN #1 on 12/11/2022 working in the facility The family member stated they brought Resident #1 to the Police station on 12/19/2022 to report the incident. The facility did not report the incident to the police because there was no police report. The family member stated that a care plan meeting was held on 12/29/2022 with the facility and Ombudsman #1 regarding the incident and the Administrator did not report the allegation citing there was no proof.
During an interview with the Administrator on 1/4/2023 at 3:39 PM they stated that on 12/10/2022 they received a call at approximately 8:00 PM from the family of Resident #1. The family reported an allegation that an unnamed staff inappropriately touched Resident #1. The family identified the staff as LPN #1 because they wheeled Resident #1 down to the lobby to go out on pass on 12/10/2022. The Administrator stated they contacted the Director of Nursing (DON) on 12/10/2022 and informed them of the allegation. The Administrator stated they reviewed the video surveillance on their cellphone on 12/10/2022 and based on video there was no sexual contact, or any inappropriate touching or physical contact. The Administrator stated the allegation was not reported to DOH or the police because they had no finding that abuse occurred. The Administrator stated they report incidents if there is an allegation of abuse and if abuse occurred.
During an interview with the DON on 1/4/2023 at 4:21 PM they stated they were not aware of any allegation of abuse involving Resident #1 and LPN #1 on 12/9/2022 or 12/10/2022. The DON stated they received a call from the administrator on 12/10/2022 and was instructed to move to Resident#1 to the 1st floor because of infection control concerns. The DON stated they first learned about the allegation during a meeting with Ombudsman #1 on 12/29/2022. The DON stated they did not do an investigation or report the allegation to the police. The DON was not aware of the facility's policy on abuse reporting and stated they have to read the policy.
During an interview with the Director of SW (DSW) on 1/6/2023 at 10:08 AM they stated that the Police came to the facility on [DATE] and informed them that Resident #1's family filed a report regarding inappropriate sexual contact with a staff member. The DSW was told by the Administrator that the allegation was unfounded.
During an interview with the Ombudsman #1 on 1/5/2023 at 11:33 AM they stated they were made aware of the allegation of inappropriate sexual contact between LPN #1 and Resident#1 on 12/22/2022 by the family member who called their program. The Ombudsman #1 stated they went to the facility on [DATE] and spoke with the Administrator about the allegation on 12/9/2022 and they stated that they did not report it to the DOH because the resident could not tell them what happened, and they had no proof. The Administrator stated they checked the video and did not find any proof. The Ombudsman #1 spoke to the resident on 12/22/2022 and resident reported that LPN #1, mentioning them by their name, touched them in their breast and over their vaginal area with their finger in a thrusting manner. Resident #1 did not say they were penetrated but was pointing to their vaginal area.
During a subsequent interview with the DON on 1/5/2023 at 12:27 PM they stated that LPN #1 was scheduled to be off on 12/9/22 and did not come to the facility for any other reasons on that date. They stated LPN #1 last worked on 12/11/2022 on the 7-3 shift. On 12/12/2022 LPN #1 filed a leave of absence and is out sick.
During a telephone interview with LPN #1 on 1/6/2023 at 11:07 AM they stated they worked on 12/11/22 on the 2nd floor. LPN #1 stated they are on leave of absence. LPN #1 stated they were not aware of any sexual allegation involving them. LPN #1 stated they have not been interviewed or asked to write a statement. LPN #1 stated they did not touch Resident #1 on their breast or vaginal area. LPN #1 stated they did not show Resident #1 their private area and did not ask Resident #1 to perform oral sex. LPN #1 was not aware of any allegation against them and was not restricted to go to the first floor. LPN #1 stated they last worked on 12/11/22 and they were off on 12/9/22.
10 NYCRR 415.4 b (2)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Investigate Abuse
(Tag F0610)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY00307797) the facility failed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY00307797) the facility failed to ensure that all allegations of abuse, neglect and mistreatment were thoroughly investigated. In addition, the facility failed to ensure the residents were free from further potential abuse. This was evident for one (Resident #1) of 7 residents reviewed for Sexual Abuse. Specifically, on 12/10/2022 Resident #1 reported to their family that Licensed Practical Nurse (LPN)#I on 12/9/2022 asked them to perform oral sex and then proceeded to touch their breast and vaginal area. The resident's family reported the incident to the Administrator on 12/10/2022. LPN #I continued to work in the facility and had access to the resident on 12/11/2022. As of 1/6/2023 the facility did not initiate an investigation. This resulted in potential abuse and harm to Resident #1 other residents that is Immediate Jeopardy and Substandard Quality of Care.
The finding is:
The facility's policy titled Abuse revised 5/2022 documented it is the policy of the facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. When any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed, reported or suspected by any employee ensure the resident is no longer being provided care and does not have any contact with the accused employee. Notify administrative staff or nursing supervisor on duty. Suspend or reassign the employee pending investigation.
Resident #1 was admitted to the facility with diagnoses including Traumatic Brain Injury, Encephalopathy (disease of the brain), Mental and behavioral disorders and Opioid Abuse. The admission Minimum Data Set (MDS-an assessment tool) dated 10/19/2022 documented the resident with Brief Interview for Mental Status score of 9 indicating moderately impaired cognition.
The Comprehensive Care Plan dated 10/13/2022 documented the resident has potential for impaired cognition. Interventions included monitor for cognitive changes or regression and report to the nurse and reorient as needed. The notes dated 10/13/022 documented the resident is able to make basic needs known.
Review of Accident/Incident (A/I) reports and Grievances for December 2022 revealed no documented evidence of an investigation related to allegation on 12/9/2022 or 12/10/2022.
Review of the progress notes dated 12/10/2022 to 1/6/2023 revealed no documented evidence of a resident assessment or investigation related to the 12/9/2022 or 12/10/2022 sexual abuse allegation.
A review of staffing sheets dated 12/8/2022 and 12/10/2022 documented LPN #1 was scheduled during 7:00 AM-3:00 PM shift as Unit Manager for the 1st and 2nd floor. LPN #1 was not scheduled to work on 12/9/2022.
Review of the progress notes dated 12/11/2022 at 2:44 AM documented the resident was transferred to 1st floor.
A review of staffing sheets revealed LPN #1 was scheduled to work on 12/11/2022 during 7:00 AM-3:00 PM shift for the 1st and 2nd floor.
Review of the care plans revealed no documented evidence that the resident was care planned for abuse as victim. The care plan was updated on 12/18/2022 and included risk for abuse. The care plan notes revealed no documented evidence it was updated related to 12/9/2022 or 12/10/2022 sexual abuse allegation.
During an interview with Resident #1 on 1/4/2023 at 12:38 PM they stated they were touched by a staff member identified as LPN #1. Resident #1 stated they could not recall the date, but it was dark, and it happened in their room. Resident #1 stated, LPN #1 went under my clothes and touched my breast and tried to make me suck their dick. Resident #1 further stated they told LPN #1 they were going to call the Police and LPN #1 stopped and left the room. Resident #1 stated they told their family member #1 the next day. Resident #1 was unsure of the date and time of the incident. Resident #1 stated they did not want this to happen again and stated they don't feel safe.
During a telephone interview on 1/4/2023 at 2:23 PM with Resident #1's family member #1 they stated that Resident #1 reported to them on 12/10/2022 during a home visit that on 12/9/2022 LPN #1 touched their breast and vaginal area and asked them to perform oral sex. Family member #1 stated they reported the incident to the Administrator on 12/10/2022 at approximately 9:00 PM-10:00 PM. They stated that the Administrator stated they will conduct an investigation and LPN #1 will be suspended. The family member #1 stated that the Administrator stated they will not report the incident to the Department of Health (DOH) because there was no proof. The family member #1 stated they saw LPN #1 on 12/11/2022 working in the facility They stated they brought Resident #1 to the Police station on 12/19/2022 to report the incident. The facility did not report the incident to the police because there was no police report. The family member #1 stated that a care plan meeting was held on 12/29/2022 with the facility and Ombudsman #1 regarding the incident and the Administrator did not report the allegation citing there was no proof.
During an interview with the Administrator on 1/4/23 at 3:39 they stated that on 12/10/2022 they received a call at approximately 8:00 PM from the family of Resident#1. The family reported an allegation that an unnamed staff inappropriately touched Resident #1. The family identified the staff as LPN #1 because they wheeled Resident#1 down to the lobby to go out on pass on 12/10/2022. The Administrator stated they contacted the Director of Nursing (DON) on 12/10/2022 and informed them of the allegation. The Administrator stated they reviewed the video surveillance on their cellphone on 12/10/2022 and based on video there was no sexual, or any inappropriate touching or physical contact. The Administrator stated the allegation was not reported to DOH or the police because they had no finding that abuse occurred. The Administrator stated they report incidents if there is an allegation of abuse and if abuse occurred.
During an interview with the DON on 1/4/2023 at 4:21 PM they stated they were not aware of any allegation of abuse involving Resident #1 and LPN #1 on 12/9/2022 or 12/10/2022. The DON stated they received a call from the administrator on 12/10/2022 and was instructed to move to Resident#1 to the 1st floor because of infection control concerns. The DON stated they first learned about the allegation during a meeting with Ombudsman #1 on 12/29/2022. The DON stated they did not do an investigation or report the allegation to the police. The DON was not aware of the facility's policy on abuse reporting and stated they have to read the policy.
During an interview with the Director of SW (DSW) on 1/6/2023 at 10:08 AM they stated that Police came to the facility on [DATE] and informed them that Resident #1's family filed a report regarding inappropriate sexual contact with a staff member. The DSW stated they immediately informed the administrator and they spoke to the Police. DSW stated they spoke to Resident #1 and the resident did not say much regarding the allegation. DSW did not document their interview with the resident or the Police inquiring about an allegation. DSW was told by the Administrator that the allegation was unfounded.
During an interview with the Ombudsman #1 on 1/5/2023 at 11:33 AM they stated they were made aware of the allegation of inappropriate sexual contact between LPN #1 and Resident#1 on 12/22/2022 by the family member who called their program. The Ombudsman #1 stated they went to the facility on [DATE] and spoke with the Administrator about the allegation on 12/9/2022 and they stated that they did not report it to the DOH because the resident could not tell them what happened, and they had no proof. The Administrator stated they checked the video and did not find any proof. The Ombudsman #1 spoke to the resident on 12/22/2022 and resident reported that LPN #1, mentioning them by their name, touched them in their breast and over their vaginal area with their finger in a thrusting manner. Resident #1 did not say they were penetrated but was pointing to their vaginal area.
The video surveillance was reviewed on 1/5/2023 at 12:55 PM and on 1/6/2022 at 10:45 AM with the Administrator and the Staffing Coordinator. Review of 1st floor video on 12/11/2022 at 12:38 PM revealed Resident #1 was taken out of the room by RNS #1. On 12/11/2022 hallway camera revealed LPN #1 punched in at 7:00:14 AM and took the elevator and was observed sitting at the 2nd floor nursing station. The LPN #1 was then observed going in and out of residents' rooms.
During an interview with the Administrator on 1/5/2023 at 1:58 PM they stated there is no investigation being conducted at this time. The Administrator stated they had no findings that the allegation actually happened to support suspending LPN #1. They moved Resident #1 from the 2nd floor to the 1st floor because of the allegation. The Administrator denied speaking to the police on 12/21/2022 and was not informed that there was an allegation involving LPN #1.
During interviews conducted between 1/5/2023 at 2:30 PM to 1/6/2023 at 5:16 PM with LPN #2, LPN #3, Certified CNA #1, RNS #1, CNA #2, RNS #2, CNA #4 and LPN #4, who all worked between 12/8/2022 to 12/11/2022 on various shift, stated that they were not aware of the allegation involving Resident #1 and LPN #1 and they were not questioned by the facility or asked to write a statement.
During an interview with the DON on 1/5/2023 at 2:59 PM they stated that there is no investigation conducted related to the allegation involving LPN #1 and Resident#1. The DON stated they initiated the investigation on 1/4/2022 and wrote down in the paper the interview conducted with Resident #1. Resident #1 stated a white, male staff, identifying LPN #1 by their name, pulled out their private area and asked Resident #1 perform oral sex. Resident #1 did not state a date, Resident #1 said it was light outside not dark when LPN #1 went in the room. The DON stated the resident denied any physical contact. The DON stated no other staff were interviewed at this time. The DON stated they were not aware that Police came to the facility and reported a family member filed a report of the allegation against LPN #1.
During a subsequent interview conducted with the Administrator on 1/6/2023 at 10:00 AM they stated that they did not interview other staff because based on video there was no evidence of inappropriate sexual contact. The administrator stated they were not aware of the facility's policy on abuse reporting and investigation.
During a telephone interview with LPN #1 on 1/6/2023 at 11:07 AM stated they worked on 12/11/22 on the 2nd floor and were assigned to Resident #1. LPN #1 stated they last worked on 12/11/2022 and they were off on 12/9/22. LPN #1 stated they brought Resident #1 sandwiches like anyone else and encouraged resident to use their left hand more. LPN #1 stated they are on leave of absence. LPN #1 stated they are not aware of any sexual allegation involving them. LPN #1 stated they have not been interviewed or asked to write a statement. LPN #1 stated they did not touch Resident #1 on their breast or vaginal area. LPN #1 stated they did not show Resident #1 their private area and did not ask Resident #1 to perform oral sex. LPN #1 was not aware of any allegation against them and was not restricted from going to the first floor.
During an interview with ADON on 1/10/2023 at 2:41 PM they stated that all allegations of abuse are handled by DON. ADON stated the DON informed them sometime in mid-December that Resident #1 was touched inappropriately by a staff, but DON did not know which staff. ADON stated they assumed the DON and Administrator was handling the investigation. ADON stated the allegation was not discussed in the morning report.
10 NYCRR 415.4 b (3)
Dec 2022
1 deficiency
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on record review and staff interviews during the Focus Infection Control Survey on 12/20/2022, the facility did not ensure that it designated one or more individual(s) as the Infection Preventio...
Read full inspector narrative →
Based on record review and staff interviews during the Focus Infection Control Survey on 12/20/2022, the facility did not ensure that it designated one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's Infection Prevention Control Program (IPCP); and the IP must have completed specialized training in infection prevention and control. Specifically, the facility's designated IP did not have documented evidence of specialized training in infection prevention and control.
Finding is:
The facility's Infection Prevention and Control policy for the position of Infection Control Officer/Preventionist dated 1/2022 documented the Infection Prevention and Control Program (IPCP) is coordinated and overseen by an Infection Prevention Specialist (Infection Preventionist). The policy did not document specialized infection control training requirements for the IP.
The Director of Nursing Services (DNS) was interviewed on 12/20/2022 at 2:30 PM and stated that they (DNS) were assigned to the DNS and the IP position on 11/16/2022. The DNS stated they started taking the infection prevention and control courses in the second week of December 2022, and they still have to complete a lot of classes to receive the IP certification. The DNS stated that the facility's corporate nurse comes to the facility two times a week to help with infection control concerns.
The Administrator was interviewed on 12/20/2022 at 2:58 pm and stated that the facility does not have a full-time qualified IP in the building since November 16, 2022, when the previous IP left the facility. The Administrator stated until the DNS completes their (DNS) infection prevention control courses, the corporate IP will come to the facility twice a week to assist with the infection control concerns.
Licensed Practical Nurse (LPN) #3, who was the corporate nurse, was interviewed on 12/20/202 at 3:12 PM and stated they (LPN #3) visit the Facility twice a week to guide the new DNS; however, they (LPN #3) did not complete the infection prevention control course and were not officially qualified infection preventionist.
415.19 (a)
Oct 2021
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey completed on 10/12/2021, the facility did not ensure tha...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey completed on 10/12/2021, the facility did not ensure that all medication irregularities identified by the Licensed Pharmacist on the monthly Medication Regimen Review (MRR) were addressed by the Physician for one (Resident #33) of five residents reviewed for Unnecessary Medications. Specifically, a recommendation was made by the Pharmacist consultant on 10/5/2021 to change Resident #33's Synthroid (thyroid medication) medication administration time from 6 AM to 2 PM. The attending Physician agreed with the recommendation on 10/6/2021; however, a Physician's order was not written to reflect the recommended change.
The finding is:
The policy the facility provided titled, Regulation 756 stated that the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it.
Resident # 33 was admitted with diagnoses of Hypothyroidism, Acute Respiratory Failure with Hypoxia and Cerebral Palsy. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview. Resident # 33 was receiving Gastrostomy tube feeding as the primary source of nutrition.
The Comprehensive Care Plan (CCP) for Altered Health Maintenance dated 6/16/2021 documented that Resident #33 had potential impairment in metabolism related to Hypothyroidism. The interventions included to administer medications as per the Physician orders, to monitor for effectiveness and adverse effects of the medications; and to assess for nutrition and medication interactions.
The Physician's order dated 7/4/2021 documented to administer Levothyroxine (Synthroid) 125 micrograms (mcg), 1 capsule via gastric tube (a tube that is inserted through the abdomen that can deliver nutrition and medicines directly into the stomach) once a daily at 6 AM for Hypothyroidism.
The Physician's order dated 7/14/2021 documented enteral formula order for Jevity 1.5 - 1250 cubic centimeter (cc) total with a rate of 80 cc per hour for 16 hours (4 PM- 8 AM) or until total amount (1250) is achieved.
Resident #33's MRR was conducted by the Consultant Pharmacist on 10/5/2021. One of three recommendations documented: Please consider changing the administration time for the Synthroid (Levothyroxine) order to 2 PM. It was recommended that Synthroid be administered on an empty stomach half to one hour before breakfast or 4 hours apart from medications that can interfere with its absorption. The report has 2 options (Yes or No) that are to be checked by the Physician. The Physician agreed with the recommendation to change the administration time of the Synthroid (Levothyroxine) order from 6:00 AM to 2:00 PM on 10/6/2021.
A nursing note dated 10/6/2021 stated the Pharmacy recommendations were received; however, the change of administration time of Synthroid (Levothyroxine) from 6 AM to 2 PM was not documented.
Licensed Practical Nurse (LPN)# 3 was interviewed on 10/12/2021 at 12:30 PM and stated that they (LPN# 3) received Resident #33's MRR on 10/6/2021 from the Physician after the Physician reviewed and responded to the recommendations. LPN# 3 stated that they recalled there were three recommendations and medical treatment updates for Resident #33 based on the reviewed MRR on 10/6/2021. LPN# 3 stated that the Physician agreed to all three recommendations and new orders needed to be made in the electronic medical record by them (LPN# 3). LPN# 3 stated that the administration time change for Synthroid (Levothyroxine) from 6 AM to 2 PM was not written. LPN# 3 stated that the active Synthroid order was Synthroid 125 mcg 1 tablet via gastric tube once a day at 6 AM and it should be changed to once a day at 2 PM.
The attending Physician for Resident #33, who was the Director of Medicine, was interviewed on 10/12/2021 at 12:52 PM and stated the MRR dated 10/5/2021 was reviewed on 10/6/2021. The Physician stated that they (the Physician) agreed that the Synthroid (Levothyroxine) administration time should be changed to 2 PM. The Physician stated that the medication should be taken on an empty stomach as food can affect the absorption of Synthroid. The Physician stated that 2 PM was a more appropriate administration time for Synthroid (Levothyroxine) for Resident #33 due to Resident #33's enteral feeding that was scheduled from 4 PM to 8 AM the next day. The Physician further stated they (the Physician) personally gave LPN #3 the MRR with the agreement to the change the administration of Synthroid to 2 PM and expected that LPN#3 would have written the order.
The Director of Nursing Services (DNS) was interviewed on 10/12/2021 at 2:56 PM and stated the MRR should be promptly reviewed by the Physician and necessary changes should be accurately implemented in the electronic medical record as per the Physician's decision based on the Pharmacist's recommendations. The DNS stated that the Physician had reviewed the MRR and agreed with the MRR recommendation to change the Synthroid administration time to 2 PM however, the order was not implemented or documented.
415.18(c)(2)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview during the Recertification Survey and Complaint Survey NY00281499, the facili...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview during the Recertification Survey and Complaint Survey NY00281499, the facility did not ensure that all residents had a clean and homelike environment. This was identified from the Resident Council meeting conducted on 10/05/2021 and observations made in 15 of 40 rooms in the facility (#101, #102, #103, #109, #113, #119, #120, #203, #204, #205, #206, #212, #216, #217, and #218). Specifically, 1) residents from the resident council voiced concerns about dirty shower drains during four resident council meetings (5/19/2021, 7/6/2021, 8/3/2021, and 9/14/2021) and observations revealed that the shower drains continued to be clogged with hair and dirt; and 2) observations revealed debris including wrappers, straws, and surgical masks, dust, and food residue in 15 of 40 rooms. Additionally, food stains were identified on the floors in the hallway of Unit 2.
The findings include but are not limited to:
The facility was requested to provide a Policy and Procedure for Housekeeping and Environmental Services. The facility Director of Housekeeping stated there currently are no Policies and Procedures developed for Housekeeping and Environmental Services.
The facility Housekeeper job description dated 9/2018 documented that the housekeeper is responsible to maintain cleanliness throughout the facility. General responsibilities include cleaning and dusting within the facility such as in the bedrooms, bathrooms, windows, offices, dining rooms, corridors, lobby elevators, nursing stations, multipurpose rooms and service areas. The housekeeper is responsible to maintain the facility in an orderly, healthy and attractive condition. The housekeeper also stocks rooms with paper towels, toilet tissue and soap.
1) Review of the Resident Council meeting minutes revealed Resident Council members complained of the shower rooms needing to be cleaned and complained of clogged drains on 5/19/2021, 7/6/2021, 8/3/2021 and 9/14/2021.
The resident council meeting was held on 10/5/2021 at 9:30 AM with ten Resident Council members present. Three of ten residents (Resident #59, #40, #26) stated that the floors are dirty, and housekeeping does not clean the rooms well. They also complained of the dirty showers and clogged drains.
On 10/05/2021 at 9:45 AM, Resident #59 stated that the facility is dirty, and the resident council brought concerns about cleanliness to the resident council meetings. The Resident #59 stated that the floors are usually dirty, and items are left on the ground. Resident #49 stated that nothing has been done to address the problem.
On 10/05/2021 9:47 AM, Resident #40 stated that the floors still look dirty after being mopped. Resident #40 stated it appears as though the dirt is just being pushed around and it does not smell like they are using any cleaning agents in the water or changing the water. Resident #40 stated that the nurses just throw their gloves on the floor in the room and Resident #40 has to put it in the trash after they leave or else it will just stay there.
On 10/05/2021 at 9:49 AM, Resident #26 stated the floor is also dirty their room and Resident #26 uses a Reacher to pick up discarded items left behind on the floor if no one cleans the floor.
On 10/8/2021 at 9:15 AM, the shower room on the 1st floor was observed with the Charge Nurse present. The bathroom drains were covered in hair and dust. The Charge Nurse stated that they did not notice the drains before and none of the staff members or residents reported it.
A tour of the 1st and 2nd floor units was completed with the Director of Housekeeping on 10/8/2021 at 9:28 AM. At 9:32 AM, the Director of Housekeeping kneeled down and pulled up one of shower drain covers in the 1st floor shower room. The Director of Housekeeping stated the drain was covered in hair and dirt. The Director of Housekeeping proceeded to clean the drain cover and then removed the second shower drain cover. The Director of Housekeeping stated that the second shower drain also had hair and dirt. The Director of Housekeeping stated that Housekeeping staff are responsible for cleaning the shower rooms including the drains. At 9:48 AM an observation was made at the 2nd floor shower room. The Director of Housekeeping looked at the shower drains in the 2nd floor shower room and stated that they are also full of hair and dirt. The Housekeeping Director stated they (the Housekeeping Director) were not aware of the multiple complaints about the shower drains being clogged and dirty. The Housekeeping Director stated that they did not notice the buildup of hair and dirt on the shower drains until today, 10/8/2021.
The Recreation Aide was interviewed on 10/8/21 at 1:20 PM and stated that they (the Recreation Aide) were responsible to record the minutes from the resident council meetings. The Recreation Aide stated that they did witness complaints on 5/19/2021, 7/6/2021, 8/3/2021, and 9/14/2021 about the shower drains being clogged and the bathrooms not being cleaned. The Recreation Aide stated that they assumed that the Director of Recreation relayed the message to the Director of Housekeeping but was not sure if the resident's concerns were followed up. The Recreation Aide further stated the Director of Recreation that was present during the Resident council meetings held on 5/19/2021, 7/6/2021, 8/3/2021, and 9/14/2021 is no longer employed at the facility.
The Assistant Administrator was interviewed on 10/08/2021 at 1:54 PM. The Assistant Administrator stated that they (the Assistant Administrator) were present for the Resident Council meetings and did recall the resident council members voicing concern about the showers not being cleaned. The Assistant Administrator stated they went to the showers to check on the condition of the showers but could not recall when. The Assistant Administrator stated that the facility only adjusted the shower head. The Assistant Administrator further stated that they did not recall the shower drain complaints specifically or what measures were taken to correct the problem.
2a) Resident #29 was admitted to the facility with the diagnosis of Anemia, Hypertension and Hemiplegia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #29 had a Brief Interview for Mental Status (BIMS) assessment score of 9, indicating moderately impaired cognition.
Resident #29 was observed sitting in a wheelchair in room [ROOM NUMBER] on 10/04/2021 at 10:27 AM. The floor was visibly soiled with food debris (wrappers and crumbs) and was white but appeared grey in color due to residue buildup. Resident #29 was not able to state when the floors were last mopped. Resident #29 stated that the housekeeping staff are very busy, they work fast, and they sometimes leave trash behind. Resident #29 stated that a family member purchased a broom for Resident #29 and pointed to the broom resting against the wall. Resident #29 stated that Resident #29 sweeps up when the housekeeping staff does not get to everything.
2b) Resident #320 was admitted to the facility with the diagnosis of Arthritis, Hypertension and Anxiety Disorder. The admission Minimum Data Set (MDS) dated [DATE] documented that Resident #320 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.
Resident #320 was observed lying in bed in room [ROOM NUMBER] on 10/04/2021 at 10:41 AM. Resident #320 stated they (Resident #320) were a new admission since 9/29/2021. Resident #320 stated the housekeeping staff have not mopped their room since Resident #320 arrived. The floors were white with grey colored residue, dirt and wrappers observed on the floor.
Housekeeper #1 was interviewed on 10/7/2021 at 10:48 AM. Housekeeper #1 stated that they (Housekeeper #1) work on the 6 AM-2 PM shift on the 2nd floor during the week. Housekeeper #1 stated that Housekeeper #1 makes separate rounds for sweeping the floor, emptying the garbage and mopping. Housekeeper #1 stated the residents and staff often make requests to clean and it is difficult to get to it all. Housekeeper #1 stated that the facility used to have a maid to do spot cleaning in addition to the housekeeper. Housekeeper #1 stated that Housekeeper #1 has had meetings with the Director of Housekeeping regarding getting additional help. The last meeting was approximately one month ago and there have not been any changes.
Housekeeper #2 was interviewed on 10/07/2021 at 2:25 PM. Housekeeper #2 stated that they (Housekeeper #2) work on the 11:30 AM-7 PM shift. Housekeeper #2 stated that they are usually assigned to the ground floor but has been providing coverage for the whole building for the past month due to lack of coverage. Housekeeper #2 stated that there is usually 1 housekeeper per floor and currently there is a housekeeper on the 1st and 2nd floor from 11:30 AM to 2:00PM and then just Housekeeper #2 from 2:00 PM to 7:00 PM. Housekeeper #2 stated they try to get to everything, and it is difficult with just one person.
A tour of the 1st and 2nd floor units was conducted with the Director of Housekeeping on 10/8/2021 at 9:28 AM. The Director of Housekeeping acknowledged observations of debris (including wrappers, straws, and a surgical mask), dust, food residue and stains on the floors in the hallway of the 2nd floor, 7 of 20 rooms on the 1st floor (#101, #102, #103, #109, #113, #119, and #120) and 8 of 20 rooms on the 2nd floor (#203, #204, #205, #206, #212, #216, #217, and #218). During the tour, the Director of Housekeeping stated that the facility does not have enough housekeeping staff to keep up with the work required. The facility currently only has 2 full time housekeeping staff members and the facility requires 3 full time housekeeping staff members to handle all of the responsibilities. There is one housekeeper from 6:00 AM to 2:00 PM and another from 11:30 AM to 7:00 PM. The 11:30 AM to 7:00 PM housekeeper also handles supplies and linens which makes it difficult to stay on top of keeping the facility clean. The Director of Housekeeping stated that the facility needs another employee to be dedicated to just handling supplies and linens to handle the workload. The Director of Housekeeping stated that they assist with cleaning, but they are also responsible for maintenance tasks such as maintaining oxygen tank supplies and doing some repairs. The Director of Housekeeping stated that they discussed concerns with the Assistant Administrator last month but was informed that they will only hire a per-diem employee. The Housekeeping Director stated that it has been difficult to recruit and retain a per-diem housekeeper. The Housekeeping Director stated that they attended one resident council meeting in September in which a resident complained about the cleanliness of the facility and the Director of Housekeeping was aware of problem.
The Assistant Administrator was interviewed on 10/08/2021 at 1:54 PM. The Assistant Administrator stated when they (the Assistant Administrator) became employed at the facility in June 2021, they observed that the facility was not clean and does not meet expectations in cleanliness. The Assistant Administrator stated that they observed the floors appearing dirty with debris and dust build up. The Assistant Administrator stated that a Housekeeper was let go on 9/14/21 and the facility has had trouble with employing another person. The Assistant Administrator stated that the facility needs 3 full time housekeepers and there are currently only 2 full time housekeepers with overlapping schedules. Housekeeper #2 is also responsible for supplies and linen distribution. The Assistant Administrator stated that they expect that Housekeeper #2 to do the supplies and linens when the employee arrives at 11:30 AM because they expect Housekeeper #1 to have most of cleaning done by that time. The Assistant Administrator further stated that he was not aware that there was no standard housekeeping policy and procedure. The Assistant Administrator expected that the facility would have one.
415.5(h)(2)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 24% annual turnover. Excellent stability, 24 points below New York's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $51,565 in fines, Payment denial on record. Review inspection reports carefully.
- • 13 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $51,565 in fines. Extremely high, among the most fined facilities in New York. Major compliance failures.
- • Grade F (26/100). Below average facility with significant concerns.
Bottom line: Trust Score of 26/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Sunrise Manor Ctr For Nursing And Rehabilitation's CMS Rating?
CMS assigns SUNRISE MANOR CTR FOR NURSING AND REHABILITATION an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New York, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Sunrise Manor Ctr For Nursing And Rehabilitation Staffed?
CMS rates SUNRISE MANOR CTR FOR NURSING AND REHABILITATION's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 24%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Sunrise Manor Ctr For Nursing And Rehabilitation?
State health inspectors documented 13 deficiencies at SUNRISE MANOR CTR FOR NURSING AND REHABILITATION during 2021 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 11 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Sunrise Manor Ctr For Nursing And Rehabilitation?
SUNRISE MANOR CTR FOR NURSING AND REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 84 certified beds and approximately 72 residents (about 86% occupancy), it is a smaller facility located in BAY SHORE, New York.
How Does Sunrise Manor Ctr For Nursing And Rehabilitation Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, SUNRISE MANOR CTR FOR NURSING AND REHABILITATION's overall rating (2 stars) is below the state average of 3.1, staff turnover (24%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Sunrise Manor Ctr For Nursing And Rehabilitation?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Sunrise Manor Ctr For Nursing And Rehabilitation Safe?
Based on CMS inspection data, SUNRISE MANOR CTR FOR NURSING AND REHABILITATION has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New York. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Sunrise Manor Ctr For Nursing And Rehabilitation Stick Around?
Staff at SUNRISE MANOR CTR FOR NURSING AND REHABILITATION tend to stick around. With a turnover rate of 24%, the facility is 22 percentage points below the New York average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 23%, meaning experienced RNs are available to handle complex medical needs.
Was Sunrise Manor Ctr For Nursing And Rehabilitation Ever Fined?
SUNRISE MANOR CTR FOR NURSING AND REHABILITATION has been fined $51,565 across 1 penalty action. This is above the New York average of $33,595. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Sunrise Manor Ctr For Nursing And Rehabilitation on Any Federal Watch List?
SUNRISE MANOR CTR FOR NURSING AND REHABILITATION is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.