Sunny Hill Care Center

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, the facility failed to answer call lights in a timely manner for 2 of 3 residents reviewed for staffing concerns(Residents #22 and #23). The facility reported a census of 52 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to prime an insulin(an injectable medication used to lower blood sugar) pen prior to administration for 1 of 1 residents observed for insulin(Resident #32). The facility reported a census of 52 residents.

Inspectors wroteBased on clinical record review, resident interview, family interview, staff interviews and policy review, the facility failed to ensure a safe transfer for 1 of 3 residents reviewed (Resident #5) . Staff attempted to transfer from the recliner to wheel chair and did not utilize a gait belt (Resident #5). The resident fell and sustained a non-displaced humeral fracture (left arm). The facility reported a census of 48 residents.

Inspectors wroteBased on staff interview, resident interview, CMS-2567 (Centers for Medicare and Medicaid Services) report, facility policy, and Quality Assurance Performance Improvement Plan (QAPI) the facility failed to ensure an effective QAPI process to address inclusion of residents in care planning process per a previously identified deficiency on the facility's prior recertification. The facility reported a census of 47 residents.

Inspectors wroteBased on resident interview, staff interviews, record review, and policy review the facility failed to ensure resident participation option in quarterly interdisciplinary team meetings for care planning for 2 of 5 residents reviewed regarding care plan meetings (Residents #31 & #38). The facility reported a census of 47 residents.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to notify the Long-Term Care Ombudsman of discharge/transfer of residents as required for 1 of 4 residents reviewed who were discharged or transferred from the facility (Resident #15). The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, policy review, resident interview, and staff interview, the facility failed to provide monitoring and timely assistance to transfer off the toilet for 1 of 3 residents reviewed for supervision (Resident #1). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, resident, family and staff interviews, and facility policy review, the facility failed to appropriately provided an assessment and interventions for the necessary care and services for a resident after a fall on 11/30/23. The nursing staff failed to provide a thorough assessment for the resident, and three hours after the fall, the next Shift Nurse assessed the resident and found an inward rotation of the left leg and associated severe pain. The resident transported to the local hospital, found to have suffered a fractured left hip, and then transferred to a tertiary hospital for higher level of care and surgical hip repair (Resident #8). The facility reported a census of 49 residents. Findings Include: [...]

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, the facility failed to follow through with Physician Orders for 1 of 15 residents reviewed (Resident #13). The facility reported a census of 49 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] for Resident #13 revealed a diagnosis of Urinary Tract infections (UTI), neuromuscular dysfunction of the bladder and stroke with left sided paralysis and required assistance of one person for toileting, hygiene and an indwelling catheter was identified. Resident #13's Brief Interview for Mental Status (BIMS) score, 15 out of 15 indicated intact cognition. The Care Plan dated 7/18/23 directed Nursing Staff to care for the catheter every shift and to follow the Physician Orders in regards to flushing and changing the catheter. [...]

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and facility policy review, the facility failed to provide catheter care for 1 of 3 residents reviewed (Resident #13). The facility reported a census of 49 residents. Findings Include: During an interview on 2/5/24 at 1:45 PM, Resident #13 stated he had a suprapubic catheter and had been an ongoing problem of spasms and Urinary Tract Infections (UTI) for him. Resident #13 stated the nurse told him she couldn't do anything without an order to care for it. During an observation on 2/6/24 at 9:36 AM, Staff A, Registered Nurse (RN) provided Resident #13's suprapubic catheter care and catheter irrigation. Staff A withdrew 60 milliliters (ml) of clear fluid into a catheter tipped syringe from a cup. [...]

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to limit as needed (PRN) psychotropic medications to 14 days without a rationale from the provider to extend the medication for 1 of 5 residents reviewed for unnecessary medications (Resident #7). The facility reported a census of 49 residents. Findings Include: The Minimum Data Set (MDS) for Resident #7 dated 11/5/23 documented a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. The MDS further revealed the resident had diagnosis including anxiety, non-Alzheimer's dementia and other depressive disorders. [...]

Inspectors wroteBased on clinical record review, Resident Group and staff interviews, observations and facility policy review, the facility failed to maintain an environment free of psychosocial and physical abuse by not identifying and/or reporting abuse immediately but not later than 2 hours- if the alleged violation involves abuse or results in serious bodily injury. Staff B, Certified Nursing Assistant (CNA) reportedly grabbed a resident's hands and made her hit herself in her face on early morning of 7/4/23 (Resident #8). This was not reported until 7/14/23. Staff B reportedly was yelling at a resident and grabbed her wrists early morning of 7/3/23. This was not reported (Resident #9). Both residents were cognitively impaired. During the investigation, staff reported other incidents that they did not report as well (Resident #10 and Resident #13). [...]

Inspectors wroteBased on clinical record review, resident and staff interviews and facility policy review, the facility failed to take steps to prevent further potential abuse by not conducting a thorough investigation of an alleged violation. Staff B, Certified Nurse Assistant (CNA) reportedly was yelling at a resident and grabbed her wrists early morning of July 3rd (Resident #9). The facility asked Resident #9, who was cognitively impaired if anything happened the night before and she said no. The Director of Nursing (DON) acknowledged this resident did have cognitive impairment and had short term memory loss. The DON talked with Staff B. No documentation was done for either of these conversations, nor was a thorough investigation completed. Three residents were present at the time of the incident and were not interviewed. Two of the residents had intact cognition. [...]

Inspectors wroteBased on clinical record review, Resident Group and staff interviews, observation and facility policy review, the facility failed to ensure residents were free from abuse when facility staff did not follow their policy of reporting, investigating and protecting the residents from abuse. Through interviews with various staff, it was found that staff did not report their concerns of potential abuse (Residents #8, #10, and #13) or reported their concerns to the Director of Nursing (DON) allowing a thorough investigation to follow (Resident #9). The facility reported a census of 54 residents. Findings Include: 1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #8 included non-Alzheimer's dementia and schizophrenia. A Brief Interview for Mental Status (BIMS) documented as being unable to complete. [...]