Sunnyside Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and implement care plan interventions to prevent a resident-to-resident altercation for 2 of 8 residents (Resident 1 and 2) reviewed for avoidable accidents. This failure placed the residents at risk for physical abuse, serious pain and injury, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to allow residents the right to make choices related to the time of day for showering for 3 of 4 residents (Residents 1, 2, and 3) reviewed for self-determination. This failure placed the residents at risk for distress, poor hygiene, and an undignified existence.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided the opportunity to be involved in making decisions about care and treatment for 2 of 3 residents (Residents 3 and 2) reviewed for rehabilitation services. This failure placed the residents at risk for a decline in physical functioning, worsening mobility, and frustration.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of drugs) to meet the needs of 1 of 3 residents (Resident 1) reviewed for pharmacy services. This failed practice placed the residents at risk for ongoing, uncontrolled pain and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASRR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) accuracy prior to admission and have the required Level 2 referral sent if the residents had a positive Level 1 PASRR as required for 3 of 5 residents (Resident 62, 33 and 8) reviewed for PASRR. This failure placed the residents at risk for inappropriate long term care placement and not receiving necessary mental health care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure cleanliness, discard expired foods, and to follow the thawing and cooling process of foods in 1 of 1 kitchen reviewed for safe and sanitary kitchen. This failed practice placed all residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff maintained components of an infection prevention control program to prevent the development and transmission of infections for, 1) hand hygiene and glove change for 5 of 9 staff (Staff Q, P, K, F, and R) reviewed during resident cares and meal service and, 2) use of Personal Protective Equipment (PPE) in an enhanced barrier precaution (EBP, indicated with high contact resident care activities with an infection, a long term wound, central line device or colonization [the presence of a bacteria that has not yet started its infection process] of an multi drug resistant organism) room for 1 of 3 residents (Resident 44) reviewed for infection control. This failure placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances (resident and/or resident representative concerns that can be voiced or written), conveyed by the resident, underwent prompt resolution through to their conclusion nor were residents appropriately updated on their grievance progress/conclusion for 2 of 5 residents (Residents 8 and 62) reviewed for the grievance process. This failure placed residents at risk for unresolved concerns and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure psychotropic medications (medications capable of affecting the mind, emotions, and behavior) had specific person-centered behaviors being monitored to reflect adequate need of the medication for 2 of 5 residents (Residents 33 and 62) and failed to obtain informed consents prior to administering psychotropic medications for 1 of 5 residents (Resident 33) reviewed for unnecessary medications. This failed practice placed residents at an increased risk for duplicate therapy, receiving medications they no longer needed and/or increased behaviors due to inadequate dosing of medication.

Inspectors wroteBased on observation, interview and record review the facility failed to develop comprehensive resident centered care plans for 2 of 6 residents (Residents 52 and 30) reviewed for care plan development. This failure placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary care and services to maintain communication abilities for 1 of 3 residents (Resident 13) reviewed for the use of hearing aid (HA) devices. This failure placed the resident at risk for unmet care needs and the inability to participate in daily activities to the highest extent possible.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice regarding a residents central venous access device (CVAD, also known as a central line, is a thin, soft tube that is inserted into a main vein in the arm, leg, or neck for long-term administration of antibiotics, medication, nutrition, and/or blood draws) for 1 of 2 residents (Resident 30) reviewed for quality of care. This failed practice placed residents at risk of further infection, a delay in treatment, and adverse outcomes regarding their CVAD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, or treat new skin issues to prevent the worsening of two facility-acquired pressure injuries (PIs, sores (ulcers) that happen on areas of the skin that are under pressure) for 1 of 3 residents (Resident 60) reviewed for PIs. This failed practice placed residents at risk for worsening or new PIs, increased pain, and unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 52) with a retention catheter (a small plastic or rubber tube inserted into the bladder to drain urine) reviewed for catheter care, received appropriate care and services to mitigate the risk of infection in the urinary tract. This failure placed residents at risk for illness and a decline in health status.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and sanitary environment for 1 of 2 shower rooms (100 hall), 1 of 1 weight room, 1 of 1 laundry room, and 5 of 3 Hoyer (a type of device that safely transfers a resident with limited mobility, such as inability to stand safely) lifts reviewed for a safe and sanitary environment. This failure placed residents at an increased risk of not feeling safe and secure with their environment and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve meals at a preferred temperature for 3 of 4 residents (Resident 1, 2, and 3) reviewed for food temperatures. This failure placed the residents at risk for inadequate nutritional intake, weight loss, and dissatisfaction with their dining experience.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment in 1 of 1 kitchen (Main Kitchen) reviewed for food preparation and storage safety. This failure placed all residents, staff, and visitors that ate out of the Main Kitchen at risk for food contamination (the unintended presence of potentially harmful substances including microorganisms or chemicals in food) and food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dining experience that promoted resident respect and dignity for 1 of 6 residents (Resident 1) reviewed for dignity. This failure placed the resident at risk for low self-esteem and an undignified dining experience.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Resident 2 and 3), reviewed for activities of daily living, received goods and services to maintain their ability to eat independently. This failure placed the residents at risk for low self-esteem, the inability to feed themselves, and dissatisfaction with their dining experience.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary and homelike environment by not consistently cleaning the heating and air exchange vents and/or changing the filters for 4 of 4 dining rooms (DR) ([NAME], Garden, Transition Care Unit [TCU], and Private), 3 of 3 hallways (Hallways 100, 200, and 300), and 1 of 1 kitchen. Additionally, the facility failed to ensure 1 of 1 laundry room was free from built-up dust and lint to the dryers and the water and exhaust pipes. This failed practice placed residents at risk for an undignified existence, infections, and safety hazards.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide goods and services that met professional standards of care for 2 of 3 residents (Resident 3 and Resident 7) reviewed for documentation before and after receiving an opioid (a powerful class of medications meant to be used for a short time after an injury or surgery to manage acute pain and enable activity) pain medication. The failure to assess and document resident's symptoms before and after receiving pain medication put the residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to set-up a visually impaired resident's room to ensure it accommodated the individualized needs and preferences for 1 of 2 residents (Resident 6) reviewed for accommodation of needs and preferences. Resident 6 experienced psychosocial harm as evidenced by changes in their activity, behavior, and mood from their baseline due to their new physical environment that was not individualized for their preference of independent functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5 percent (%, unit of measure). During observation of 25 opportunities for error, 1 of 3 Licensed Nurses (LNs, Staff O), made three errors, an error rate of 12 %. This placed residents at risk for side effects, unnecessary medications, and/or reduced medication effectiveness due to improper administration.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, sanitary environment by not providing scheduled maintenance services for repairs or cleaning for 1 of 1 kitchen. This failed practice placed the residents at risk for cross contamination, food borne illness and negative health outcome.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notification of room changes including the reason for the move to the resident/resident representative for 1 of 2 resident (Residents 6) reviewed for room changes. This failure placed the resident at risk for feelings of frustration and an increased risk for accidents.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of potential abuse and/or neglect to the State Agency, for 1 of 5 residents (Residents 69), reviewed for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect, and the potential continued exposure to abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation into an allegation of abuse for 1 of 5 residents (Resident 69), reviewed for abuse and neglect. This failure placed the residents at risk for unidentified abuse, unmet care needs, and the potential for continued exposure to abuse and/or neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident had the cognitive capacity to understand the nature and implication of entering into a binding arbitration agreement used to settle disputes without a jury trial for 1 of 4 residents (Resident 72) reviewed for arbitration. This failure placed the resident at risk for a lack of understanding of the legal contract they had signed and their right to make a choice for a jury trial in the event of a dispute with the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement components of their infection prevention and control precautions regarding Legionella (a bacteria that can cause a severe respiratory disease) testing protocols and procedures when the control measures (actions or steps taken), adopted to reduce the potential growth/spread of pathogens (bacteria, virus or other microorganisms that can cause diseases) in water, were not met for the water management program (WMP) reviewed for infection control. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to monitor the effectiveness of medications that affect blood pressure (BP [the force of blood against the walls of the arteries]) and heart rate (HR [the number of times the heart beats in one minute]) for 1 of 3 residents (Resident 1) reviewed for unnecessary medications. This deficient practice placed the resident at risk of developing abnormal vital signs (body temperature, heart rate, respiration rate, and BP) , experiencing adverse side effects, and the potential of receiving medications unnecessarily.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and implementation of care plan interventions to prevent a fall for 1 of 3 residents (Resident 45) reviewed for falls with injury. Resident 45 experienced an avoidable fall when left alone in the restroom, despite the care plan interventions that showed the resident required supervision while in the restroom. This failure resulted in actual harm to Resident 45 who fell in the restroom, experienced a four-to-five-centimeter (cm) hematoma (an abnormal collection of blood outside of a blood vessel that results from an injury or trauma) and required a transfer to the local emergency room for evaluation and intervention.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a dignified dining experiences for 4 of 9 residents (Residents 30, 29, 37, and 8) reviewed for dignity. The staff delayed feeding assistance to Resident 30, did not engage with residents during the mealtime, disallowed Resident the opportunity to experience home cooked meals in the dining room, referred to the residents that required meal assistance as feeders, and administered medications during mealtime in the assisted dining room. These failures placed the residents at risk of a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient staff to provide care and services for 2 of 3 residents (Resident 24 and 31) reviewed for restorative nursing programs, and 1 of 9 residents (Resident 30) reviewed for assistance in the dining room. These failures placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control standards for hand hygiene (HH) were maintained during dining service for 6 of 6 residents (Residents 16, 56, 43, 8, 12, and 48), and during personal care for 1 of 1 resident (Resident 48) reviewed for urinary catheter use. Additionally, the facility failed to ensure infection prevention measures were implemented for 1 of 1 laundry rooms reviewed for cleanliness. These failed practices placed residents at risk for exposure to infectious organisms and transmission of diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services to ensure residents activities of daily living (self-care activities) did not decline for 2 of 3 residents (Residents 24 and 31) reviewed for mobility. The facility failed to consistently implement restorative nursing for the developed standing and ambulation programs, which placed the residents at risk for an avoidable decline in function and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent. Two medication errors were identified for 2 of 8 residents (Residents 38 and 4) observed during 25 medication administration opportunities that resulted in an error rate of 8%. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication was discarded when expired for one of two medication carts reviewed for medication storage. This failure placed residents at risk of receiving compromised or ineffective medication.