Sunshine Health & Rehab

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents, families and visitors had access to grievance forms if they wanted to file a grievance anonymously. The facility also failed to ensure residents knew the process for filing grievances for 4 of 4 residents (Resident's 61,15, 66 and 51) reviewed for the grievance process in Resident Council. Additionally, staff were unaware of the location of grievance forms in the event a resident, family member or visitor requested a form. This failure placed the residents at risk for not being able to voice concerns and have their concerns resolved in a timely manner.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 6 of 7 residents (Residents 44, 7, 64, 61, 20, and 49) were accurately assessed for activity preferences to mitigate the risk of boredom and enhance quality of life. Additionally, the facility failed to have a registered nurse ensure the activity assessments were timely and appropriately completed. This failure placed the residents at risk for unmet psycho-social needs 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. Four medication errors were identified for 3 of 8 residents (Residents 31, 61 and 75) observed during 25 medication administration opportunities that resulted in an error rate of 16%. This failure placed 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 staff followed infection control measures, including Personal Protective Equipment [(PPE) protective garments and gear used to minimize exposure to hazards that can cause injury or illness], intended to mitigate the transmission of shingles (a viral infection that causes a painful, burning rash with blisters) were followed for transmission-based precautions [(TBP) additional precautions used with residents that are suspected or confirmed to have an infection] for 7 of 7 staff members (Staff L, M, N, O, P, Q, K); Additionally the facility failed to ensure medical supplies were maintained in a manner to prevent healthcare-associated infections by failing to remove expired sterile and non-sterile clinical supplies from 1 of 1 treatment storage rooms, reviewed for infection control. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that resident dignity was maintained for 2 of 3 residents (Resident's 32 and 58) reviewed for resident rights to privacy and a dignified existence. Residents 32 and 58 had their medical information discussed and were assessed in front of other residents and visitors while in the common area. This failure placed them at risk for embarrassment and lack of confidentiality related to their medical care.

Inspectors wroteBased on observation, interview, and record review the facility failed to review, and validate the Preadmission Screening and Resident Reviews (PASARR, 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) were correct on admission or updated for 1 of 5 residents (Resident 64) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on interview and record review, the facility failed to: A) establish a Quality Assurance Performance Improvement (QAPI) policy for the inclusion/utilization of information from all resident care departments, including residents/resident representatives (RR) feedback/input data that would be used to identify high risk, problem prone areas or opportunities for improvement and, B) implement an effective QAPI program that incorporated a thorough collection/analysis of resident/RR feedback data and information from all departments/staff involved in 1 of 1 QAPI Program. This failure placed residents at an increased risk for unidentified complications, prompted corrective action towards high-risk/problem prone areas and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee included the required members and met at least quarterly (once every quarter of the year or every three months) for 2 of 4 quarters (Q2 and Q3) reviewed for QAA. The failure to meet quarterly increased the facility's risk of unrecognized quality deficiencies, the facility's ability to effectively correct identified issues and ongoing unmet care needs regarding residents' quality of life.

Inspectors wroteBased on observation and interview the facility failed to provide a safe and sanitary (relating to the conditions that affect hygiene and health) environment for 1 of 1 Laundry room (LR 1), reviewed for a functional environment. This failure placed residents and staff at an increased risk of cross-contamination (the harmful spread of diseases).

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 5 sampled residents (Resident 5) were fully informed of their care in language they could understand. This failure placed the resident at risk of poor understanding in their health care decisions and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure services provided met professional standards of practice related to nursing assessments for 1 of 5 residents (Resident 1), reviewed for quality of care. This failure placed the resident at risk for injury and adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure that direct care staffing information was accurate upon submission to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2024 (July 1, 2024 through September 30, 2024) reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure caused CMS to have inaccurate data related to facility staffing levels and had the potential to impact resident care and services.

Inspectors wroteBased on interview and record review the facility failed to not request or require residents to waive their rights to retain personal property including items of value to admit to the facility for 4 of 4 sampled residents (Resident 23, 76, 184, and 185), reviewed for resident rights. This failure placed all residents at risk of inability to exercise their resident rights, unmet needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to review policies and/or procedures yearly as required, perform hand hygiene when indicated, and store soiled laundry in a manner to prevent the spread of infection. In addition, the facility failed to implement, follow, and discontinue transmission-based precautions when indicated for 2 of 3 sampled residents (Resident 23 and 135), reviewed for infection control. This failure placed all residents, staff, and visitors at risk of development of a multi-drug-resistant organisms (MDRO), communicable diseases, and diminished quality of life

Inspectors wroteBased on interview and record review, the facility failed to ensure the designated Infection Preventionist met the qualifications for experience, education, training and/or certification for the role to assume responsibility of the facility's Infection Prevention and Control Program for 1 of 1 sampled staff (Staff C), reviewed for infection preventionist qualifications. This failure placed all residents, staff, and visitors at risk of contracting communicable diseases, unmet infection control issues, and lack of oversite of the facility staff's infection control practices.

Inspectors wroteBased on interview and record review the facility failed to routinely encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 7 of 7 sampled residents (Residents 6, 7, 8, 25, 48, 50, and 53), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide bathing for 2 of 4 sampled residents (Resident 28 and 234), reviewed for activities of daily living (ADLs). This failure placed residents at risk for poor personal hygiene, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to routinely implement a system with sufficient detail to enable an accurate reconciliation of all controlled drugs, including the facilities emergency medication supply in 1 of 1 sampled medication rooms (Victorian Rose) reviewed for medication storage. This failure placed the facility at increased risk for potential controlled substance drug diversion and detracted from the facility's ability to promptly identify drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to routinely provide education on benefits and potential side effects of vaccinations, offer pneumococcal (bacteria that could cause respiratory infections) and influenza (flu, contagious viral respiratory illness) vaccinations when indicated, and document in the resident's medical record accordingly for 3 of 5 sampled residents (Resident 4, 52 and 78), reviewed for immunizations. These failures placed residents at risk of being unable to make informed decisions regarding immunizations, acquiring communicable diseases, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of the required annual 12-hours of in-service training, which included dementia training for 5 of 5 nursing assistants (I, L, M, O, V ), reviewed for nursing assistant continuing education and abuse prevention for 2 of 5 staff (I, V), as required. This deficient practice placed the residents at risk of being cared for by inadequately trained staff, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident was evaluated and assessed by the interdisciplinary team (IDT), a physician order was obtained, and care planned for safe self-administration of medications, as required for 1 of 4 sampled residents, (Resident 23), reviewed for resident rights. This failure placed residents at risk of medication errors, adverse side effects, and 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. Specifically, two medication errors were identified during 26 medication administration opportunities. This resulted in an error rate of 7.69 %. This failure placed residents at risk of receiving subtherapeutic effects of their medications, possible adverse side effects, and diminished quality of life.

Inspectors wroteF801 Based on interview and record review the facility failed to employ a dietician that had the licensure and/or certification to practice as a Registered Dietician in Washington State, as required for 1 of 1 staff (Staff U), reviewed for Registered Dietician qualifications. This failure placed all residents at risk for unmet nutritional needs and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to implement antibiotic protocols to ensure antibiotics were appropriately prescribed for 1 of 6 sampled residents (Resident 4), reviewed for antibiotic stewardship. This failure placed residents at risk of development of [NAME]-drug-resistant organisms (MDRO), adverse side effects, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized care plan for 1 of 3 residents (1) reviewed who had unique environmental fall risk concerns. Specifically, Resident 1 was at risk for tripping over their lengthy oxygen tubing, and this was not identified and included in their fall prevention care plan. This failure placed Resident 1 and other residents at risk for avoidable falls, injury and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure orders for oxygen were implemented during a transportation to the facility for admission for 1 of 3 residents (1) reviewed. Specifically, Resident 1 did not wear oxygen when transported from the hospital to the facility. Shortly after arrival, the resident had low blood pressure and developed chest pain and was returned to the emergency department for evaluation. This failure put the resident at risk for decompensation and unintended deterioration of their health.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 sample residents (Resident 1), admitted with impaired skin integrity, and at increased risk for continued skin breakdown, was consistently monitored to prevent development of pressure areas and worsening of identified areas. This failure caused a diminished quality of life for Resident 1 when they developed a pressure ulcer on their coccyx (tailbone area) and worsening of identified at risk areas on both heels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 4 dietary staff members (Staff K, L, M, and N) wore facial hair coverings while in the kitchen, as required. In addition, the facility failed to monitor the temperature and contents of 2 refrigerators that contained resident food. Failure to monitor refrigerator temperatures and contents for expired or spoiled food, and staff not wearing beard coverings in the kitchen placed all residents at risk for food-borne illness and contamination.

Inspectors wroteBased on interview and record review, the facility failed to implement infection surveillance (an ongoing, systematic collection, analysis, and interpretation of data relating to infections to reduce spread of infections), for 6 of 7 sampled residents (Residents 20, 28, 238, 236, 3 and 21), who were reviewed for physician orders related to infections. These failures placed the residents and staff at risk for development of contagious disease.

Inspectors wroteBased on interview and record review, the facility failed to identify an allegation as potential misappropriation of resident property, report the allegation to the State Survey Agency, and complete a thorough investigation as required for 1 of 1 sampled residents (Resident 1), reviewed for personal property. This failure placed residents at risk for potential misappropriation of personal property and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist recommendation reports for 3 consecutive months, for 1 of 5 sampled residents (Resident 10), reviewed for unnecessary medications. This failure placed the resident at risk of adverse medication effects and a diminished quality of life.