Villas at Sunny Acres, the

Inspectors wroteBased on record review and interviews, the facility failed to prevent misappropriation of property for one (#7) of three residents reviewed for misappropriation of personal property out of 18 sample residents. Specifically, the facility failed to prevent the theft of Resident #7's narcotic medication card containing 89 pills.

Inspectors wroteBased on observations and interviews, the facility failed to consistently serve food that was palatable in taste. Specifically, the facility failed to ensure resident food was palatable in taste and texture.

Inspectors wroteBased on record review and interviews, the facility failed to inform the resident's representative of the change in condition for one (#176) out of five residents reviewed out of 49 sample residents. Specifically, the facility failed to timely notify Resident #176's representative of a fall, the need for medical imaging (Xray) of her left hip, new orders for pain medication and an appointment for a diagnostic imaging procedure to show detailed internal images (CT) scan in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide residents who were unable to carry out activities of daily living (ADL's) the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (#326 and #8) of five residents out of 49 sample residents. Specifically the facility failed to -Offer repositioning to Resident #326 and Resident #8, who were dependent residents; and, -Provide assistance with toileting for Resident #326.

Inspectors wroteBased on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record one (#376) of five residents reviewed for advance directives out of 49 sample residents. Specifically, the facility failed to ensure: -Resident #376 had a physician's order for their cardiopulmonary resuscitation (CPR) wishes in the resident's electronic medical record (EMR); and, -Resident #376's care plan included the resident's CPR wishes.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide adequate supervision to keep residents free from accidents/hazards for one (#276) of one resident out of 49 sample residents. Specifically, the facility failed to prevent an elopement from the secured unit building for Resident #276.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#116) of two residents reviewed for dialysis out of 49 sample residents. Specifically, the facility failed to: -Consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center; and, -Ensure thorough documentation was completed for Resident #116 dialysis treatments. I. Facility policy and procedure The Renal Dialysis, Care of Resident, Hemodialysis Access Site policy and procedure, revised December 2020, was provided by the nursing home administrator (NHA) on 4/6/25 at 1:12 p.m. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were diagnosed with dementia received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#276) of one resident out of 49 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #276.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure all drugs and biologics were properly stored and labeled for one (#101) of two residents reviewed out of 49 sample residents. Specifically, the facility failed to ensure medications that were not administered were not left unsecured at Resident #101's bedside.

Inspectors wroteBased on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of seven units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for Resident #326 and #95, who were both on enhanced barrier precautions (EBP) for pressure wounds.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident's environment was free from accident hazards for three (#95, #12 and #19) of eight residents reviewed for falls out of 53 sample residents. Resident #95, who had a previous history of falls at the facility and was identified to be at high risk for falling, experienced a fall on 1/9/24 which resulted in a left hip fracture that required hospitalization and a left partial hip replacement. The facility failed to ensure effective and timely interventions were in place after 11/27/23 to prevent Resident #95 from sustaining a fall on 1/9/24 which resulted in a left hip fracture. The facility failed to ensure effective interventions to prevent additional falls on 2/6/24 and 3/1/24. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#130) of three residents reviewed for colostomy care out of 53 sample residents. Resident #130 was admitted to the facility on [DATE] with diagnoses of cognitive-communication deficit, anxiety disorder and with toxic megacolon (swelling and inflammation of the colon) that required a colostomy (a surgical operation in which a piece of the colon was diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#26) of three out of 53 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #26 displayed slurred speech, confusion, and left sided weakness resulting in an admission to the hospital on 1/17/24. It was concluded he had suffered from a stroke and was readmitted to the facility on [DATE]. On 1/21/24, the resident weighed 161.9 pounds (lbs). On 2/19/24, a month later, Resident #26 weighed 143.3 lbs. which was a 11.49% weight loss and a difference of 18.6 lbs. On his next weight on 3/7/24 (during the survey), the resident weighed 137.6 lbs. which was a 3.98% loss and a difference of an additional 5.7 lbs with a total of 18.6 lbs and 15.02% weight loss. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email) and telephone numbers of all pertinent State Agencies and advocacy groups. Specifically, the group interview revealed the residents were not aware of where the State Agency phone numbers were posted in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents retained the rights to their personal belongings for two (#11 and #51) of five out of 53 sample residents. Specifically, the facility failed to obtain Resident #11 and Resident #51's permission prior to searching and confiscating items from their rooms.

Inspectors wroteBased on observations and interviews, the facility failed to ensure two (#6 and #56) of two residents reviewed for abuse out of 53 sample residents were free from abuse. Specially, the facility failed to prevent a resident to resident altercation between Resident #6 and Resident #56.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure that one (#19) of six residents out of 53 sample residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility failed to ensure Residents #19, residing on the secure locked unit, had the required documentation to justify such restrictions including documentation such as doctor orders, documentation reflecting secure/locked placement was the least restrictive approach possible and documentation the impact or reaction to the resident was assessed.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to one (#191) of three out of 53 sample residents to ensure a safe discharge from the facility. Specifically, the facility failed to provide evidence and documented confirmation that home health services were arranged upon Resident #191's discharge from the facility, per physician orders.

Inspectors wroteBased on interviews and record review, the facility failed to assist one (#60) of two sample residents reviewed for vision/ancillary services out of 53 sample residents. Specifically, the facility failed to offer to arrange Resident #60 an appointment for optometry services.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#101) of three residents reviewed for oxygen therapy was provided respiratory care consistent with professional standards of practice out of 53 sample residents. Specifically, the facility failed to: -Ensure Resident #101 received oxygen as ordered by the physician; and, -Ensure Resident #101's oxygen saturation level (amount of oxygen in the blood) was monitored appropriately.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in one of three units. Specifically, the failed to: -Ensure clean technique was followed during wound care for Resident #72; and, -Ensure wound care scissors were cleaned and disinfected according to standards of practice.

Inspectors wroteIV. Resident #119 A. Resident status Resident #119, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician's orders (CPO) diagnoses included legal blindness, cognitive communication deficit, muscle wasting and weakness, abnormalities of gait and mobility, and repeated falls. The minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition as evidenced by a brief interview for mental status with a (BIMS) score of five out of 15. The resident had severely impaired vision, adequate hearing, and did not reject care. The resident required extensive assistance from one staff member for toileting and personal hygiene. The resident needed limited assistance (guided maneuvering) with bed mobility and transfers. [...]

Inspectors wroteBased on observations and interviews the facility failed to provide a clean, safe, homelike environment for the residents, on four of seven hallways and in the common areas. Specifically the facility failed to: -Provide clean shared spaces throughout the facility, -Ensure shower rooms were clean and in good repair, -Ensure the walls were repaired throughout the facility, -Ensure the walls were painted throughout the facility, -Ensure the resident doors were in good repair, -Ensure the floor tiles were in good condition, -Ensure the call cords in resident bathrooms were clean, -Ensure the call light indicator above the resident doors were in good condition. I. Facility policy and procedures The Safe and Environment policy and procedure, revised December 2020, was received from the nursing home administrator (NHA) on 12/7/22 at 11:00 a.m. [...]

Inspectors wroteBased on record review and interviews, the facility failed to satisfactorily respond to resident grievances for food related concerns. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to ongoing food concerns.

Inspectors wroteBased on record review and interviews, the facility failed to take the necessary steps to ensure seven (#32, #46, #115, #124, #128, #131, and #296) of seven residents, who all resided on the secure memory care unit, were free from abuse out of 55 sample residents. Specifically, the facility failed to: -Prevent an altercation between Resident #296 and Resident #115; -Prevent an altercation between Resident #32 and Resident #128; -Prevent a secondary altercation between Resident #32 and Resident #128; -Prevent an altercation between Resident #46 and Resident #124; and, -Prevent an altercation between Resident #115 and Resident #131. Cross-reference F744, dementia care and services.

Inspectors wroteBased on record review and interviews, the facility failed to provide the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for three of three units within the memory care unit, affecting seven (#296, #115, #32, #128, #46, #124 and #131) of seven residents reviewed out of 55 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care to prevent resident-to-resident altercations in the memory care unit. Cross-reference F600, resident-to-resident abuse.

Inspectors wroteBased on record review and interviews the facility failed to ensure each resident had the right to formulate an advanced directive for one (#116) of three residents reviewed out of 55 sample residents. Specifically, the facility failed to: -Ensure the medical orders for scope and treatment (MOST) forms were completed accurately and thoroughly for Resident #116; -Ensure Resident #116 signed her MOST form upon completion to document end of life choice were of the resident choosing; -Obtain the legal paperwork for the resident's power of attorney before letting another person be entered on the Resident #116's MOST form as the resident legal medical power of attorney (MDPOA)

Inspectors wroteBased on observations, interviews, and record review the facility failed to implement an ongoing resident centered activities program to enhance the interests of, and support the physical, mental, and psychosocial well-being for two Residents (#119 and #101) of six residents out of 55 sample residents. Specifically, the facility failed to ensure: -Resident #119 and #101 were provided with meaningful activities and social engagement; -Ensure Resident #119 activities programming was adapted to meet his visual deficits and reduce boredom; -Ensure Resident #119 had staff assistance to engage in activities and social engagement; -Ensure Resident #101 had access to supplies for preferred independent activities that could be easily accessed in the resident's room.