Sunnyside Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . Based 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 their inability to participate fully in daily activities to the highest extent possible. Findings included . Resident 13 Review of the resident's medical record showed they were admitted to the facility with diagnoses which included. Alzheimer disease (a progressive brain disorder that slowly destroys memory) and congestive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included .Review of the facility's guidance titled, Central Venous Catheter Care and Dressing Change, revised June 2025, showed the facility's purpose was to prevent complications associated with intravenous therapy (IV, the administration of medications or fluids directly into a person's vein) and central line related infections .with contaminated, loosened, soiled, or wet dressings.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings included .Review of the 09/2020 policy titled Skin at Risk/Skin Breakdown showed when a resident has a PI, they were to receive treatment and services to promote healing, prevent infection, and prevent worsening or new PIs. The policy showed when a new PI was identified the Licensed Nurse (LN) would document the skin impairment (measurements, size, and description), assess pain, document on the skin form, notify the provider and obtain new orders, update the Treatment Administration Record (TAR), and notify the Resident Representative (RR). Additionally, the policy showed if the PI was identified after admission, the LN was to initiate alert charting,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . Record review of the facility's policy titled Catheter Care, Urinary dated 08/2022 showed that staff were to always position the drainage bag lower than the resident's bladder to prevent urine from flowing back into the urinary bladder. Review of Lippincott's Essentials for Nursing Assistants 4th edition page 574 showed, * Raising the urine drainage bag up higher than the bladder can cause old, contaminated urine to run back into the bladder, which can lead to infection. * Always make sure that the drainage bag is placed at a level lower than the person's bladder. Resident 52 Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . Laundry Room During a concurrent observation and interview on 12/10/2025 at 4:30 PM, Staff E, Maintenance Director, was in the laundry's dirty linen sorting room with the surveyor. On the wall, by the door that entered the rest of the laundry area, was a six inch (a unit of measure) long by five inches wide hole in the dry wall behind the rubber base board that was peeling off. The section of missing dry wall had been broken into numerous pieces that lay in a pile below the hole in the wall. Staff E stated they were unsure of what happened, but it needed to be fixed and was an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), paraplegia (the loss of muscle function in the lower half of the body, including both legs), and depression. The 03/27/2025 comprehensive assessment showed Resident 1 was independent with activities of daily living (ADLs); dependent on one to two staff for transfers and showering. The assessment also showed Resident 1 was cognitively intact. A concurrent observation and interview on 06/17/2025 at 12:16 PM, showed Resident 1 sitting in their wheelchair in their room at their over the bed table. They stated they were waiting for their lunch tray. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . Review of a policy titled, Sanitation, dated 11/2022, showed the facility would maintain a clean and sanitary food service area. During an interview on 03/25/2025 at 3:58 PM, Staff F, Maintenance Director, stated there was a pipe under the kitchen floor, about four feet underground that had broken. They stated they had put the restrooms, located on the other side of the kitchen wall of the dishwasher area, out of service and the doors were locked so they could not be used. They stated the dishwasher was also out of service, not because it was broken, but because it could not drain. They stated the incident happened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . Review of a policy titled, Resident Rights, dated 02/2021, showed federal and state laws guarantee certain rights to all residents, including the right to a dignified existence and the right to be treated with respect, kindness, and dignity. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including heart failure, arthritis, and weakness. The 03/12/2025 comprehensive assessment showed Resident 1 required substantial assistance of one staff member for activities of daily living and supervision for eating. The assessment also showed Resident 1 had a moderately impaired cognition. Resident 1 was able to make their needs known. A concurrent observation and interview on 03/25/2025 at 3:16 PM, showed Resident 1 sitting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including rheumatoid arthritis (a chronic arthritis that affects the small joints in the hands and feet, often causing joint deformity) and muscle weakness. The 12/09/2024 comprehensive assessment showed Resident 2 was independent with eating. The assessment also showed Resident 2 was cognitively intact. A concurrent observation and interview on 03/26/2025 at 11:59 AM, showed Resident 2 lying in bed. Both hands were on top of the blankets and showed deformed fingers. Resident 2 was able to slightly flex their fingers with difficulty. They stated they preferred to eat with metal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . <Dining Rooms> An observation in the Garden DR on 01/30/2025 at 10:19 AM, showed a white vent to the wall directly across from the refrigerator had visible built-up brown dust to the slats that extended to the white walls surrounding the vent. The DR showed three white vents along the length of the window that also had built-up brown dust to the slats. An observation in the Private DR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . Record review of the facility's policy titled, Pain Assessment and Management, dated 10/2022, showed that when opioids were used for pain management, the resident was monitored for medication effectiveness. Record review of the facility's policy titled, Charting and Documentation, dated 04/2008, showed that all medications administered must be documented in the resident's clinical record that included date and time medication given, assessment data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . Review of the policy titled Medication Administration-General Guidelines dated 08/2018, showed LNs would follow the Five Rights of medication administration: right resident, right drug, right dose, right route, and right time. The five rights should be followed with each medication and verified three times; when the medication is selected, removed from the container, and after the dose was prepared and put away. Review of the policy titled Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy dated 08/2018, showed medications would be ordered five to seven days before running out to ensure adequate supply is on hand.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . <Ceiling> During an observation on 11/17/2024 at 9:00 AM, the ceiling over the hood where the dishwasher was located had chunks of plaster and dry wall locate on top of the hood. Above was part of missing plaster and or dry wall which had been missing and fell onto the hood. Additionally, there were hanging dust balls on the ceiling over the freezers and refrigerators in a 10-foot span across the ceiling with fuzzy black spots. During an interview on 11/17/2024 at 9:05 AM, Staff H, Dietary Manager (DM), stated that there had been a water leak above the area of where the dishwasher/hood had been located and it was patched. The ceiling fell out onto the hood and had been there for some time. They reported it to maintenance and the administrator.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . Review of the facility's policy titled, Room/Roommate & Change Notification, updated 05/2022, showed the Social Services Director/Designee notifies the resident and/or representative of the new room change or roommate (prior to the change), documents the decision and notification in the medical record and monitors the resident's acclimation to the new environment/roommate for 24 hours and documents in the medical record. <RESIDENT 6> Review of the medical record showed Resident 6 admitted on [DATE] with diagnosis to include blindness, anxiety (a feeling of worry, nervousness, or unease). The 09/30/2024 comprehensive assessment showed that the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . Review of the facility's policy titled, Abuse - Screening, Training, Identification, Investigation, Reporting, and Protection, revised January 2023, showed that it was the facility's policy to report allegations of abuse to the appropriate reporting authority. <Resident 69> Review of the resident medical record showed they were admitted on [DATE] with a diagnosis including heart complications. Review of the 10/10/2024 comprehensive assessment showed the resident was cognitively intact an able to make their needs known. During an interview on 11/17/2024 at 3:42 PM, Resident 69 stated a night shift nursing assistant (NA) was rough when assisting the resident with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . Review of the facility's policy titled, Abuse - Screening, Training, Identification, Investigation, Reporting, and Protection, revised January 2023, showed that it was the facility's policy to protect residents from abuse and .All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated . The policy showed that facility staff were to identify inappropriate behaviors such as .derogatory language, rough handling . and that if a staff member was involved in allegation of abuse they were to be removed from their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . Review of the Code of Federal Regulations 483.70 (m)(2)(i,ii), F847 Entering Into Binding Arbitration Agreements, showed the facility must ensure the agreement is explained to the resident and/or their representative in a form and manner that the resident understands. The resident or their representative acknowledges that they understand the agreement. <Resident 72> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnosis including fracture of leg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarifying Requirements to Reduce Legionella Risk in Healthcare Facility Water Systems, dated 09/18/2018, showed the facility's WMP must, at a minimum: • Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of dementia (a disease causing impaired ability to remember and interferes with ability to complete everyday tasks), heart attack (event that occurs when blood flow to the heart muscle is blocked causing the muscle to die and the heart to not operate as efficiently), stroke (event that occurs when blood flow to the brain is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . Review of the facility's undated policy titled Federal Resident Rights, stated residents must be treated with respect and dignity and ensure residents could exercise their rights without interference or retaliation from the facility. Review of Centers for Medicare and Medicaid Services (CMS) guidance §483.10(a)-(b)(1)&(2) in Appendix PP, last revised on 02/03/2023, for treating residents with dignity and respect while dining, showed staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . <Restorative Nursing> <Resident 24> Review of Resident 24's medical record showed they were admitted to the facility on [DATE] with a diagnosis of myasthenia gravis (a condition that causes muscle weakness). The most recent assessment, dated 09/13/2023, showed the resident was not ambulatory (able to walk around) and required extensive assistance from two staff members for standing transfers and mobility. The resident was alert and cognitively intact. Review of Resident 24's care plan, dated 09/15/2023, showed the resident had a restorative nursing program (a program that promotes the resident's ability to adjust to living as independently and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . Review of the facility's policy titled, Hand Hygiene, revised 12/15/2021, showed the recommended process for washing hands included wetting the hands with clean, warm, running water, applying soap, rubbing hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers, then rinsing hands with water and drying thoroughly with a disposable towel. Alcohol based hand rub (ABHR) could be used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . <Resident 24> Review of Resident 24's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of myasthenia gravis (a progressive disease that causes muscle weakness). Review of Resident 24's most recent assessment, dated 09/13/2023, showed the resident was cognitively intact and required extensive assistance from two staff members for standing and transfers. Review of the resident's most recent care plan, dated 09/15/2023, showed the resident had a restorative nursing program, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Finding included . Review of the Instructions for use by the U.S. Food and Drug Administration, (USFDA) dated 12/2022, showed to keep the needle in the skin for at least 6 seconds, and keep the push button pressed all the way in until the needle has been pulled out of the skin. This process is to ensure the full dosage was provided. <Resident 38> Review of Resident 38's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including Diabetes (a disease that results in too much sugar in the blood)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included . Review of the facility's policy Medication Administration General Guidelines, dated 01/2023, stated nurses should date the medication when the medication was opened, and some multi-dose vials have shortened expiration dates once opened, to ensure medication purity and potency .expiration dates were to be checked and expired medication will not be administered to residents. Review of the U.S. Food and Drug Administration's (USFDA) Information Regarding Insulin Storage, dated 09/19/2017, showed insulin contained in vials supplied by manufacturers may be used up to 28 days. During and observation and concurrent interview on 10/06/202 at 11:35 AM, Staff G, Licensed Practical Nurse, retrieved a vial of Insulin from Hall 100 medication cart drawer that had a date of 07/24/2023 on a vial of insulin.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.