Avamere Transitional Care at Sunnyside

In the surveyor’s words

From the most serious findings on record at Avamere Transitional Care at Sunnyside, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 9, 2021

  1. Based on observation, interview, and record review it was determined the facility failed to provide supervision for swallowing safety for 5 of 22 residents (#s 20, 25, 26, 27 and 28) identified at risk for aspiration and who were to be supervised while eating. All identified residents were observed to be left unattended with meals and/or fluids during continuous observations. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: The 8/2017 Dysphagia Diets and Aspiration Precautions policy statement indicated residents with observed indicators of dysphagia or required altered textures and/or thick liquids would have general aspiration precautions taken. a. […]

• Actual harm, isolatedF550Jun 9, 2022

  Based on interview and record review it was determined the facility failed to ensure a resident who was continent was not checked by CNA staff for incontinence for 1 of 3 sampled residents (#1) reviewed for dignity. This caused Resident 1 to have increased anxiety, persistent anger and tearfulness. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/26/22 Admission Nursing Database indicated Resident 1 was alert, oriented but was agitated. The resident was assessed to be continent of bowel and bladder and independent with transfers, toileting and bed mobility. The resident usually went to bed at 9:00 PM and woke up at 8:00 AM. […]

• Actual harm, isolatedF686Nov 9, 2021

  Based on interview and record review it was determined the facility failed to assess and monitor a pressure ulcers for 1 of 3 sampled residents (#10) reviewed for pressure ulcers. This resulted in a worsening pressure ulcers. Findings include: Resident 10 was admitted to the facility in 8/27/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 8/27/20 Admission Nursing Database revealed Resident 10 was admitted to the facility with blanchable redness to her/his bilateral heels [indicating no pressure ulcers]. The 9/11/20 Facility Investigation revealed Resident 10's right heel had a blood blister or maroon area which measured 3.3 cm x 2.5 cm. The left heel had a blood blister which popped and was now a reddened area which measured 1.7 cm x 3.2 cm. […]

• Actual harm, isolatedF697Nov 9, 2021

  Based on interview and record review it was determined the facility failed to ensure residents received pain medications timely for 1 of 6 sampled residents (#7) reviewed for physician orders. This in resulted Resident 7 experiencing unrelieved pain and placed residents at increased risk for pain and psychosocial harm. Findings include: Resident 7 admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 7/26/21 BIMS indicated Resident 7 was cognitively intact. The 9/22/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF760Nov 9, 2021

  Based on interview and record review it was determined the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Resident 22 being hospitalized and placed residents at risk for adverse drug reactions. Findings include: 1. Resident 22 admitted to the facility in 1/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 9/14/21 Skin and Wound Evaluation indicated Resident 22 had a facility acquired open lesion to the lower right abdomen. The wound appeared two weeks prior, measured 1.8 cm x 0.6 cm and had no signs of infection. Treatment was in place. The 9/22/21 Progress Notes revealed the abdominal wound was raised, red, warm to touch, painful with moderate yellow drainage. […]