Sunny Acres Skilled Nursing and Rehabilitation CTR

In the surveyor’s words

From the most serious findings on record at Sunny Acres Skilled Nursing and Rehabilitation CTR, in the surveyor’s own words.

• Actual harm, isolatedF760Aug 11, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was free from a significant medication error. While at an outside provider appointment on 7/05/22, Resident #1 was assessed to have a change in mental status, and upon speaking to nursing staff at the Facility it was determined that Resident #1 had not been administered [MEDICATION(S)] as ordered for several days (missing a total of seven doses). Resident #1 was transferred to the Hospital Emergency Department for evaluation, and admitted related to mental status changes caused by the abrupt cessation in his/her [MEDICATION(S)]. […]

• Actual harm, isolatedF689Jun 15, 2022

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was non-ambulatory, had a diagnosis of [CONDITION(S)] (paralysis of the legs and lower body), and therefore had no control or feeling in his/her bilateral lower extremities (legs and feet), the Facility failed to ensure he/she was provided with assistive devices (bilateral leg/foot rests) for his/her wheelchair, in an effort to prevent incidents/accidents resulting in an injury. - On 05/29/22, Certified Nurse Aide (CNA) #1 transferred and repositioned Resident #1 in his/her wheelchair but did not attach leg/foot rests to the wheelchair to support his/her bilateral lower extremities. […]

• No harm, potential for more than minimal, widespreadF882Feb 27, 2023

  Based on interview, the facility failed to ensure its staff designated an Infection Preventionist (IP) who had completed specialized training in infection prevention and control prior to assuming the role of IP at the facility. Specifically, the facility designated an IP in November 2022 who had not completed specialized training in infection prevention and control before assuming the IP role, still had not completed the specialized training by the time survey began in February 2023 and continued to work as the designated IP at the facility. Findings include: During an interview on 2/22/23 at 7:52 A.M., the Director of Nurses (DON) said the facility's designated IP had not yet completed specialized training in infection prevention and control as required. […]

• No harm, potential for more than minimal, patternF812Feb 27, 2023

  Based on observation, policy review, and interview, the facility failed to ensure its staff maintained a clean and sanitary environment in the kitchen where food items were stored for resident consumption. The facility also failed to ensure its staff adhered to food storage requirements in the kitchen. Specifically, the facility failed to ensure its staff: 1) labeled and dated all open food stored for resident consumption, in the kitchen's reach-in refrigerator and freezer, 2) kept scoops from directly touching the ice and rice, 3) maintained a sanitary surface where clean dishes and pans were stored, and 4) maintained the microwave to be free of dried food and debris. […]

• No harm, potential for more than minimal, patternF880Feb 27, 2023

  Based on observation, record review, and interview, the facility failed to ensure its staff implemented infection control practices relative to 1) the facility's water management program, to provide a safe, sanitary, and clean water supply, for all residents and staff, and 2) required hand hygiene practices during care of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) for one Resident (#54), out of a total sample of 18 residents. Specifically, the facility failed to ensure its staff: a) cleaned the ice machine every three months, as indicated in the facility's water management program, as an intervention to prevent waterborne pathogens, and b) implemented proper hand hygiene practices before and after glove use during a dressing change for… […]