Sunnybrook Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sunnybrook Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF835Jun 27, 2023

  Based on record review, resident and staff interviews the facility failed to provide effective oversight and leadership to correct an identified issue of a resident (Resident #4) being discharged from the facility with another resident ' s medication (Resident #8). This discharge occurred on 4/6/23 and the facility was notified of the error by Resident #4 on 4/17/23. On 5/16/23 the error occurred again when Resident #2 was discharged with medication prescribed for Resident #6. This affected 2 of 4 sampled residents reviewed for discharge and had the high likelihood for serious adverse outcomes for any resident discharged from the facility. […]

• Immediate jeopardy, isolatedF678Jun 8, 2026

  Based on observation, record review, and interviews with staff, Emergency Medical Services (EMS) staff, Nurse Practitioner, and Medical Director, the facility failed to ensure basic lifesaving support was provided effectively when there was a delay in initiating Cardio Pulmonary Resuscitation (CPR) to a resident who had no signs of life and was a full code (an official directive to perform all necessary life-sustaining measures, including CPR and defibrillation, if a person stops breathing or their heart stops). […]

• Immediate jeopardy, isolatedF684Aug 18, 2023

  Based on record review, staff, friend, Nurse Practitioner, Physician Assistant and Medical Director interviews, the facility failed to monitor 1 of 1 resident (Resident #1) when her blood sugar was dangerously high, 544 milligrams per deciliter (normal blood sugar levels are considered to be between 70mg/dL (milligrams per deciliter) to 100mg/dL). Fast-acting insulin (Humalog insulin 12 units) was administered to Resident #1 by Nurse #1 on 8/5/23 at 5:47 PM. On 8/5/23 at 9:00 PM Nurse #1 found Resident #1 unresponsive, and her blood sugar was 33mg/dL, critically low. […]

• Immediate jeopardy, isolatedF660Jun 27, 2023

  Based on record review, interviews with resident, family member, pharmacist, physician, and staff the facility failed to implement an effective discharge plan when 2 residents (Resident #2 and Resident #4) were discharged to the community with medications that were prescribed for other residents. On 4/6/23 Nurse #2 provided Resident #4 with medications prescribed for Resident #8 and on 5/16/23 Nurse #1 provided Resident #2 with medications that were prescribed for Resident #6. Resident #4 reported not feeling well and was assessed by Emergency Medical Services in his home with no negative outcome or treatment required. Resident #2 suffered an allergic reaction and was hospitalized for baclofen (a muscle relaxer) toxicity. […]

• Actual harm, isolatedF697Jun 21, 2024

  Based on record review, resident interview, staff interview, and pharmacy manager interview the facility failed to obtain and administer narcotic pain medication as ordered for moderate to severe pain for one (Resident #3) of one resident reviewed for pain control. The findings included: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses some of which included a healing hip fracture, anxiety disorder, and depression. Documentation on the hospital medication administration record (MAR) revealed Resident #3 was administered one tablet of Acetaminophen 650 milligrams (mg) and one tablet of Oxycodone 5 mg immediate release on 6/14/2024 at 5:18 PM. […]