Sunnyvale Gardens Post Acute

In the surveyor’s words

From the most serious findings on record at Sunnyvale Gardens Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 27, 2024

  Based on observation, interview and record review, the facility failed 1) To implement and inform all residents of their Smoking Policy upon admission. Census during the survey on 11/21/24 was 127. 2) To ensure a safe environment free from accidents when one (Resident 1) out of six sampled residents suffered burns from an electronic cigarette (e-cigarette, a cigarette-shaped battery-operated device that contains nicotine, flavorings, and other chemicals that create an aerosol that is inhaled into the lungs, used to simulate the experience of smoking tobacco) explosion. […]

• Actual harm, isolatedF689Aug 15, 2024

  Based on interview and record review the facility failed to provide required supervision and assistance and failed to implement a resident's minimum data set (MDS: clinical and functional assessment tool) assessment for assistance for bed mobility, transfers, toileting, ambulation, and risk for falls care plan for transfer and ambulation assistance, to prevent a fall on 2/3/2024 for one of 2 sampled residents (Resident 1). These failures resulted in Resident 1's fall and subsequent transfer to acute hospital (AH: where residents receive short term treatment for an urgent medical condition or severe illness) where Resident 1 was diagnosed with left wrist fracture (broken wrist bones). […]

• No harm, potential for more than minimal, widespreadF802Nov 18, 2024

  Based on observation, interview, and record review, the facility failed to ensure staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. One dietary support staff did not know how to properly test the sanitizer in the red bucket (bucket containing sanitizer solution used for sanitizing food contact surfaces), and 2. Two dietary support staff members did not correctly demonstrate how to calibrate a thermometer used to test food temperatures These failures had the potential to expose residents to bacterial contamination, which could result in food borne illnesses for all residents who consumed food from the kitchen. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF761Nov 18, 2022

  Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medication for two out of three medication storage rooms and three out of five medication carts, when: 1.Seven insulin (medication to treat high blood sugar) pens (devise to use to give preloaded insulin) had the pharmacy label on the caps instead of the body of the pens. 2.Two opened bottles of [MEDICATION(S)] ( medication used to treat anxiety disorder) were found in the medication refrigerator with no open date . 3.One inhaler (handheld portable device that delivered medication into the lungs) was found in the medication cart without open date. 4. […]

• No harm, potential for more than minimal, patternF550Nov 18, 2024

  Based on observation, interview, and record review, the facility failed to maintain dignity and privacy to five of five residents (Residents 29, 11, 100, 76 and 64) when: 1. Residents 29, 11, 100, and 76's personal information and care guide were posted in their rooms visible to their roommate's visitors; and, 2. Registered nurse L (RN L) did not close the privacy curtain and door during medication administration thru gastric tube (GT - a surgical opening into the stomach for administration of nutrition, and medications). These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: 1a. During an observation on 11/12/2024 at 11:18 a.m., inside Resident 29's room, Resident 29 was in bed. […]