A list of the most recent deficiencies for Sunny Acres Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-07 | 2024-01-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-07 | 2023-12-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-07 | 2023-12-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-07 | 2023-12-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-08 | 2023-12-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-08 | 2023-12-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-08 | 2023-12-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-08 | 2023-12-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-12-08 | 2023-12-21 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-12-08 | 2023-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-08 | 2023-12-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-10-07 | 2023-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-17 | 2023-06-02 | Y |
| Develop a communication plan. | Fire Safety | 2023-02-08 | 2023-03-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-02-08 | 2023-03-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-08 | 2023-03-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-02-08 | 2023-03-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-08 | 2023-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-08 | 2023-03-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-03 | 2023-03-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-02-03 | 2023-03-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-03 | 2023-03-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-02-03 | 2023-03-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-03 | 2023-03-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-03 | 2023-03-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-03 | 2023-03-01 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-11-17 | 2022-12-09 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-11-03 | 2022-12-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-03 | 2022-12-02 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-25 | 2022-04-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-25 | 2022-04-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-03-25 | 2022-04-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-25 | 2022-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-25 | 2022-04-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-25 | 2022-04-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-25 | 2022-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-25 | 2022-04-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-25 | 2022-03-25 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-12-01 | 2021-12-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-14 | 2021-09-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-08 | 2021-09-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-16 | 2021-09-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-01 | 2021-07-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-27 | 2021-06-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-14 | 2021-05-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-14 | 2021-05-02 | Y |
