Deficiency Records for Avamere Transitional Care at Sunnyside
Updated as of March 01, 2024
A list of the most recent deficiencies for Avamere Transitional Care at Sunnyside. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-26 | 2024-03-12 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-26 | 2024-03-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-26 | 2024-03-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-26 | 2024-03-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-26 | 2024-03-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-26 | 2024-03-12 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-01-26 | 2024-03-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-26 | 2024-03-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-26 | 2024-03-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-26 | 2024-03-12 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-26 | 2024-03-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-03-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-26 | 2024-03-12 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-01 | 2024-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-01 | 2024-03-12 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-10-06 | 2023-10-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-07 | 2023-10-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-07 | 2023-10-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-09-07 | 2023-10-19 | 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 | 2023-09-07 | 2023-10-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-07 | 2023-10-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-07 | 2023-10-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-10-19 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-09-07 | 2023-10-19 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-09-07 | 2023-10-19 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-09-07 | 2023-10-19 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-09-07 | 2023-10-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-07 | 2023-10-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-07 | 2023-10-19 | Y |
| Keep all essential equipment working safely. | Health | 2023-09-07 | 2023-10-19 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-12-29 | 2023-01-16 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-07 | 2022-12-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-07 | 2022-12-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-07 | 2022-12-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-07 | 2022-12-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-07 | 2022-12-06 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-07 | 2022-12-06 | 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 | 2022-11-07 | 2022-12-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-07 | 2022-12-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-07 | 2022-12-06 | N |
| Provide or obtain dental services for each resident. | Health | 2022-11-07 | 2022-12-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-07 | 2022-12-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-07 | 2022-12-06 | Y |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-11-07 | 2022-12-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-11-07 | 2022-12-06 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-07 | 2022-12-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-04 | 2022-08-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-04 | 2022-08-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-09 | 2022-07-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-09 | 2022-07-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-09 | 2022-07-12 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-09 | 2022-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-09 | 2022-07-12 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-09 | 2022-07-12 | Y |
| 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 | 2022-06-22 | 2022-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-22 | 2022-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-22 | 2022-07-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-22 | 2022-07-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-22 | 2022-07-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-22 | 2022-07-12 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-09 | 2022-07-12 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-04-18 | 2022-05-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-18 | 2022-05-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-18 | 2022-05-17 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-18 | 2022-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-18 | 2022-05-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-18 | 2022-05-17 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-18 | 2022-05-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-09 | 2022-01-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-09 | 2022-01-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-09 | 2022-01-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-09 | 2021-12-16 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-11-09 | 2021-12-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-09 | 2021-12-16 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-09 | 2021-12-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-09 | 2021-12-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-09 | 2021-12-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-09 | 2021-12-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-09 | 2021-12-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-11-09 | 2021-12-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-09 | 2021-12-16 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-09 | 2021-12-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-09 | 2021-12-16 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-11-09 | 2021-12-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-09 | 2021-12-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-09 | 2021-12-16 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-11-09 | 2021-12-16 | Y |
