Sunny Hills Assisted Living (memory Care)

Based on observation and record review, the licensee did not comply with the section cited above in four (4) out of five (5) Staff S1-S4 did not have First Aid/CPR, which poses/posed a potential health, safety or personal rights risk to persons in care.

Regular observation and documentation of resident changes

The licensee shall ensure that residents are regularly observed for changes in physical... and... assistance is provided when such observation reveals unmet needs. When changes... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and... responsible person...This requirement was not met as evidence by: Based on interviews and record review, the licensee did not ensure R1 receive assistance after fall(s) and complaints of low back pain. This posed an immediate health risk to resident.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This regulation is not met as evidenced by: Based on interview with S1 revealed that two staff members admitted to putting multiple diapers on a resident which poses a potential health and safety risk to persons in care.

Personal rights of residents in all facilities

87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This regulation is not met as evidenced by: Based on interview with S1 revealed that two staff members admitted to putting multiple diapers on a resident which poses a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in not haveing an evacuation chair, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 3 out of 5 resident records not having an updated Medical Assessment and Appraisal & Needs Service Plan, which poses a potential health, safety or personal rights risk to persons in care.

Health screening and fitness requirements

Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff records did not have a health screening report and a tuberculosis test, which poses a potential health, safety or personal rights risk to persons in care.

On-the-job training requirements

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance Based on file review, observation, and interviews the licensee failed to provide on the job training to staff. Investigation revealed staff did not receive job specific trainings which poses a potential health andsafety hazard for residents in care.

Facility personnel sufficiency and competence

87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by. Based on interviews, record review Licensee did not insure to have sufficientnumber of compitenat staff. During 8 hours shift staff is only assisting residents requiring extensive care. This possess potential Health & Safety risk to residents in care.

Maintain separate complete record for each resident

87506 Resident Record (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Based on file review, and observation the licensee failed to maintain a complete and current record for residents in care. During record review LPA observed the MAR for 05/20/23 is incomplete. Which poses a potential health and safety hazard for residents in care.

General Food Service Requirements. (b) The following food service requirements shall apply: (6) In facilities for 16 persons or more, menu shall be written at least 1 week in advance & copies of the menu... shall be dated & kept on file... This requirement is not met as evidenced by. LIcensee did not ensure that the facility menu is meeting food services requirement. 5 out of 7 day resident are served the same food for breakfast . This poses a potential personal rights violation to residents in care.

Planned Activities (f) In facilities licensed for 50 persons or more, 1 staff member shall have full-time responsibility to organize, conduct, planned activities... The activities shall be written, planned in advance.. be available to all residents… This requirement is not met as evidenced by. Based on observation & record review Licensee did not provide planned activities as required. This posses potential personal right risk to resident in care.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair...Maintenance shall include...maintenance services and procedures...of residents, employees and visitors.This requirement was not met at evidenced by: Based on observations and interviews conducted, the licensee failed to ensure that the facility was clean, safe and sanitary on 10/19/2022. LPA observed evidence of rats presence at facility which poses a potential health, safety and personal rights risk to residents in care.

Facility maintenance and healthful environment

Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement was not met as evidenced by: Based on observations and interviews conducted, the licensee failed to provide a safe and healthful environment, on 10/19/2022 LPA and LPM observed evidence of cockroaches in resident bedrooms which poses a potential health, safety and personal rights risk to residents in care.

87468.1(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on observation and interviews the facility had bed bugs which poses a potential health, safety to persons in care.

87468.1(3)3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.his requirement is not met as evidencedby: based on obervation and interviews the facility locked residents in their rooms. Which poses a potential health, safety to persons in care.