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Deficiency Records for Sunny Ridge Operations LLC
A list of the most recent deficiencies for Sunny Ridge Operations LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sunny Ridge Operations LLC. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-08-19 | 2024-09-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-19 | 2024-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-11 | 2024-08-07 | 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 | 2024-07-11 | 2024-08-07 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-29 | 2024-04-05 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-28 | 2024-03-27 | Y |
| 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 | 2024-02-28 | 2024-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-28 | 2024-03-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-28 | 2024-03-27 | N |
| Use approved construction type or materials. | Fire Safety | 2024-02-29 | 2024-03-27 | 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 | 2024-02-29 | 2024-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-02-29 | 2024-03-27 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-01-17 | 2024-02-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-17 | 2023-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-17 | 2023-05-17 | 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 | 2023-04-17 | 2023-05-17 | 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 | 2023-04-17 | 2023-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-17 | 2023-05-17 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-27 | 2023-03-24 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-01-27 | 2023-03-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-27 | 2023-03-09 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-01-25 | 2023-02-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-25 | 2023-02-23 | 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 | 2023-01-25 | 2023-02-23 | N |
| 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 | 2023-01-25 | 2023-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-25 | 2023-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-25 | 2023-02-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-25 | 2023-02-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-25 | 2023-02-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-25 | 2023-02-23 | Y |
| Meet other general requirements. | Fire Safety | 2023-01-27 | 2023-02-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-27 | 2023-02-23 | 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 | 2023-01-27 | 2023-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-27 | 2023-02-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-01-27 | 2023-02-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-27 | 2023-02-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-21 | 2022-12-16 | 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 | 2022-11-21 | 2022-12-16 | Y |
| 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 | 2022-11-21 | 2022-12-16 | 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 | 2022-11-21 | 2022-12-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-21 | 2022-12-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-31 | 2022-10-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-31 | 2022-10-01 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-08-31 | 2022-10-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-08 | 2022-07-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-04 | 2022-04-28 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-04-04 | 2022-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-04 | 2022-04-28 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-01-24 | 2022-02-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-24 | 2022-02-24 | 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 | 2022-01-24 | 2022-02-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-24 | 2022-02-24 | N |
| Respond appropriately to all alleged violations. | Health | 2022-01-24 | 2022-02-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-24 | 2022-02-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-24 | 2022-02-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-24 | 2022-02-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-24 | 2022-02-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-24 | 2022-02-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-24 | 2022-02-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-24 | 2022-02-24 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-01-24 | 2022-02-24 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-01-24 | 2022-02-24 | 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 | 2022-01-24 | 2022-02-24 | N |
| 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 | 2022-01-24 | 2022-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-24 | 2022-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-24 | 2022-02-24 | N |
| Post nurse staffing information every day. | Health | 2022-01-24 | 2022-02-24 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Develop a communication plan. | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-21 | 2022-02-24 | 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 | 2022-01-21 | 2022-02-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-21 | 2022-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-27 | Not Fixed | N |
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