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Deficiency Records for Sunnyside Conv. Hospital
A list of the most recent deficiencies for Sunnyside Conv. Hospital. 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 Sunnyside Conv. Hospital. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-16 | 2024-06-04 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-01-04 | 2024-03-01 | 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 | 2023-08-22 | 2023-09-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-22 | 2023-09-05 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-16 | 2023-08-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-06-16 | 2023-08-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-16 | 2023-08-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-16 | 2023-08-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-16 | 2023-08-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-16 | 2023-08-01 | 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 | 2023-06-16 | 2023-08-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-16 | 2023-08-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-16 | 2023-08-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-16 | 2023-08-01 | 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 | 2023-06-16 | 2023-08-01 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-06-16 | 2023-08-01 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-06-16 | 2023-08-01 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-16 | 2023-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-16 | 2023-08-01 | N |
| Dispose of garbage and refuse properly. | Health | 2023-06-16 | 2023-08-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-16 | 2023-08-01 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-06-16 | 2023-08-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-16 | 2023-08-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-16 | 2023-08-01 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-21 | 2023-07-21 | 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 | 2023-06-21 | 2023-07-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-21 | 2023-07-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-05-30 | 2023-07-14 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-05-30 | 2023-07-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-05 | 2023-04-16 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-05 | 2023-04-16 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-16 | 2023-04-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-16 | 2023-04-05 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-03-16 | 2023-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-08 | 2022-12-05 | Y |
| Provide appropriate foot care. | Health | 2022-11-08 | 2022-12-05 | Y |
| 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 | 2022-11-08 | 2022-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-08 | 2022-12-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-08 | 2022-12-05 | Y |
| 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 | 2022-11-08 | 2022-12-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-08 | 2022-12-05 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-07-15 | 2022-09-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-15 | 2022-07-23 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-07-15 | 2022-07-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-20 | 2022-04-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-01 | 2021-12-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-01 | 2021-12-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-31 | 2020-02-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-31 | 2020-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2020-02-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-31 | 2020-02-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-31 | 2020-02-21 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-10-31 | 2020-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2020-02-21 | N |
| Dispose of garbage and refuse properly. | Health | 2019-10-31 | 2020-02-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-10-31 | 2020-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2020-02-21 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-10-31 | 2020-02-21 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-14 | 2019-12-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-11-14 | 2019-12-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-11-14 | 2019-12-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-14 | 2019-12-31 | 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 | 2019-11-14 | 2019-12-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-14 | 2019-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-14 | 2019-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-14 | 2019-12-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-14 | 2019-12-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-14 | 2019-12-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-14 | 2019-12-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-30 | 2019-04-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-11-30 | 2019-04-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-30 | 2019-04-03 | N |
| 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 | 2018-11-30 | 2019-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-30 | 2019-04-03 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-11-30 | 2019-04-03 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-11-30 | 2019-04-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-30 | 2019-04-03 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2018-11-30 | 2019-04-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-11-30 | 2019-04-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-12-03 | 2019-01-10 | 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 | 2018-12-03 | 2019-01-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-03 | 2019-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-03 | 2019-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-03 | 2019-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-03 | 2019-01-10 | N |
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