Pennsylvania Department of Health
SUNNYVIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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SUNNYVIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  106 surveys for this facility. Please select a date to view the survey results.

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SUNNYVIEW NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to three complaints, completed on January 24,2024, it was determined that Sunnyview Nursing and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to implement infection prevention and control monitoring policies for one of three residents (Resident R1).

Review of facility policy "Transmission Based Precautions" 4/28/2023, indicated transmission-based precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. When transmission-based precautions are implemented the infection preventionist or designee shall post the appropriate notice on the room entrance door so that all personnel will be aware of precautions or be aware that they must see nurse to obtain additional information about the situation before entering the room. The facility will implement a system to alert staff to the type of precautions resident requires.

Review of the Facility's system for identification of contact precautions for staff and visitors. Place signage that includes instructions for the identification of contact precautions for staff and visitors. Place signage that includes instructions for the use of a specific personal protective equipment (PPE) in a conspicuous location outside the resident's room. The facility will implement a system to alert staff to the type of precaution resident requires. Contact precautions require use of gown and gloves on every entry into a resident's room, regardless of the level of care. Residents are restricted to their rooms and/or restricted for participation in group activities. In addition, implement droplet precautions (large particle droplets that can be generated by the individual coughing, sneezing, talking) for an individual documented or suspected to be infected with microorganisms transmitted by droplets. Place the resident in private room if possible. When a private room is not available, residents with the same infection with the same microorganism but with no other infection may be cohorted. When a private room is not available and cohorting is not achievable, use a curtain and maintain at least 3 feet of space between the infected resident and other residents and visitors.

Observation on 1/24/24 at 10:00 a.m. on sunflower unit indicated a door with yellow partitioned storage bin, items available were N95 mask, face shields, gloves, and gowns. No sign identifying contact precautions, or to see nurse prior to entering was present.

During an observation 1/24/24 at 10:41 a.m. Resident was noted to be sitting in her room with a visitor, neither utilizing personal protective equipment, not maintaining 3 feet of space between.

Interview 1/24/24 10:42 a.m. Resident R1 and visitor indicated unaware of usage for items in yellow storage bin on door.

Review of Resident R1's nursing progress notes 1/18/24, 2:48 p.m. indicated admitted to facility Covid positive.

Review of Resident R1's diagnosis indicated Covid 19, dementia, hypertension (high blood pressure).

Review of Resident R1's physician orders 1/18/24, indicated Covid isolation for 10 days every shift for Covid positive.

Review of Resident R1's care plan 1/18/24, indicated active diagnosis of Covid 19.

Review of Resident R1's treatment record 1/18/24, indicates documentation for Covid isolation for 10 days.

Interview on 1/24/24, 11:06 a.m. with RN Employee E5 indicated that resident R1 was in contact and droplet precautions with a diagnosis of Covid 19. RN Employee E5 confirmed that no signage was on door.

Interview on 1/24/24, at 1:30 p.m. with RN Employee E1confirmed that resident was in contact and droplet precautions and that no signage was on door.

Interview on 1/24/24, at 2:30 p.m. the Director of Nursing confirmed the facility failed to implement infection prevention and control monitoring policies for one of two residents (Resident R1).

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

28 Pa. Code: 211.12(d)(3) Nursing services.


 Plan of Correction - To be completed: 02/21/2024

On 1.24.2024, the appropriate isolation signage was replaced on the door of the resident room on Sunflower unit.

An audit of current residents with active infections will be conducted by Infection Preventionist to ensure isolation signage is in place as indicated.

Re-education to nursing staff will be conducted by the Infection Preventionist/designee related to maintaining proper infection control signage according to Transmission Based precautions policy.

Audits of isolation precaution signage on nursing units will be conducted by Infection Preventionist/designee 3 x's week for 4 weeks. Report of findings will be given to QAPI committee for review.


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