Inspection Reports for
Sunny Ridge

.009.01 Criminal History and Background Check: one of four employees did not have a Department Criminal History and Background Check completed as confirmed by the administrator and human resources director.

.009.06.c Use of Previous Criminal History and Background Check: one employee did not have the Idaho State Police background check completed prior to working alone with residents; the check was still pending at the time of survey.

.215.01 Administrator Responsibility: the administrator did not ensure all facility policies were developed to fulfill IDAPA16.03.22; the abuse/neglect/exploitation policy lacked required definitions, reporting procedures, documentation, investigation steps, and interventions to prevent recurrence; technical assistance was previously given on October 7, 2022.

.250.09 Plumbing: the facility's water temperatures were not consistently maintained between 105 and 120 degrees F; on 7/1/24 and 7/2/24, water temperatures in several resident rooms ranged from 131 to 137 degrees F, and the maintenance person was unaware of the high temperatures.

.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a clean, safe and orderly manner; observed issues included cracked and chipped tile around the shower room door jamb, chipped and missing laminate on nurse's station countertops, separating baseboards, a strong urine odor in a resident's room, and scratched and gouged exit doors.

.319 Comprehensive Assessment Requirements: Resident #2 did not have a comprehensive assessment, including a nursing assessment, completed prior to admission on 3/2/23 as confirmed by the administrator.

.404 Fire and life safety standards: no documented weekly or monthly inspections for dry system and wet system gauges and control valves, and no documented emergency light testing monthly or annually.

.405.03 Medical gases: signs for oxygen use were not placed at rooms 101 and 110 or their entrances as required.

.405.04 Fuel-fired heating: no documented annual inspection for fuel-fired heating.

.260.07 Toxic Chemicals: toxic chemicals were observed to be stored in an unlocked area accessible to cognitively impaired residents on three occasions from 10/5/22 to 10/6/22.

.305.02.b Current Medication Orders and Treatment Orders: the facility did not ensure residents received their diets as ordered; Resident #2 was not provided a mechanical soft diet and Resident #1 was not provided a consistent or controlled carbohydrate diet on 10/5/22 and 10/6/22.

F 0578 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: the facility failed to help 1 of 7 residents develop an advance directive, with no documentation that Resident #18 was offered information to formulate an advanced directive.

F 0641 Ensure each resident receives an accurate assessment: the facility failed to ensure MDS assessments accurately reflected residents' status for 2 of 13 residents; Resident #3's PASRR Level II was not coded correctly and Resident #6 was incorrectly coded as having a foley catheter when she did not.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to include toenail care in the comprehensive care plan for Resident #32, who had brittle, thick, and discolored toenails possibly indicating fungal infection.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide toenail care services to Resident #32, placing her at risk of social embarrassment due to the appearance of her toenails and lack of referral to the podiatrist.

F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to ensure professional standards of practice for Resident #49's psychotropic medication; the indication for Mirtazapine was not clarified.

F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to adequately assess and provide nutritional needs for Resident #32 who experienced significant weight loss; dietary preferences were not documented or communicated, and non-dairy supplements were unavailable.

F 0761 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: expired medications were found in two medication carts and the medication storage room, and refrigerator temperature logs were not updated for several days.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to maintain a clean and sanitary kitchen environment, including staff not wearing hair nets, serving undercooked eggs, improper food temperature monitoring, cross-contamination risks, inadequate cleaning and sanitizing of equipment, and use of damaged cooking utensils.

F 0880 Provide and implement an infection prevention and control program: the facility failed to perform hand hygiene and don gloves appropriately during medication administration, and Resident #49's graduated cylinder and syringe were not changed as ordered, increasing infection risk.

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status: the facility failed to ensure Resident #32 received the COVID-19 vaccine despite consent and documentation that the vaccine was not available; no evidence of rescheduling was found.

F 0578 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: the facility failed to help Resident #18 develop an advance directive, with no documentation that the resident was offered this opportunity.

F 0641 Ensure each resident receives an accurate assessment: the facility failed to ensure MDS assessments accurately reflected residents' status for Residents #3 and #6, including incorrect PASRR level II coding and erroneous documentation of an indwelling catheter.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: Resident #32's care plan did not include care for her toenails despite observed fungal infection and brittle, thick, discolored nails.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: Resident #32, dependent on staff for ADLs, did not receive toenail care and was not referred to the podiatrist as needed.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #49's psychotropic medication Mirtazapine was not clarified for its indication, raising concerns about adherence to professional standards of practice.

F 0692 Provide enough food/fluids to maintain a resident's health: Resident #32 experienced significant weight loss and was not consistently provided ordered nutritional supplements; dietary preferences were not fully assessed or documented.

F 0761 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: expired medications were found in two medication carts and the medication storage room, and refrigerator temperature logs were not updated as required.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to maintain a clean and sanitary environment in the kitchen, including staff not wearing hair nets, serving undercooked eggs, improper glove use, dirty cutting boards, inadequate sanitizing solution concentration, black residue in ice machine, dirty dishes in clean areas, and damaged cooking skillets.

F 0880 Provide and implement an infection prevention and control program: staff failed to perform hand hygiene and don gloves appropriately during medication administration, and Resident #49's graduated cylinder and syringe were not changed as ordered, increasing infection risk.

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status: Resident #32's COVID-19 vaccination was not administered or documented despite consent and risk factors.

F 0684 Provide appropriate treatment and care according to orders: medications for two residents were not administered as prescribed due to unavailability, resulting in missed doses of essential medications including vitamin B12, lysine, topiramate, Venclexta, Breztri inhaler, methylprednisolone, and cefdinir.

.F 0550 Honor the resident's right to a dignified existence: residents seated at the same table were served meals at different times causing delays up to 38 minutes, impacting dignity and psychosocial well-being.

.F 0552 Ensure informed consent: the facility failed to obtain informed consent prior to initiation of Trazodone for Resident #144, risking medication without resident knowledge.

.F 0623 Provide timely notification of transfers: the facility failed to notify the ombudsman of Resident #6's hospital transfers, potentially limiting resident rights.

.F 0625 Notify residents or representatives of bed hold rights: the facility failed to provide bed hold notices to Residents #6 and #40 upon hospital transfer, risking loss of bed rights.

.F 0641 Ensure accurate assessments: Resident #16's MDS assessments inaccurately reflected PASARR level II status, risking improper monitoring and care.

.F 0658 Ensure professional medication administration: Resident #17's insulin pen was administered without priming, risking incorrect dosing and blood sugar control.

.F 0689 Ensure fall prevention and supervision: Resident #143 sustained a head laceration from a wheelchair fall due to lack of foot pedal use and inadequate safety measures.

.F 0725 Provide sufficient nursing staff: residents and representatives reported insufficient staffing causing delays in care and unmet needs, contributing to falls and accidents.

.F 0756 Ensure pharmacist recommendations are followed: the facility failed to address pharmacist recommendations for Resident #31's antipsychotic use, risking unnecessary medication.

.F 0760 Prevent significant medication errors: multiple medication errors occurred for Residents #4, #16, and #145 including overdose, missed doses, and delayed administration.

.F 0812 Maintain food safety and sanitation: expired spices, undated opened food items, inadequate cleaning, dust accumulation, and improper food storage were observed, risking food contamination.

.F 0880 Implement infection control: Resident #144's medications were administered without wearing a protective gown despite signage requiring gown use for infection prevention.

.F 0883 Ensure immunization administration: Resident #39 consented to influenza vaccine but it was not administered, risking influenza transmission and complications.

F 0550 Honor the resident's right to a dignified existence: residents seated at the same table were served meals at different times causing distress and potential decrease in self-worth.

F 0623 Provide timely notification to the resident and ombudsman before transfer or discharge: the facility failed to notify the ombudsman of Resident #6's hospital transfers.

F 0625 Notify resident or representative in writing how long the nursing home will hold the resident's bed during hospital transfer: bed hold notices were not provided to Residents #6 and #40 or their representatives.

F 0641 Ensure each resident receives an accurate assessment: Resident #16's MDS assessments did not accurately reflect his PASSAR level II status.

F 0658 Ensure services meet professional standards: Resident #17's insulin pen was administered without priming, risking incorrect dosing.

F 0689 Ensure nursing home area is free from accident hazards and provides adequate supervision: Resident #143 fell from wheelchair without foot pedals causing a head laceration; safety measures were not followed.

F 0725 Provide enough nursing staff every day to meet resident needs: insufficient staffing led to delayed responses to call lights and increased fall risk for Residents #19, #30, and #36.

F 0756 Ensure licensed pharmacist performs monthly drug regimen review and physician addresses recommendations: pharmacist recommendations for Resident #31 were not addressed by the physician.

F 0760 Ensure residents are free from significant medication errors: Residents #4, #16, and #145 experienced medication administration errors including overdose, missed doses, and lack of documentation.

F 0812 Procure food from approved sources and store, prepare, distribute, and serve food safely: expired spices, undated opened food items, inadequate cleaning, and improper food storage were observed in the kitchen.

F 0880 Provide and implement an infection prevention and control program: Resident #144's medications were administered without wearing a protective gown despite signage requiring enhanced barrier precautions.

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: Resident #39 consented to influenza vaccine but it was not administered.

F 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged: the facility failed to ensure all pertinent information was provided to the receiving facility when a resident was transferred, resulting in potential adverse outcomes.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to develop and implement comprehensive resident-centered care plans for two residents, placing them at risk of negative outcomes due to lack of person-centered interventions.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to ensure a resident's care plan was reviewed and revised after a fall, creating potential for harm.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide adequate supervision to prevent a resident's fall, resulting in harm.

F 0697 Provide safe, appropriate pain management for a resident who requires such services: the facility failed to ensure residents were monitored appropriately and offered non-pharmacological interventions while receiving opioid pain medications, increasing risk of adverse reactions and unmanaged pain.

F 0760 Ensure that residents are free from significant medication errors: the facility failed to ensure a resident received ordered medication due to medication not being available, creating potential for harm.

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options: the facility failed to honor food preference requests for two residents, risking hunger or weight loss.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to ensure food items were dated and labeled and hygiene practices were followed, risking foodborne illness.

F 0814 Dispose of garbage and refuse properly: the facility failed to ensure waste was properly contained with lids or otherwise covered on one dumpster, risking pest infestation.

F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure infection control practices were maintained when hand hygiene was not performed during wound care for two residents, risking cross-contamination and infection.

F 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged: the facility failed to ensure all pertinent information was provided to the receiving facility when a resident was transferred.

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to develop and implement comprehensive resident-centered care plans for two residents, lacking person-centered details and interventions.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to ensure a resident's care plan was reviewed and revised after a fall incident.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide adequate supervision to prevent a resident's fall, resulting in injury.

F 0697 Provide safe, appropriate pain management for a resident who requires such services: the facility failed to ensure residents were monitored appropriately and offered non-pharmacological interventions while receiving opioid pain medications.

F 0760 Ensure that residents are free from significant medication errors: the facility failed to ensure a resident received ordered medication due to medication not being available.

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options: the facility failed to honor two residents' food preferences, risking hunger or weight loss.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to ensure food items were dated and labeled and hygiene practices were followed in food handling.

F 0814 Dispose of garbage and refuse properly: the facility failed to ensure waste was properly contained with lids or otherwise covered, risking pest infestation.

F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure infection control practices were maintained when hand hygiene was not performed during wound care for two residents.