Sunny Vista Living Center

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Pharmacy Service Deficiencies

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.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Keep all essential equipment working safely.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Pharmacy Service Deficiencies

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.

A complaint survey, prompted by #CO37101 and #CO37216 was conducted on 8/20/24 to 9/4/24. Two deficiencies were cited. Based on record review and interviews, the facility failed to ensure one (#2) of three residents reviewed for psychosocial concerns out of four sample residents received the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being.Specifically, the facility failed to:-Provide Resident #2 with psychosocial support who had increasing depression since February 2024;-Update Resident #2' s comprehensive care plan to identify the resident' s increasing depression and recent wish to die; and,-Develop a comprehensive care plan that depicted Resident #2' s accurate antidepressant medication.Findings include:I. Facility policy and procedureThe Psychosocial Evaluation policy and procedure, dated November 2022, was provided by the nursing home administrator (NHA) on 9/4/24 at 2:30 p.m. It revealed in pertinent part, "The community will evaluate and intervene in residents' psychosocial unmet needs to improve their well-being."A member of the interdisciplinary team (IDT) notices the resident has element(s) of psychosocial unmet needs, such as but not limited to: self-injurious behavior; anger, agitation and/or distress that caused aggression - hitting, shoving, biting, suicide ideation, crying, moaning, screaming, expressions of avoidable pain that is severe, fear or anxiety that may be manifested as panic, immobiliza.. Based on record review and interviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two (#3 and #4) of three residents reviewed out of four sample residents.Specifically, the facility failed to identify Resident #3 and Resident #4' s post traumatic stress disorder (PTSD) and identify triggers which may retraumatize them.Findings include:I. Facility policy and procedureThe Trauma Informed Care policy and procedure, undated, was provided by the director of nursing (DON) on 9/4/24 at 4:38 p.m. It read in pertinent part, "It is the policy of the community to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice."Each resident will be screened for a history of trauma upon move-in by the community' s social service or designee."If the screening indicates that the resident has a history of trauma and/or trauma-related symptoms, an order will be obtained for the resident to be evaluated by mental health professional who is qualified and experienced in working with those exposed to trauma."Once the order is received, t..

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms.6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference. The Colorado Department of Public Health and Environment conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID prefix Tag # K 000) are informational and a representation of the facility' s general characteristics.The facility consist of a two story limited combustible structure, Type II (111) construction, with a partial basement used for support services and is not used by residents. Basement has a 2 hour occupancy separation from the parking garage. The facility is classified as fully protected by a National Fire Protection Agency (NFPA) 13 automatic wet and dry fire sprinkler systems. Sprinkler system coverage- does not include protection of the concealed attic space, which will not be used for storage.NOTE: the facility has chosen not to provide sprinkler coverage to the exterior patios with non- combustible overhangs that extended over 4-ft. from the building. Those areas are not to be allotted to be used for combustible items and/ or storage; and if at any time in the future, these unprotected ares are found to be used for combustible items, to include but not be limited to, picnic tables, furniture, chairs, tables, BBQ grills, etc ..., the area shall be required to be equipped with fire sprinkler coverage.The survey was conducted on December 19, 2023 for compliance to fire safety requirements of NFPA 101, Life Safety Code (lSC), 2012 edition, Chapter 19 for Existing Health Care Occupancies. It was reported that there was a census of 107 residents at the time of survey. The facility is currently licensed for 116 beds.