Sunny View Care Center

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to ensure the 5 rights of medication administration were followed resulting in 1 of 1 residents receiving another resident's medications (Resident #6) in addition to the resident's own medication which required an admission to the hospital due to sinus bradycardia (resting heart rate that is slower than normal) requiring further hemodynamic (blood flow movement and circulation through the heart and blood vessels) monitoring. The facility reported a census of 92 residents.

Inspectors wroteBased on clinical record review, resident interview, family interview, staff interview and policy review, the facility failed to complete a comprehensive assessment and evaluation of a resident for readmission to the facility, and failed to have the appropriate documentation in the medical record prior to issuing an involuntary discharge to 1 of 3 residents reviewed for discharge (Resident #1). This failure caused the resident to experience a negative impact on her psycho-social well being. The facility further failed to have the resident or the resident representative sign the discharge summary. The facility reported a census of 91 residents.

Inspectors wroteBased on observations, staff interview and policy review the facility staff failed to provide care for a resident in an environment that maintained or enhanced dignity for two of five residents observed and required assistance for eating. The facility reported a census of 81 residents.

Inspectors wroteBased on interviews, providers' orders review and IPOST review, the facility failed to have the updated IPOST (Iowa Physician Orders for Scope of Treatment) for 1 out of 24 residents reviewed (Resident #8). Resident had a provider's order directing the code status for Resident #8 was Do Not Resuscitate (DNR) and an IPOST directing the code status for Resident #8 was CPR (Cardiopulmonary Resuscitation)/Attempt Resuscitation. The facility reported a census of 82 residents

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to provide the required Center for Medicare Services (CMS) Notice of Medicare Non-Coverage (NOMNC) forms to address beneficiary appeals and liability notice for one of three residents reviewed for advanced beneficiary notices (ABN) (Resident #72). The facility reported a census of 81 residents.

Inspectors wroteBased on interview, observations, and record review, the facility failed to ensure 1 out of 3 residents' property was inventoried and failed to replace his personal property after he reported that it was missing (Resident #81). The facility reported a census of 82 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview the facility failed to complete upon discharge the recapitulation for a resident's stay for 1 of 3 residents reviewed (Resident #95). The facility reported a census of 81 residents. The Discharge Minimum Data Set for Resident #95, dated 12/1/25, revealed the resident was admitted to the facility on [DATE] and discharged to home/community on 12/1/25. Review of Resident #95's clinical record lacked a recapitulation of stay. Facility Discharge Policy with Criteria, undated, instructed the facility staff will develop a post-discharge plan of care and a discharge recapitulation form will be completed. Interview on 01/14/2026 at 1:19 PM, the Director of Nursing stated he was unable to find that a recapitulation of the resident's stay was completed. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure 1 out of 1 resident reviewed received his prescribed medication upon a hospital return (Resident #8). Resident #8 returned from the hospital on [DATE] and did not receive the majority of his medications until 1/2/26 and 1/3/26. The facility reported a census of 82 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 2 of 3 residents reviewed (Resident #44 and Resident #68). The facility failed to ensure use of enhanced barrier precautions (EBP) when required. The facility reported a census of 81 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain mechanical and electrical patient care equipment in safe operating condition for 5 out of 5 residents reviewed (Residents #1, #7, #10, #11, and #12). Resident's #1 and #12 had care delayed related to batteries not working in stand lifts. Resident #7's bed would raise but not lower (beds in low position are a standard of safety). During separate observations of Residents #10 and #11 it was observed that 1 of the 4 wheels on the mechanical lift used to transfer the residents came off of the ground during the transfer. The facility reported a census of 86 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure dignity was promoted for 2 out of 2 residents (Resident #1 and Resident #12). The facility had ongoing issues with batteries not staying charged in stand lifts used for daily transferring of residents. Resident #1 waited 30 minutes after staff answered her call light to toilet her related to 2 different batteries not working and the need to go get another stand lift from the other side of the building. A stand lift battery died after staff raised Resident #12 to a standing position and could not lower her due to the lift's battery dying. She remained in the standing position until staff could retrieve another battery. The facility reported a census of 86 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow document and/or carry out physician orders for 2 of 16 residents reviewed (Resident #2 and Resident #3). Resident #2 had an order to check her oxygen saturation (POx) once per shift. She had a second PRN (as needed order) to apply oxygen if the oxygen saturation was below 90%. There was no documentation of oxygen application for oxygen saturation below 90%. Resident #3 had an order to check Hgb A1c (a test that measures the average blood sugar) every 6 months. This was not done. The facility reported a census of 86 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure doctor's orders for oxygen (O2) were being followed for 3 out of 3 residents reviewed (Residents #2, #8 and #9. Resident #2 had an order for PRN (as needed) oxygen to be placed when her oxygen saturation was below 90%. Documentation showed she had a least 2 occasions when her oxygen saturation read by a pulse oximeter (Pox) was 89% and oxygen was not documented as being applied. Staff reported not knowing there was an order for PRN oxygen, but they were applying oxygen without clarifying the order. Residents #8 and #9 were observed to have oxygen administered at flow rates that differed from their doctor ordered oxygen flow rates. [...]

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to maintain complete and accurate medical records for 2 of 3 residents reviewed for discharge planning (Resident #15 and Resident #16). The facility reported a census of 86.

Inspectors wroteBased on clinical record review, staff interview, and facility policy/procedures the facility failed to clarify a medication when a resident was admitted on [DATE] for which delayed the resident getting the medication as directed until 4/7/25. (Resident #1). The facility reported a census of 82 residents.

Inspectors wroteBased on observations, staff interview, and facility cleaning procedures, the facility failed to ensure resident rooms were free of odors to create a home-like environment for 1 of 59 resident rooms (Resident #71). The facility reported a census of 82.

Inspectors wroteBased on observation, family and staff interviews, and clinical record review, the facility failed to follow the physician's orders for 1 of 20 residents (#32). The facility reported a census of 82 residents.

Inspectors wroteBased on health record review, facility document review, and staff interviews, the facility failed to communicate throughout departments current resident staff assistance level for 1 of 5 residents reviewed for nursing supervision (Resident #71). The facility reported a census of 82.

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to provide resident assistance or follow-up with medical equipment for 1 of 2 residents reviewed for respiratory care (Resident #235). The facility reported a census of 82.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a yearly psychotropic medication (a medication that affects a person's mental state) gradual dose reduction (GDR) was attempted or appropriately declined for 3 of 3 resident (#32, #44, & #66). The facility reported a census of 82.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 1 resident reviewed (Resident #5) for weight monitoring. The facility failed to obtain weights per physician order. The facility reported a census of 82 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to provide bathing assistance for 1 of 4 residents reviewed for bathing (Resident #1). The facility reported a census of 82 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to provide interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 1 of 6 resident reviewed (Resident #2). The facility failed to complete and document nursing assessments including neurological assessments after a report that a resident had hit his head on a wall. The facility reported a census of 82 residents.

Inspectors wroteBased on clinical record reviews, observations, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 1 residents reviewed (Resident #2). The facility reported a census of 82 residents.

Inspectors wroteBased on staff interview, and clinical record review the facility failed to monitor and provide appropriate urinary assessment after a indwelling catheter was removed for 1 of 4 residents reviewed (Resident #4) for catheters. The facility also failed to document accurate urine output and follow a physician order when inserting an indwelling catheter. The facility reported a census of 82 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 resident reviewed for catheter care (Resident #5 and #3). The facility reported a census of 82 residents.

Inspectors wroteBased on observation, clinical record review, a photograph and facility policy review, the facility failed to properly provide perineal cares for 2 of 3 residents reviewed (Resident #2 and #3 ). The facility identified a census of 88 residents.

Inspectors wroteBased on family interview, resident interview, staff interview, Ombudsman email, Resident Council Minutes, and facility policy review the facility failed to answer resident call lights within 15 minutes for 2 of 3 residents reviewed (Residents #2 and #5). The facility identified a census of 88 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to maintain a complete and accurate Care Plan for 1 of 3 resident's reviewed (Resident #2). The facility identified a census of 88 residents.

Inspectors wroteBased on observation, clinical record review, resident interview and staff interview, the facility failed to follow physician's orders for 1 of 3 residents reviewed (Resident #13). In addition, the facility failed to properly administer medications according to the nursing standards of practice for 2 of 3 residents (Residents #12 and #11). The facility identified a census of 88 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to assess and implement interventions for a 1 of 3 residents following a fall (Resident #3). The facility identified a census of 88 residents.

Inspectors wroteBased on observation, resident and staff interview, and policy review the facility failed to answer call lights in a timely manner within 15 minutes for one of two nursing units reviewed. The facility reported a census of 85 residents.

Inspectors wroteBased on observations, policy review, and staff interviews, the facility failed to provide a clean and sanitary environment when they failed to clean shower chairs between residents. The facility also failed to create and implement a water control plan to protect the facility from legionella and other water borne illnesses. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to notify residents families of falls for 1 of 3 residents reviewed for falls (Resident #40). The facility reported a census of 85.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to update the comprehensive care plans when a resident had a change in advanced directives for one of twenty-four residents reviewed (Residents #10). The facility reported a census of 85 residents.

Inspectors wrote3. The MDS assessment dated [DATE] revealed Resident #74 has diagnoses of frontal temporal neurocognitive disorder, PICK's disease (a form of dementia that affects behavior, personality, and speech), aphasia, and receiving hospice care. The Care Plan dated 2/19/24 revealed Resident #74 is nonverbal, staff must anticipate resident's needs, including the need to be fed meals. The resident had an unavoidable weight loss. Staff directives included to encourage oral fluids and supplements as ordered by the physician. Review of resident #74's physician orders indicated: [...]

Inspectors wroteBased on clinical record review, observation, family interview, staff interview, and policy review, the facility failed to assist a dependent resident with dining assistance when the resident demonstrated an inability to feed themselves for 1 of 3 residents reviewed for feeding assistance. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility failed to provide proper supervision as it relates to a resident at risk for choking in 1 of 4 sampled residents (Resident #40), and failed to ensure a resident's bed left in low position and the equipment in safe operating condition for 1 of 4 residents reviewed for falls (Resident #10). The facility reported a census of 85 residents.

Inspectors wroteBased on observation, staff interviews and policy review, the facility failed to ensure the medication cart remained locked in a resident care area when not under staff supervision. The facility reported a census of 85 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, resident interview and facility policy review, the facility failed to properly provide perineal cares for 1 of 3 residents reviewed (Resident #6), failed to provide oral cares to 3 of 3 residents reviewed (Resident #6, #11, #12), failed to provide dining assistance for 1 of 3 residents reviewed (Resident #9 ) and failed to provide toileting assistance for 1 of 3 residents reviewed. (Resident #5). The facility identified a census of 86 residents.

Inspectors wroteBased on observation, clinical record review, staff interview and resident interview, the facility failed to assure resident belongings were returned to one (1) resident and/or family post discharge from the facility (Resident #3). The facility identified a census of 86 residents.

Inspectors wroteBased on observation, clinical record review and facility policy review the facility failed to provide the necessary assessments for 1 of 3 residents reviewed with a skin condition and/or a condition change. (Resident #4) The facility identified a census of 86 residents.