Sunnyview Nursing Home & Apartments

Inspectors wroteBased on observation, record review, and interview, the facility failed to protect one cognitively impaired resident (Resident #1) from physical abuse, when Resident #2, who had a history of multiple instances of physical abuse including slapping, grabbing, and pushing Resident #1 and/or staff did not put any interventions in place to prevent further abuse. On 9/26/25, Resident #2 shoved Resident #1 into a bird aviary which caused broken glass to scratch Resident #1's back. Furthermore, the facility failed to provide protection to all other residents, from the potential of physical abuse, when no safety measures were put into place for Resident #2 after the 9/26/25 incident of abuse. The facility census was 58. The Director of Nursing was notified on 10/2/2025 at 2:49 P.M. of an Immediate Jeopardy (IJ) which began on 8/22/25. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents or their responsible party were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers prior to being placed on psychotropic medications for, four of the 14 sampled Residents ( Residents #15, #7, #8, and #34). The facility census was 56. Review of the facility's policy Psychotropic Medication Use undated., showed: A psychotropic medication is any medication that affects brain activity and behavior. These medications would include anti-psychotics, anti-depressants, anti-anxiety, and hypnotic medications. [...]

Inspectors wroteBased on observations and interviews, the facility failed to post nurse staffing data in a prominent place, readily accessible to all residents and visitors on a daily basis at the beginning of each shift. The facility census was 56. Review of the facility's policy for posting direct care daily staffing numbers, revised August 2022 showed:Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to discard expired medications and biologicals stored in the medication cart and the medication room, failed to date two opened vials of Lorazepam (used to treat anxiety) for two of the 14 sampled residents, (Resident #26 and #62) and failed to ensure medication had a pharmacy label to indicate who it belonged to. The facility census was 56. Review of the facility's policy for medication labeling and storage, revised February 2023 showed:- Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.- The medication label includes, at a minimum: medication name (generic and/or brand); prescribed dose; strength; expiration date, when applicable; resident's name; route of administration; [...]

Inspectors wroteBased on interview and record review, the facility failed to use the correct form to provide one resident out of 14 sampled residents notification of changes in coverage to items and services covered by Medicare and/or by the Medicaid State plan, the facility additionally failed to provide notice to residents of the change as soon as is reasonably possible. The facility census was 54. Review of facility's Medicare Advance Beneficiary and Medicare Notice, policy undated showed:-Residents are informed in advance when changes occur to their bills. -CMS (Center for Medicare/Medicaid Services) form 10055 will be provided to the resident prior to discharging from Medicare part A. 1. Review of Resident #31's face sheet showed the Resident was admitted to Medicare part A on 2/19/25 with a diagnosis included COPD, renal failure, and heart failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who used psychotropic drugs did not exceed 14 days of use without a physician evaluation and renewal of the medication, and documentation of the rationale, in the resident's medical record, to indicate the duration for the PRN order, which affected two of the 14 sampled residents, (Resident #7 and #8). The facility census was 56. Review of the facility's policy for psychotropic medications use, dated July 2022 showed: - Residents will not receive medications that are not clinically indicated to treat a specific condition. - A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure staff followed facility's policy to timely update one Resident's care plan (Resident #15) out of the 14 sampled residents after the resident eloped from the facility. The facility census was 56. Review of the facilities Emergency Procedure- Missing Resident policy, not dated, showed:-Nursing staff is tasked with updating the care plan after a resident who eloped is found;-The DON is to ensure the care plan is updated. 1. Review of Resident #15's care plan, updated on 08/03/2025, showed:-The resident was at an increased risk for wandering related to repeated attempts to exit the facility;-The resident had impaired decision making related to dementia;-The resident had a diagnosis of depression;-The resident's care plan had not been updated after the resident eloped on 09/13/2025. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure they maintained a safe, clean, comfortable environment for the residents, when staff failed to keep all areas of the facility clean and free from mold-like substance throughout areas in the building. The facility census was 46. No policy regarding housekeeping or maintaining the environment was provided. Observation of the facility on 9/10/24 at 6:30 A.M. showed a strong, damp and musty (having a stale, moldy or damp smell) smell outside of a resident room [ROOM NUMBER]. Observation of the facility on 9/10/24 at 11:45 A.M. showed a black, mold-like substance on the outside of the air return vents above the nurse's station on the 300 hall; above the kitchenette on the ceiling of the closed wing; on the return air vents in the kitchen area on the 300 hall; and on the ceiling tile behind kitchen freezer in dry storeroom. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure resident were appropriately assessed and had documentation to support the use of wander guards for two of two residents (Residents (R) 34 and R12) reviewed for wander guards of 16 sample residents. This failure could result in residents with unwarranted use of wander guards.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of manufacturer's instructions, the facility failed to provide respiratory care in accordance with professional standards for two of two residents (Residents (R) 3 and R99) reviewed for respiratory care out of 16 sample residents. This failure has the potential for the residents to be subjected to contaminated respiratory equipment and to not receive proper airflow. The facility census was 46.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure nursing staff properly stored nebulizer masks when not in use for two of two residents (Resident (R) 35 and R7) reviewed for nebulizers and ensure proper wound care procedures for one of one resident (R99) reviewed for wound care of 16 sample residents. This failure had the potential to contribute to the potential of contamination and spread of infection. The facility census was 46.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to complete a significant change assessment after a resident was started on hospice services for one of two residents (Resident (R) 7) reviewed for hospice of 16 sample residents. This has the potential to affect all residents with a Minimum Data Set (MDS) assessment ensuring proper care and services. The facility census was 46.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a care plan for a resident receiving hospice services for one of two residents (Resident (R) 7) reviewed for hospice services of 16 sample residents. This has the potential to affect all residents receiving hospice services. The facility census was 46.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails for one of two residents (Resident (R) 22 and R37) reviewed for side rails of 16 sample residents. The lack of alternative side rail measures could lead to potential restraint or side rail entrapment. The facility census was 46.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents received the correct medication as ordered by the physician for two of eight residents (Resident (R) 20 and R38) reviewed for medications of 16 sample residents. This failure could result in unwarranted medication side effects and mismanaged medical conditions. The facility census was 46.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure there was documented rationale and a stop date for a PRN (as needed) psychotropic medication for one of eight residents (Resident (R) 12) reviewed for medications of 16 sample residents. This failure has the potential to lead to unwarranted medication side effects. The facility census was 46.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure one of one resident (Resident (R) 99) was free from significant medication errors when the facility administered R99 someone else's medication, out of 16 sample residents. This medication error had the potential to cause R99 to become hypotensive (low blood pressure). The facility census was 46.

Inspectors wroteThis deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 3/22/22. Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. This deficiency had the potential to affect all residents. The census was 53. Review of the May 2022 staffing sheets showed no RN coverage on: -May 14, 2022; -May 21, 2022; -May 22, 2022. Review of clock in times for May 14, May 21 and May 22, 2022 showed: -No clock in times for the Director of Nursing (DON); -No clock in times for RN A; -No clock in times for RN B . Record review of the staffing sheets showed: - 2 RNs: DON and RN A. Review of a letter from the DON, dated 5/24/22, showed: -He/she was available on May 14, May 21 and May 22, 2022 by phone and able to enter the facility as needed. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain the kitchen in sanitary condition and to store food in a sanitary manner. The facility census was 53. Review of the facility's policy titled, Food Labeling and Storage, dated 2/19/2020, showed it did not include seasonings on the list to be dated. Review of the facility's kitchen cleaning checklists showed the following: - Clean shelves under toaster- weekly; - Clean shelves- weekly. 1. Observation on 5/23/22 beginning at 10:35 A.M., showed the following in the kitchen: - There was a sticky substance on the drying rack that contained clean pots and pans; - The following seasoning containers were opened and did not contain a date: o 12.5 ounce (oz) Ground Ginger; o 16 oz. Ground Nutmeg; o 32 oz. Celery Salt; o 12 oz. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable disease and infections and failed to have written standards, policies and procedures in place for their IPCP. Staff failed to ensure they completed a two step tuberculosis (TB) skin test (TST) accurately for three of five residents sampled for immunizations and TB testing (Residents #27, #53, and #54). The facility's census was 53. 1. Review of the Infections - Clinical Protocol, revised April 2012, showed: - Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals who have had a recent infection or who are at risk for developing an infection. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed develop and implement policies and procedures and to maintain documentation to show they established an infection prevention and control program (IPCP) which included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 53. Review of the facility's polices and procedures addressing infection control showed they did not have a policy and procedure to direct staff how to establish an IPCP, including an antibiotic stewardship program. Review of the Infection Summary Report, dated 5/1/22 through 5/31/22, form showed the form listed the source of the infection, if it was acquired in-house or of the resident admitted with the infection in a table at the top of the form. [...]

Inspectors wroteBased on interview and record review, the facility failed to put measures in place to honor residents' or their responsible parties' do not resuscitate order when staff allowed a resident who had been deemed incapacitated to sign his/her Outside the Hospital Do Not Resuscitate (OHDNR) form, failed to transcribe physician's orders when the resident signed his/her OHDNR, and allowed a resident with severe cognitive impairment to sign their OHDNR. This failure affected three of 14 sampled residents (Residents #26, #40 and #53). The facility census was 53. 1. Review of the facility's undated Advanced Health Care Directives/Code Status Policy showed in part: - Annual discussion will be handled either in a group or one on one basis, in regards to their current advance directives and code status. [...]

Inspectors wroteBased on record review and interview, the facility failed assess residents using the quarterly assessment review instrument no less than every three months or at least every 92 days after the last assessment which affected four of 14 sampled residents (Residents #1, #2, #3, and #9). The census was 53. The facility did not provide a policy for completing the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff. 1. Review of Resident #3's electronic medical record (EMR) on 5/31/22 showed: - A quarterly MDS assessment date of 3/15/22; - The MDS coordinator signed the MDS assessment on 5/17/22 that she completed sections A ,B, E, G, GG, H, I, K, M, N, P; - The MDS coordinator electronically signed that she completed sections C-Interview, D, D-Interview, J, J-Interview, L, O, Q, Z on 5/20/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered plan of care which included measurable objectives and timeframe's to meet each resident's medical, nursing, and mental psychosocial needs identified in the comprehensive assessment for six of 14 sampled residents (Resident #9, #18 #35, #39, #46 and #50). The facility census was 53. Review of the facility's policy for care plan, dated October 2010, showed in part: - An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental, and psychological needs is developed for each resident. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed ensure the proper use of bed rails when staff failed to complete assessments for the use of bed rails prior to applying to residents beds, failed to provide education and obtain consents for the use of bed rails from the residents and/or their responsible parties, failed to obtain physician's orders and failed to implement interventions for the use of bed rails for four of 14 sampled residents with bed rails (Residents #27, #39, #40, and #46). The facility census was 53. Review of the facility policy for Proper use of side rails, dated December 2010, showed in part: - The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a residents medical symptoms. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments for four of 14 sampled residents with side rails and/or therapeutic mattresses (Residents #9, #39, #40, and #46) to ensure the environment remained safe and free of accident hazards. The facility census was 53. Review of the facility policy for Bed Safety, dated December 2007, showed in part: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort and freedom of movement, as well a input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: [...]

Inspectors wroteBased on record review and interview, the facility failed to issue the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) from Centers of Medicare and Medicaid (CMS) form 10055 to each resident. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid by Medicare and assume financial responsibility. This affected two of the three sampled residents (Residents #36 and #46). The facility census was 53. The facility did not provide a policy regarding ABN. 1. Review of Resident #36's medical records showed: [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a copy of their bed hold policy before transferring one of 14 sampled residents (Resident #26) to the hospital when they could not meet the needs of the resident. The facility's census was 52. Review of the facility's undated Bed Hold policy showed: - It is the policy of the facility that during the absence of any resident for any reason, the regular charge herein shall apply until the room is released and all belongings are removed, unless otherwise specified by administration. - The resident or their representative shall notify the facility's social service department regarding whether the resident's bed should be held, or whether the resident should be discharged . If notice is received, the resident's bed will automatically be held and charges will continue to accrue. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change in condition comprehensive assessment for one of 14 sampled resident's (Resident #9). The facility census was 53. The facility did not provide a policy for determining a significant change condition and completing the comprehensive assessment timely after the change had been identified. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by the facility staff, dated 12/16/21, showed: - A brief interview of mental status (BIMS) score of 10, which indicated a moderate cognitive impairment. - Resident required extensive assistance with all activities of daily living (ADLs). - Resident was occasionally incontinent of bowel and bladder. - Resident was at risk of pressure ulcer. Required staff to assist with turning and repositioning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed implement pressure ulcer precautions for one resident (Resident #46) per physician orders and facility care plan. This affected one of 14 sampled residents. The facility census was 53. Review of Prevention of Pressure Ulcer policy dated October 2010 showed in part: Purpose of this procedure: Is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. Preparation: - Review the residents' care plan to assess for any special needs of the resident. - See policy and procedure for specific tasks, such as bathing, incontinence care, and repositioning. General Guidelines: - Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing decrease of circulation to that area. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an environment free from accident hazards when staff did not implement interventions to prevent falls for one of 14 sampled residents (Resident #27) who was at risk for falls and who had both experienced multiple falls. The facility census was 53. The facility did not provide a policy for falls. 1. Review of Resident #27's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/26/22, showed: - A Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment; - Extensive assistance with bed mobility; total dependence on staff for transferring, moving on and off the unit, personal hygiene, toilet use, dressing, and eating; - Diagnoses included stroke and one sided paralysis; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided care to prevent urinary tract infections (UTIs) for a resident with a suprapubic catheter (a catheter which enters the bladder through the lower abdomen) which affected one resident (Resident #46) out of 14 sampled residents. The facility census was 53. Review of the facility policy regarding perineal care, dated October of 2010, showed in part: - If the resident has an indwelling catheter, gently wash the junction of the tubing from the urethra down the catheter tubing about 3 inches. Gently rinse and dry area. Hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. -The policy does not show where to place the bedside drainage bag during or after care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident #27) received the appropriate treatment and services to prevent complications of enteral feeding when staff failed to enter orders for upgrading the resident's diet, failed to monitor intake and output to ensure the resident received adequate calories when staff upgraded his/her diet, and failed to implement interventions after the resident's diet was upgraded. The facility census was 53. Review of the facility's policy on enteral nutrition, revised December 2011, showed adequate nutritional support through enteral feeding will be provide to residents as ordered. The policy interpretation and implementation included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #46) of 14 sampled residents received a gradual dose reduction (GDR), and/or a rationale from the physician as to why the GDR was not attempted and failed to contact the physician once the resident no longer needed an antipsychotic medication. The facility census was 53. The facility policy titled psychotropic medication use, dated January 2022, showed in part: - Psychotropic medication is prescribed for a diagnosed condition and not being used for convince or discipline. - Facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social, and environmental cause of the residents behaviors. -Gradual dose reduction is used in an effort to discontinue antipsychotic medications. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to collaborate with hospice in the development of a coordinated plan of care for residents receiving hospice care. This affected one of 14 sampled residents (Resident #9). The facility census was 53. Review of the facility's contracted agreement with hospice providers, dated 08/25/2020, under Provision of Services, showed in part: - Hospice plan of care (HPOC) must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have ben agreed upon and included in the HPOC. - HPOC reflects participation by the hospice, facility, patient and patient's family. - Discussions of changes to the HPOC with the facility or patient. - Design of POC states facility shall coordinate with hospice in developing a POC. [...]