Sunshine Terrace Skilled Nursing

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the walk-in refrigerator temperature was above 41 degrees Fahrenheit and food was stored in the danger zone. The food temperatures were above 41 degrees. This was cited at an Immediate Jeopardy (IJ). In addition, there were opened and undated food items in the walk-in refrigerator, freezer, and dry storage. Dietary staff were observed during lunch tray line service to touch food and other surfaces. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator (ADM), Dietary Manager (DM), and Director of Nursing (DON) on 4/6/26 at 10:31 AM. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, for 3 out of 32 residents, the facility did not provide a resident additional treatment for constipation which resulted in hospitalization for a bowel obstruction; a resident with Moisture Associated Skin Damage (MASD) did not have their wound evaluated by a wound care provider and received wound care without a physician order; and a resident with open wounds on their buttocks did not have wound prevention or skin assessments completed weekly as ordered. Resident identifiers: 3, 28, and 63.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that each resident who was given a psychotropic drug had an adequate indication for use of the medication; that psychotropic drugs received a gradual dose reduction and behavioral interventions, unless clinically contraindicated; as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the practitioner documented a clinical rationale to extend beyond 14 days with a duration of use for the order; and PRN orders for anti-psychotics were limited to 14 days and cannot be renewed unless the attending physician evaluated the resident for the appropriateness of the medication. Specifically, for 5 out of 32 sampled residents, the facility did not document an adequate indication of use for Seroquel and Haldol; [...]

Inspectors wroteBased on interview, observation, and record review, the facility did not ensure that allegations of abuse and neglect were reported immediately to the State Survey Agency (SSA) and other agencies. Specifically, for 4 of 32 sampled residents, the facility did not report allegations of abuse to Adult Protective Services (APS) and the facility did not report when a resident eloped from the facility to the SSA. Resident Identifier: 3, 41, 47 and 58.

Inspectors wroteBased on interview and record review, the facility did not have evidence of a thorough investigation in response to allegations of abuse, neglect, exploitation, or mistreatment. Specifically, for 4 of 32 sampled residents, there were no thorough investigations into bruising on residents with dementia, Certified Nursing Assistants (CNA)'s being rough during a brief change and a resident eloping from the facility. Resident identifiers:

Inspectors wroteBased on interview and record review, the facility did not ensure that when they transferred a resident that it was documented in the resident's medical record and that the information contained the contact information of the practitioner responsible for the care of the resident; resident representative information; Advanced Directive information; all special instructions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, for 3 of 32 sampled residents, the facility did not document in the residents' medical record the information that was given to the receiving provider, notify the Ombudsman, and provide the bedhold policy when residents were transferred to a hospital. Resident identifier: 3, 6, and 50.

Inspectors wroteBased on observation, interview and record review, for 2 of 32 sampled residents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident eloped from the facility after being identified as wandering prior and the same resident sustained falls with no new interventions. In addition, another resident eloped from the facility. Resident identifiers: 47 and 72.

Inspectors wroteBased on observation, interview, and record review, the facility did not 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. Specifically for 3 out of 32 sampled residents, Enhanced Barrier Precautions (EBP) was not implemented for a resident with an indwelling medical device. Additionally, hand hygiene was not performed during wound care for a resident and there was cross-contamination during dining when a Certified Nursing Assistant (CNA) touched a chair and then a resident's food. Resident identifiers: 6, 17, and 28. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically for 2 out of 32 sampled residents, residents were observed to have medications in their rooms and were not evaluated to determine if they were safe to self-administer medications. Resident identifiers: 6 and 28.

Inspectors wroteBased on interview and record review, the facility did not maintain evidence demonstrating the results of all grievances for a period of no less than three years from the issuance of the grievance decision. Specifically, for 1 out of 32 sampled residents, a resident's family member reported a missing purse, wallet, and glasses, but the facility did not document a prompt resolution or follow-up. Resident identifier: 5.

Inspectors wroteBased on observation, interview and record review, for 1 of 32 sampled residents, the facility did not develop and implement comprehensive person-centered care plans for each resident. Specifically, a resident's care plan was not updated with interventions after each fall. Resident identifier: 47.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Specifically, for 1 out of 32 sampled residents, the facility did not address a resident's pain when Semi-Effective pain control was reported by the resident. Resident identifier: 63.

Inspectors wroteBased on observation, interview, and record review, the facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 32 sampled residents, a resident receiving dialysis did not have a physician's order for dialysis and communication notes with the dialysis center were missing. In addition, the staff were not monitoring the dialysis fistula and there were no physician orders to monitor the dialysis fistula. Resident identifier: 50.

Inspectors wroteBased on interview and record review the facility did not ensure that individuals working in the facility as a nurse aide had completed a training and competency evaluation program within 4 months from date of hire. Specifically, for 1 out of 5 sampled staff members, the facility had employed a Nurse Aide since May of 2025 without them having completed their certification course. Staff identifier: Nurse Aide (NA) 1.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued; or any combination of the above. Specifically, for 2 out of 32 sampled residents, the facility did not monitor residents' pain management for non-pharmacological interventions and adverse side effects. Resident identifiers: 50 and 58.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that nurse aides received in-service training for continued competency of no less than 12 hours per year and included dementia management and abuse prevention training. Specifically, for 2 out of 5 sampled employees, the nurse aides did not receive 12 hours per year of continued competency training. Staff identifiers: Certified Nurse Assistant (CNA)1 and Nurse Assistant (NA) 1.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to adhere to professional standards for food safety when preparing, storing, and distributing food to residents who were served food from the facility's kitchen. This failure had the potential to affect 50 of 50 residents who received nutrition from the kitchen.

Inspectors wroteBased on interview and facility policy review, the facility failed to ensure the provision of the right to file grievances anonymously. This failure had the potential to impact facility residents who were able to execute their right to file grievances.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to report allegations of abuse within two hours for 2 (Resident #28 and Resident #39) of 2 residents reviewed for abuse prohibition.

Inspectors wrote2. A review of a facility policy titled, Handwashing/Hand Hygiene, revised in October 2023, revealed, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The policy revealed, 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Under a section titled Indications for Hand Hygiene, the policy noted, in part, 1. Hand hygiene is indicated: a. immediately before touching a resident; c. after contact with blood, body [sic] fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; and g. immediately after glove removal. Further review revealed 5. The use of gloves does not replace hand washing/hand hygiene. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident #50 and Resident #3) of 7 residents. Specifically, the facility failed to provide wound care per physician orders for Resident #50 and failed to verify an order for antibiotic use with the ordering physician for Resident #3.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 25 sample residents, that the facility did not ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. Specifically, the facility did not ensure that a gas-powered fireplace in the residents' common area of the dementia unit was set up in such a way that ensured the protection of residents from possible burns. Resident identifiers: 31, 37, and 49.

Inspectors wroteBased on interview and observation, the facility did not ensure that 3 of 25 sample residents were provided assistance with dining by a feeding assistant who had completed a state-approved training course before feeding residents. Specifically, music therapists and a community volunteer were feeding residents without training or supervision. Resident identifier: 2, 21, and 31.

Inspectors wroteBased on observation and interview, it was determined that the facility did not distribute and serve food in accordance with the professional standards of food service safety. Specifically, food items in a walk-in freezer were open to air and food items in the walk-in refrigerator were not dated or were past the use by period, the log on 2 refrigerators revealed the temperature was above a safe storage temperature, and there were chipped tiles in the food preparation area.

Inspectors wroteBased on record review the facility did not ensure that medical records were complete and accurate for 4 of 25 sampled residents. Specifically, resident Provider Order for Life-Sustaining Treatment (POLST) form did not match in their electronic medical record with the one in the paper chart and resident documents were in the wrong resident's medical record. Resident identifiers: 25, 39, 32, 8, and 38.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure that the interdisciplinary team (IDT) had evaluated and determined that the resident's right to self-administer medications was clinically appropriate. Specifically, a resident was observed to have medication at her bedside without staff supervision and had not been assessed to determine if she was able to self-administer medication. Resident identifier:

Inspectors wroteBased on observation, interview and record review, it was determined that for 1 of 25 sample residents, the facility did not provide the necessary services to maintain or improve the residents' activities of daily living. Specifically, a resident did not receive assistance with eating. Resident identifier: 48.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight, unless the resident's clinical condition demonstrated that this was not possible. Specifically, a resident that lost weight and nutritional interventions developed were not implemented. Resident identifier: 48.

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 25 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, residents with oxygen did not have their tubing and the humidifier changed. Resident identifiers: 8 and 32.