Inspection Reports for Sunny Hill Care Center
1708 Harding Street, IA, 523391098
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 22, 2025 found the facility in substantial compliance with no deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to resident supervision and accident hazard prevention, including incidents of resident falls during transfers. Prior reports also noted issues with care planning, notification procedures, and failure to follow physician orders, with some substantiated complaints involving inadequate monitoring and abuse reporting. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, correcting previous deficiencies and achieving substantial compliance in recent surveys.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
48 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 22, 2025
Visit Reason
A complaint investigation for complaint #2676699-C was conducted from December 22, 2025 to December 23, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #2676699-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 30, 2025
Visit Reason
A revisit of the survey ending August 21, 2025 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior survey were corrected and the facility was found to be in substantial compliance effective September 8, 2025.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Aug 19, 2025
Visit Reason
The inspection was conducted as a result of complaints #129625-C and #129750-C from August 19 to August 21, 2025, focusing on ensuring the facility's compliance with accident hazard prevention and supervision requirements.
Findings
The facility failed to ensure a safe transfer for one of three residents reviewed, resulting in a resident falling and sustaining a non-displaced humeral fracture. Multiple witness statements and clinical records confirmed the incident and inadequate use of gait belts during transfers.
Complaint Details
The investigation was triggered by complaints #129625-C and #129750-C. Complaint #129750-C resulted in a deficiency related to accident hazards and supervision. The resident involved had a history of stroke and mobility issues, and the fall incident was substantiated by multiple witness statements and clinical documentation.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision and assistance devices to prevent accidents, resulting in a resident fall and injury. | G |
Report Facts
Complaint numbers: 2
Resident census: 48
MDS assessment score: 12
Pain rating: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | CNA | Documented transfer attempts and fall incident involving Resident #5 |
| Staff C | CNA | Witnessed fall and assisted with Resident #5 transfers |
| Staff A | Registered Nurse (RN) | Assisted Resident #5 during fall incident and documented progress notes |
| Staff B | Registered Nurse (RN) | Recalled fall incident and communicated with family and emergency services |
| Staff E | CNA | Assisted during fall incident and provided witness statements |
| Staff F | CNA | Recalled fall incident and assisted Resident #5 |
| DON | Director of Nursing | Relayed gait belt policy and staff training requirements |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 19, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective February 17, 2025.
Inspection Report
Renewal
Census: 47
Deficiencies: 3
Feb 19, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #126243-C from January 31, 2025 to February 6, 2025.
Findings
The facility was found not to have notified the Long-Term Care Ombudsman of discharge/transfer of residents as required by federal regulation, specifically for Resident #15. Additionally, the facility failed to ensure resident participation in quarterly interdisciplinary care planning meetings for 2 of 5 residents reviewed. The Quality Assurance Performance Improvement (QAPI) program was found to need revision to include resident and interdisciplinary team participation and to address prior deficiencies.
Complaint Details
Complaint #126243-C was investigated from January 31, 2025 to February 6, 2025 and was not substantiated.
Deficiencies (3)
| Description |
|---|
| Failure to notify the Long-Term Care Ombudsman of discharge/transfer of residents as required by federal regulation. |
| Failure to ensure resident participation in quarterly interdisciplinary care planning meetings for 2 of 5 residents reviewed. |
| Quality Assurance Performance Improvement (QAPI) program did not adequately address inclusion of residents and prior survey results. |
Report Facts
Resident census: 47
Residents reviewed for care plan participation: 5
Residents with care plan participation deficiency: 2
Residents discharged/transferred without Ombudsman notification: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Reported maintaining the Discharge Tracking form and acknowledged lack of notification for Resident #15. | |
| Administrator | Reported new process for Care Plan meetings and acknowledged previous Director of Nursing did not follow best practices for resident inclusion. |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 24, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective December 6, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Nov 25, 2024
Visit Reason
The inspection was conducted as a result of investigations into complaints #123318-C and #124803-C, and a facility reported incident #124816-I, occurring from November 25 to November 26, 2024.
Findings
The facility was found not in compliance with regulations regarding accident hazards and supervision, specifically failing to provide adequate monitoring and timely assistance to transfer off the toilet for one resident. Complaint #124803-C and the facility reported incident #124816-I were substantiated, while complaint #123318-C was not substantiated.
Complaint Details
Complaint #124803-C was substantiated. Complaint #123318-C was not substantiated. Facility reported incident #124816-I was substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to provide monitoring and timely assistance to transfer off the toilet for 1 of 3 residents reviewed for supervision. |
Report Facts
Census: 51
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 6, 2024
Visit Reason
An on-site revisit of the Recertification and Complaint Survey ending February 08, 2024 was conducted to verify correction of deficiencies.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective February 23, 2024. The Denial of Payment for New Admits (DPNA) was not effectuated.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 5
Feb 5, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and an investigation of Complaint #118706-C from February 5, 2024 to February 8, 2024.
Findings
The facility was found to have deficiencies related to failure to follow physician orders for catheter care, inadequate assessment and intervention after a resident fall resulting in a fractured hip, and failure to provide proper catheter care leading to urinary tract infections. The complaint was substantiated. Education and monitoring plans were implemented for nursing staff.
Complaint Details
Complaint #118706-C was substantiated based on findings related to catheter care and resident falls.
Deficiencies (5)
| Description |
|---|
| Failure to follow physician orders for catheter care for Resident #13, including improper catheter irrigation and site cleansing. |
| Failure to provide appropriate assessment and interventions after a resident fall resulting in a fractured left hip (Resident #8). |
| Failure to provide catheter care for Resident #13 leading to urinary tract infections. |
| Failure to limit psychotropic medications to 14 days without proper rationale for Resident #7. |
| Failure to report a major injury fall for Resident #8 within required timeframe. |
Report Facts
Census: 49
Residents reviewed: 15
Residents reviewed: 3
Residents reviewed: 5
PRN Lorazepam administrations: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in catheter care deficiency for Resident #13 |
| Staff B | Certified Nursing Assistant (CNA) | Named in catheter care deficiency for Resident #13 |
| Staff D | Certified Nursing Assistant (CNA) | Named in catheter care deficiency for Resident #13 |
| Staff F | Licensed Practical Nurse (LPN) | Named in fall assessment deficiency for Resident #8 |
| Staff G | Certified Nursing Assistant (CNA) | Named in fall assessment deficiency for Resident #8 |
| Staff H | Certified Nursing Assistant (CNA) Coordinator | Named in fall assessment deficiency for Resident #8 |
| Administrator | Administrator | Acknowledged medication administration issues for Resident #7 |
| Staff I | Assistant Director of Nursing (ADON) | Stated expectations for nursing assessments after resident falls |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 7, 2023
Visit Reason
An on-site revisit of the complaint survey ending October 3, 2023 was conducted on November 6-7, 2023 to verify correction of deficiencies.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective October 19, 2023. The Denial of Payment for New Admits (DPNA) was not effectuated.
Complaint Details
This was a revisit of a complaint survey ending October 3, 2023. All deficiencies were corrected and substantial compliance was achieved.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Sep 19, 2023
Visit Reason
The inspection was conducted as part of an investigation of multiple complaints (#111659-C, #112054-C, #114218-C) and a Facility Self-Reported Incident (#114267-M) from September 19, 2023 to October 3, 2023.
Findings
The facility failed to ensure residents were free from abuse when staff did not follow policies for reporting, investigating, and protecting residents from abuse. Several incidents involving staff and residents were documented, including physical abuse and failure to report incidents timely. The complaint #114218-C was substantiated.
Complaint Details
Complaint #114218-C was substantiated. The investigation found multiple incidents of abuse involving staff and residents, including failure to report and investigate abuse allegations timely. The facility reported a census of 54 residents during the investigation period.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were free from abuse when staff did not follow policy of reporting, investigating, and protecting residents from abuse. | SS=D |
| Staff B, Certified Nursing Assistant, reportedly grabbed a resident's hands and made her hit herself in the face early morning of 7/14/23; this was not reported until 7/14/23. | SS=D |
| Failure to report possible abuse in a timely manner created immediate jeopardy to resident health and safety. | SS=D |
Report Facts
Census: 54
Dates of incidents: Jul 14, 2023
Dates of education: Sep 28, 2023
Dates of incidents: Jul 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Named in multiple abuse incidents including grabbing resident's hands and pushing Resident #8's hands into her face. |
| Staff A | Certified Nurse Aide (CNA) | Witnessed and reported abuse incidents involving Staff B and residents. |
| Staff F | Registered Nurse (RN) | Witnessed and reported incidents involving Staff B and residents; provided statements during investigation. |
| Director of Nursing (DON) | Director of Nursing | Involved in investigation and coaching related to abuse incidents; monitored staff and residents for signs of abuse. |
| Administrator | Administrator | Received reports of abuse, coordinated investigation, and took disciplinary actions including suspension and termination of Staff B. |
| Staff C | Certified Medication Aide (CMA)-CMA/CNA Coordinator | Reported to have changed a report from flicking a resident to brushing his ear; spouse of Staff B. |
| Staff D | Staff | Reported observations of Staff B holding down residents and excessive force; involved in reporting and investigation. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Involved in investigation and monitoring of staff behavior. |
| Staff E | Staff | Reported concerns about Staff B's behavior and participated in investigation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 13, 2022
Visit Reason
The document is a plan of correction accepted by the facility following a prior inspection, indicating compliance certification.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective December 13, 2022.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 3
Dec 8, 2022
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and the investigation of Complaint #105252-C from December 5 to December 8, 2022. The complaint was not substantiated.
Findings
The facility was found deficient in developing and implementing comprehensive, person-centered care plans for residents, including failure to address specific medical needs such as diabetes and oxygen therapy. The facility also failed to ensure resident participation in care planning meetings and did not have all required members present at quarterly Quality Assessment and Assurance (QAA) committee meetings.
Complaint Details
Complaint #105252-C was investigated during the survey period and was not substantiated.
Severity Breakdown
SS=D: 2
SS=B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive person-centered care plan for Resident #25, lacking information on diabetes mellitus and insulin needs. | SS=D |
| Failed to implement new interventions on care plans for Residents #5 and #15 and failed to ensure resident participation in quarterly care planning meetings for Resident #32. | SS=D |
| Failed to maintain minimum required members at quarterly Quality Assessment and Assurance (QAA) meetings, missing key staff such as the Infection Preventionist, Director of Nursing, and Medical Director at various meetings. | SS=B |
Report Facts
Resident census: 50
Care Plan Meeting dates: 3
QAA meetings missing required members: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Thiessen | Administrator | Signed the inspection report |
| Staff A | Licensed Practical Nurse (LPN) | Assisted Resident #15 with oxygen application during observation |
| Staff B | Certified Nursing Assistant (CNA) | Provided incontinence care to Resident #5 during observation |
| Staff C | Certified Nursing Assistant (CNA) | Provided incontinence care to Resident #5 during observation |
| Director of Nursing | Interviewed regarding care plan expectations and acknowledged deficiencies | |
| Administrator | Interviewed regarding expectations for QAA committee attendance |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Aug 5, 2021
Visit Reason
The inspection was conducted as a Complaint Survey and investigation of Facility Self-Reported Incidents #98912 and #98916 from 7/29/21 to 8/5/21. Both incidents were not substantiated.
Findings
The facility was found deficient in updating Care Plans for residents, following Physician Orders, food safety requirements, quality assessment and assurance committee meetings, and infection prevention and control standards. Specific deficiencies included failure to update care plans for two residents, failure to follow physician orders for one resident, and failure to maintain food safety standards in the kitchen.
Complaint Details
The visit was complaint-related based on Facility Self-Reported Incidents #98912 and #98916. Both incidents were not substantiated.
Severity Breakdown
SS=D: 4
SS=B: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Care Plan Timing and Revision - failed to update Care Plans for two of thirteen residents reviewed. | SS=D |
| Services Provided Meet Professional Standards - failed to follow Physician Orders for one of thirteen residents observed. | SS=D |
| Food Procurement, Store, Prepare, Serve - failed to keep foods dated, check for outdated items, maintain clean kitchenware, and provide a sanitary dining environment. | SS=D |
| QAA Committee - failed to conduct required quarterly Quality Assurance and Performance Improvement (QAPI) meetings. | SS=B |
| Infection Prevention & Control - failed to establish and maintain an infection prevention and control program including proper hand hygiene and use of gloves. | SS=D |
Report Facts
Census: 49
Number of residents reviewed: 13
Number of residents with deficient care plans: 2
Number of residents with deficient physician order follow-up: 1
Number of QAPI meetings held: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Interviewed on 8/05/21 regarding care plan and stocking issues. |
| Director of Nursing | Director of Nursing | Interviewed on 8/05/21 regarding care plan documentation and Electronic Medical Administration Record. |
| Dietary Supervisor | Dietary Supervisor | Interviewed on 8/05/21 regarding food safety and kitchen observations. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Feb 11, 2021
Visit Reason
A Focused Infection Control (FIC) Survey for COVID-19 and an investigation of Complaint #88618 was conducted by the Department of Inspections & Appeals from 2/8/21 through 2/11/21.
Findings
The facility was found to be in substantial compliance with current Centers of Medicare & Medicaid Services (CMS) and Centers for Disease Control (CDC) recommended practices. Complaint #88618 was not substantiated.
Complaint Details
Complaint #88618 was investigated and found not substantiated.
Report Facts
Total residents: 44
Inspection Report
Routine
Census: 49
Deficiencies: 0
Jul 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 7/21/20 to 7/23/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 48
Deficiencies: 0
Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/10/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 48
Loading inspection reports...
