Inspection Reports for
Sunny View Care Center

The facility failed to ensure resident dignity due to malfunctioning stand lift batteries causing delays in toileting for residents #1 and #12. Oxygen therapy orders were not consistently followed for residents #2, #8, and #9, including improper documentation and incorrect oxygen flow rates. The facility also failed to maintain complete and accurate medical records for discharge planning for residents #15 and #16. Mechanical and electrical patient care equipment, including beds and mechanical lifts, were not maintained in safe operating condition for several residents.

The investigation was triggered by multiple complaints alleging noncompliance with resident rights and care standards. The complaints were substantiated as deficiencies were found related to resident dignity, equipment maintenance, and oxygen therapy management.

The facility was found deficient in ensuring residents' rights and dignity, particularly related to malfunctioning stand lifts and battery issues causing delays and safety concerns. Additionally, the facility failed to meet professional standards in following physician orders for oxygen administration and maintaining accurate medical records for residents requiring oxygen therapy.

The facility failed to clarify a medication order for a resident admitted in early April 2025, resulting in a delay in the resident receiving the medication as prescribed until April 7, 2025. The investigation included review of clinical records, staff interviews, and facility policies.

Complaint #128063-C was substantiated.

The facility failed to clarify a medication order for a resident admitted on 4/3/25, delaying medication administration until 4/7/25. Deficiencies included inadequate pharmacy services, unclear medication orders, and failure to maintain accurate drug records and reconciliation.

The facility was found deficient in several areas including failure to maintain a clean and odor-free environment in resident rooms, failure to follow physician's medication orders, inadequate communication regarding resident assistance levels, failure to provide appropriate respiratory care assistance, and failure to ensure yearly gradual dose reductions for psychotropic medications were attempted or appropriately declined.

The facility failed to ensure resident rooms were free of odors, specifically an ammonia odor in one resident's room, and failed to communicate current resident staff assistance levels across departments, leading to inconsistent care recommendations and increased falls for one resident.

Complaint #125495-C was substantiated. Facility reported incident #126585-I was also substantiated.

The facility was found deficient in maintaining a safe, clean, and homelike environment, following physician's orders for medication administration, ensuring adequate supervision to prevent accidents, providing necessary respiratory care, and managing psychotropic medications appropriately. Several residents' care plans and medication administration records showed lapses in compliance with professional standards.

Investigation of Complaints #122711-C and #122668-C were substantiated. The deficiencies resulted from these complaints and facility reported incidents #122134-I.

The facility failed to meet professional standards of quality in care and services, including failure to provide weight monitoring for Resident #5, bathing assistance for Resident #1, neurological assessments after incidents for Resident #2, adequate supervision to prevent accidents, and proper urinary output monitoring for catheterized residents. Multiple deficiencies were identified related to care planning, documentation, and staff education.

The facility failed to obtain weights per physician order for Resident #5, failed to provide bathing assistance as required for Resident #1, failed to complete neurological assessments and provide adequate supervision for Resident #2 after a fall, failed to monitor urinary output and follow physician orders for Resident #4 after catheter removal, and failed to provide appropriate catheter care and infection control for Residents #3 and #5.

The investigation was triggered by multiple complaint intakes (#119718, #120038, #120098, and #120615), all of which were substantiated. The facility reported incident #121000-M will be addressed separately.

The facility was found non-compliant with several federal requirements including failure to maintain comprehensive care plans, failure to follow physician medication orders, improper medication administration, inadequate perineal care for dependent residents, failure to assess and intervene after a resident fall, and insufficient nursing staff leading to delayed response to resident call lights.

The facility was found deficient in multiple areas including incomplete care plans, failure to follow physician medication orders, improper medication administration, inadequate perineal care, failure to perform follow-up assessments after a fall, and failure to respond to resident call lights timely. The deficiencies were associated with minimal harm or potential for actual harm affecting few to some residents.

Complaint #117117-C, #118700-C, and #119300-C were substantiated. Facility reported incident #118435-I was substantiated.

The facility was found to have multiple deficiencies related to notification of changes, care plan timing and revision, services provided meeting professional standards, assistance with activities of daily living, free of accident hazards, sufficient nursing staff, storage of drugs and biologicals, and infection prevention and control. The facility reported a census of 85 residents during the survey.

The facility was found deficient in multiple areas including failure to notify families of resident falls, improper transcription and administration of physician orders, inadequate feeding assistance for dependent residents, insufficient supervision to prevent choking and falls, delayed call light response times, and failure to maintain a clean and sanitary environment including shower chair sanitation and lack of a water management plan.

The facility was found deficient in multiple areas including failure to notify families of resident falls, failure to update care plans with changes in advanced directives, failure to transcribe and administer physician orders correctly, inadequate feeding assistance for dependent residents, inadequate supervision to prevent accidents, failure to keep medication carts locked, delayed call light responses, and failure to maintain a clean and sanitary environment including shower chair sanitation and lack of a water management plan.

The visit was triggered by investigations of complaints #111942-C, #112666-C, #113637-C, #114457-C, #114458-C, #114516-C, #115029-C, #115050-C, #116063-C, #116200-C, #116233-C, #116582-C, #116673-C and facility self-reported incidents #115715-I and #116068-I. The following complaints were substantiated: #112666-C, #115050-C, #116063-C, #116200-C, #116233-C, and #116673-C.

The facility was found not in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. Deficiencies included failure to return resident belongings post-discharge, inadequate assistance with activities of daily living such as oral care, toileting, and dining, and failure to properly assess and document skin conditions and injuries for residents.

The complaint involved failure to return resident belongings post discharge, including a missing teddy bear and flowers, and concerns about inadequate care including perineal care, oral care, dining assistance, toileting assistance, and skin condition assessments. The family reported items missing and improper room cleaning timing. Staff interviews and observations confirmed care deficiencies.

The facility failed to assure resident belongings were returned to one resident post discharge, failed to provide proper perineal and oral care, dining and toileting assistance, and failed to provide necessary assessments for a resident with a skin condition. The facility identified a census of 86 residents.

Based on clinical record review, policy review, and staff interview, the facility failed to follow physician's orders for 1 of 12 residents reviewed (Resident #37).

The facility failed to administer levothyroxine as ordered to Resident #37, resulting in a delay from 02/13/2023 to 02/25/2023. The facility has a triple check policy for new orders, but it was not followed in this case.

The facility was found deficient in multiple areas including failure to ensure staff completed required abuse training, failure to notify the Ombudsman of resident hospital transfers, failure to follow physician's medication orders, inadequate infection prevention and control practices during a COVID-19 outbreak, and failure to ensure nurse aides completed required continuing education.

Complaint #111276-C was substantiated. Complaint #111099-C was not substantiated.

The facility was found deficient in multiple areas including failure to ensure staff completed required abuse training, failure to notify the Ombudsman of resident transfers, failure to follow physician's orders, inadequate infection prevention and control practices, and failure to ensure nurse aides completed required in-service training.

The investigation was triggered by complaints 106559-C and 107427-C, both of which were substantiated.

The facility failed to notify a resident or responsible party/physician of significant changes in condition, including injury and decline. Deficiencies were found in medication administration documentation, notification processes, and professional standards of care related to apical pulse monitoring and pressure ulcer prevention and treatment. The facility reported a census of 80 residents at the time of investigation.

Complaint #104983-C was investigated and found not substantiated. Facility reported incident #105411-I was substantiated. Complaint #103991-I and facility reported incident #103991-I were not substantiated.

The facility failed to follow physician orders for medication administration for 4 residents, resulting in significant medication errors including an overdose incident. The facility reported a census of 80 residents and identified multiple deficiencies related to medication administration and care plan compliance.

Complaints #93100-C, #93813-C, and facility-reported incidents #95229-I, #99746-I, and #100074-I were substantiated. Complaints #89493-C and #90856-C did not result in deficiency.

The facility was found deficient in multiple areas including documentation of advanced directives, Medicaid/Medicare coverage notices, development and implementation of comprehensive care plans, quality of care including skin assessments and fall prevention, bed rail usage, and infection prevention and control. Several complaints and incidents were substantiated.

Complaint #87108 was investigated and found not substantiated.

The facility failed to notify the Ombudsman of hospital transfers for 2 residents, failed to resubmit PASRR after diagnosis changes for 4 residents, failed to update care plans timely for one resident, failed to ensure treatment was completed as ordered for one resident, and failed to secure wheelchair armrests for one resident, posing safety risks.