Inspection Report
Annual Inspection
Census: 44
Capacity: 57
Deficiencies: 12
Mar 12, 2025
Visit Reason
A recertification survey and a complaint investigation were conducted at Sunny View Nursing Home from 03/10/2025 through 03/12/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Multiple deficiencies were identified related to Medicaid coverage notices, bed-hold policies, activities of daily living, quality of care, medication administration, food safety, pressure ulcer care, training requirements, and life safety code compliance. The facility failed to meet several regulatory requirements and did not achieve a passing score on the Life Safety Code survey.
Complaint Details
Complaint investigation ACTS 99863 was conducted concurrently with the recertification survey to determine compliance with federal regulations.
Deficiencies (12)
| Description |
|---|
| Facility failed to properly inform Medicaid-eligible residents of changes in coverage and services as required by Medicare and Medicaid regulations. |
| Facility failed to provide required bed-hold policy notices upon resident transfer to hospital. |
| Facility failed to ensure a resident received appropriate assistance with activities of daily living, including grooming and shaving. |
| Facility failed to ensure residents received treatment and care in accordance with professional standards, including care for hospitalization related to fecal impaction and urinary tract infection. |
| Facility failed to follow bowel protocol and ensure administration of bowel medications as ordered. |
| Facility failed to ensure residents received necessary treatment and services to prevent and treat pressure ulcers. |
| Facility failed to complete annual performance evaluations for nursing aides. |
| Facility failed to ensure residents were free of significant medication errors, including failure to administer prescribed insulin. |
| Facility failed to procure, store, prepare, and serve food in accordance with professional food safety standards. |
| Facility failed to develop and maintain an effective training program for all new and existing staff, including training on abuse, neglect, dementia management, and infection control. |
| Facility failed to conduct quarterly medication technician evaluations and document compliance. |
| Facility failed to comply with Life Safety Code requirements, including building construction type, fire alarm system maintenance, sprinkler system maintenance, fire drills, and number of exits. |
Report Facts
Residents involved in Medicaid coverage deficiency: 4
Residents involved in bed-hold policy deficiency: 1
Residents involved in ADL assistance deficiency: 1
Residents involved in quality of care deficiency: 1
Residents involved in medication error deficiency: 1
Residents involved in pressure ulcer deficiency: 3
Nursing aides missing annual performance evaluations: 4
Facility capacity: 57
Facility census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Medication Technician | Named in medication administration deficiency |
| Staff N | Certified Medication Technician | Named in medication administration deficiency |
Inspection Report
Follow-Up
Deficiencies: 0
Apr 23, 2024
Visit Reason
This document is a follow-up to a previous recertification survey conducted at the facility on 04/23/2024 to verify correction of previously identified deficiencies.
Findings
No new deficiencies were identified during this follow-up visit, and all previous deficiencies were corrected.
Inspection Report
Annual Inspection
Census: 52
Capacity: 57
Deficiencies: 7
Mar 25, 2024
Visit Reason
A Recertification Survey was conducted at Sunny View Nursing Home from 03/20/2024 through 03/25/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. A State licensure and emergency preparedness survey was also conducted.
Findings
Deficiencies were cited related to quality of care, comprehensive assessment after significant change, treatment and prevention of pressure ulcers, food safety, infection prevention and control, resident call system, and life safety code compliance. Immediate jeopardy was identified and removed during the survey period.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure residents receive treatment and care in accordance with professional standards, including failure to assess and report vomiting episodes leading to resident death. | Immediate Jeopardy |
| Failure to complete significant change in status assessments within 14 days for 4 of 5 residents reviewed. | — |
| Failure to provide treatment and care to prevent pressure ulcers for 1 of 4 residents reviewed. | — |
| Failure to properly store and serve food under sanitary conditions and maintain proper food temperatures. | — |
| Failure to maintain an effective infection prevention and control program, including failure to prevent transmission of infections and conduct appropriate surveillance. | — |
| Failure to adequately equip residents with call system devices to allow staff assistance. | — |
| Life Safety Code deficiencies related to building construction type, height, sprinkler system, means of egress, and emergency power supply system. | — |
Report Facts
Capacity: 57
Census: 52
Residents reviewed for significant change in status assessment: 5
Residents with pressure ulcers reviewed: 4
Residents affected by infection control deficiencies: 6
Residents reviewed for call system adequacy: 1
Residents affected by life safety deficiencies: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Named in relation to immediate jeopardy and survey interviews |
| Administrator | Administrator | Named in relation to immediate jeopardy and survey interviews |
| MDS Coordinator | MDS Coordinator | Responsible for ensuring timely MDS assessments and implementing corrective plan |
| Director of Maintenance | Director of Maintenance | Responsible for life safety code corrective actions and reporting |
| Food Service Manager | Food Service Manager | Responsible for food safety corrective actions and education |
| Infection Preventionist | Infection Preventionist | Responsible for infection control program and staff education |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 22, 2023
Visit Reason
A revisit survey was conducted on March 22, 2023, for all previous deficiencies cited on February 10, 2023, related to the Re-certification/Licensure Life Safety Code survey.
Findings
All deficiencies have been corrected and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 22, 2023
Visit Reason
A follow-up survey was conducted to verify correction of previous deficiencies cited on February 10, 2023, during the recertification/licensure Life Safety Code survey.
Findings
All previous deficiencies were corrected and no new deficiencies or noncompliance were found. The facility is in compliance with all regulations surveyed.
Inspection Report
Recertification
Deficiencies: 5
Feb 10, 2023
Visit Reason
A Recertification Survey and complaint investigation survey were conducted at Sunny View Nursing Home from 02/07/2023 through 02/10/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to treatment and services to prevent and heal pressure ulcers, nutrition and hydration status maintenance, respiratory and tracheostomy care, drug regimen free from unnecessary drugs, and food safety and nutritional adequacy. The facility failed to provide necessary care and services consistent with professional standards for multiple residents, including failure to offload heels, maintain acceptable nutritional parameters, provide respiratory care, and ensure proper medication and food safety practices.
Complaint Details
The survey included a complaint investigation with ACTS Reference Numbers 88822 and 88648.
Severity Breakdown
Level 3: 2
Level 2: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to provide necessary treatment and services to prevent and heal pressure ulcers for 3 of 6 residents reviewed for skin conditions. | Level 3 |
| Facility failed to ensure residents maintain acceptable nutritional status and failed to follow weight change policy for 2 of 9 residents reviewed. | Level 2 |
| Facility failed to provide respiratory care consistent with professional standards for 3 of 5 residents reviewed for oxygen therapy. | Level 3 |
| Facility failed to ensure drug regimen is free from unnecessary drugs for 1 of 2 residents reviewed for pain. | Level 2 |
| Facility failed to provide food that meets nutritional needs and failed to follow food safety requirements. | Level 2 |
Report Facts
Residents reviewed for skin conditions: 6
Residents reviewed for nutritional status: 9
Residents reviewed for oxygen therapy: 5
Residents reviewed for drug regimen: 2
Residents observed during lunch meal: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Acknowledged resident heels were not offloaded as ordered |
| Staff B | Registered Nurse (RN) | Acknowledged resident heels should be offloaded and resident oxygen use |
| Director of Nursing Services (DNS) | Director of Nursing Services | Acknowledged expectations for offloading heels and oxygen administration |
| Staff C | Registered Nurse | Acknowledged admission weight was not obtained per facility policy |
| Staff E | Dietary Staff | Observed not wearing hair restraint and improper sanitation |
| Food Service Director | Food Service Director | Acknowledged dietary staff not wearing hair restraints and improper sanitation |
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