Inspection Reports for
Sunnyview Nursing Home & Apartments

The complaint investigation substantiated that Resident #2 physically abused Resident #1 multiple times between 8/22/25 and 9/26/25, including pushing Resident #1 into a bird aviary causing injury. The facility failed to implement adequate safety interventions after these incidents. Immediate jeopardy was identified and later removed after corrective actions.

The facility failed to protect Resident #1 from physical abuse by Resident #2, who had multiple prior aggressive incidents. No adequate interventions or safety measures were implemented after repeated aggressive episodes, culminating in Resident #2 pushing Resident #1 into a bird aviary causing injury.

The complaint investigation found that the resident eloped on 09/13/2025 and the care plan was not updated as required. Interviews with nursing staff and the Director of Nursing confirmed the failure to update the care plan and implement new preventive measures.

The facility failed to ensure staff followed policy to update Resident #15's care plan after the resident eloped on 09/13/2025. No new measures were added to the care plan to prevent future elopements despite the resident's increased risk for wandering.

The facility failed to ensure informed consent for psychotropic medications, proper use and documentation of psychotropic drugs, timely care plan updates after resident elopement, correct Medicaid/Medicare coverage notices, posting of nurse staffing data, and proper medication labeling and disposal of expired drugs. Several residents lacked documented consent for psychotropic medication use, and PRN psychotropic orders exceeded allowed durations without physician evaluation.

The facility failed to maintain a clean environment free from mold-like substances in multiple areas, including air vents, ceilings, and resident rooms. There was no policy regarding housekeeping or mold prevention provided.

The facility failed to maintain a safe, clean, and comfortable environment due to mold-like substances and damp, musty odors in multiple areas. There was no policy regarding housekeeping or mold prevention training for staff.

The facility was found to be in noncompliance with several Life Safety Code requirements including egress door locking, illumination of means of egress, exit signage, hazardous area enclosures, cooking facilities, fire alarm system testing and maintenance, sprinkler system out of service, smoking regulations, and essential electrical systems. Deficiencies had the potential to affect residents and staff.

The facility was found deficient in multiple areas including failure to complete significant change assessments for hospice residents, incomplete care plans for hospice services, improper use and documentation of wander guards, unsafe respiratory care practices, improper use of bed rails without documented alternatives, medication errors including incorrect medication administration and lack of proper order documentation, and infection control issues related to nebulizer mask storage and wound care procedures.

The survey was a Recertification and Complaint investigation conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri. The facility was found not in substantial compliance with federal regulations.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to significant change assessments, comprehensive care plans, free of accident hazards, respiratory care, pharmacy services, bedrails, psychotropic medication use, and infection control.

The facility failed to ensure hazardous areas were separated by a one-hour fire-resistant rating or smoke-resistant partitions and doors. An open doorway was observed between the kitchen and dining room where a freezer used to be.

The facility failed to maintain written statements signed by a licensed physician or designee for certain employees, and food items were found unlabeled and undated, posing potential risks to residents.

The complaint was substantiated. The Certified Medication Technician admitted to making the comment, describing it as a dark joke. Staff delayed reporting the incident, not initially recognizing it as abuse. The Director of Nursing suspended the employee pending investigation.

The facility staff failed to immediately notify facility administration after the inappropriate comment was made. The comment was confirmed by the Certified Medication Technician and reported late by staff. The Director of Nursing suspended the employee pending investigation.

The facility failed to maintain exit sign illumination, inspect and maintain the sprinkler system, maintain the building in good repair, and maintain electrical wiring in compliance with applicable codes. Deficiencies affected all 19 residents present during the inspection.

Complaint MO216595 involved an allegation by Resident #1 of sexual abuse. The allegation was not substantiated after investigation. The resident's Durable Power of Attorney did not want law enforcement contacted or the resident sent to the hospital.

The facility failed to ensure staff immediately reported allegations of abuse to the Department of Health and Senior Services and law enforcement. The allegation involved Resident #1 reporting a sexual assault, which was not reported within the required two-hour timeframe. The facility conducted an internal investigation and concluded the allegation was not substantiated.

Complaint MO216595 involved an allegation that Resident #1 was raped in the facility. The allegation was investigated through interviews, medical record reviews, and camera footage. The facility's internal investigation and assessment concluded the allegation was not substantiated. Resident #1 and family did not want law enforcement contacted or Resident #1 sent to the hospital.

The facility failed to immediately report an allegation of sexual abuse involving Resident #1 to the Department of Health and Senior Services and law enforcement as required by regulations. The internal investigation concluded the allegation was not substantiated.

The facility failed to ensure the resident environment was free of accident hazards due to the use of portable electric heaters in shower rooms. The violation was initially at Immediate Jeopardy level but was lowered to level 'E' after corrective actions were implemented.

The complaint investigation was substantiated as the facility failed to immediately report suspected sexual abuse of Resident #1 and did not perform required assessments. The administrator and nursing staff did not follow proper protocols, resulting in delayed reporting to the police and hospital evaluation.

The facility staff failed to immediately report an allegation of sexual abuse and did not perform a full head-to-toe skin assessment on the resident. The investigation revealed delays and incomplete assessments by nursing staff and inadequate reporting to the administrator and primary care provider.

The facility failed to ensure smoke sections were properly separated by one-hour fire-rated smoke partitions and failed to prohibit the use of portable heaters, posing fire hazards. Observations included gaps in smoke partitions and the presence of a space heater with combustible materials nearby.

The facility had multiple deficiencies including failure to honor residents' do not resuscitate orders, failure to provide Skilled Nursing Facility Advance Beneficiary Notices, failure to provide bed hold policy copies, incomplete significant change assessments, incomplete quarterly assessments, incomplete and inaccurate care plans, failure to implement pressure ulcer prevention measures, inadequate fall prevention interventions, improper catheter care, failure to properly manage feeding tube orders and monitoring, improper use and assessment of bed rails, unsanitary kitchen conditions, failure to coordinate hospice care, incomplete infection prevention and control program including TB testing and antibiotic stewardship, failure to maintain safe bed environments, and failure to maintain adequate RN staffing.

The facility failed to meet several regulatory requirements including tuberculosis screening for staff, monthly resident record summaries, food safety and labeling, cleaning of nonfood contact surfaces, dishwasher sanitization, and resident rights review. The facility census was 15 at the time of inspection.

The facility failed to provide RN coverage for eight consecutive hours per day, seven days a week, as required. The Director of Nursing position was not staffed full-time, and the facility did not have a policy for RN coverage.

The facility failed to maintain unobstructed means of egress as evidenced by bedsheets tied to exit doors, obstructing emergency exits. Additionally, exit discharge doors were improperly marked with STOP signs that could confuse residents, and the facility's evacuation and fire drill plans had deficiencies.

The facility failed to provide protective oversight for a resident who eloped and was found outside in cold weather. The facility lacked a current policy on protective oversight and elopement, and the door alarm was not working at the time of the incident.

The facility failed to complete weekly skin assessments for a resident at risk for pressure ulcers, and documentation was incomplete or missing. The wound nurse and nursing staff did not consistently complete or document required skin assessments as per facility policy.

The investigation was complaint-related focusing on COVID-19 infection prevention and control practices. The complaint was substantiated based on observations and interviews.

The facility failed to maintain an infection control program during the COVID-19 pandemic, including failure to ensure staff offered and assisted residents with hand hygiene before meals, improper handling of food containers, and failure to change gloves and perform hand hygiene between residents. Multiple observations and interviews confirmed these deficiencies.

The complaint investigation substantiated that the facility failed to notify the resident's responsible party and physician of significant weight loss and a fall. The facility also failed to implement appropriate care plans and interventions for these issues.

The facility failed to notify the resident's responsible party and physician about significant weight loss and a fall. The facility also failed to implement comprehensive care plans for residents with weight loss and falls, and did not follow professional standards for care and treatment.

The complaint investigation was substantiated based on observations, interviews, and record reviews showing the administrator forcibly removed a resident from the entrance door and the facility failed to properly implement abuse and neglect policies and procedures.

The facility failed to treat a resident with dignity and respect, as the administrator forcibly removed the resident from the entrance door. The facility also failed to develop and implement appropriate abuse and neglect policies and procedures, and failed to properly investigate and suspend staff pending abuse allegations.

The facility failed to properly document monthly fire extinguisher checks, conduct required fire drills, maintain the sprinkler system inspection, and provide adequate emergency lighting. These deficiencies affected all twenty-one residents present during the inspection.

The facility failed to maintain required fire protection measures including sprinkler system integrity, corridor door smoke resistance, smoke barrier walls, electrical receptacle testing, and safe use of power strips. Multiple deficiencies were cited affecting smoke compartments and fire safety systems.

The facility was found to have multiple deficiencies including failure to promote resident self-determination, inadequate notice before transfer or discharge, failure to develop comprehensive care plans, improper medication management, and infection control issues. Several residents were affected by these deficiencies.

The complaint investigation was substantiated. Resident #1 was injured during transport when not secured in the van, resulting in multiple injuries including fractured cervical spine and facial lacerations. The facility failed to report the incident timely and did not follow safe transportation policies.

The facility failed to report the alleged abuse promptly and did not ensure the resident environment was free from accident hazards during transport. Resident #1 suffered multiple injuries including a fractured cervical spine and facial lacerations due to being unsecured in a moving van. The facility was found noncompliant with reporting and safety regulations.

The facility failed to ensure proper storage and handling of controlled substances, including improperly stored medications and damaged bubble packs with pills taped inside. The facility also lacked an accurate system for controlled substance reconciliation.

The facility failed to implement a safe and effective medication administration system, resulting in a 7.69% error rate affecting sampled residents. Additionally, the facility failed to store and serve food under sanitary conditions, with improper temperature monitoring and handling practices observed.

The facility was found deficient in multiple areas including failure to develop and implement abuse/neglect policies, inadequate monitoring of resident care and transfers, incomplete resident assessments, insufficient nursing staff training and competency, medication errors, and infection control issues. The facility submitted a plan of correction addressing these deficiencies.

The facility failed to meet several fire safety requirements including maintaining fire barriers, means of egress, fire extinguisher inspections, corridor door integrity, smoke barrier construction, fire drills, and safe storage of oxygen cylinders. Deficiencies had the potential to affect residents, staff, and visitors.

The facility failed to properly document fire drill records, certify all curtains and drapes as flame-resistant, and maintain the electrical system, including broken outlets and switches. These deficiencies affected all 25 residents present during the inspection.

The complaint investigation found that the facility did not notify the resident's responsible party about the fall on 4/26/18 and failed to obtain timely x-rays after the resident complained of rib pain. The complaint was substantiated based on interviews and record reviews.

The facility failed to notify the responsible party of a resident's fall and did not follow physician orders to obtain an x-ray in a timely manner. The resident complained of rib pain after the fall, and the facility's communication and follow-up on the x-rays were inadequate.

The complaint involved allegations that a staff member removed a fentanyl patch from Resident #1 without authorization. The facility's investigation was ongoing, and the police were notified after the incident. The state agency found the facility failed to notify law enforcement immediately as required. The allegations of misappropriation of property were found unsubstantiated after investigation.

The facility failed to report a reasonable suspicion of a crime involving the unauthorized removal of a fentanyl patch from a resident. The investigation revealed the facility did not notify local law enforcement at the time of the incident, violating reporting requirements.

The facility failed to meet professional standards of quality related to medication administration for one resident, specifically regarding timely ordering and documentation of antibiotics. The facility census was 79 at the time of the survey.