Sunnycrest Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interview the facility failed to accurately code a diagnosis for 1 of 1 resident reviewed for hospitalization (Resident #7). The facility identified a census of 72 residents.Findings include:Resident #7's Electronic Medicare Record (EMR) Census showed the resident transferred to the hospital on 1/3/26.Resident #7's 1/3/26 chest x-ray under Impression documented findings suggesting congestive heart failure exacerbation with pulmonary edema (a progressive condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs, causing blood to back up and fluid to build up (congestion) in the lungs, legs, and other tissues).A 1/7/26 Hospital Medicine Discharge Summary documented Resident #7 had a diagnosis of acute heart failure with preserved ejection fraction (HFpEF, congestion of the heart caused by increased stiffening and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to provide 1 of 1 resident unable to carry out activities of daily living (ADLs) with the services necessary to maintain good personal hygiene (Resident #69). The resident had a brown substance under his nails for 3 days during the survey. The facility reported a census of 72 residents.Findings include:Resident #69's Minimum Data Set (MDS) dated [DATE] identified they had okay short-term memory with moderately impaired decision-making skills for daily decisions. The MDS included diagnoses of mild intellectual disability, legal blindness, and altered mental status. Resident #69 required partial/moderate assistance with personal hygiene. A Care Plan (CP) intervention revised 12/16/25 listed certified nurses' aides (CNAs) and nurses as responsible for checking Resident #69's nail length. The Intervention directed them to trim and clean nails on bath day and as necessary. Resident #69's March 2026 Documentation Survey Report indicated they had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review, policy review and staff interview the facility failed to provide an updated pneumococcal vaccination per the Center for Disease Control and Prevention (CDC) Immunization schedule for 1 of 5 residents sampled (Resident #7). The facility identified a census of 72 residents.Findings include:An Electronic Healthcare Record (EHR) Census documented Resident #7 admitted to the facility on [DATE]. The Census Record listed Resident #7 as [AGE] years old. The Immunization Care Plan initiated 9/15/25 contained a Goal Resident would accept screening process for immunizations and directed to administer the vaccines. A review of the Pneumococcal Immunization Consent Form showed Resident #7 signed a consent to receive an updated pneumococcal vaccination on 10/3/25.The EHR Census Record documented Resident #7 discharged to the hospital on 1/3/26.A 1/3/26 Hospital Transfer Summary documented a history of pneumonia from 10/8/25. A 1/7/26 Hospital Medicine Discharge Summary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure staff treated each resident with dignity and respect for one of four residents reviewed (Resident #1). The facility reported a census of 75 residents. Findings include:The MDS (Minimum Data Set) dated 7/30/2025 revealed Resident #1 had no cognitive impairment, required set up assistance with eating, required staff assistance to transfer from one surface to another, and used a wheel chair for mobility. The resident had diagnoses including legal blindness, hard of hearing, depressive disorder and anxiety.The resident's Care Plan revealed the resident had verbal aggression and outbursts related to mental illness initiated 9/11/2013. At times of increased agitation and difficulty with communication, it instructed staff to ensure the resident's cochlear processor (external component of cochlear implant) is placed with charged batteries. The resident, being blind and deaf required the cochlear implant in order to hear. The Care Plan directed staff to monitor the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, kitchen record review, staff interview, and policy review the facility failed to store foods according to professional standards and maintain effective sanitizing solution during 4 of 4 kitchen and 2nd floor dining room observations. The facility reported a census of 73 residents. Findings include: 1. On 02/24/25 between 9:56 AM and 10:27 AM the initial kitchen observation revealed the following: a. Staff B, [NAME] was observed cleaning the sink with a damp, white rag. There were no filled sanitizer buckets visible. Staff B used the same rag to wipe out the sink and 2 food prep areas. The prep counter in the center of the kitchen and the sink contained food particles and splashes of unidentified light brown and off white liquids. b. A walk in cooler, with a temperature of 22 degrees, contained a cart of milk and a cart of juice. The drinks remained in pans of ice used to keep them cold when transported through the building. 6 jugs of milk were open and undated. The milk was frozen to the sides of the container and lumpy. 6 containers of lemonade and juice did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on CMS (Centers for Medicare and Medicaid Services) Statements of Deficiencies, the facility Quality Assessment and Performance Improvement (QAPI) Plan, and staff interviews the facility failed to fully implement Quality Assurance (QA) activities to ensure kitchen related deficiencies were corrected and to prevent repeat occurrences. The facility reported a census of 73 residents. Findings include: Form CMS-2567, with a correction date of 05/08/24, included tag F812 and documented in part that the facility failed to date open foods. Form CMS-2567, with a correction date of 01/12/23, included tag F812 and documented in part that the facility failed to meet professional standards of food service safety and food had not been prepared under sanitary conditions. The current survey, conducted between 2/24/25 and 2/27/25, revealed concerns in the same areas including in part undated open foods, not monitoring refrigerator and freezer temperatures, not monitoring sanitizer chemical levels, dented cans, expired food, and a dusty vent. The facility QAPI Plan titled Facility Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interviews, and policy review the facility failed to review and revise a resident's Care Plan for 1 of 5 residents reviewed for unnecessary medications (Resident #63). The resident's Care Plan did not include focus areas, goals, or interventions for the use of medications for mental health. The facility reported a census of 73 residents. Findings include: The Minimum Data Set (MDS) for Resident #63, dated 01/22/25, documented a Brief Interview for Mental Status score of 14/15 which indicated intact cognition. Diagnoses included anxiety disorder, depression, and schizophrenia. The resident's medication administration record listed the following medications: Divalproex Sodium ER Extended Release 500 MG for schizoaffective bipolar type Invega Sustenna Intramuscular Suspension 234 MG/1.5 ML for schizoaffective bipolar type Lithium Carbonate ER Extended Release 300 MG for schizoaffective bipolar type Quetiapine Fumarate 50 MG for schizoaffective disorder bipolar type Vortioxetine HBr 20 MG for depression During an interview on 02/24/25 at 11:25 AM Resident #63,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review the facility failed to use proper technique to administer insulin for 1 out of 1 residents injected with an insulin pen (Resident #18). The facility identified a census of 73 residents. Findings include: Review of Resident #18 Medication administration record for February 2025 revealed an order for Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 unit/milliliter inject 26 unit subcutaneously before meals related to type 2 diabetes mellitus. She also had an order for sliding scale insulin. If blood sugar 150-200 inject 3 units Fiasp FlexTouch Subcutaneous Solution Pen-injector. Observation on 2/25/25 at 11:01 AM Staff A, Licensed Practical Nurse (LPN) obtained a blood sugar of 186 for Resident # 18. Staff A dialed up 19 units of Fiasp insulin for Resident #18 and failed to waste 2 units to prime the needle. Staff A needed a second pen to administer the prescribed dose of 29 units. Staff A obtained a second insulin pen and dialed up 10 units of Fiasp insulin. Staff A entered Resident #18 room and administered both pens…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review the facility failed to provide proper hand washing and wound care to prevent the spread of infection in 1 out of 1 wound care observed (Resident #34). The facility identified a census of 73 residents. Findings include: Review of Resident #34 physician visit/consult form dated 11/14/24 revealed the resident had a left heel blister drained on 10/29/24 and indicated the area positive for Methicillin-resistant Staphylococcus aureus (MRSA) bacteria. Review of the Care Plan for Resident #34 with a revision date of 12/17/24 revealed an open area to right great toe and left heel. The Care Plan revealed resident had an active infection to left heel and left lower extremity cellulitis. The Care Plan directed staff during active infection institute CONTACT ISOLATION: Wear gowns when changing contaminated linens and prior to entering residents room, gowns and gloves should be removed prior to exiting the room, staff should use good hand-washing before entering and prior to exiting room. Place soiled linens in bags prior to exiting room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interview the facility failed to date opened foods, wear hair nets, use gloves appropriately for assembling and serving meals, and wash hands between glove use in order to serve meals under sanitary conditions. The facility reported a census of 62 residents. Findings include: During an observation of the kitchen on 4/09/24 at 9:12 AM the following items were found opened and undated: elbow macaroni, rigatoni noodles, and spiral noodles in an unlabeled plastic bag. At 9:22 AM Staff B, [NAME] failed to wear a hair net while cutting dessert bars. She was observed again at 11:51 AM without a hair net on while serving the noon meal. An observation of the puree process on 4/09/24 from 9:24 AM to 10:12 AM revealed the following: a. Staff A, [NAME] wore gloves and placed cooked riblet meat in a blender by hand. He then wiped his gloves on his apron and grabbed a recipe binder off a shelf. He used his hands to flip through the binder pages and then used a rubber spatula to scrape the ground meat into a measuring container. He again touched the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, policy review, and staff interviews the facility failed to maintain appropriate food holding temperatures to prevent food-borne illness and utilize the menu-approved serving sizes to meet resident nutritional needs. The facility reported a census of 62 residents. Findings include: During an observation of the puree preparation on 4/09/24 from 9:24 AM to 10:12 AM a milk carton was observed sitting directly on the counter. The temperature of the milk at 10:09 AM was 49.6 degrees Fahrenheit (F). Staff A, [NAME] failed to dispose of the milk and placed it back in the refrigerator at 10:11 AM. During an observation of the noon meal on 4/09/24 from 11:33 AM to 1:06 PM revealed the following: A. The sliced onions, pickles, and tomatoes in containers were placed directly on a serving cart not on ice and used throughout meal service B. Staff C, Food Service Worker was observed serving residents with the following scoop sizes: a. Pureed BBQ riblets- scoop #12 (2 2/3 ounces (oz)) b. Diced BBQ riblets- scoop #12 c. Diced carrots- scoop #12 d. Mashed potatoes- scoop #12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, and staff interview the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) Assessment within the required time frame for 1 of 2 residents sampled on hospice care (Resident #2). The facility reported a census of 62 residents. Findings include: Resident #2's Hospice Plan of Care documented a hospice admission date of 7/21/23 for a primary diagnosis of malignant neoplasm of colon. Resident #2's MDS assessment dated [DATE] showed a Brief Interview for Mental Status score of 12/15 indicating a moderate cognitive impairment. The MDS lacked documentation in section O, Special Treatments, Procedures and Programs, of Resident #2 receiving hospice services. The MDS 3.0 Summary Page showed the 8/02/23 MDS with a completion date of 8/15/23. The facility failed to complete the significant change in status assessment (SCSA) MDS for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessment for 3 of 3 residents sampled (Resident #2, #23, and #32). The facility identified a census of 62 residents. Findings include: 1. Resident #2's Hospice Plan of Care documented a hospice admission date of 7/21/23 for a primary diagnosis of malignant neoplasm of colon. Resident #2's MDS assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12/15 indicating a moderate cognitive impairment. The MDS lacked documentation in section O, Special Treatments, Procedures and Programs, of Resident #2 receiving hospice services. On 4/08/24 at 1:40 PM Staff D, Registered Nurse verbalized Resident #2 currently receives hospice care from a local provider. On 4/10/24 at 9:16 AM the MDS Coordinator reported she must have accidentally miscoded the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff and resident interviews, the facility failed to follow the resident's care plan for one of three residents reviewed (Resident #3). The facility reported a census of 56 residents. Findings include: The MDS (Minimum Data Set), an assessment tool, dated 3/1/2023, revealed Resident #3 had intact cognitive skills for daily decision making, and transferred from one surface to another with extensive assistance of two staff. The MDS dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making and transferred with extensive assistance of two staff. The resident had diagnoses including Cerebral Palsy, diabetes, anxiety, and depressive disorder. The resident's Care Plan revealed the resident required assistance with activities of daily living and had a fall risk. On 11/21/2022, the revised Care Plan directed staff to transfer the resident using a mechanical stand up lift and with the assistance of two staff. The Incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.