Sunny Hill Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff and resident interviews, the facility failed to answer call lights in a timely manner for 2 of 3 residents reviewed for staffing concerns(Residents #22 and #23). The facility reported a census of 52 residents. Findings:1. Minimum Data Set (MDS) assessment tool, dated 1/23/26, listed diagnoses for Resident #23 which included difficulty walking, weakness, and a history of falling. The MDS stated the resident required partial to moderate assistance with chair to bed and toilet transfers and substantial to maximal assistance with walking. The MDS listed the resident's Brief Interview for Mental Status(BIMS) as 12 out of 15, indicating moderately impaired cognition. On 3/3/26 at 9:06 a.m., Resident #23 stated call lights took more than 30 minutes. He stated that he looked at the clock to time it. He stated it made him feel miserable to sit and wait. A Care Plan entry, dated 11/20/15, stated the resident had an activity of daily living impairment and required…

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, policy review, and staff interviews, the facility failed to prime an insulin(an injectable medication used to lower blood sugar) pen prior to administration for 1 of 1 residents observed for insulin(Resident #32). The facility reported a census of 52 residents. Findings:1. The Minimum Data Set (MDS) assessment tool, dated 12/19/25, listed diagnoses for Resident #32 which included diabetes (a disease which caused fluctuations in blood sugar), heart failure, and shortness of breath. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The 1/13/26 Care Plan entries stated the resident had diabetes and directed staff to administer diabetes medication as ordered by the doctor. The March 2026 Medication Administration Record (MAR) listed an order for Tresiba (a type of insulin) FlexTouch Pen-injector 100 units/milliliter (ml) 40 units in the morning. The Tresiba Flextouch Instructions For Use, retrieved from https://www.novo-pi.com/tresiba.pdf#IFU on 3/4/26, stated prior to…

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 staff interview, resident interview, CMS-2567 (Centers for Medicare and Medicaid Services) report, facility policy, and Quality Assurance Performance Improvement Plan (QAPI) the facility failed to ensure an effective QAPI process to address inclusion of residents in care planning process per a previously identified deficiency on the facility's prior recertification. The facility reported a census of 47 residents. Findings include: The CMS-2567 form referring to the facilities recertification survey outcome dated 12/8/22 revealed a deficient practice, lacked resident participation in quarterly interdisciplinary meetings for care planning. The facility correction response dated 1/1/23 included invitations would be given to residents. 1. The Minimum Data Set (MDS) assessment for Resident #31 dated 12/6/24 included a cognitive assessment, The Brief Interview for Mental Status (BIMS) scored 15 out of 15 indicated residents' cognition as intact. In an interview on 2/3/25 at 9:51 AM Resident #31 queried about care plan meetings, if they had participated in plan of care discussions…

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 resident interview, staff interviews, record review, and policy review the facility failed to ensure resident participation option in quarterly interdisciplinary team meetings for care planning for 2 of 5 residents reviewed regarding care plan meetings (Residents #31 & #38). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #31 dated 12/6/24 included diagnoses of anemia, heart failure, peripheral vascular disease, anxiety, and depression. The MDS listed the Resident's BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating intact cognition. A Care Conference Summary form dated 9/5/24 for Resident #31 revealed a column of discussion topics and comments. The form included a column to identify resident discussion, if agreed or disagreed that was left blank. Signature lines for staff in attendance included written staff names along with Resident #31 name written on resident signature line. The boxes to identify if resident agreed, disagreed, or understood was disregarded, not completed. In…

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 clinical record review, policy review, resident interview, and staff interview, the facility failed to provide monitoring and timely assistance to transfer off the toilet for 1 of 3 residents reviewed for supervision (Resident #1). The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 9/13/24, listed diagnoses for Resident #1 which included amyotrophic lateral sclerosis (ALS-a progressive neurological disease that affected the nerve cells in the brain and spinal cord), heart failure, and diabetes. The MDS stated the resident was dependent on staff to transfer on and off the toilet and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. 7/1/17 Care Plan entries stated the resident was dependent on staff for transfers and position changes, and utilized a mechanical lift. On 11/25/24 at 12:36 p.m., Resident #1 stated staff left him on the toilet for 2.5 hours. He stated his body hurt when he sat on the toilet but it subsided after staff assisted him off the toilet.…

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, resident and staff interviews, the facility failed to follow through with Physician Orders for 1 of 15 residents reviewed (Resident #13). The facility reported a census of 49 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] for Resident #13 revealed a diagnosis of Urinary Tract infections (UTI), neuromuscular dysfunction of the bladder and stroke with left sided paralysis and required assistance of one person for toileting, hygiene and an indwelling catheter was identified. Resident #13's Brief Interview for Mental Status (BIMS) score, 15 out of 15 indicated intact cognition. The Care Plan dated 7/18/23 directed Nursing Staff to care for the catheter every shift and to follow the Physician Orders in regards to flushing and changing the catheter. The Discharge Order from a local hospital dated 1/16/24 identified the resident with a suprapubic catheter. During an interview on 2/5/24 at 1:45 PM, Resident #13 stated he had a suprapubic catheter 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.

Based on observation, clinical record review, resident and staff interviews, and facility policy review, the facility failed to provide catheter care for 1 of 3 residents reviewed (Resident #13). The facility reported a census of 49 residents. Findings Include: During an interview on 2/5/24 at 1:45 PM, Resident #13 stated he had a suprapubic catheter and had been an ongoing problem of spasms and Urinary Tract Infections (UTI) for him. Resident #13 stated the nurse told him she couldn't do anything without an order to care for it. During an observation on 2/6/24 at 9:36 AM, Staff A, Registered Nurse (RN) provided Resident #13's suprapubic catheter care and catheter irrigation. Staff A withdrew 60 milliliters (ml) of clear fluid into a catheter tipped syringe from a cup. Staff A removed a plastic vial of 0.9% Sodium Chloride from her pocket to show what she was using for the irrigation (flush). Staff A disconnected the catheter from the catheter tubing, wiped with alcohol and connected the syringe and flushed the fluid into the resident. Resident #13 requested Staff A to clean 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 clinical record review, staff interview, and facility policy review, the facility failed to limit as needed (PRN) psychotropic medications to 14 days without a rationale from the provider to extend the medication for 1 of 5 residents reviewed for unnecessary medications (Resident #7). The facility reported a census of 49 residents. Findings Include: The Minimum Data Set (MDS) for Resident #7 dated 11/5/23 documented a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. The MDS further revealed the resident had diagnosis including anxiety, non-Alzheimer's dementia and other depressive disorders. The Care Plan initiated 5/15/23 identified Resident #7 with the potential for altered mood function with occasional episodes of mood dysfunction and behaviors and directed staff to administer antianxiety medication (scheduled and PRN) and observed for effectiveness and side effects. Review of the November 2023 Medication Administration Record (MAR) for Resident #7 revealed an order for Lorazepam (antianxiety medication) every 8…

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, Resident Group and staff interviews, observation and facility policy review, the facility failed to ensure residents were free from abuse when facility staff did not follow their policy of reporting, investigating and protecting the residents from abuse. Through interviews with various staff, it was found that staff did not report their concerns of potential abuse (Residents #8, #10, and #13) or reported their concerns to the Director of Nursing (DON) allowing a thorough investigation to follow (Resident #9). The facility reported a census of 54 residents. Findings Include: 1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #8 included non-Alzheimer's dementia and schizophrenia. A Brief Interview for Mental Status (BIMS) documented as being unable to complete. The MDS identified the resident's cognitive skills for daily decision making was severely impaired. Resident #8 required extensive assist of 2 staff for bed mobility, transfer, dressing and toilet…

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.