Inspection Report Summary
The most recent inspection on November 6, 2025 found the facility in substantial compliance with no deficiencies noted. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including issues with medication administration, equipment maintenance, and ensuring residents’ rights and dignity. Several complaint investigations substantiated concerns about supervision, documentation, and infection control, but enforcement actions such as fines or license suspensions were not listed in the available reports. The facility addressed prior deficiencies through accepted plans of correction and demonstrated periods of substantial compliance. The overall trend suggests improvement over time, with the most recent inspections showing no cited deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
16.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
282% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
86 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 6, 2025
Visit Reason
A complaint investigation was conducted for complaints #2657352-C, #2657893-C, #2657915-C and facility reported incidents #2657934-I from November 4, 2025 to November 6, 2025.
Complaint Details
Investigation involved multiple complaints and facility reported incidents; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
A complaint investigation for complaints #2602348-C and #2629938-C was conducted from October 14, 2025 to October 16, 2025.
Complaint Details
Complaint investigation for complaints #2602348-C and #2629938-C; facility found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 25, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was certified in compliance effective July 25, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in the report.
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 4
Date: Jul 2, 2025
Visit Reason
The inspection was conducted as an annual survey of Sunny View Care Center to assess compliance with regulatory requirements related to resident dignity, oxygen therapy, discharge planning, and equipment safety.
Findings
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.
Deficiencies (4)
Failure to ensure dignity was promoted for residents due to ongoing issues with batteries not staying charged in stand lifts, causing delays in toileting.
Failure to follow physician orders for oxygen therapy and documentation for residents #2, #8, and #9, including oxygen not administered when saturation was below 90% and incorrect oxygen flow rates.
Failure to maintain complete and accurate medical records for discharge planning for residents #15 and #16, including lack of documentation of social services interactions and discharge plans.
Failure to maintain mechanical and electrical patient care equipment in safe operating condition, including malfunctioning beds and mechanical lifts with wheels lifting off the ground during transfers.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 5
Census: 86
Oxygen saturation readings: 89
Oxygen saturation readings: 81
Oxygen flow rate: 2
Oxygen flow rate: 3.5
Oxygen flow rate: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in oxygen therapy documentation and administration deficiencies for Resident #2 |
| Staff B | Certified Medication Aide (CMA) | Named in oxygen therapy administration and documentation deficiencies for Resident #2 |
| Staff D | Certified Nurse Aide (CNA) | Involved in stand lift battery issues and resident transfers for Resident #1 |
| Staff E | Certified Medication Aide (CMA)/CNA | Involved in stand lift battery issues and resident transfers for Resident #1 |
| Chief Nursing Officer (CNO) | Acknowledged concerns regarding battery dying and oxygen therapy issues | |
| Director of Nursing (DON) | Acknowledged concerns regarding battery dying and oxygen therapy issues | |
| Director of Operations | Acknowledged concerns regarding battery dying in stand lifts | |
| Social Services Representative | Named in failure to document discharge planning and family communications for Residents #15 and #16 | |
| Staff C | Certified Nurse Aide (CNA) | Observed Resident #8 removing oxygen tubing |
| Staff F | Licensed Practical Nurse (LPN) | Involved in oxygen therapy administration and observations for Residents #8 and #9 |
| Staff G | Certified Medication Aide (CMA)/Certified Nurse Aide (CNA) | Involved in oxygen therapy administration and observations for Resident #9 |
| Staff H | Certified Nurse Aide (CNA) | Acknowledged Resident #7's bed not working properly |
| Staff I | Certified Nurse Aide (CNA) | Acknowledged Resident #7's bed not working properly and mechanical lift wheel issue |
| Staff J | Certified Medication Aide (CMA)/Certified Nurse Aide (CNA) | Acknowledged Resident #7's bed not working properly and mechanical lift wheel issue |
| Staff K | Certified Nurse Aide (CNA) | Acknowledged mechanical lift wheel issue |
| Staff L | Maintenance | Responded to work orders for Resident #7's bed and mechanical lift wheel issue |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 4
Date: Jul 2, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#128324-C, #128580-C, #128730-C, #128767-C, #128908-C, #129017-C, #129659-C) and facility reported incidents between June 23, 2025 and July 2, 2025.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failure to ensure dignity and respect for residents due to malfunctioning stand lifts and battery issues causing delays in toileting and transfers.
Failure to follow physician orders for oxygen administration for multiple residents, including lack of documentation and improper oxygen flow rates.
Failure to maintain accurate and complete medical records, including documentation of oxygen administration and discharge planning.
Failure to maintain mechanical and electrical patient care equipment in safe operating condition, specifically stand lifts with battery issues.
Report Facts
Census: 86
Number of residents reviewed for oxygen orders: 3
Number of residents with oxygen saturation below 90%: 2
Number of residents with documented oxygen therapy issues: 3
Number of residents reviewed for dignity and equipment issues: 2
Number of residents reviewed for medical record deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide (CNA) | Involved in resident transfers and battery issues with stand lifts |
| Staff E | Certified Medication Aide (CMA)/CNA | Assisted with resident transfers and reported battery issues |
| Chief Nursing Officer (CNO) | Licensed Nursing Home Administrator (LNHA) | Acknowledged concerns regarding battery issues and resident dignity |
| Director of Nursing (DON) | Acknowledged concerns regarding battery issues and resident dignity | |
| Director of Operations | Verified issues with batteries and chargers on facility lifts | |
| Staff A | Licensed Practical Nurse (LPN) | Documented oxygen saturation and administration for Resident #2 |
| Staff B | Certified Medication Aide (CMA) | Checked oxygen saturation and administered oxygen for Resident #2 |
| Staff C | Certified Nurse Aide (CNA) | Reported Resident #8's oxygen use behavior |
| Staff F | Licensed Practical Nurse (LPN) | Explained lab order process and oxygen administration documentation |
| Staff G | Certified Nurse Aide (CNA) | Acknowledged oxygen setting issues for Resident #9 |
| Staff H | Certified Nurse Aide (CNA) | Provided personal care and reported bed issues for Resident #7 |
| Staff I | Certified Nurse Aide (CNA) | Acknowledged Resident #7's bed not working |
| Staff J | Certified Medication Aide (CMA) | Acknowledged Resident #7's bed not working |
| Staff K | Certified Nurse Aide (CNA) | Explained mechanical lift behavior during transfers |
| Staff L | Maintenance | Reported first work order regarding Resident #7's bed |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, leading to certification effective May 13, 2025.
Inspection Report
Census: 82
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical service requirements, specifically regarding the clarification and administration of a resident's medication upon admission.
Findings
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.
Deficiencies (1)
Failure to clarify a medication order upon resident admission, delaying medication administration until 4/7/25.
Report Facts
Census: 82
Medication frequency: 4
Medication frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed and verified the need to clarify resident's medication upon admission |
| Advanced Registered Nurse Practitioner | Advanced Registered Nurse Practitioner | Signed and dated the clarified medication order on 4/7/25 |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Facility Reported Incident #128061-1 and Complaints #127784-C and #128063-C, with Complaint #128063-C substantiated.
Complaint Details
Complaint #128063-C was substantiated.
Findings
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.
Deficiencies (1)
Failure to clarify a medication order resulting in delayed medication administration for a resident.
Report Facts
Census: 82
Correction date: May 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Drett Yarmin | Administrator | Signed the statement of deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 14, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective March 14, 2025.
Inspection Report
Routine
Census: 82
Deficiencies: 5
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, safety, medication administration, and facility environment at Sunny View Care Center.
Findings
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.
Deficiencies (5)
Failed to ensure resident rooms were free of odors to create a home-like environment for 1 of 59 resident rooms (Resident #71).
Failed to follow the physician's orders for 1 of 20 residents (#32) regarding medication administration.
Failed to communicate current resident staff assistance level for 1 of 5 residents reviewed for nursing supervision (Resident #71).
Failed to provide resident assistance or follow-up with medical equipment (CPAP) for 1 of 2 residents reviewed for respiratory care (Resident #235).
Failed to ensure a yearly psychotropic medication gradual dose reduction (GDR) was attempted or appropriately declined for 3 of 3 residents (#32, #44, & #66).
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Facility census: 82
Falls: 7
Deep clean rooms goal: 6
Deep clean rooms actual: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Housekeeping | Explained resident rooms are vacuumed and dusted daily |
| Staff G | Environmental Supervisor | Discussed carpet cleaning frequency and deep cleaning goals |
| Staff A | Registered Nurse | Documented missed medication doses for Resident #32 |
| Staff B | Licensed Practical Nurse | Described medication cart stock procedures and documentation |
| Staff C | Central Supply staff | Unable to verify stock medication availability for October |
| Director of Nursing | DON | Provided statements on medication policies and resident assistance status |
| Staff I | Certified Nursing Assistant | Unable to explain Resident #71's current staff assistance level |
| Staff J | Licensed Practical Nurse | Unable to explain Resident #71's current staff assistance level |
| Staff L | Licensed Practical Nurse | Voiced Resident #71 not needing much assistance |
| Director of Rehab | DOR | Indicated Resident #71 should have staff present during transfers |
| Staff M | Registered Nurse | Not aware of Resident #235's CPAP during daytime shift |
| Staff N | Registered Nurse | Confirmed presence of CPAP machine and no assistance provided |
| Staff O | Registered Nurse | Acknowledged presence of CPAP machine on bedside nightstand |
| Staff E | Registered Nurse | Described medication administration and documentation processes |
| Staff F | Licensed Practical Nurse | Stated where resident target behaviors are documented |
Inspection Report
Routine
Census: 82
Deficiencies: 2
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident environment safety, nursing supervision, and care standards at Sunny View Care Center.
Findings
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.
Deficiencies (2)
Facility failed to ensure resident rooms were free of odors to create a home-like environment for 1 of 59 resident rooms (Resident #71).
Facility failed to communicate current resident staff assistance level for 1 of 5 residents reviewed for nursing supervision (Resident #71).
Report Facts
Residents affected: 1
Residents affected: 1
Falls: 7
Resident rooms deep cleaned daily: 3
Resident rooms deep cleaning goal: 6
Resident rooms with odor issue: 59
Facility census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Housekeeping | Explained resident rooms are vacuumed and dusted daily; carpets cleaned as needed |
| Staff G | Environmental Supervisor | Noted carpet cleaning procedures and frequency; acknowledged no extra scheduled carpet cleaning despite frequent spills |
| Staff I | Certified Nursing Assistant | Unable to explain Resident #71's current staff assistance level |
| Staff J | Licensed Practical Nurse | Unable to explain Resident #71's current staff assistance level |
| Staff L | Licensed Practical Nurse | Voiced Resident #71 not needing much assistance and believed resident has been staff assistance level 1 since October |
| Director of Nursing | DON | Stated Resident #71's independent status is reflective of current status |
| Assistant Director of Nursing | ADON | Participated in interview regarding Resident #71's care status |
| Director of Rehab | DOR | Did not feel Bio Worksheet reflected Resident #71's current status; noted inconsistency in therapy recommendations and care plan |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 5
Date: Feb 13, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and included investigation of substantiated complaints and a facility reported incident.
Complaint Details
Complaint #125495-C was substantiated. Facility reported incident #126585-I was also substantiated.
Findings
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.
Deficiencies (5)
Failure to maintain a safe, clean, comfortable, and homelike environment, including odor control and carpet cleaning.
Failure to meet professional standards in services provided, including following physician's orders and medication administration.
Failure to ensure the resident environment is free of accident hazards and provide adequate supervision to prevent accidents.
Failure to provide necessary respiratory care and follow-up with medical equipment orders.
Failure to ensure residents do not receive unnecessary psychotropic medications and to perform gradual dose reductions as required.
Report Facts
Resident census: 82
Resident census: 59
Residents reviewed: 20
Residents reviewed: 5
Residents reviewed: 2
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tasha Stauffer | Signed the initial comments section of the report on 3-19-25 | |
| Staff A | Registered Nurse (RN) | Documented medication administration issues for Calcium Carbonate |
| Staff B | Licensed Practical Nurse (LPN) | Described medication cart stock checking and notification procedures |
| Staff C | Central Supply (CS) | Stated lack of method to check stock medications in October |
| Director of Nursing (DON) | Director of Nursing | Provided statements on medication administration and supervision |
| Staff E | Registered Nurse (RN) | Described medication administration and refusal documentation |
| Staff G | Housekeeping | Discussed carpet cleaning procedures and frequency |
| Staff H | Housekeeping | Explained resident room cleaning procedures |
| Staff I | Certified Nursing Assistant | Interviewed regarding resident assistance levels |
| Staff J | Licensed Practical Nurse | Interviewed regarding resident assistance levels |
| Staff L | Licensed Practical Nurse | Interviewed regarding resident assistance levels |
| Staff M | Registered Nurse | Interviewed regarding CPAP machine use |
| Staff N | Registered Nurse | Confirmed presence of CPAP machine during overnight shift |
| Staff O | Registered Nurse | Acknowledged presence of CPAP machine on bedside nightstand |
| Staff F | Licensed Practical Nurse | Stated TAR documentation for resident target behaviors |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
A complaint investigation for complaint #124912-C and facility reported incident #125249-I was conducted from December 16, 2024 to December 17, 2024.
Complaint Details
Investigation was related to complaint #124912-C and facility reported incident #125249-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility in compliance effective September 20, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification of compliance effective September 20, 2024.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 6
Date: Aug 20, 2024
Visit Reason
The inspection resulted from investigation of Complaints #122711-C, #122668-C, and Facility Reported Incidents #122134-I conducted from August 13, 2024 to August 20, 2024. Complaints #122711-C and #122668-C were substantiated.
Complaint Details
Investigation of Complaints #122711-C and #122668-C were substantiated. The deficiencies resulted from these complaints and facility reported incidents #122134-I.
Findings
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.
Deficiencies (6)
Failure to provide care and services according to accepted standards for weight monitoring of Resident #5.
Failure to provide bathing assistance for Resident #1.
Failure to complete and document neurological assessments after a reported head injury for Resident #2.
Failure to provide adequate supervision and assistance to prevent accidents for Resident #2.
Failure to monitor and document urinary output appropriately for catheterized residents.
Failure to establish and maintain an infection prevention and control program.
Report Facts
Resident census: 82
Correction date: Sep 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tasha Stauffer | Administrator | Signed the initial comments on the Statement of Deficiencies |
Inspection Report
Routine
Census: 82
Deficiencies: 5
Date: Aug 20, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, including weight monitoring, bathing assistance, nursing assessments, accident prevention, catheter care, and infection control.
Findings
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.
Deficiencies (5)
Failed to obtain weights per physician order for Resident #5.
Failed to provide bathing assistance for Resident #1 as required.
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.
Failed to provide appropriate catheter care and infection control for Residents #3 and #5.
Report Facts
Census: 82
Weight loss percentage: 13.2
Weight measurements: 235.6
Weight measurements: 205.2
Weight measurements: 219
Weight measurements: 230.2
Urine output: 750
Urine output threshold: 200
Antibiotic dosage: 875
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Reported Resident #2 required assistance of two staff members with transfers |
| Staff D | Certified Nursing Assistant (CNA) | Involved in transfer of Resident #2 during fall incident |
| Staff G | Certified Nursing Assistant (CNA) | Performed catheter care for Resident #5 |
| Staff H | Certified Nursing Assistant (CNA) | Assisted with catheter care for Resident #5 |
| Staff K | Registered Nurse (RN) | Inserted catheter for Resident #4 and reported monitoring practices |
| Director of Nursing | Director of Nursing (DON) | Provided multiple statements and interviews regarding deficiencies and expectations |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reported on bathing education and catheter monitoring policies |
| Nurse Practitioner | Nurse Practitioner | Reviewed Resident #4's catheter and urine output orders |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 17, 2024
Visit Reason
The visit was conducted to evaluate the facility's compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on a credible allegation of compliance and plan of correction.
Findings
The Sunny View Care Center was found to be in substantial compliance effective 6/27/24, with no specific deficiencies cited in this report.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 5
Date: Jun 5, 2024
Visit Reason
The inspection was conducted due to an investigation of multiple complaint intakes (#121000-M, #119718-C, #120038-C, #120098-C, and #120615-C) from May 21, 2024 to June 5, 2024. Several complaints were substantiated.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to maintain a complete and accurate Care Plan for Resident #2, specifically not addressing continence status.
Failed to follow physician's orders and properly administer medications for Residents #11, #12, and #13.
Failed to properly provide perineal care for Residents #2 and #3.
Failed to assess and implement interventions following a fall for Resident #3.
Failed to have sufficient nursing staff to respond to resident call lights within 15 minutes for Residents #2 and #5.
Report Facts
Residents: 88
Medication administration audit time delay: 168
Call light response time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Medication Aide (CMA) | Named in medication administration delay for Resident #13 |
| Staff F | Licensed Practical Nurse (LPN) | Observed leaving medications unattended for Resident #12 |
| Staff H | Certified Nursing Assistant (CNA) | Reported frequent leaving of medications unattended |
| Staff I | Certified Nursing Assistant (CNA) | Confirmed witnessing residents left unattended with medications |
| Staff J | Certified Nursing Assistant (CNA) | Confirmed failure to answer resident call lights timely |
| Staff A | Certified Nursing Assistant (CNA) | Involved in perineal care deficiencies for Resident #2 and #3 |
| Staff B | Assistant Director of Nursing (ADON) | Involved in perineal care deficiency observation and responsible for ongoing compliance |
| Director of Clinical Services | Confirmed care plan and medication administration deficiencies | |
| Director of Nursing | Responsible for ongoing compliance and staff re-education | |
| Assistant Director of Nursing | Responsible for ongoing compliance and staff re-education |
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 5
Date: Jun 5, 2024
Visit Reason
The inspection was conducted to evaluate compliance with federal and state regulations regarding resident care, medication administration, perineal care, fall follow-up, and staffing adequacy at Sunny View Care Center.
Findings
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.
Deficiencies (5)
Failed to maintain a complete and accurate Care Plan for Resident #2, specifically not addressing continence status.
Failed to follow physician's orders and properly administer medications for Residents #11, #12, and #13.
Failed to properly provide perineal care for Residents #2 and #3.
Failed to assess and implement interventions following a fall for Resident #3.
Failed to answer resident call lights within 15 minutes for Residents #2 and #5.
Report Facts
Census: 88
Medication administration time: 168
Call light response time: 30
Call light response time: 45
Call light response time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Medication Aide (CMA) | Administered medications late to Resident #13 |
| Staff F | Licensed Practical Nurse (LPN) | Observed leaving medications unattended for Resident #12 |
| Staff A | Certified Nursing Assistant (CNA) | Observed during perineal care and confirmed soiled sheets for Resident #2 |
| Staff B | Assistant Director of Nursing (ADON) | Confirmed soiled sheets for Resident #2 |
| Staff C | Certified Nursing Assistant (CNA) | Provided improper perineal care for Resident #3 |
| Staff D | Certified Nursing Assistant (CNA) | Provided perineal care for Resident #3 and confirmed incontinence |
| Staff E | Certified Nursing Assistant (CNA) | Provided perineal care for Resident #3 |
| Staff H | Certified Nursing Assistant (CNA) | Reported staff frequently left medications unattended and call light response issues |
| Staff I | Certified Nursing Assistant (CNA) | Confirmed witnessing residents left unattended with medications and call light response issues |
| Staff J | Certified Nursing Assistant (CNA) | Confirmed witnessing residents left unattended with medications and call light response issues |
| Director of Clinical Services | Confirmed care plan deficiencies and expectations for fall follow-up assessments |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 8, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective April 8, 2024, based on acceptance of the credible allegation of substantial compliance and Plan of Correction.
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 10
Date: Mar 11, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #117117-C, #117950-C, #118700-C, #119300-C, and facility reported incident #118435-I.
Complaint Details
Complaint #117117-C, #118700-C, and #119300-C were substantiated. Facility reported incident #118435-I was substantiated.
Findings
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.
Deficiencies (10)
Failed to notify resident families of falls for 1 of 3 residents reviewed for falls (Resident #40).
Failed to update comprehensive care plans when a resident had a change in advanced directives for 1 of 24 residents reviewed (Resident #10).
Failed to meet professional standards of quality in transcription of physician orders for 3 of 85 residents reviewed (#10, #22, #74).
Failed to assist a dependent resident with feeding for 1 of 3 residents reviewed.
Failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 4 residents at risk for choking (Resident #40) and failed to ensure a resident's bed was in the lowest position for 1 of 4 residents reviewed (Resident #10).
Failed to follow professional standards to ensure physician orders were transcribed accurately for 3 of 3 residents reviewed (#22, #10, #74).
Failed to administer medications as ordered and failed to transcribe orders correctly for Resident #74.
Failed to provide sufficient nursing staff to assure resident safety and maintain highest practicable well-being.
Failed to ensure medication cart remained locked in a resident care area when not under staff supervision.
Failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and prevent communicable diseases and infections.
Report Facts
Census: 85
Residents reviewed for falls: 3
Residents reviewed for care plan updates: 24
Residents reviewed for transcription accuracy: 3
Residents reviewed for feeding assistance: 3
Residents reviewed for choking risk: 4
Residents reviewed for medication order transcription: 3
Residents reviewed for medication administration: 1
Residents reviewed for nursing staff sufficiency: 85
Inspection Report
Routine
Census: 85
Deficiencies: 6
Date: Mar 11, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident safety, medication administration, feeding assistance, fall prevention, staffing adequacy, and infection control at Sunny View Care Center.
Findings
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.
Deficiencies (6)
Failed to notify residents' families of falls for 1 of 3 residents reviewed (Resident #40).
Failed to follow professional standards to ensure physician orders were transcribed and administered correctly for 3 of 3 residents reviewed (Residents #22, #10, and #74).
Failed to assist a dependent resident with feeding when resident demonstrated inability to feed themselves (Resident #74).
Failed to provide proper supervision related to choking risk (Resident #40) and failed to ensure bed left in low position and equipment safe for 1 of 4 residents reviewed for falls (Resident #10).
Failed to answer call lights in a timely manner within 15 minutes for one of two nursing units reviewed.
Failed to provide a clean and sanitary environment by not cleaning shower chairs between residents and failed to implement a water control plan to protect from legionella and other waterborne illnesses.
Report Facts
Residents affected: 85
Residents reviewed for falls: 4
Residents reviewed for feeding assistance: 3
Residents reviewed for medication transcription: 3
Call light response time: 15
Fall incident time: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse (RN) | Interviewed regarding fall notification and supervision of choking risk |
| Assistant Director of Nursing (ADON) | Interviewed regarding fall notification and medication order transcription | |
| Director of Nursing (DON) | Interviewed regarding fall notification, medication order transcription, call light response, and bed safety | |
| Staff I | Certified Nursing Assistant (CNA) | Observed and interviewed regarding feeding assistance |
| Staff C | Registered Nurse (RN) | Interviewed regarding medication administration changes |
| Staff B | Registered Nurse (RN) | Interviewed regarding medication order transcription process |
| Staff D | Speech Therapist (ST) | Interviewed regarding feeding and swallowing therapy |
| Staff N | Certified Nursing Assistant (CNA) | Interviewed regarding feeding assistance and staffing |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed regarding call light response and fall prevention |
| Staff Q | Registered Dietician | Interviewed regarding aspiration risk and feeding |
| Staff P | Certified Nursing Assistant (CNA) | Interviewed regarding supervision of choking risk |
| Staff M | Certified Medication Aide | Observed administering nebulizer treatment with bed in high position |
| Staff F | Universal Worker | Observed transporting soiled shower chair |
| Staff G | Observed shower chair sanitation practices | |
| Staff H | CNA/Bath Aide | Interviewed regarding shower chair cleaning |
| Director of Clinical Services | Observed call light response | |
| Administrator | Provided information on water management plan and shower chair cleaning responsibilities |
Inspection Report
Routine
Census: 85
Deficiencies: 8
Date: Mar 11, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including resident care, safety, medication management, and infection control.
Findings
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.
Deficiencies (8)
Failed to notify resident's family of falls for 1 of 3 residents reviewed (Resident #40).
Failed to update comprehensive care plans when a resident had a change in advanced directives for 1 of 24 residents reviewed (Resident #10).
Failed to ensure physician orders were transcribed and administered correctly for 3 of 3 residents reviewed (Residents #22, #10, and #74).
Failed to assist a dependent resident with feeding when the resident demonstrated inability to feed themselves (Resident #74).
Failed to provide proper supervision related to choking risk and bed safety for 2 of 4 residents reviewed (Residents #40 and #10).
Failed to answer call lights in a timely manner within 15 minutes for one of two nursing units reviewed.
Failed to ensure medication cart remained locked when not under staff supervision.
Failed to provide a clean and sanitary environment by not cleaning shower chairs between residents and lacked a water management plan to protect from legionella.
Report Facts
Residents reviewed for falls: 4
Residents reviewed for feeding assistance: 3
Residents reviewed for medication transcription: 3
Residents interviewed for call light response: 5
Fall risk residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse (RN) | Interviewed regarding fall notification and supervision of choking risk |
| Assistant Director of Nursing (ADON) | Interviewed about fall notification and medication order transcription | |
| Director of Nursing (DON) | Interviewed about fall notification, care plan updates, medication order transcription, call light response expectations, and bed safety | |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed about care plan use, feeding assistance, and call light response |
| Staff I | Certified Nursing Assistant (CNA) | Observed and interviewed regarding feeding assistance |
| Staff N | Certified Nursing Assistant (CNA) | Interviewed about feeding assistance and staffing |
| Staff C | Registered Nurse (RN) | Interviewed about medication administration route change |
| Staff B | Registered Nurse (RN) | Interviewed about medication order transcription process |
| Staff D | Speech Therapist (ST) | Interviewed about swallowing and medication route orders |
| Staff P | Certified Nursing Assistant (CNA) | Interviewed about supervision of choking risk |
| Staff Q | Registered Dietician | Interviewed about care plan monitoring for aspiration risk |
| Staff A | Licensed Practical Nurse (LPN) | Observed medication cart unlocked and acknowledged it should be locked |
| Staff H | CNA/Bath Aide | Interviewed about shower chair cleaning |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 3
Date: Nov 7, 2023
Visit Reason
The inspection was conducted as a result of investigations of multiple complaints and facility self-reported incidents between October 18, 2023 and November 7, 2023. Several complaints were substantiated.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to assure resident belongings were returned post discharge, including missing personal items such as a teddy bear.
Failure to properly provide perineal care, oral care, dining assistance, and toileting assistance to multiple residents.
Failure to provide necessary assessments and documentation for a resident with skin conditions and injuries, including bruising and fractures.
Report Facts
Total Residents: 86
Number of substantiated complaints: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA), Certified Medication Aide (CMA) | Mentioned in relation to failure to provide oral care and perineal care |
| Staff B | Certified Nursing Assistant (CNA), Certified Medication Aide (CMA), Human Resources | Observed feeding assistance and toileting care |
| Staff C | Registered Nurse (RN) | Interviewed regarding oral care deficiencies |
| Staff E | Certified Nursing Assistant (CNA) | Involved in toileting and perineal care observations |
| Staff F | Certified Nursing Assistant (CNA) | Involved in toileting and perineal care observations |
| Staff G | Registered Nurse (RN) | Confirmed observations of inadequate oral care |
| Staff H | Registered Nurse (RN) | Confirmed observations of inadequate oral care |
| Administrator | Confirmed facility policies and discussed missing resident belongings | |
| Staff D | Housekeeping | Confirmed cleaning of resident's room and disposal of flowers |
| Activity Director | Recalled missing teddy bear in resident's belongings |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 3
Date: Nov 7, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to return resident belongings post discharge and concerns about care deficiencies including perineal care, oral care, dining assistance, toileting assistance, and skin condition assessments.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to assure resident belongings were returned post discharge, including a missing teddy bear and improper room cleaning timing.
Failed to properly provide perineal care for 1 of 3 residents reviewed, failed to provide oral care to 3 of 3 residents, failed to provide dining assistance for 1 of 3 residents, and failed to provide toileting assistance for 1 of 3 residents.
Failed to provide necessary assessments for 1 of 3 residents with a skin condition or condition change, including failure to document bruising and swelling.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Census: 86
Policy timeframe: 72
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective April 12, 2023.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Mar 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow physician's orders for one resident (Resident #37).
Complaint Details
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).
Findings
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.
Deficiencies (1)
Failure to follow physician's orders for medication administration for Resident #37.
Report Facts
Residents Affected: 1
Census: 81
Residents Reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding triple check policy and expectations for discharge orders |
| ARNP | Advanced Registered Nurse Practitioner | Wrote new order to add levothyroxine on 02/24/2023 |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 5
Date: Mar 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including staff training, resident notification, medication administration, infection control, and nurse aide education.
Findings
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.
Deficiencies (5)
Failed to ensure 1 of 5 staff members completed the two hour Dependent Adult Abuse training within 6 months of hire date.
Failed to notify the Ombudsman of residents transferring to the hospital for 1 of 1 residents reviewed.
Failed to follow physician's orders for 1 of 12 residents reviewed; levothyroxine dose was delayed.
Failed to follow infection control practices including lack of signage, improper PPE use, and failure to change N95 masks during a COVID-19 outbreak.
Failed to ensure 5 of 5 Certified Nurse Aides completed 12 hours of in-person continuing education annually.
Report Facts
Census: 81
Staff members not completing abuse training: 1
Residents with hospital transfer notification failure: 1
Residents with medication order noncompliance: 1
Certified Nurse Aides not completing required education: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Named in deficiency for failure to complete Dependent Adult Abuse training |
| Staff G | Certified Nursing Assistant (CNA) | Observed during infection control deficiency |
| Staff H | Certified Nursing Assistant (CNA) | Observed during infection control deficiency |
| Staff I | Hospice Certified Nursing Assistant (CNA) | Observed during infection control deficiency |
| Staff J | Certified Medication Aide (CMA) | Observed during infection control deficiency and medication administration |
| Staff A | Certified Nursing Assistant (CNA) | Named in deficiency for failure to complete required continuing education |
| Staff B | Certified Nursing Assistant (CNA) | Named in deficiency for failure to complete required continuing education |
| Staff C | Certified Nursing Assistant (CNA) | Named in deficiency for failure to complete required continuing education |
| Staff D | Certified Nursing Assistant (CNA) | Named in deficiency for failure to complete required continuing education |
| Staff E | Certified Nursing Assistant (CNA) | Named in deficiency for failure to complete required continuing education |
| Administrator | Interviewed regarding training expectations and facility processes | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding policies and infection control expectations |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 5
Date: Mar 16, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of two complaints, one substantiated and one not substantiated.
Complaint Details
Complaint #111276-C was substantiated. Complaint #111099-C was not substantiated.
Findings
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.
Deficiencies (5)
Failed to ensure 1 of 5 staff members completed the two hour Dependent Adult Abuse training within 6 months of hire date.
Failed to notify the Ombudsman of residents transferring to the hospital for 1 of 1 residents reviewed.
Failed to follow physician's orders for 1 of 12 residents reviewed related to medication administration delay.
Failed to follow infection control practices including signage, PPE use, mask changing, and hand hygiene during a COVID-19 outbreak.
Failed to ensure 5 of 5 Certified Nurse Aide staff completed the required 12 hours of in-service training annually.
Report Facts
Census: 81
Staff members reviewed for abuse training: 5
Residents reviewed for physician order compliance: 12
Certified Nurse Aides reviewed for in-service training: 5
In-service attendance: 6
In-service attendance: 10
In-service attendance: 11
In-service attendance: 0
In-service attendance: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant | Named in deficiency for failure to complete Dependent Adult Abuse training |
| Staff G | Certified Nursing Assistant | Observed during infection control deficiencies |
| Staff H | Certified Nursing Assistant | Observed during infection control deficiencies |
| Staff I | Hospice Certified Nursing Assistant | Observed during infection control deficiencies |
| Staff J | Certified Medication Aide | Observed during infection control deficiencies |
| Staff A | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Staff B | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Staff C | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Staff D | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Staff E | Certified Nursing Assistant | Named in deficiency for failure to complete required in-service training |
| Administrator | Provided multiple interviews regarding facility policies and deficiencies | |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
The inspection was conducted to investigate Complaint 109062-C and a facility reported incident 110441-I.
Complaint Details
Complaint 109062-C and facility reported incident 110441-I were investigated and not substantiated.
Findings
The complaint and reported incident were investigated and found to be not substantiated during the visit from January 17-25, 2023.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
Complaint 108633-C was investigated from October 31 to November 3, 2022.
Complaint Details
Complaint 108633-C was investigated and found not substantiated.
Findings
The complaint investigation was not substantiated and no deficiencies were identified at the time of the investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 12, 2022
Visit Reason
The document reports acceptance of the facility's credible allegation of compliance and plan of correction following an investigation ending September 21, 2022.
Findings
The facility was certified in compliance effective October 12, 2022, based on acceptance of the plan of correction and credible allegation of compliance.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 3
Date: Sep 21, 2022
Visit Reason
The inspection was conducted as a result of complaints 106559-C and 107427-C, which were substantiated. The visit aimed to investigate these complaints regarding resident care and notification of changes.
Complaint Details
The investigation was triggered by complaints 106559-C and 107427-C, both of which were substantiated.
Findings
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.
Deficiencies (3)
Failure to notify resident, responsible party, or physician of significant changes in condition including injury or decline.
Failure to meet professional standards of quality including obtaining apical pulse before administering beta blocker medication.
Failure to provide treatment and services to prevent and heal pressure ulcers consistent with professional standards.
Report Facts
Resident census: 80
Medication administration documentation: 23
Medication quantity: 62
Pressure ulcer assessments: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 20, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Sunny View Care Center, certifying the facility as in compliance based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was found to be in compliance effective July 20, 2022, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Date: Jul 19, 2022
Visit Reason
The inspection was conducted as an investigation of complaints #104983-C and facility reported incidents #105411-I and #103991-I from July 11-19, 2022.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility failed to follow physician orders for 4 residents reviewed, resulting in missed or incorrect administration of medications.
Residents are not free from significant medication errors; one resident received 1,750 mg more Vancomycin than ordered.
Report Facts
Residents reviewed: 4
Census: 80
Medication overdose amount: 1750
Medication overdose total dose: 2750
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 7
Date: Sep 30, 2021
Visit Reason
The inspection was conducted as the facility's annual health survey and included investigations of several complaints and facility-reported incidents.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Facility failed to document an accurate code status for one out of 24 residents reviewed for advanced directives.
Facility failed to comply with all applicable Federal Regulations regarding Medicare requirements governing billing practices for three residents reviewed for liability and appeal notices.
Facility failed to develop a care plan to address the resident need for oxygen and hospice care for one of 20 sampled residents reviewed for comprehensive care plans.
Facility failed to assess and document follow-up skin assessments for one of three residents reviewed.
Facility failed to provide adequate supervision to prevent falls and provide a safe environment for two of five residents reviewed for falls.
Facility failed to ensure proper use and maintenance of bed rails for four residents reviewed.
Facility failed to establish and maintain an infection prevention and control program including proper COVID-19 specimen collection and infection control practices.
Report Facts
Residents reviewed for advanced directives: 24
Facility census: 71
Residents reviewed for comprehensive care plans: 20
Residents reviewed for skin assessments: 3
Residents reviewed for fall prevention: 5
Residents reviewed for bed rail usage: 4
Residents reviewed for infection control: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Reported reviewing IPOST in resident's chart to verify code status. |
| Staff D | Licensed Practical Nurse (LPN) | Reported reviewing IPOST in resident's chart. |
| Corporate Nurse | Reported checking IPOST, EHR, and purple dot system for resident code status. | |
| Staff H | Director of Clinical Services | Reported on hospice services and oxygen use for Resident #10. |
| Staff J | MDS Coordinator | Reported on oxygen and hospice care plans and policy compliance. |
| Staff E | Registered Nurse (RN) | Reported facility followed directives in RAI to complete MDS assessments. |
| Staff M | Registered Nurse (RN) | Reported on fall interventions and care plans for Resident #79. |
| Staff O | Certified Nursing Assistant (CNA) | Documented last visual of Resident #79 before fall. |
| Staff P | Licensed Practical Nurse (LPN) | Received coaching regarding failure to place intervention on Bio sheet. |
| Staff R | Certified Medication Assistant (CMA) | Reported on side rail use for Resident #79. |
| Staff A | Certified Nursing Assistant (CNA) | Reported on fall interventions and use of Bio sheets. |
| Staff Q | Certified Nursing Assistant (CNA) | Reported on care interventions and side rail use for Resident #79. |
| Staff L | Licensed Practical Nurse (LPN) | Completed report on environmental concerns and side rail use. |
| Staff F | Performed COVID-19 antigen testing and specimen collection. | |
| Staff K | Certified Nursing Assistant (CNA) | Reported on fall and care interventions for Resident #40. |
Inspection Report
Routine
Census: 71
Deficiencies: 0
Date: Jul 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 2020-06-23 to 2020-07-06 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Investigation into Complaint #89873-C was not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Additionally, an investigation into Complaint #89873-C was not substantiated.
Report Facts
Total residents: 71
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 5
Date: Feb 6, 2020
Visit Reason
The inspection was conducted as part of the facility's annual health survey and included review of incident #87241 and complaint #87108, which was not substantiated.
Complaint Details
Complaint #87108 was investigated and found not substantiated.
Findings
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.
Deficiencies (5)
Failed to notify Ombudsman of hospital transfers for 2 residents.
Failed to resubmit PASARR after change in diagnosis for 4 residents.
Failed to update care plan timely for one resident.
Failed to ensure treatment to skin tear was completed as ordered for one resident.
Wheelchair armrest could be unlatched, posing accident hazard for one resident.
Report Facts
Resident census: 81
Hospital transfers not notified: 2
Residents with PASRR resubmission failure: 4
Residents reviewed for care plan update: 19
Residents with care plan update failure: 1
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