Sunny Hill Care Center

In the surveyor’s words

From the most serious findings on record at Sunny Hill Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF609Oct 3, 2023

  Based on clinical record review, Resident Group and staff interviews, observations and facility policy review, the facility failed to maintain an environment free of psychosocial and physical abuse by not identifying and/or reporting abuse immediately but not later than 2 hours- if the alleged violation involves abuse or results in serious bodily injury. Staff B, Certified Nursing Assistant (CNA) reportedly grabbed a resident's hands and made her hit herself in her face on early morning of 7/4/23 (Resident #8). This was not reported until 7/14/23. Staff B reportedly was yelling at a resident and grabbed her wrists early morning of 7/3/23. This was not reported (Resident #9). Both residents were cognitively impaired. […]

• Immediate jeopardy, patternF610Oct 3, 2023

  Based on clinical record review, resident and staff interviews and facility policy review, the facility failed to take steps to prevent further potential abuse by not conducting a thorough investigation of an alleged violation. Staff B, Certified Nurse Assistant (CNA) reportedly was yelling at a resident and grabbed her wrists early morning of July 3rd (Resident #9). The facility asked Resident #9, who was cognitively impaired if anything happened the night before and she said no. The Director of Nursing (DON) acknowledged this resident did have cognitive impairment and had short term memory loss. The DON talked with Staff B. No documentation was done for either of these conversations, nor was a thorough investigation completed. […]

• Actual harm, isolatedF689Aug 21, 2025

  Based on clinical record review, resident interview, family interview, staff interviews and policy review, the facility failed to ensure a safe transfer for 1 of 3 residents reviewed (Resident #5) . Staff attempted to transfer from the recliner to wheel chair and did not utilize a gait belt (Resident #5). The resident fell and sustained a non-displaced humeral fracture (left arm). The facility reported a census of 48 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed diagnosis of heart disease, stroke, hemiplegia or hemiparesis referring to left side paralysis. The MDS coding reflected dependence on transfer from a bed or chair. The Brief Interview of Mental Status (BIMS) assessment scored 12 out of 15 indicated moderately cognitive impairment. […]

• Actual harm, isolatedF684Feb 8, 2024

  Based on clinical record review, resident, family and staff interviews, and facility policy review, the facility failed to appropriately provided an assessment and interventions for the necessary care and services for a resident after a fall on 11/30/23. The nursing staff failed to provide a thorough assessment for the resident, and three hours after the fall, the next Shift Nurse assessed the resident and found an inward rotation of the left leg and associated severe pain. The resident transported to the local hospital, found to have suffered a fractured left hip, and then transferred to a tertiary hospital for higher level of care and surgical hip repair (Resident #8). The facility reported a census of 49 residents. […]

• No harm, potential for more than minimal, patternF865Feb 6, 2025

  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. […]