Sunnyview Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sunnyview Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 25, 2025

  Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision, which resulted in an elopement for two of 36 residents (Resident R12 and R37). This failure created an immediate jeopardy situation.Findings include: Review of the facility Elopement Prevention policy last revised 3/26/25, and reviewed 5/25, indicated it is the facility's policy to strive to prevent resident elopement. The facility strives to provide an environment that is free from hazards over which the facility has control and provide supervision and assistance to each resident to prevent avoidable accidents. […]

• Actual harm, patternF600Jan 10, 2024

  Based on review of facility policies, clinical records, and a Commonwealth of Pennsylvania Police Criminal Complaint, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse and neglect for six of 40 residents reviewed (Residents 1, 2, 3, 4, 5, 6) after a noted change in their condition, including a low blood sugar after receiving large doses of insulin by a registered nurse, who later confessed that she intentionally administered the insulin and/or an air bolus to harm the residents, resulting in the residents being transferred to the hospital and/or ceasing to breathe. […]

• Actual harm, patternF658Jan 10, 2024

  Based on review of Pennsylvania's Nursing Practice Act, clinical records, and a Commonwealth of Pennsylvania Police Criminal Complaint, it was determined that the facility failed to ensure that a registered nurse followed professional standards regarding care and the administration of medications, after the registered nurse confessed to administering large doses of insulin to residents and/or injecting an air bolus into venous access lines, which caused a change in their conditions and/or death for six of 40 residents reviewed (Residents 1, 2, 3, 4, 5, 6). […]

• Actual harm, patternF760Jan 10, 2024

  Based on review of facility policies, clinical records, and a Commonwealth of Pennsylvania Police Criminal Complaint, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors after a registered nurse confessed to administering large doses of insulin, which caused a change in their conditions and/or death for six of 40 residents reviewed (Residents 1, 2, 3, 4, 5, 6). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding medication administration, dated [DATE], revealed that medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required timeframe. […]

• No harm, potential for more than minimal, widespreadF812Dec 22, 2025

  Based on a review of facility policy, review of facility documents, resident representative concerns, resident interviews, and staff interview, it was determined that the facility failed to properly monitor food temperatures creating the potential for food borne illness in the Main Kitchen of the facility.Findings include: Review of facility policy Food: Preparation dated 4/1/25, indicated that cooks ensure that all foods are held at appropriate temperatures, greater than 135 degrees for hot holding and less than 41 degrees for cold food holding. Review of a Resident Representative concern dated 11/21/25, stated He is also receiving cold food. Review of an additional Resident Representative concern dated 12/1/25, stated The food comes out cold. […]