Sunshine Terrace Skilled Nursing

In the surveyor’s words

From the most serious findings on record at Sunshine Terrace Skilled Nursing, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Apr 13, 2026

  Based on observation, interview, and record review it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the walk-in refrigerator temperature was above 41 degrees Fahrenheit and food was stored in the danger zone. The food temperatures were above 41 degrees. This was cited at an Immediate Jeopardy (IJ). In addition, there were opened and undated food items in the walk-in refrigerator, freezer, and dry storage. Dietary staff were observed during lunch tray line service to touch food and other surfaces. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator (ADM), Dietary Manager (DM), and Director of Nursing (DON) on 4/6/26 at 10:31 AM. […]

• Actual harm, isolatedF684Apr 13, 2026

  Based on observation, interview, and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, for 3 out of 32 residents, the facility did not provide a resident additional treatment for constipation which resulted in hospitalization for a bowel obstruction; a resident with Moisture Associated Skin Damage (MASD) did not have their wound evaluated by a wound care provider and received wound care without a physician order; and a resident with open wounds on their buttocks did not have wound prevention or skin assessments completed weekly as ordered. Resident identifiers: 3, 28, and 63. […]

• No harm, potential for more than minimal, widespreadF812Feb 22, 2024

  Based on observation, interview, and facility policy review, the facility failed to adhere to professional standards for food safety when preparing, storing, and distributing food to residents who were served food from the facility's kitchen. This failure had the potential to affect 50 of 50 residents who received nutrition from the kitchen. Findings included: Review of a facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised in November 2022, revealed, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Under a Policy Interpretation and Implementation section, the policy noted 1. […]

• No harm, potential for more than minimal, patternF605Apr 13, 2026

  Based on interview and record review it was determined that the facility did not ensure that each resident who was given a psychotropic drug had an adequate indication for use of the medication; that psychotropic drugs received a gradual dose reduction and behavioral interventions, unless clinically contraindicated; as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the practitioner documented a clinical rationale to extend beyond 14 days with a duration of use for the order; and PRN orders for anti-psychotics were limited to 14 days and cannot be renewed unless the attending physician evaluated the resident for the appropriateness of the medication. […]

• No harm, potential for more than minimal, patternF609Apr 13, 2026

  Based on interview, observation, and record review, the facility did not ensure that allegations of abuse and neglect were reported immediately to the State Survey Agency (SSA) and other agencies. Specifically, for 4 of 32 sampled residents, the facility did not report allegations of abuse to Adult Protective Services (APS) and the facility did not report when a resident eloped from the facility to the SSA. Resident Identifier: 3, 41, 47 and 58. Findings included: 1. Resident 41 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's, chronic venous hypertension, and dementia. An incident report form submitted to the SSA revealed on 2/17/26 at 10:00 AM, The resident was assessed promptly by the attending nurse following identification of the contusion. […]