The Pavilion at Sunny Hills

In the surveyor’s words

From the most serious findings on record at The Pavilion at Sunny Hills, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 16, 2021

  Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure labeling and dating of food items in the refrigerator and open, dry storage area used for resident food. * The facility failed to ensure the clean sippy cups were stored properly and not mixed with dirty sippy cups. * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the ice machine drainpipe had an air gap and not touching the drain. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. […]

• No harm, potential for more than minimal, patternF552Jul 2, 2026

  Based on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent for the psychotropic medications and treatments were complete for five of 34 final sampled residents (Residents 3, 6, 9, 69, and 231). * The facility failed to ensure Resident 3's informed consent for the sertraline hydrochloride (antidepressant medication), mirtazapine (antidepressant medication), Ativan (antianxiety medication), and Ativan-Benadryl-Haldol (ABH, antipsychotic medication) medications included the behavioral manifestation related to the use of the medications per physician's orders. […]

• No harm, potential for more than minimal, patternF578Jul 2, 2026

  Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary services on the formulation of an advance directive was provided for four of seven final sampled residents (Residents 41, 225, 231, and 232) reviewed for advance directive. * The facility failed to follow up the advance directive status after providing the educational materials to Residents 41, 231, and 232 and/or the residents' representative. In addition, the facility failed to ensure assistance in the formulation of an advance directive was offered to Residents 41, 231, and 232. * The facility failed to provide Resident 225's representative with the written information regarding the rights to formulate an advance directive. […]

• No harm, potential for more than minimal, patternF605Jul 2, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for one of 34 final sampled residents (Resident 226) and four of five residents (Residents 3, 6, 9, and 69) reviewed for unnecessary medications. * The facility failed to ensure nonpharmacological interventions were provided prior to the use of Ativan (antianxiety), mirtazapine (antidepressant), and sertraline (antidepressant) medications for Resident 3. The facility failed to ensure Resident 3 was monitored for side effects related to the use of the mirtazapine medication. In addition, the facility failed to ensure the behavior related to the use of the sertraline medication was monitored for Resident 3. […]

• No harm, potential for more than minimal, patternF628Jul 2, 2026

  Based on interview, medical record review, and facility P&P review the facility failed to timely notify and accurately sent the Notification of Proposed Transfer/Discharge to the Office of the State Long-Term Care (LTC) Ombudsman, notified the resident's representative in writing of the reason for transfer and/or bed hold for two of 34 final sampled residents (Residents 49 and 98) and three of three sampled residents (Residents 221, 222, and 223) reviewed for closed records.* The facility failed to ensure the notification of proposed transfer was sent to the Ombudsman for Residents 49, 221, 222, and 223.* The facility failed to ensure Resident 98's family member was notified in writing of reason of transfer to the acute care hospital and bed hold; and the copy of transfer was sent to the… […]