Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunnycrest Manor during CMS and state inspections, most recent first.
MDS did not accurately code a resident’s heart failure diagnosis after a hospital transfer. The resident had chest x-ray findings suggesting CHF exacerbation with pulmonary edema and a hospital discharge summary documenting acute HFpEF exacerbation, but the MDS diagnoses list did not include heart failure. The care plan also lacked direction for CHF monitoring, while the EMAR showed a daily diuretic order and daily weight monitoring for fluid retention.
Failure to Maintain Resident Nail Hygiene: A resident with mild intellectual disability, legal blindness, and altered decision-making needed partial/moderate help with personal hygiene, but staff did not keep the resident’s nails clean and trimmed as directed in the care plan. Surveyors observed brown substance under multiple fingernails on repeated checks, and the resident stated the nails still needed to be trimmed and cleaned. Staff said CNAs and nurses were expected to monitor nail hygiene on bath days and as needed.
Failure to complete updated pneumococcal vaccination for a resident with consent and a care plan directing immunizations. The resident had intact cognition, later experienced hospitalization with pneumonia and acute hypoxic respiratory failure, and the MDS listed pneumococcal status as up to date even though the EHR showed the vaccine pending. Review of notes, EMARs, and orders found no documentation of contraindications, a hold order, administration of the vaccine, or a reason it was not given; staff reported the screening was done but follow-through did not occur.
A resident with blindness and hearing impairment, dependent on a cochlear implant for communication, became agitated during a meal and was removed from the dining room by a CNA. The CNA, frustrated by the resident's behavior, removed the resident's cochlear processor, leaving the resident unable to hear until it was replaced in the elevator. This action was witnessed by staff and confirmed by the resident, constituting a failure to treat the resident with dignity and respect.
The facility failed to maintain professional standards for food storage and sanitization, with observations revealing undated and improperly stored food items, incomplete temperature logs, and inadequate sanitization practices. Staff interviews highlighted unclear responsibilities and missing documentation, contributing to the deficiencies.
The facility failed to implement effective QA activities to address kitchen-related deficiencies, including undated open foods and unsanitary food preparation. Repeated issues were noted, such as improper food labeling and lack of monitoring of refrigerator temperatures. Despite conducting audits, there was no documentation of staff education to correct these deficiencies.
A facility failed to update a care plan for a resident with anxiety, depression, and schizophrenia, who was on multiple psychotropic medications. The care plan lacked focus areas, goals, or interventions for these medications and did not monitor for side effects like involuntary movements. Staff interviews revealed that the MDS Coordinator missed entering the medications into the care plan, despite the facility's policy requiring continuous updates by the interdisciplinary team.
A resident with type 2 diabetes mellitus received insulin from an LPN who failed to prime the insulin pen as per manufacturer instructions, leading to improper administration. Nursing staff interviews revealed a lack of awareness about the priming requirement, and the Co-DON acknowledged the need to follow manufacturer guidelines.
A resident with MRSA was not provided proper infection control during wound care. An LPN failed to change gloves and wash hands between treating wounds on the resident's left heel and right great toe, contrary to the facility's infection prevention protocols. Staff interviews and facility policy emphasized the need for hand hygiene and proper PPE use, which were not followed during the observed care.
The facility failed to maintain proper food safety and hygiene standards during food preparation and service. Observations revealed undated food items, improper glove use, lack of hand hygiene, and improper utensil handling by staff, affecting multiple residents' meals.
The facility failed to maintain appropriate food holding temperatures and utilize menu-approved serving sizes. Observations revealed milk left on the counter, foods served at incorrect temperatures, and milk transported without ice. The Dietary Director was unaware of these discrepancies.
The facility failed to complete a Significant Change in Status MDS Assessment within the required time frame for a resident on hospice care. The MDS Coordinator was unaware of the 14-day requirement, and the facility lacked a specific policy, leading to the late completion of the assessment.
The facility failed to accurately code the MDS assessments for three residents, including errors in documenting hospice care, the presence of a suprapubic catheter, and insulin injections. The MDS Coordinator admitted to miscoding due to handling multiple assessments and a lack of specific policy.
MDS did not accurately code heart failure diagnosis
Penalty
Summary
The facility failed to accurately code a diagnosis on the MDS for one resident who had been transferred to the hospital. The resident’s EMR census showed a hospital transfer on 1/3/26, and the chest x-ray from that date documented findings suggesting congestive heart failure exacerbation with pulmonary edema. The hospital discharge summary dated 1/7/26 documented acute heart failure with preserved ejection fraction (HFpEF) exacerbation. However, the resident’s MDS dated [DATE] did not include heart failure in the diagnoses list, and the MDS dated [DATE] also lacked documentation of heart failure. The resident’s care plan reviewed on 3/3/26 did not provide direction to staff on monitoring for congestive heart failure. The January 2026 EMAR showed an active order for a daily diuretic medication for congestive heart failure and daily weight monitoring for fluid retention. During interview on 3/4/26, the MDS Coordinator reviewed the resident’s medical diagnoses list and the hospital discharge summary and stated that when she completed the 1/13/26 MDS, the facility had not yet received the hospital records. She confirmed the discharge summary documented heart failure and that it should have been coded on the MDS.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to provide a resident who was unable to perform activities of daily living with the services needed to maintain good personal hygiene. Resident #69 had diagnoses including mild intellectual disability, legal blindness, and altered mental status, and the MDS indicated the resident required partial/moderate assistance with personal hygiene and had moderately impaired decision-making skills for daily decisions. The care plan directed CNAs and nurses to check nail length, trim and clean the nails on bath day, and do so as necessary. During the survey, Resident #69 was observed with fingernails and toenails that still needed trimming and cleaning after a shower had been documented. On one observation, the resident stated the nails needed to be trimmed, and brown substance was noted under nails on both hands. A later observation showed the nails remained the same length, with brown substance under multiple nails on both hands and a jagged pinky nail on the left hand. The resident again reported the nails still needed to be trimmed and cleaned and stated he did not think anyone had checked them since Monday. Staff interviews indicated CNAs and nurses were expected to monitor, clean, and trim nails on bath days and as needed.
Failure to Complete Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide an updated pneumococcal vaccination for one sampled resident despite documentation showing the resident had signed consent to receive the vaccine and had a care plan directing that immunizations be administered. The resident was admitted with intact cognition, later discharged to the hospital, and subsequently returned with diagnoses including pneumonia and acute hypoxic respiratory failure. The resident’s MDS listed pneumococcal vaccination status as up to date, but the EHR immunization record showed a pneumococcal vaccine pending with a confirmation date and did not show that the updated vaccine had been given. Review of progress notes, EMARs, physician orders, and the problem list from January through early March 2026 did not show documentation of contraindications, an order to hold the vaccine, administration of an updated pneumococcal vaccine, or a rationale for why it was not administered. Staff interviews indicated the resident remained on the problem list for the vaccination and that the immunization screening had been addressed, but follow-through to complete the vaccination had not occurred. The facility’s policy required following CDC recommendations, obtaining a physician order, and administering the vaccine per manufacturer and pharmacy guidance, and the CDC schedule reviewed in the report indicated a PCV20 or PCV21 dose was due based on the resident’s prior pneumococcal vaccination history.
Resident's Hearing Device Removed During Agitation Incident
Penalty
Summary
A resident with legal blindness, hearing impairment requiring a cochlear implant, depressive disorder, and anxiety was dependent on staff for set-up assistance with eating and transfers, and used a wheelchair for mobility. The resident's care plan indicated a need for the cochlear processor to be in place with charged batteries during times of agitation and communication difficulty, as the device was essential for hearing. The care plan also instructed staff to monitor the resident's eating, encourage slow eating, and alternate liquids and solids. During a mealtime, the resident became verbally agitated and exhibited unsafe eating behaviors, such as cramming food into his mouth. Staff attempted to manage the situation by cutting up the resident's food and providing verbal cues to slow down, which further upset the resident. Staff A, a CNA, became frustrated with the resident's behavior and, while transporting the resident out of the dining room, removed the resident's cochlear processor, leaving the resident unable to hear. Staff A kept the processor in his pocket and only replaced it after less than a minute, once inside the elevator. This action was observed by another staff member and reported to nurse management. Interviews with staff and the resident confirmed that the removal of the cochlear processor occurred during the incident, and the resident recalled similar actions by the same staff member during other care activities. The facility's policy states that all residents have the right to be free from acts of personal degradation and involuntary seclusion, and the removal of the hearing device deprived the resident of the ability to communicate and participate in his environment, violating his right to dignity and respect.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitization, as observed during multiple inspections of the kitchen and dining areas. Staff were seen using a damp rag without sanitizer to clean food preparation areas, and there were no filled sanitizer buckets available. The walk-in cooler contained improperly stored and undated food items, including open and frozen milk jugs, undated juice containers, and exposed raisins. Temperature logs for refrigerators were incomplete, and some food items were stored inappropriately, such as cheese and butter left unwrapped and exposed to air. Further observations revealed that the dry storage area contained expired and improperly stored food items, such as undated chicken gravy mix and dusty containers of Caesar dressing. The area also had a vent covered in a grey, brown substance, which was not cleaned despite being identified as a priority. Staff interviews indicated a lack of clarity regarding responsibilities for monitoring refrigerator temperatures and maintaining sanitizer logs, with some staff unaware of where to find necessary documentation. The facility's policies on food storage were not followed, as evidenced by the lack of labeling and dating of open food packages and the absence of daily temperature recordings for refrigeration units. The Certified Dietary Manager acknowledged the issues but did not provide logs for sanitizer bucket checks, citing a lack of test strips. The facility's failure to maintain proper food storage and sanitization practices was compounded by inadequate documentation and unclear staff responsibilities, contributing to the observed deficiencies.
Failure to Implement Effective QA Activities in Kitchen
Penalty
Summary
The facility failed to fully implement Quality Assurance (QA) activities to address and correct kitchen-related deficiencies, as evidenced by repeated issues identified in the CMS Statements of Deficiencies. The deficiencies included undated open foods, failure to meet professional standards of food service safety, and food not being prepared under sanitary conditions. During the current survey, additional concerns were noted, such as not monitoring refrigerator and freezer temperatures, not monitoring sanitizer chemical levels, dented cans, expired food, and a dusty vent. The facility's QAPI Plan indicated that information from the Facility Assessment was used to inform the QAPI process, with the QAPI steering committee setting SMART goals each year. However, interviews with the Certified Dietary Manager (CDM) and the Administrator revealed that while audits were conducted, there was a lack of effective corrective actions and education provided to staff regarding the audit results. The CDM's audits showed that 13 out of 44 entries indicated improper labeling of food, yet there was no documentation of staff education to address these issues.
Failure to Update Care Plan for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was receiving unnecessary medications. The resident, who had intact cognition and was diagnosed with anxiety disorder, depression, and schizophrenia, was on multiple psychotropic medications. However, the care plan did not include focus areas, goals, or interventions related to these medications or the resident's mental health diagnoses. Additionally, the care plan lacked monitoring for side effects such as involuntary movements, which the resident experienced and reported during an interview. Interviews with facility staff revealed that the responsibility for updating the care plan was shared among nurses, the MDS Coordinator, and the Social Worker. The MDS Coordinator acknowledged that the psychotropic medications were not entered into the care plan, which was an oversight. The facility's policy required the interdisciplinary team to develop and update the care plan continuously, addressing resident goals, problems, needs, strengths, and preferences. However, this process was not followed for the resident in question, leading to the deficiency.
Improper Insulin Administration Technique
Penalty
Summary
The facility failed to adhere to proper insulin administration techniques for a resident with type 2 diabetes mellitus, who was prescribed Fiasp FlexTouch insulin pen. The resident's medication administration record indicated a requirement for 26 units of insulin before meals and additional sliding scale insulin based on blood sugar levels. During an observation, a Licensed Practical Nurse (LPN) administered insulin to the resident without priming the insulin pen by wasting 2 units, as per the manufacturer's instructions. The LPN used two insulin pens to deliver the prescribed dose but did not ensure the pens were functioning correctly by failing to waste the required units. Interviews with nursing staff revealed a lack of awareness regarding the necessity to prime insulin pens before administration. A Registered Nurse (RN) admitted to not knowing about the requirement to waste 2 units, while another RN mentioned priming with about 5 units. The Co-Director of Nursing acknowledged the need to follow manufacturer instructions, which were not adhered to in this instance. The package insert for the Fiasp Insulin FlexTouch Pen clearly directed the priming process, which was not followed, leading to the deficiency.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during wound care for a resident with a history of MRSA infection. The resident had a left heel blister that was drained and tested positive for MRSA, as well as an open area on the right great toe. The care plan for the resident required contact isolation and specific hand hygiene practices to prevent the spread of infection. However, during an observation, a Licensed Practical Nurse (LPN) did not follow these protocols. The LPN double-gloved and removed soiled dressings from both the right great toe and left heel without washing hands or changing gloves between the wounds. The LPN also failed to perform hand hygiene after completing the wound care and before leaving the room, which involved touching various surfaces and equipment. Interviews with other staff members, including Registered Nurses (RNs) and the Infection Preventionist, highlighted the correct procedures that should have been followed, such as treating one wound at a time, changing gloves, and washing hands between each step of the wound care process. The facility's policy on hand washing, which was reviewed in 2024, emphasized the importance of hand hygiene before and after changing a dressing as a primary means of preventing infection transmission. Despite these guidelines, the observed actions of the LPN did not align with the facility's infection control policies, leading to a deficiency in the care provided to the resident.
Failure to Maintain Proper Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards during food preparation and service. Observations revealed that opened food items such as elbow macaroni, rigatoni noodles, and spiral noodles were undated and stored improperly. Staff B, a cook, was observed not wearing a hair net while cutting dessert bars and serving the noon meal. During the puree process, Staff A, another cook, did not change gloves after touching various surfaces and used a soiled scoop to transfer pureed carrots. Additionally, Staff B and Staff C did not perform hand hygiene between glove changes during meal service, and utensils were improperly handled, with tongs and scoops falling into food pans and being used to serve food without being cleaned. These actions affected multiple residents during meal service. The Dietary Director acknowledged the expectations for staff to wear hair restraints, wash hands between glove changes, and use utensils properly. However, the facility lacked provisions for hand hygiene on portable carts during meal service. The facility's policies on proper hand washing, glove use, and hair restraint were not followed by the staff. The undated policies directed staff to wash hands before donning gloves, change gloves when contaminated, and ensure all food handlers wear hair restraints. The failure to adhere to these policies resulted in unsanitary conditions during food preparation and service, affecting the residents' meals.
Failure to Maintain Food Holding Temperatures and Proper Serving Sizes
Penalty
Summary
The facility failed to maintain appropriate food holding temperatures and utilize the menu-approved serving sizes to meet resident nutritional needs. During an observation of the puree preparation, a milk carton was left on the counter, reaching a temperature of 49.6°F before being placed back in the refrigerator. Additionally, during the noon meal, sliced onions, pickles, and tomatoes were placed on a serving cart without ice, and various foods were served at incorrect temperatures. The scoop sizes used for serving pureed BBQ riblets, diced BBQ riblets, diced carrots, and mashed potatoes did not match the menu-approved sizes, leading to discrepancies in portion sizes. Further observations revealed that milk was not kept on ice while being transported and served to residents. A CNA removed milk from the refrigerator and placed it on a utility cart without ice, leaving it outside the dining room for an extended period before serving it to residents. The temperature of the chocolate milk served was 43.9°F, which is above the recommended holding temperature for cold foods. Interviews with the Dietary Director indicated a lack of awareness regarding the discrepancies in scoop sizes and the importance of maintaining proper food temperatures during meal service.
Failure to Complete Timely MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) Assessment within the required time frame for a resident on hospice care. Resident #2, who was admitted to hospice care for a primary diagnosis of malignant neoplasm of the colon, had an MDS assessment that did not document the hospice services in section O. The MDS 3.0 Summary Page showed that the MDS was completed late, beyond the required 14-day period after the significant change in status was identified. Staff interviews revealed that the MDS Coordinator was unaware of the requirement to complete the MDS within 14 days of identifying a significant change. The facility did not have a specific policy in place but followed the RAI manual for completing the MDS. The Co-Director of Nursing expected the RAI guidelines to be followed but deferred to the MDS Coordinator for the process. The LTC RAI 3.0 User's Manual specifies that an SCSA must be performed when a terminally ill resident enrolls in a hospice program, which was not done in this case.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents. Resident #2's MDS assessment did not document the resident's hospice care, despite the resident being on a hospice plan of care for a malignant neoplasm of the colon. The MDS Coordinator admitted to accidentally miscoding the MDS and acknowledged the lack of a specific policy, relying instead on the RAI manual for guidance. The Co-Director of Nursing expected the RAI to be followed for accurate MDS coding but deferred to the MDS Coordinator for the process details. Resident #32's MDS assessments failed to document the presence of a suprapubic catheter, instead incorrectly coding it as an ostomy. The MDS Coordinator admitted to the error and indicated the need for correction. Additionally, Resident #23's MDS inaccurately documented seven days of insulin injections, despite the absence of any physician orders for insulin. The RN/MDS Coordinator attributed this to a probable miscoding error due to handling multiple MDS assessments simultaneously.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dubuque
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonehill Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Bethany Home | 0.9 mi | ★★★★★ | 0 | 0 |
| Harmony Dubuque | 2.8 mi | ★★★★★ | 10 | 0 |
| Dubuque Specialty Care | 2.9 mi | ★★★★★ | 0 | 0 |
| Luther Manor At Hillcrest | 3.5 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.