Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunnybrook Rehabilitation Center during CMS and state inspections, most recent first.
A resident who was full code was found unresponsive, without respirations, and without a pulse, but CPR was delayed while the nurse left to confirm code status and look for another nurse. Staff did not clearly activate a code blue right away, EMS was not notified immediately, and the AED was not brought to the room; the first crash cart also lacked an AMBU bag. EMS arrived later, continued resuscitation, and pronounced the resident deceased.
Narcotic lock boxes were not permanently affixed to medication refrigerators in 2 medication rooms. During observations with nurses, black lock boxes containing Marinol and Ativan were found loose inside the refrigerators, and the nurses confirmed they should have been bolted in place. The DON stated the boxes should have been immediately bolted to the refrigerators when the units were replaced, and the Administrator said she expected them to be affixed.
MDS assessment was inaccurately coded for Level II PASRR for a resident with unspecified bipolar disorder and recurrent major depressive disorder. The EMR contained a Level II PASRR Determination Notification stating the resident's nursing home placement was appropriate, but the annual MDS indicated the resident was not currently considered by the state PASRR process to have a serious mental illness. The MDS nurse confirmed the document was in the record and said it should have been coded on the assessment, and the Administrator agreed the coding should have reflected the documentation in the chart.
A resident with bipolar disorder and recurrent major depressive disorder had a Level II PASRR determination in the record, but the care plan did not include PASRR-related interventions. The MDS nurse confirmed a PASRR care plan was required, stated a prior care plan had been resolved, and said she did not see the PASRR notification when completing the MDS. The Administrator stated the MDS nurse was responsible for ensuring the care plan reflected the resident’s PASRR status.
A resident with schizoaffective disorder and Alzheimer's Disease was assessed as at risk for elopement, had an active order for an ankle alerting bracelet, and was coded on the MDS for severe cognitive impairment, daily wandering, and daily use of a wander/elopement alarm. However, the comprehensive care plan did not include interventions for elopement risk or the bracelet, and the MDS nurse, DON, and Administrator acknowledged the care plan had not been updated to reflect the resident's current status.
Wrong Resident Transported to Scheduled Appointment: A resident with HF and impaired mobility was prepared for an ortho appt, but a transport driver picked up the resident’s roommate instead. The wrong resident was taken to the appt, identified there as not being the scheduled patient, and returned to the facility while the intended resident never arrived.
The facility failed to post accurate daily nurse staffing data, with posted RN, LPN, and NA counts not matching the staffing schedule across multiple shifts. Record review showed repeated discrepancies in both licensed and non-licensed staffing totals, and interviews revealed the previous Scheduler had not been adjusting the postings when staffing changes occurred. The DON had only recently taken over scheduling after the previous Scheduler left, and the Administrator was unsure why the postings were not corrected.
A facility failed to conduct a timely AIMS assessment for a resident receiving Geodon for bipolar disorder, as required every six months. Despite a Pharmacist Consultation Report recommending the assessment due to the risk of Tardive Dyskinesia, it was not completed within the necessary timeframe. Interviews with the Pharmacy Consultant and DON confirmed the oversight, and the resident's record lacked a psychotropic medication side effect monitoring tool.
The facility failed to notify the Ombudsman in writing of hospital transfers for two residents. One resident was transferred for evaluation after a fall, and another for chest pain and cough. The Social Worker, who started in October, did not notify the Ombudsman of hospital discharges, only home discharges. The Ombudsman confirmed not receiving notifications for the past two months, and the Administrator acknowledged the oversight.
The facility failed to notify two residents or their responsible parties of the bed hold policy during hospital transfers. One resident with moderate cognitive impairment was transferred twice without receiving the notice, leading to their belongings being removed and room reassigned. Another resident with severe cognitive impairment was also transferred without the notice being completed or communicated. Staff interviews revealed confusion about responsibility for notifying responsible parties, and there was no documentation to support that the notices were completed.
A resident admitted with a healing hip fracture experienced extreme pain due to the facility's failure to provide timely narcotic pain medication. Despite having a physician's order for Norco, the medication was not available upon admission, and the staff lacked access to the automated medication dispensing cabinet. The resident's pain was inadequately managed with Tylenol, leading to significant distress until the ordered medication was administered the following night.
A resident admitted with multiple diagnoses did not receive medications from an approved pharmacy source due to late order submission and lack of access to the automated dispensing cabinet. Nurses borrowed medications from other residents, which is against protocol. The DON and pharmacy confirmed that access to the cabinet and STAT orders were possible but not utilized.
A resident with dementia and a neurological disorder fell and sustained a head injury, leading to hospitalization. The facility failed to notify the family promptly due to issues accessing electronic medical records. Nurse #1 could not provide identifying information to EMS, and the family was informed only after the hospital contacted them. The President of Operations acknowledged the availability of backup systems for medical information but was uncertain about accessing emergency contact details.
A resident with dementia and a neurological disorder was transferred to the hospital without necessary documentation due to a failure in accessing the electronic medical record system. The resident fell and sustained a head injury, and the facility's staff did not utilize the backup system to provide identifying information, medication list, or contact details to EMS. The family was not notified until contacted by the hospital.
Delay in CPR and Missing Emergency Equipment During Code Blue
Penalty
Summary
The facility failed to provide effective basic life support when a resident who was full code was found unresponsive, without respirations, and without a palpable pulse. The resident had diagnoses including atherosclerotic heart disease, diabetes, and unspecified dementia, and the admission MDS described severe cognitive impairment and unclear speech. Nursing documentation and staff interviews showed that Nurse #8 identified the resident as having no visible chest rise and fall and no palpable radial pulse, then left the room to confirm code status and locate another nurse before CPR was started. The report states that staff did not immediately activate the emergency response process when the resident was found without signs of life. Nurse #8 reported attempting to announce a code blue but being unable to use the intercom system, then yelling in the hall and walking to two nursing stations to find Nurse #3. Multiple staff members stated they did not hear a code blue announcement or hear Nurse #8 call for help, and they said they were not aware of the emergency until Nurse #3 later told them it was a code blue. The EMS record showed the emergency call was received at 1:37 am, EMS arrived at 1:45 am, and the resident was pronounced deceased at 2:15 am. The report also found that emergency equipment was not immediately available and that the AED was not brought to the room during the code. Nurse #8 stated the first crash cart did not have an AMBU bag, so CPR continued without rescue breaths until a second crash cart was brought. Nurse #3 stated she thought the AED was stored in the crash cart and did not know it was mounted on the wall in the emergency closet, and other staff similarly reported the AED was not brought to the room. The facility’s own policy required immediate identification of code status, activation of the emergency response system, use of the AED as soon as possible, and continuation of CPR until EMS arrived.
Narcotic Lock Boxes Not Permanently Affixed to Medication Refrigerators
Penalty
Summary
The facility failed to ensure narcotic lock boxes were permanently affixed to the medication refrigerators in 2 of 2 medication rooms observed for medication storage. During an observation of one medication room with a nurse, two black lock boxes were seen in the medication refrigerator, and one lock box labeled #2 was picked up and found not to be permanently affixed. That lock box was unlocked and opened and contained one card of Marinol 5 mg with 14 tablets. The other lock box in that refrigerator was permanently affixed, and the nurse confirmed the non-affixed box should have been permanently attached. During an observation of the second medication room with another nurse, two black lock boxes were seen in the medication refrigerator, and lock box #1 was picked up and found not to be permanently affixed. That box was unlocked and opened and contained one card of Marinol 5 mg with 5 tablets, Marinol 10 mg with 9 tablets, and three vials of Ativan 2 mg/ml. The nurse confirmed the lock box should have been permanently affixed and stated the facility had recently replaced the refrigerators due to needing more storage space. The DON stated the narcotic boxes should have been immediately bolted to the medication refrigerator when they were exchanged, and the Administrator stated she expected the boxes to have been immediately affixed.
MDS Assessment Incorrectly Coded for Level II PASRR
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for Level II Preadmission Screening and Resident Review (PASRR) for one resident. The resident was admitted with diagnoses including unspecified bipolar disorder and major depressive disorder, recurrent. The electronic medical record contained a Level II PASRR Determination Notification dated 4/04/22 stating that the resident's nursing home placement was appropriate, but the annual MDS assessment dated [DATE] indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness. During interview, the MDS nurse confirmed the Level II PASRR Determination Notification was in the record and stated the resident should have been coded for Level II PASRR on the assessment, explaining that she must have missed the document when completing the annual MDS. The Administrator confirmed the MDS nurse was responsible for accurately coding the assessment and stated the resident should have been coded for Level II PASRR based on the documentation in the health record.
Missing PASRR Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with a Level II PASRR determination. Resident #3 was admitted with diagnoses including unspecified bipolar disorder and major depressive disorder, recurrent. The resident’s record included a Level II PASRR Determination Notification dated 4/04/22 stating that nursing home placement was appropriate, and the annual MDS noted the resident was not currently considered by the state Level II PASRR process to have a serious mental illness. However, the resident’s care plan, last reviewed on 4/17/26, did not include any care plan related to the Level II PASRR determination. During interview, the MDS nurse confirmed the resident had a Level II PASRR determination and that a care plan was required, but stated the prior care plan had been resolved on 12/05/24 and she did not know why it was resolved. She also stated she did not have a care plan in place because she did not see the Level II PASRR Determination Notification in the resident’s health record when completing the 1/15/26 MDS assessment. The Administrator stated the MDS nurse was responsible for ensuring the care plan reflected the resident’s Level II PASRR status.
Care plan not revised for elopement risk and wander alarm use
Penalty
Summary
The facility failed to revise the person-centered care plan for Resident #54 in the areas of elopement risk and use of a wander/elopement alarm bracelet. Resident #54 was admitted with diagnoses including schizoaffective disorder, bipolar type, and Alzheimer's Disease, and later returned to the facility after hospitalization. An elopement risk assessment identified the resident as at risk for elopement, and there was an active physician order for an alerting bracelet on the left ankle with directions to check functionality every day shift and placement every shift. The quarterly MDS assessment showed severe cognitive impairment, with inattention and disorganized thoughts continuously present, and the resident was coded for wandering daily and use of a wander/elopement alarm daily. However, the care plan last reviewed on 3/11/26 did not include a care plan or interventions for elopement risk or the wander/elopement alarm bracelet. In interviews, the MDS Nurse stated she was responsible for the comprehensive care plan and had missed initiating it for the elopement risk and bracelet use, and the DON and Administrator stated the care plan should have reflected the resident's current status.
Wrong Resident Transported to Scheduled Appointment
Penalty
Summary
The facility failed to ensure that a resident was transported to a scheduled orthopedic appointment and instead sent a different resident to the appointment. Resident #95 was admitted with diagnoses including heart failure and difficulty walking, and the admission MDS indicated moderate cognitive impairment. On 2/25/26, Medical Records Staff #1 prepared Resident #95 for the appointment and seated him by the reception area to wait for his driver, but later learned that a mix-up had occurred and Resident #95 never went to the appointment. During interviews, staff and the transportation driver stated that Driver #1 arrived to transport Resident #95, went to the resident’s room, and picked up Resident #45, who was Resident #95’s roommate, instead. Driver #1 stated that Resident #45 responded when called by name and was taken to the appointment, where the doctor’s office discovered he was not the scheduled resident and sent him back to the facility. The transportation manager and the previous administrator both confirmed that the wrong resident had been taken to the appointment, and the family member stated that Resident #95 never arrived while Resident #45 appeared at the appointment and was returned to the facility.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to post accurate daily nurse staffing data for 14 of 30 days reviewed. Record review showed that the posted staffing sheets did not match the daily nursing staff schedule for multiple shifts across the review period, including discrepancies in both licensed nursing staff and non-licensed nursing staff counts. For licensed staff, the posted sheets overstated or misstated RN and LPN numbers on several day, evening, and night shifts, such as showing an RN when the schedule showed none, or listing more LPNs than were scheduled. For non-licensed staff, the posted sheets also reflected inaccurate NA counts on multiple shifts, with the posted numbers frequently higher than the scheduled numbers. During interviews, the previous Scheduler stated she no longer worked at the facility and would not answer questions about the staffing sheets. The DON stated she had only begun managing staff posting and scheduling within the last week because the previous Scheduler had left the position. The DON reported that the previous Scheduler had not been adjusting the staff posting when changes were needed. The Administrator stated the DON had taken over scheduling responsibilities during the previous week after the previous Scheduler's employment ended and said she was not sure why the previous Scheduler did not correct the staffing posting when changes occurred.
Failure to Conduct Timely AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was receiving psychotropic medications, specifically Geodon, for bipolar disorder. The resident was admitted with diagnoses including manic depression and depression. Although an AIMS assessment was completed on 5/17/24, a subsequent assessment was not conducted within the recommended six-month interval. The Pharmacist Consultation Report dated 12/6/24 highlighted the absence of an AIMS assessment in the previous six months and recommended its completion due to the potential for the antipsychotic medication to cause involuntary movements, such as Tardive Dyskinesia. Interviews with the Pharmacy Consultant and the Director of Nursing (DON) confirmed that an AIMS assessment should have been conducted every six months to monitor for involuntary movements or side effects from the antipsychotic medication. The DON noted that the assessment should trigger in the resident's electronic record when due, but was unsure why it was not completed. The Administrator expressed the expectation that the AIMS assessment would be completed according to the facility's protocol and the Pharmacy Consultant's recommendation. The resident's electronic medical record also lacked a psychotropic medication side effect monitoring tool in the medication administration report (MAR).
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Ombudsman in writing of resident transfers to the hospital for two residents reviewed for hospitalization. Resident #1 was transferred to the hospital for evaluation after a fall and was discharged from the facility on the same day, returning later. However, the Ombudsman Discharge and Transfer report for January 2025 did not contain documentation of this transfer. The Social Worker, who began working at the facility in October 2024, admitted to not notifying the Ombudsman of hospital discharges, only home discharges. The Ombudsman confirmed not receiving written notifications of hospital discharges for the past two months. Similarly, Resident #18 was transferred to the hospital for evaluation of chest pain and cough and was discharged from the facility on the same day, returning later. The Ombudsman Discharge and Transfer reports for November and December 2024 also lacked documentation of this transfer. The Social Worker reiterated the same practice of not notifying the Ombudsman of hospital discharges. The Administrator acknowledged that the Social Worker should send a monthly notice to the Ombudsman of all residents sent out.
Failure to Notify Residents of Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their responsible parties (RPs) of the bed hold policy during hospital transfers, affecting two residents. Resident #1, with moderate cognitive impairment, was transferred to the hospital twice without receiving the bed hold notice. The responsible party for Resident #1 was not contacted by the Admission Director to discuss the bed hold policy for either discharge. Upon returning from the hospital, Resident #1 found their personal belongings removed and another resident occupying their room, indicating a lack of communication regarding the bed hold policy. Resident #2, with severe cognitive impairment, was also transferred to the hospital without the bed hold notice being completed or communicated to their RP. The Admission Director admitted to not discussing the bed hold policy for long-term care residents, assuming a bed would be available upon Resident #2's return. This oversight highlights a systemic issue in the facility's process for handling bed hold notifications during hospital transfers. Interviews with staff, including the nurse responsible for discharges and the Business Office Manager, revealed confusion and lack of clarity regarding the responsibility for notifying RPs about the bed hold policy. The Director of Nursing and the Administrator confirmed that the process was not adequately monitored, and there was no documentation to support that the bed hold notices were completed or communicated to the RPs for the residents involved.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was admitted with a healing hip fracture, anxiety disorder, and depression. Upon admission, the resident had a physician's order for Norco, a narcotic pain medication, to be administered every six hours as needed for moderate to severe pain. However, the facility did not have the medication available upon the resident's arrival, and the pharmacy was unable to deliver it until the following night. As a result, the resident experienced extreme pain and distress, which was not adequately managed with the available Tylenol. Interviews with staff revealed that the resident was in significant pain and became hysterical due to the lack of effective pain relief. Nurse Aide #7 and Nurse #6 both confirmed the resident's distress and attempts to manage her pain with Tylenol, which was ineffective. The automated medication dispensing cabinet contained narcotic pain medication, but the staff did not have access to it, and the dosage did not match the physician's order. The Director of Nursing was not informed of the situation, which could have allowed for remote access to the medication cabinet or a one-time order adjustment. The pharmacy manager confirmed that the facility had the ordered medications in the automated dispensing cabinet, but the staff did not request a STAT delivery or a one-time order adjustment. The lack of communication and coordination between the facility staff and the pharmacy resulted in a delay in administering the appropriate pain medication, causing the resident to suffer unnecessarily. The resident's pain was finally managed when the ordered Norco was administered late on the night following her admission.
Failure to Dispense Medications from Approved Source
Penalty
Summary
The facility failed to dispense medications from an approved pharmacy source for a resident who was admitted with multiple diagnoses, including a healing hip fracture, anxiety disorder, acute embolism and thrombosis of the right femoral vein, and depression. Upon admission, the resident's medications were not available at the facility as expected. The nurse on duty faxed the medication orders to the pharmacy, but the orders were submitted too late for the evening delivery, and a STAT order could not be arranged due to the lack of a driver. The nurse also did not have access to the automated medication dispensing cabinet, and it was noted that no administrative staff were available after 5:00 PM to assist. The following day, another nurse discovered that the resident still did not have any medications. This nurse took medications from other residents' medication cards to administer to the resident, except for Vitamin D3, which was available from house stock. The medications borrowed included Apixaban and Ezetimibe. The nurse confirmed that borrowing medications from other residents was against protocol, but felt it was necessary to ensure the resident received their prescribed medications. Interviews with the Director of Nursing (DON) and the facility's consultant pharmacist revealed that there should have been access to the automated medication dispensing cabinet at all times, and that a STAT order could have been arranged if the pharmacy had been contacted. The pharmacy manager confirmed that the medications were available in the automated dispensing cabinet, except for Norco and Lorazepam, which were available in alternate strengths. The facility did not utilize the automated dispensing cabinet or request a STAT delivery, leading to the deficiency in pharmaceutical services for the resident.
Failure to Notify Family After Resident's Fall and Hospitalization
Penalty
Summary
The facility failed to notify a responsible party after a resident fell, sustained a head injury, and was transferred to the hospital. The resident, who had multiple diagnoses including dementia and a chronic progressive neurological disorder, was admitted to the facility on an unspecified date. On June 5, 2024, the resident fell at an exit door, hitting his forehead, and was sent to the hospital. Nurse #1 documented the incident but crossed it out as an error, indicating that the power of attorney was notified. However, the hospital emergency department records showed that the resident arrived without identifying information. Nurse #1 explained during an interview that she called 911 and attempted to access the electronic medical record to print information for the hospital but found it unavailable. Consequently, she could not send any information with the resident when EMS arrived, although she did inform EMS of the resident's name. After the resident was taken to the hospital, a family member called the facility and was informed of the incident. The family member stated that the hospital contacted her first, and she was unaware of the situation until she called the facility. The President of Operations later confirmed that nursing staff had access to medical information on backup systems but was unsure how they could access emergency contact information if the electronic medical record was inaccessible.
Failure to Provide Documentation During Emergency Transfer
Penalty
Summary
The facility failed to provide necessary documentation during an emergency transfer of a resident to the hospital. The resident, who had multiple diagnoses including dementia and a chronic progressive neurological disorder, fell and sustained a head injury. Nurse #1, who was responsible for the resident at the time, attempted to access the electronic medical record to print out necessary information but found the system was down. As a result, the resident was sent to the hospital without identifying information, a medication list, physician contact information, or responsible party contact information. Interviews with staff revealed that Nurse #1 informed EMS of the resident's name and requested that they take the resident to the hospital from which he was originally admitted, assuming they would have prior medical information. However, the hospital records indicated that the resident arrived without any identifying information or confirmation of medication orders. The family member of the resident was not notified by the facility due to the lack of access to emergency contact information, and only learned of the situation when contacted by the hospital. The Director of Nursing and the President of Operations acknowledged the failure to access the backup system for electronic medical records. The facility had a backup plan in place, but the nursing staff did not utilize it during the incident. The President of Operations stated that more training had been implemented for the nursing staff on how to access the backup system in the event of electronic medical record system downtime.
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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 Raleigh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capital Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 6 | 0 |
| Tower Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 2 | 0 |
| Raleigh Rehabilitation Center | 3.7 mi | ★★★★★ | 8 | 0 |
| Bloomsbury At Hayes Barton Place | 4.3 mi | — | 0 | 0 |
| The Cardinal At North Hills | 4.4 mi | ★★★★★ | 2 | 0 |
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