Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Sunnyslope Nursing Home during CMS and state inspections, most recent first.
A former CNA who had verbally abused a resident with dementia and other conditions was allowed to re-enter the facility multiple times after his employment ended, including attending events and waiting in resident care areas. Staff reported these incidents to the DON, but no action was taken to restrict the former employee's access, resulting in a failure to enforce abuse prevention policies.
A resident with dementia in a secured unit was verbally abused by a CNA, who threatened to hit the resident and used inappropriate language. The incident was overheard by an LPN and a housekeeper, leading to a report and investigation. The CNA admitted to the statement, claiming it was accidental, and was suspended pending investigation.
A facility failed to invite a resident's representative to a care planning conference, affecting a resident with multiple diagnoses and moderate cognitive impairment. The resident's daughter, who is the power of attorney, was not notified or invited, contrary to the facility's policy requiring advance notification.
The facility inaccurately coded MDS assessments for three residents, marking them as using physical restraints when enabler bars and bedrails were used for mobility and positioning. Staff interviews and observations confirmed these devices did not restrict movement, indicating a misunderstanding of CMS guidelines.
A resident with multiple mental health diagnoses did not receive all recommended PASARR level II services, including a safety plan and behavior management plan. The resident frequently isolated in his room, slept during the day, and did not participate in activities. Staff were unaware of any safety or behavior management plans, and the facility lacked a comprehensive individualized care plan to address the resident's needs.
A resident admitted with multiple mental health diagnoses, including major depressive disorder and bipolar disorder, had an inaccurate PASARR assessment. The assessment failed to document all mental disorders and medications, such as Mirtazapine for depression. The social worker confirmed the inaccuracies, which were against the facility's policy requiring accurate PASARR completion for residents with serious mental illness.
A resident with chronic respiratory conditions was observed receiving oxygen therapy at 10 liters per minute, contrary to the physician's order of two to five liters per minute. This discrepancy was confirmed by an RN, highlighting a failure in adhering to the prescribed oxygen therapy settings.
Failure to Implement Effective Dementia Behavioral Care Leading to Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized, and effective behavioral health treatment plans and services, including non‑pharmacological interventions, for residents with dementia and behavioral disturbances, which resulted in resident‑to‑resident altercations and actual harm. Two residents with dementia and significant behavioral histories repeatedly wandered, entered other residents’ rooms, and displayed agitation and aggression without evidence of effective monitoring or individualized non‑pharmacological strategies to manage these behaviors or prevent altercations. The facility relied heavily on psychotropic medication adjustments and brief periods of increased supervision, without documenting or care‑planning specific behavioral interventions tailored to each resident’s needs. One resident had vascular dementia with behavioral disturbance, agitation, anxiety, sundowning, combative behavior at night, and a history of throwing a chair, walking naked, and visual hallucinations. Orders included multiple psychotropic medications such as Haldol, Ativan, Vistaril, Depakote, Trazodone, and later Klonopin, with several dose changes over time. Nursing notes repeatedly documented this resident wandering the halls, entering other residents’ rooms, pacing, yelling, slamming chairs and doors, being verbally and physically aggressive, and having explosive episodes. The care plan identified mood and behavior problems, including disruptive behavior, resisting care, socially inappropriate behavior, wandering into other rooms, exit seeking, and combativeness, but listed only general interventions such as consulting social services, administering medications, monitoring behaviors, and gentle redirection. There was no documented evidence of specific non‑pharmacological interventions being planned or implemented to address these behaviors. The second resident had diagnoses including behavioral disturbance and agitation, intermittent explosive disorder, major depressive disorder, psychotic disorder, delirium, and later severely impaired cognition, with documented behaviors such as wandering daily, rejecting care, and physical and verbal behaviors toward others. This resident frequently wandered into other residents’ rooms and was found in their recliners or beds, yet the record showed no non‑pharmacological interventions to address wandering or to prevent altercations. Multiple incidents occurred between the two residents: one resident hit the other on the jaw while the victim sat near the nurse’s station; on another occasion, one resident repeatedly rammed a walker into the other’s legs, leading to mutual hitting and facial scratches; and later, the wandering resident entered the other’s room, resulting in a serious altercation where the victim was found on the floor with significant facial trauma, periorbital swelling, scalp laceration, and a large bruise from hip to knee. Despite these escalating events and the known mutual dislike between the two residents, interviews and record review confirmed that no new, individualized non‑pharmacological interventions were added beyond temporary increased or one‑on‑one supervision, and the facility did not effectively implement behavioral health services to prevent further resident‑to‑resident altercations. Title: Failure to Implement Effective Dementia Behavioral Care Leading to Resident Altercations ShortSummary: Two residents with dementia and significant behavioral histories repeatedly wandered, entered other rooms, and displayed agitation and aggression without individualized non‑pharmacological interventions or effective behavioral health care plans. Staff documented frequent wandering, pacing, yelling, slamming furniture, and explosive episodes, and the care plans relied largely on psychotropic medications and general redirection rather than specific, person‑centered strategies. Multiple altercations occurred, including one resident striking another near the nurse’s station, an incident involving a walker being rammed into another resident’s legs with mutual hitting and facial scratches, and a later episode in which a wandering resident entered another’s room and sustained significant facial trauma, scalp laceration, and extensive bruising. Records and interviews confirmed that, despite these events and awareness that the two residents did not get along, the facility did not develop or implement comprehensive, individualized non‑pharmacological interventions to manage behaviors or prevent further resident‑to‑resident altercations.
Failure to Prevent Former Employee with Substantiated Abuse from Facility Access
Penalty
Summary
A deficiency occurred when a former Certified Nursing Assistant (CNA) who had previously verbally abused a resident was allowed to re-enter the facility, including resident care areas, after his employment had ended. The resident involved had diagnoses including Alzheimer's disease, dementia with agitation, and was receiving hospice services at the time. The abuse incident involved the CNA threatening to hit the resident and using inappropriate language, after which the CNA was suspended and subsequently resigned. Despite this, multiple staff members and an anonymous individual reported witnessing the former CNA in the facility on several occasions, including attending a Christmas party and waiting in the nursing station to pick up his wife, who was an employee. These occurrences were reported to the Director of Nursing (DON), but no action was taken to prevent the former CNA's entry into the facility. Interviews with various staff confirmed that the former CNA was present in the facility multiple times after the abuse incident, often in resident care areas and in the presence of staff, including the DON. The Administrator only became aware of the situation after being notified by staff and then contacted the former CNA to instruct him not to enter the facility. The facility's policy requires protections to prevent abuse and ensure the safety and rights of residents, but this policy was not enforced in this case, resulting in a failure to prevent the former employee from accessing the facility after substantiated abuse.
Verbal Abuse Incident Involving Resident with Dementia
Penalty
Summary
The facility failed to protect a resident from verbal abuse, which was identified during a review of a self-reported incident. The incident involved a resident with a history of Alzheimer's disease, dementia with agitation, and other medical conditions, who required substantial assistance with daily activities and resided in a secured unit due to behavioral issues. On the day of the incident, the resident was moved to the dining room by an LPN to allow a breakfast tray cart to pass. However, the resident returned to the nurse's station, blocking the cart's path. A CNA approached the resident and verbally threatened to hit them in the nose, which the resident responded to by asking not to be hit. The CNA then moved the resident back to the dining room, using inappropriate language. This interaction was overheard by an LPN and a housekeeper, who reported the incident. The CNA later admitted to making the statement but claimed it was accidental and apologized. The facility's policy on abuse, neglect, and misappropriation was reviewed, and it was found that the policy was followed in the investigation of the incident. The CNA involved had received training on abuse prevention and had no prior substantiated incidents of abuse, although there were two unsubstantiated reports in the past. The incident was reported, and the facility took immediate action to address the situation, including suspending the CNA pending investigation.
Failure to Invite Resident Representative to Care Conference
Penalty
Summary
The facility failed to ensure that a resident representative was invited to attend a care planning conference for a resident. This deficiency affected a resident who was admitted with multiple diagnoses, including multiple sclerosis, diabetes mellitus, anxiety disorder, depression, and suicidal ideation. The resident was moderately cognitively impaired and required staff assistance with activities of daily living. The care conference form for the resident did not indicate that the family or responsible party was invited or attended the conference. Interviews with the resident's daughter, who is also the power of attorney, and facility staff confirmed that the daughter was not invited to the care conference. The facility's policy requires that a notification letter be sent to the resident and/or their responsible party two weeks in advance of the scheduled conference, which was not adhered to in this case.
Inaccurate MDS Coding for Physical Restraints
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for three residents, leading to deficiencies in the documentation of their care needs. Resident #1, who was admitted with multiple mental health diagnoses, was inaccurately coded on the MDS as not having a serious mental illness, despite meeting the criteria according to the Preadmission Screening and Resident Review (PASARR). Additionally, Resident #1 was incorrectly documented as using a physical restraint due to the presence of an enabler bar, which was actually used for positioning and did not restrict movement. Interviews with staff confirmed these inaccuracies, highlighting a misunderstanding of CMS guidelines regarding enabler bars and bedrails. Similarly, Resident #10 and Resident #17 were also inaccurately coded on their MDS assessments as using physical restraints. Both residents had enabler bars or bedrails that were assessed by the therapy department as aids for mobility and positioning, not as restraints. Observations and interviews with the Director of Nursing confirmed that these devices did not restrict the residents' movement. The inaccuracies in the MDS coding for these residents were attributed to a misinterpretation of CMS guidelines, resulting in the facility marking all residents with enabler bars or bedrails as using physical restraints.
Failure to Implement PASARR Level II Services and Comprehensive Care Plan
Penalty
Summary
The facility failed to implement all Pre-Admission Screening and Resident Review (PASARR) level II services and did not complete a comprehensive individualized plan of care for a resident with multiple mental health diagnoses. The resident, who was admitted with conditions including schizoaffective disorder, mood disorder, and obsessive-compulsive disorder, was recommended to have a safety plan, behavior management safety plan, and socialization activities to improve mood and interaction. However, the resident's PASARR Level II plan of care only mentioned following PASARR recommendations without specific interventions. Observations and interviews revealed that the resident frequently isolated himself in his room, slept during the day, and did not participate in activities. Despite recommendations for socialization and behavior management, there was no evidence of a safety plan or behavior management safety plan in the resident's medical records. Staff interviews confirmed the resident's isolation and overeating behaviors, and they were unaware of any safety or behavior management plans. The Director of Nursing and Activity's Director acknowledged the resident's frequent refusal to participate in activities and the lack of documentation or efforts to encourage engagement. The facility did not have a comprehensive individualized plan of care to address the resident's social and activity needs as per PASARR level II recommendations, leading to the identified deficiency.
Inaccurate PASARR Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) assessments were completed accurately upon admission for a resident with multiple mental health diagnoses. Resident #37 was admitted with diagnoses including major depressive disorder, intermittent explosive disorder, bipolar disorder, and generalized anxiety disorder. The admission orders included medications such as Mirtazapine for depression, Rivastigmine for dementia, Ativan for anxiety/agitation, and Risperdal for dementia. However, the PASARR assessment inaccurately documented the resident's mental disorders and medications. Specifically, it failed to include intermittent explosive disorder, bipolar disorder, generalized anxiety disorder, and the anti-depressant medication Mirtazapine. The social worker confirmed that the PASARR was inaccurate at the time of admission, missing critical information about the resident's mental health conditions and prescribed medications. The facility's policy required a resident review for any nursing facility resident with a serious mental illness or intellectual developmental disability who experienced a change in mental diagnoses or psychotropic medication. The policy also mandated accurate completion and submission of the PASARR form to the department for further review if serious mental illness or developmental disabilities were indicated. This deficiency highlights a failure in the facility's adherence to its own policy and regulatory requirements for accurate PASARR assessments.
Incorrect Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that a resident's oxygen therapy was set to the correct liters per minute, affecting one resident who was reviewed for oxygen therapy. The resident, who had been admitted with diagnoses including asthma, chronic obstructive pulmonary disease (COPD), morbid obesity, and chronic respiratory failure with hypoxia, had a physician's order for oxygen to be administered at two to five liters per minute via nasal cannula continuously. However, observations on two consecutive days revealed that the resident's oxygen was set at 10 liters per minute, which was confirmed by a registered nurse. The comprehensive care plan for the resident indicated the need to maintain oxygen saturation at greater than 90 percent, with oxygen therapy set between two to five liters per minute as needed.
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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 Bowerston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bowerston Hills Nursing & Rehabilitation | 1.4 mi | ★★★★★ | 5 | 0 |
| Claymont Health And Rehabilitation | 9 mi | ★★★★★ | 6 | 0 |
| Schoenbrunn Healthcare | 11.1 mi | ★★★★★ | 8 | 0 |
| Carroll Healthcare Center Inc | 12.2 mi | ★★★★★ | 2 | 0 |
| Park Village Hc Np Llc | 13.6 mi | ★★★★★ | 0 | 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.