Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunnyview Nursing Home & Apartments during CMS and state inspections, most recent first.
A resident with cognitive impairment was repeatedly subjected to physical abuse by another resident with a known history of aggression, including being shoved into a bird aviary and sustaining injuries. Despite multiple incidents of aggression, no effective interventions or increased monitoring were implemented, and staff, including the DON and PCP, acknowledged the lack of safety measures to protect residents.
A resident with dementia and a history of wandering eloped from the facility and was found outside without a wander guard bracelet. Staff did not update the care plan to address the new exit-seeking behavior, despite facility policy requiring such updates after an elopement. Nursing staff and the DON confirmed that no new interventions were added to the care plan following the incident.
The facility failed to maintain a clean and safe environment, with observations revealing a mold-like substance in various areas, including air return vents and heating/cooling units. Staff interviews indicated a lack of awareness and absence of a policy for mold mitigation, contributing to the deficiency.
The facility failed to assess and document the use of wander guards for two residents, lacking a policy for their use. Despite past incidents, there were no current assessments for elopement risk or wandering behaviors. Observations and staff interviews indicated that the residents did not exhibit exit-seeking behavior, yet wander guards were used based on previous incidents.
The facility failed to provide proper respiratory care for two residents, leading to potential exposure to contaminated equipment. Observations showed that oxygen tubing and cannulas were found on the floor, and oxygen filters were not cleaned as required. Staff interviews revealed discrepancies in understanding the cleaning schedule, contributing to the deficiency.
The facility failed to properly store nebulizer masks for two residents, leaving them uncovered and risking contamination. Additionally, an LPN did not follow proper wound care procedures for a resident, placing supplies on the floor and failing to maintain a clean field. These actions were against the facility's infection control policies, posing a risk of infection spread.
A facility failed to conduct a significant change in status assessment (SCSA) for a resident who was started on hospice services. The MDS coordinator, new to the role, was confused about the need for an SCSA despite a quarterly assessment being open. The DON confirmed awareness of the hospice enrollment, but the required assessment was not completed, leading to a deficiency in ensuring proper care.
A facility failed to develop and implement a care plan for a resident receiving hospice services, despite a physician's order. The MDS coordinator admitted to forgetting to update the care plan, which is crucial for staff awareness of the resident's hospice status. This oversight could potentially affect all residents receiving hospice services.
The facility failed to attempt alternative measures before installing bed rails for two residents, one with muscle weakness and another with chronic kidney disease and severe cognitive impairment. The facility did not document any alternative measures, and staff were unaware of the requirement to explore alternatives before using bedrails.
Two residents in a LTC facility received incorrect medication dosages due to staff errors. One resident with severe cognitive impairment was given the wrong form and dosage of metoprolol, while another resident with Parkinson's disease received an incorrect frequency of carbidopa-levodopa. The errors were attributed to incorrect order entry and a flawed process for handling phone orders.
A facility failed to document the rationale and stop date for a PRN lorazepam order for a resident with severe cognitive impairment and anxiety. Despite multiple requests from the clinical pharmacist, the prescriber continued the order without providing the necessary documentation, leading to a potential risk of unwarranted medication side effects.
A resident with moderately impaired cognition was mistakenly given another resident's medications by a student nurse, leading to a significant drop in blood pressure. The error occurred during a morning medication pass in the dining room, where the nurse confused two residents. The resident, with a history of heart failure and kidney disease, was hospitalized for observation and treatment after experiencing hypotension.
Failure to Protect Resident from Repeated Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from physical abuse by another resident with a known history of aggression. Despite multiple documented incidents where the aggressive resident engaged in physical altercations—including slapping, grabbing, pushing, and throwing objects at both residents and staff—no effective interventions or safety measures were implemented to prevent further abuse. On one occasion, the aggressive resident shoved the other resident into a bird aviary, resulting in broken glass and a scratch on the victim's back. The aggressive resident had a documented history of behavioral issues, including physical and verbal aggression, wandering, and difficulty with redirection. Medical records indicated the use of psychotropic medications and as-needed interventions for aggression and anxiety. Despite repeated incidents of aggression towards both residents and staff, the care plan for the aggressive resident did not include new or updated interventions after each event. Staff and the DON acknowledged that no increased monitoring or checks were put in place following these incidents, and the aggressive resident continued to have unsupervised access to other residents. Interviews with staff, the DON, the primary care provider, and the resident's guardian confirmed awareness of the ongoing behavioral issues and the lack of adequate safety measures. The primary care provider and guardian both expressed concerns about the appropriateness of the placement and the absence of interventions to protect other residents after each incident. Observations during the survey showed the two residents together without staff intervention or increased supervision, even after the most recent incident of physical abuse.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
Staff failed to update the care plan for a resident who eloped from the facility, despite facility policy requiring nursing staff to revise the care plan after such an event. The resident, who had a history of dementia, impaired decision making, depression, and repeated attempts to exit the facility, was found to be at increased risk for wandering. The care plan had last been updated prior to the elopement and did not reflect the new exit-seeking behavior following the incident. On the night of the elopement, the resident left the facility without a walker and was found outside 25 minutes later without the wander guard bracelet, which is intended to alert staff when a resident approaches an exit. Nursing staff, including the RN on duty, acknowledged that the wander guard had not been checked as ordered, and the DON confirmed that no new interventions were added to the care plan after the incident. The MDS Coordinator also stated that the care plan was not updated as required, and that the charge nurse on duty was responsible for this task.
Facility Fails to Maintain Clean and Safe Environment Due to Mold Presence
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, staff, and the public, as evidenced by the presence of a mold-like substance in various areas of the building. Observations conducted on September 10, 2024, revealed a strong, damp, and musty smell outside a resident's room and in the dining room adjacent to nursing station number three. Additionally, a black, mold-like substance was observed on the air return vents above the nurse's station on the 300 hall, above the kitchenette on the ceiling of the closed wing, in the kitchen area, and on the ceiling tile behind the kitchen freezer in the dry storeroom. The mold-like substance was also found on heating/cooling units in the activity room and in several occupied resident rooms. Interviews with facility staff indicated a lack of awareness and action regarding the mold issue. The administrator was unaware of the mold presence but acknowledged ongoing roof leaks and mentioned that a new roof had been approved for installation. Certified Medication Technicians (CMTs) interviewed did not notice the mold and were not in the habit of looking for it. Furthermore, a housekeeper confirmed the absence of a policy for mold mitigation or staff training on mold prevention. The facility's failure to provide a policy regarding housekeeping or maintaining the environment contributed to the deficiency.
Inadequate Assessment and Documentation for Wander Guard Use
Penalty
Summary
The facility failed to ensure that residents were appropriately assessed and had documentation to support the use of wander guards for two residents. The Director of Nursing (DON) confirmed that the facility did not have a policy related to wander guard use. Resident 34 was admitted with diagnoses including unspecified dementia and anxiety, and was marked as having a wander guard despite no documented assessments for elopement risk or wandering behaviors. Observations showed Resident 34 was calm and compliant, and staff interviews indicated that the resident did not exhibit exit-seeking behavior. Similarly, Resident 12, who was admitted with dementia and severe cognitive impairment, was also marked as having a wander guard without documented assessments for elopement risk. Although there was a past incident where Resident 12 attempted to leave the facility, staff interviews revealed that the resident no longer exhibited wandering behaviors since being in a wheelchair. The facility's lack of formal evaluation for elopement risk or wander guard use was acknowledged by the DON, who stated that wander guards were placed based on past elopement incidents or exit-seeking behaviors. The facility's decision to place wander guards on these residents was influenced by previous incidents, such as an Immediate Jeopardy (IJ) for an elopement involving Resident 34 before admission to long-term care. However, the absence of a formal evaluation process and documentation for current elopement risk or wandering behaviors led to the deficiency, as the facility relied on past incidents rather than ongoing assessments to justify the use of wander guards.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for two residents, leading to potential exposure to contaminated respiratory equipment and improper airflow. Resident 3, who was admitted with diagnoses including unspecified dementia and chronic heart failure, had a physician's order for oxygen therapy as needed. However, observations revealed that the nasal cannula and oxygen tubing were repeatedly found on the floor, and the care plan did not include the use of oxygen. Interviews with staff confirmed that the equipment should not have been on the floor and should have been stored properly when not in use. Similarly, Resident 99, admitted with heart failure and hypertension, had an order for oxygen therapy but the care plan did not address this. Observations showed that the oxygen filter was covered with thick white dust, and the tubing and cannula were on the floor. Staff interviews indicated a misunderstanding about the frequency of cleaning the oxygen filters, with discrepancies between the stated policy and actual practice. The Director of Nursing confirmed that the filters should have been cleaned weekly, aligning with the manufacturer's guidelines.
Infection Control Deficiencies in Nebulizer Storage and Wound Care
Penalty
Summary
The facility failed to ensure proper storage of nebulizer masks for two residents, leading to potential contamination and infection spread. One resident with severe cognitive impairment had their nebulizer machine and mask left uncovered on paper towels by the sink in their room. Similarly, another resident with mild intermittent asthma had their nebulizer machine and mask uncovered on paper towels by the sink and on top of a dresser. Interviews with staff revealed a lack of awareness and adherence to proper storage procedures, as the masks were supposed to be stored in plastic bags to prevent contamination. Additionally, the facility did not follow proper wound care procedures for a resident with multiple diagnoses, including anxiety disorder and chronic kidney disease. During an observation, an LPN placed wound care supplies directly on the floor and did not use a protective barrier under the resident's feet. The LPN also failed to cleanse scissors after they were placed on the floor and improperly stored contaminated supplies back in the treatment cart. The DON confirmed that these actions were against the facility's wound care policy, which required maintaining a clean field and proper handling of supplies. These deficiencies in infection prevention and control practices were identified through observations, interviews, and record reviews, highlighting lapses in staff training and adherence to established protocols. The facility's failure to properly store nebulizer masks and conduct wound care procedures posed a risk of contamination and infection spread among residents.
Failure to Complete Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) for a resident who was started on hospice services. According to the Resident Assessment Instrument (RAI) manual, an SCSA is required when a resident enrolls in a hospice program and experiences a new onset of symptoms or a condition not part of the expected course of deterioration. In this case, the resident was re-admitted to the facility with a diagnosis of mild intermittent asthma and later had a physician order for hospice dated 07/09/24. However, the facility did not complete the necessary SCSA, which is crucial for ensuring proper care and services. The MDS coordinator, who was new to the position, admitted to being confused about whether a significant change assessment was needed since a quarterly assessment was already open. The Director of Nursing confirmed that the facility became aware of the resident's hospice enrollment on the 11th, following a request from the resident's wife to the provider. Despite this awareness, the required assessment was not completed, indicating a lapse in following the guidelines for assessing significant changes in a resident's condition.
Failure to Implement Hospice Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident receiving hospice services, which was identified during a review of records and interviews. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the required MDS assessment. However, for one resident, identified as R7, who was re-admitted to the facility with a diagnosis of mild intermittent asthma, the care plan did not include hospice services despite a physician's order for hospice dated 07/09/24. Interviews revealed that the MDS coordinator, who was new to the position, acknowledged forgetting to implement the hospice care plan for R7, although it was necessary to ensure staff were aware of the resident's hospice status. The Director of Nursing confirmed that the facility became aware of the hospice request on the 11th, but the care plan was not updated to reflect this. This oversight has the potential to affect all residents receiving hospice services in the facility.
Failure to Attempt Alternative Measures Before Bed Rail Installation
Penalty
Summary
The facility failed to ensure that alternative measures were attempted before the installation of side rails for two residents, R22 and R37, out of a sample of 16 residents. For R22, who was re-admitted with a diagnosis of muscle weakness, the facility's records showed that side rails were ordered and installed without documentation of any alternative measures being considered. The resident's care plan indicated the use of side rails for bed mobility, but the side rail assessment lacked evidence of exploring other options. Similarly, for R37, who had chronic kidney disease and severe cognitive impairment, side rails were used as a fall prevention measure at the resident's request. However, the facility did not document any attempts to explore alternative measures before proceeding with the installation of side rails. Interviews with the MDS coordinator, Administrator, and DON revealed a lack of awareness regarding the requirement to consider and document alternative measures before using bedrails, indicating a gap in the facility's compliance with safety protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received the correct medication as ordered by their physicians, affecting two residents. Resident 20, who has severe cognitive impairment and a diagnosis of chronic diastolic heart failure and hypertension, was prescribed metoprolol succinate 75 mg once daily. However, due to an error by the Director of Nursing, the resident received metoprolol tartrate 75 mg twice daily for at least three days. This error was identified as an incorrect dose, medication, and time, and was documented in an event report. Resident 38, with a diagnosis of Parkinson's disease and intact cognition, was supposed to receive 1.5 tablets of carbidopa-levodopa four times a day. However, due to a miscommunication and incorrect entry by a registered nurse, the resident received the medication three times daily instead. The Director of Nursing acknowledged an issue with the process of taking phone orders, which led to the omission of a second check for accuracy, resulting in the incorrect medication administration.
Failure to Document Rationale and Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure there was documented rationale and a stop date for a PRN psychotropic medication for one resident, which could lead to unwarranted medication side effects. The facility's policy requires PRN orders for psychotropic medications to be limited to 14 days unless extended with documented rationale and duration by the prescriber. However, for one resident with severe cognitive impairment and anxiety, the PRN order for lorazepam was active for nearly three months without the required documentation. The clinical pharmacist made multiple requests to the prescriber to either discontinue the order or provide justification and a duration for its continuation, but the prescriber only responded to continue the order without providing the necessary documentation. The Director of Nursing confirmed the issue, noting that the medication was used to manage the resident's combative behavior during showers, but efforts to have the prescriber document justification and a stop date were unsuccessful.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a student nurse administered another resident's medications to a resident with moderately impaired cognition. The error occurred during the morning medication pass in the dining room, where the student nurse confused two residents sitting at the same table. The medications given included several antihypertensive drugs, which were not prescribed to the resident, leading to a significant drop in blood pressure. The resident, who had a history of anxiety disorder, congestive heart failure, and chronic kidney disease, experienced a decrease in blood pressure and was sent to the hospital for further evaluation and treatment. The resident's blood pressure dropped to 94/43, and they were admitted for observation and received intravenous fluids. The incident was promptly reported, and the resident was assessed by a registered nurse who notified the physician and the resident's family.
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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 Trenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastview Manor Care Center | 0.1 mi | — | 3 | 0 |
| Stonebridge Chillicothe | 19.7 mi | — | 0 | 0 |
| Morningside Center | 19.9 mi | — | 1 | 0 |
| Grand River Health Care | 20.2 mi | — | 3 | 1 |
| Livingston Manor Care Center | 20.6 mi | — | 2 | 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 August 2026) and official state health department websites.