Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Sunnybrook Rehabilitation Center during CMS and state inspections, most recent first.
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.
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 | — | 0 | 0 |
| Tower Nursing And Rehabilitation Center | 1.2 mi | — | 2 | 0 |
| Raleigh Rehabilitation Center | 3.7 mi | — | 3 | 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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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.