Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
notified the Administrator and Director of Nursing (DON) immediately of an injury to a
resident’s forehead which cause significant bruising to his/her forehead and eyes when
staff hit the resident in the head with the mechanical lift and failed to provide training
in use of the mechanical lift to non-certified nurse aides (NA) caring for and
transferring the resident which affected one of 18 sampled residents (Resident #25); and
failed to perform a complete and thorough investigation of an injury which affected one
sampled resident (Resident #27). The facility census was 77.
1. Review of the facility’s undated Abuse Prevention Plan showed:
– Any known or suspected incidents of physical abuse should be reported to the
Administrator or Director of Nursing immediately after accident occurred.
– The policy requires staff to report witnessed mistreatment or injuries to the
supervisor, charge nurse, DON and Administrator immediately.
– Goal: To establish an atmosphere encouraging the reporting of any indications of
mistreatment or abuse.
– If an incident occurs, the Administrator of designee will investigate.
– The person doing the investigation will complete a Resident Abuse/Neglect Investigation
Report.
– The Administrator will sign and maintain all completed Resident Abuse/Neglect
Investigation Reports and the investigations will remain confidential.
– Any witnessed incidents are to be immediately reported to a supervisor or the charge
nurse who will report the incident to the Administrator or designee. Any person may also
report directly to the DON or Administrator.
– The charge nurse and/or DON will immediately assess the resident and determine and
provide any care needed and record findings in the medical record.
– The DON or designee shall inform the resident, responsible party, and the physician of
the incident.
– The charge nurse will complete a Resident Abuse Neglect Report and request a written,
signed, and dated statement form the persons reporting and or witnessing the incident.
Review of the facility’s Accidents and Incidents- Investigating and Reporting policy,
dated December, 2011, showed:
– All accidents or incidents involving residents, employees, visitors, vendors, etc.,
occurring on the premises shall be investigated and reported to the Administrator.
– The nurse supervisor/charge nurse and/or the department director or supervisor shall
promptly initiate and document investigation of the accident or incident.
– Included in the report: Date and time the incident/accident took place; the nature of
the injury/illness (e.g. bruise, fall, nausea, etc.); the circumstances surrounding the
incident/accident; where the incident/accident took place; names of witnesses and their
accounts of the incident/accident; the injured person’s account of the incident/accident;
the time the injured person’s attending physician was notified as well as the time the
physician responded and his/her instructions; the date and time the injured person’s
family was notified and by whom; the condition of the injured person, including his/her
vital signs; the disposition of the injured (i.e. transferred to hospital, put to bed,
sent home, returned to work, etc.); any corrective action taken; follow up information;
other pertinent data as necessary or required; and the signature and title of the person
completing the report.
– The nurse supervisor/charge nurse and or the department director/supervisor shall

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
complete a Report of Incident/Accident form and submit the original to the Director of
Nursing (DON) within 24 hours of the incident/accident.
– The DON shall ensure the Administrator receives a copy of the Report of
Incident/Accident form for each occurrence.
2. Review of the Incident/Accident Report for Resident #25, dated 2/13/18, showed:
– Staff getting the resident up for lunch, unhooking mechanical lift sling and bumped the
resident’s head.
Review of a nurse’s progress note, dated 2/9/18, and written by Licensed Practical Nurse
(LPN) B showed:
– History of previous head injury from mechanical lift;
– Staff getting the resident up for lunch, had the resident in wheelchair, unhooking lift
seat from the mechanical lift, lift accidentally hit the resident above the right eyebrow;
– No redness, bruising or scratch noted to skin; pupils, grips, movement of extremities
normal, pain response appropriate, notified physician, and family member.
Review of Resident #25’s quarterly Minimum Data Set (MDS), a federally mandated assessment
tool completed by facility staff, dated 8/2/18, showed:
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident made
his/her own decisions;
– Extensive assist of two or more staff for bed mobility, toileting and hygiene;
– Total dependence of two or more staff for transfers;
– Only able to stabilize with staff assistance for surface to surface transfers between
bed and chair or wheelchair;
– Impairment of the lower extremities;
– Wheelchair;
– [DIAGNOSES REDACTED].
Review of the care plan, updated 10/4/18, showed:
– Transfer with the assist of two staff and the mechanical lift;
– The hooks of the lift should be covered during transfer and staff should hold on to the
arm to keep it from swinging and hitting the resident.
Review of the Resident Care Guidelines/Messages used by certified nurse aides (CNA) to
determine type of care for residents, dated 10/26/18, showed:
– Extensive assist of two staff with mechanical lift for all transfers.
Review of a nurse’s progress note, dated 10/27/18, at 11:36 A.M., and written by LPN D
showed:
– Noted resident with bruise over left eyebrow;
– CNAs reported that the mechanical lift hit the resident;
– Primary Care Physician (PCP) notified via fax, family notified via phone;
– Will continue to monitor.
– LPN D did not record he/she notified the DON and did not complete an incident report.
Review of a nurse’s progress note, dated 10/27/18, at 10:38 P.M., and written by
Registered Nurse (RN) A showed:
– Resident denied pain/discomfort related to bruise over left eye;
– Neurological checks (pupil size, grips, movement of extremities, cognition) within
normal limits for the resident.
Review of a nurse’s progress note, dated 10/28/18, at 7:55 A.M., and written by LPN E
showed:
– At 7:05 A.M., aides reported the resident hit on head with mechanical lift related to
aide lowering lift quickly;
– Upon entering room, the resident in wheelchair with purple, golf-ball size knot located
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
on right side of forehead;
– Bruise located on left side of forehead related to mechanical lift lowering too quickly
yesterday morning as well;
– Resident reported pain to forehead; neuro checks started;
– Instructed aide to apply ice;
– Vital signs: Blood pressure (B/P) 173/85, Pulse (P) 61, Respirations (R) 20, Temperature
(T) 98.2, Oxygen saturation 97%;
– Resident alert, pupils equal and reactive to light, grips equal, moves all extremities
well;
– Called and left message for on-call physician at 7:15 A.M
– Called family member to notify;
– PCP returned call to facility.
– LPN E did not record that he/she contacted the DON or the Administrator of the incident.
Review of a nurse’s progress note, dated 10/28/18, at 7:26 P.M., written by RN A showed:
– Neurochecks and vital signs within normal limits;
– Oriented to person, place and time;
– Denies pain;
– Area above right eye swollen and purple in color;
– Area above left eye purple in color and color spreading around eye orbit.
Review of a nurse’s progress note, dated 10/29/18, at 11:05 P.M., and written by LPN C
showed:
– At 3:00 P.M., noted fax from PCP related to head injury; no new orders, and DON
notified;
– Bruising continues to left orbital area and forehead.
During an interview on 11/1/18, at 10:07 A.M., NA E said:
– He/she had not attended CNA class at this time and the next class was scheduled four
months from now.
– He/she assisted CNA I to transfer the resident from his/her bed to his/her wheelchair on
10/27/18.
– They used an old crank-style mechanical lift.
– Both CNA I and NA E hooked the mechanical lift sling to the arm of the lift.
– CNA I raised the resident off the bed and NA E pulled the resident back into the chair
with the handles on the sling.
– The wheelchair was in the upright position, not leaned back and CNA I lowered the
resident to the wheelchair.
– CNA I did not pull back the lift fast enough and the arm of the lift hit the resident in
the left temple area of the face; it happened fast.
– If CNA I had pulled the lift back and away from the wheelchair a little bit, it would
not have hit the resident.
– The resident started screaming and CNA I and NA E quickly unhooked the sling loops from
the arm of the lift.
– Both tried to talk with the resident to calm him/her.
– NA E reported the incident to RN A, the night charge nurse who gave report to the
oncoming charge nurse.
– CNA I finished dressing the resident and about five minutes after the incident, the
resident wheeled him/herself to the nurses’ station to tell the charge nurse of the
incident.
– Neither charge nurse went to the resident’s room to assess the resident after the
incident.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
– There was a raised bruise the size of a golf ball on the resident’s forehead near the
temple area.
– He/she wrote a statement about the incident today (11/1/18).
– He/she was in-serviced on the use of lift when he/she started to work at the facility in
September, (YEAR).
During an interview on 11/1/18, at 10:37 A.M., and 11:26 A.M., the DON said:
– The incident form was completed on 2/13/18, for the 2/9/18 incident and no statements
were written by the staff involved in the incident.
– In-services had not been given since the incident.
– The investigation of the 10/27/18 and 10/28/18 incidents were not completed because the
facility’s annual survey had started and she did not have time to do it.
– She was notified on 10/28/18, of the incident that happened on 10/28/18 by LPN E.
– She was not notified of the 10/27/18 incident until Monday morning 10/29/18.
– Staffing this past week end was a mess so NAs were used to staff the facility but there
should have been a CNA assigned to work with the NAs.
– Interviews from staff involved in both incidents were taken on 11/1/18.
During an interview on 11/1/18, at 11:26 A.M., NA B said:
– He/she only worked in the facility two days, had not been to class, and had not been
instructed in the use of the mechanical lift use and operation.
– LPN E demonstrated the use of the lift to him/her on 11/28/18, but he/she did not return
demonstrate the use and operation of the lift.
– NA B and NA C performed the transfer of the resident with the mechanical lift on
10/28/18, the second time the resident was hit in the head.
– NA C operated the lift to raise the resident off the bed but he/she had NA B lower the
resident into the wheelchair.
– When he/she lowered the resident to the wheelchair, he/she lowered the lift too fast and
the lift hit the resident in the center of the forehead.
– There was a golf ball size raised area of bruising to the center of the resident’s
forehead; there was no bleeding and the resident did not lose consciousness.
– NA C informed LPN E of the incident and LPN E came immediately to assess the resident
and notified the physician.
– LPN E asked the NAs to put ice to the area.
– NA B did not know the lift could be lowered slower when the lift was used correctly.
– No CNA was in the resident’s room with NA B and NA C during the transfer.
– LPN E told NA B to be hands off the lift and only watch transfers until he/she could be
trained to use the lift.
– NA B said he/she had no instruction since on the use of the lift and was not told when
he/she would receive training.
– He/she wrote statement on 11/1/18 that matched the interview above.
During an interview on 11/1/18, at 11:45 A.M., RN A said:
– He/she worked from 5:00 P.M. on 10/26/18, until 6:00 A.M. on 10/27/18.
– He/she was in report with LPN A, the oncoming day shift charge nurse, when CNA I and NA
B came to the desk to report the mechanical lift hit the resident above the left eye.
– LPN A and RN A discussed neuro checks.
– RN A did not go to the room to assess because the resident came to the desk after the
incident.
– The resident was mad and a bruise began to form.
– LPN A did a neuro check on the resident.
– All checks were normal.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
– LPN A was charge nurse on days and LPN D was a new nurse and on orientation.
– RN A discussed neuro checks with LPN A and thought all would be taken care of on the day
shift.
– RN A would have expected LPN A to notify the physician, continue neuro checks, notify
family, but protocol did not say to call the Administrator or DON.
– If the injury was serious, we should call.
– RN A said he/she would not notify DON or Administrator for a simple bump to the head.
– RN A saw a written statement by NA D and said that his/her statement was from the
February, (YEAR), incident when the resident was hit in the head with the mechanical lift,
not the incident that happened on 10/27/18.
– He/she thought that the incidents happened because of the technique used by the staff.
– LPN A should have assessed the resident immediately as RN A was leaving the facility.
– RN A thought LPN A contacted the physician and family but did not contact the DON or
Administrator.
– No written statement provided from RN A on 11/1/18.
During an interview on 11/1/18, at 2:17 P.M., LPN A said:
– He/she was charge nurse on 10/27/18.
– A NA (did not know who) told him/her the resident bumped his/her head when they
transferred the resident with the mechanical lift.
– The resident came to the desk and there was a dime size red area, not raised on his/her
forehead.
– LPN A did not chart any information but assigned the charting to LPN D, the new nurse
and on orientation.
– The bump was not that bad so neuro checks were not done.
– The resident did not complain of pain and was not upset or mad.
– The resident went to breakfast and they checked on him/her later that day,
– LPN A contacted the physician and family but did not contact the Administrator or the
DON.
– LPN A did not feel the need to contact the Administrator or DON about the red area above
the left brow.
– LPN A said he/she only checked neuros if the area was bulging or if the resident acted
differently.
– No written statement provided from RN A on 11/1/18.
During an interview on 11/1/18, at 2:35 P.M., CNA I said:
– He/she worked the night of 10/26/18, and the early morning of 10/27/18.
– He/she assisted NA E to transfer the resident with the mechanical lift.
– The resident leaned forward in the wheelchair and he/she tried to pull the lift back to
keep it from hitting the resident.
– CNA I worked the lift and NA E guided the resident, but the lift hit the resident in the
forehead.
– There was a small goose egg on the resident’s forehead and the next day there was
bruising around the resident’s eyes.
– CNA I informed RN A and LPN A, but neither went down immediately to assess the resident.
– CNA I and NA E dressed the resident, which took about 10 minutes, then the resident
wheeled him/herself to the nurses’ desk.
– The resident yelled out after he/she was hit.
– CNA I also worked with NA D two to three months ago when the resident was hit in the
forehead with the lift.
– The lift hit the resident in his/her right temple area during that incident.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
– The cause was due to the old mechanical lift; staff needed to turn the knob slowly to
not let the resident down too fast and because the resident leaned forward during the
transfers.
– Three staff were needed to safely transfer the resident.
– Wrote statement on 11/1/18 that matched the interview above.
During a telephone interview on 11/6/18, at 3:48 P.M., LPN E said:
– He/she worked the 10/28/18.
– Around 7:00 A.M., NA C came to the desk and told him/her the mechanical lift hit the
resident again in the forehead.
– LPN E immediately went to assess the resident.
– There was a golf ball size purple area to the resident’s right temple area.
– LPN E started neuro checks immediately on the resident which were normal.
– The resident did not lose consciousness, had no bleeding, complained of head pain, but
refused pain medication.
– NA B worked the lift and lowered the resident too fast and hit the resident.
– NA B was new to facility and had not had any instruction on how to work the lift.
– LPN E said he/she did not show or work with NA B on how to use the lift prior to NA B
operating the lift for the resident.
– LPN E told NA B to be hands off the lift until instruction could be provided to him/here
on how to operate the lift.
– LPN E notified the physician and could not reach a family member.
– LPN E informed the family member when they came to the facility later in the day.
– LPN E notified the DON later in the morning of the incident.
– LPN E spoke to DON about need for in-servicing the NAs in use of lift.
During an interview on 11/1/18, at 6:26 P.M., the DON said:
– Staff should notify the Administrator or the DON within 24 hours of an incident.
– Neuro checks should be performed with head injuries.
– If just a bump and no injury to the head, they do not have to notify the Administrator
or DON.
– LPN A should have started neuro checks on the resident on 10/27/18, because of the head
injury from the mechanical lift and should have notified the DON or Administrator
immediately of the injury.
– The nurse on duty starts the investigation and the DON completes an investigation.
– Statements should be taken from all parties involved in the incident.
– NAs should always have a CNA working with them.
– The facility had NAs working that were not attending CNA class because class size
consists of 15 seats and it was difficult to get the NAs into the class.
– NAs have to complete the class within four months of hire or they are fired and then
re-hired and the four months starts over again.
– Some NAs have worked here a long time without attending CNA classes and without
certification.
– The facility had a full time NA Trainer in the facility that worked with the NAs that
are hired.
– The NAs should go through 16 hours of training with the NA Trainer.
– The DON doubted if the NAs went through another 16 hours of training each time they were
rehired.
– After 16 hours of training, the NAs could work with a CNA.
– A CNA should always work with a NA.
During a telephone interview on 11/8/18, at 12:39 P.M., NA C said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
– He/she started to work at the facility five months ago.
– He/she worked at the facility previously but was terminated and then rehired.
– He/she did not remember the dates of hire.
– He/she worked with NA B on 10/28/18, and they transferred the resident with the
mechanical lift.
– There was a problem with the lift knob that raised and lowered the residents.
– Other staff had problems with the lift too.
– The knob got stuck and would lower the residents really fast.
– On 10/28/18, he/she had to get another staff to help him/her with the stuck knob before
the resident was raised off the bed.
– The other staff left; he/she raised the resident off the bed and NA B guided the
resident to the wheelchair.
– NA B had trouble pulling the resident back far enough into the seat of the wheelchair so
they switched and NA B was to lower the resident.
– As NA B turned the knob, the resident lowered really fast into the wheelchair and the
lift hit the resident in the forehead.
– He/she immediately informed the charge nurse, LPN E, that the lift hit the resident.
– LPN E immediately went to the room and assessed the resident, and called to notify the
physician and family.
– He/she did not know if LPN E contacted the DON or Administrator.
– There were other CNAs working, but none were available to assist NA C and NA B.
– LPN B told him/her previously that two NAs could work the lift without a CNA to help
them, so they performed the transfer without a CNA.
– He/she said he/she was uncomfortable working with NA B because NA B had no training on
how to use the lift.
– He/she said he/she also worked with another NA that had no training and had been
uncomfortable doing so.
– He/she told LPN E that he/she was uncomfortable working with NAs that had not had
training using the lift and LPN E said he/she did not have to work with them.
– He/she said three staff were needed to work the lift and keep the lift from hitting the
resident when the resident was transferred.
– He/she said he/she was given training on the use of the lift the first day of the first
time he/she was hired but received no training when hired five months ago.
– He/she said he/she did not know there was a NA Trainer at the facility.
3. Review of the Resident #27’s quarterly MDS, dated [DATE], showed:
– No cognitive impairment;
– Assistance of one staff for activities of daily living (ADLs);
– Used a wheelchair and walker for mobility;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan updated on 10/30/18, showed:
– Recent fall which resulted in a laceration and fractured ankle.
Review of the nurses’ notes, dated 10/23/18, at 10:50 A.M., showed:
– The resident slipped in the shower room and fell , laceration to right ankle from
hitting the bottom of the shower chair;
– Applied pressure to laceration, but it would not stop bleeding;
– The resident was sent by ambulance to the emergency room .
– Family and physician notified.
Review of the resident’s hospital discharge instructions, dated 10/23/18, showed:
– Displaced [MEDICAL CONDITION] fibular diametaphysis (ankle fracture, or broken bone, of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
the end of the fibula bone. The fibula is one of two bones that support the ankle joint);
– Medial laceration (tearing of the skin that results in an irregular wound);
– External casting material applied to the right ankle fracture;
– Soft tissue swelling noted and wound dressing present.
Review of the nurses’ notes, dated 10/23/18, at 2:27 P.M., showed:
– The resident returned from the emergency room with a fractured right ankle with orders
for two oral antibiotics (medications to prevent infection) and a narcotic pain
medication.
– Resident to be non-weight bearing on his/her right foot;
– Podiatry appointment needed, will call tomorrow for appointment.
During an interview on 11/1/18, at 5:30 P.M., LPN A said:
– He/she was the charge nurse on 10/23/18;
– Resident #27 had an incident in the shower room that caused a right ankle fracture.
– The resident also obtained a very deep laceration to his/her right ankle with exposed
bone.
– He/she applied pressure to the area, but the bleeding could not be controlled;
– The resident was transported via ambulance to the emergency room .
– He/she inspected the shower chair for sharp edges and none were identified;
– He/she does not know how the resident received the laceration.
– The aide providing the shower reported the resident started to go down and the aide
lowered the resident to the floor.
– The resident returned from the emergency room later the same day with a soft cast;
– The cast did not contain a window to visualize the sutures to the laceration.
– However, now the soft cast does have a window to observe the laceration.
– The resident has an upcoming appointment on 11/4/18, for suture removal.
– He/she did not start an investigation of the incident or obtain a written statement from
all involved.
During an interview on 11/1/18, at 7:00 P.M., the Director of Nursing (DON) said:
– The charge nurse should have obtained statements from staff to attempt to determine the
cause of the injury for Resident #27 and the resident should have been interviewed;
– She is responsible to ensure investigations are initiated and completed.
– A thorough investigation for Resident #27 was not done.

F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Encode each resident’s assessment data and transmit these data to the State within 7
days of assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure they
transmitted discharge Minimum Data Set (MDS, a federally mandated resident assessment
tool) assessments within the federally mandated timeframes for two residents of 18 sampled
residents (Resident #1 and #2). The facility censes was 77.
Review of the facility policy titled, MDS Completion and Submission Timeframes, with a
revision date of (MONTH) 2010, showed:
– Discharge, Return Not Anticipated assessments should have a transmission date of 14
calendar days after the completion of the assessment.
Review of the MDS 3.0 Resident Reviewer (a federally maintained database of all MDS

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
transmissions) showed:
– Resident #1 discharged to the residential care facility on 1/26/18; staff partially
completed the discharge MDS, did not transmit it; the resident readmitted on [DATE];
– Resident #2 admitted on [DATE]; discharged to home on 6/30/18; staff did not complete
any or transmit a discharge MDS for the resident.
During an interview on 11/1/18, at 6:00 P.M., Registered Nurse (RN) A said:
– He/she is responsible for completing and submitting the MDS.
– Resident #2 was admitted on [DATE], and discharged to home on 6/30/18, which was a
Saturday and he/she believes this is why the assessment was not done.
– Resident #1 returned to the facility on [DATE], and discharged to the facility’s
apartments on 1/26/18. He/she was unaware that the assessment was only partially completed
and had not been submitted.
– An MDS should have a transmission date of 14 calendar days after the completion of the
assessment.
During an interview on 11/1/18, at 7:00 P.M., the Director of Nursing (DON) said:
– The facility should complete and submit resident assessments in accordance with current
federal and state submission timeframes.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a
comprehensive person-centered care plan for one of 18 sampled resident (Resident #25) and
failed to ensure care plans were accurate and complete for three sampled residents
(Resident #1, #36 and #53). The sample was 77.
Review of the facility’s Care Plan Policy revised in (MONTH) 2008, showed:
– The care plan should include instructions needed for effective and person-centered care
that meets professional standards of quality care.
1. Review of the Resident #36’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 9/6/18, showed:
– Moderate cognitive impairment;
– Independent with activities of daily living (ADLs), dressing set up only;
– Hospice services;
– Diagnoses included: [MEDICAL CONDITION] (affects the nerve cells in the brain that
produce [MEDICATION NAME], symptoms include muscle rigidity, tremors, and changes in
speech and gait).
Review of the Resident’s Care Guidelines/Messages dated 4/14/16, showed:
– No updates or interventions since (YEAR).
Review of the resident’s hospital discharge instructions, dated 5/26/18, showed:
– Previous history of stroke and TIAs ([MEDICAL CONDITION] which is like a stroke,
producing similar symptoms, but usually [MEDICATION NAME] only a few minutes and causing
no permanent damage);
– Referred to hospice.
Review of a fax from the facility to the resident’s primary physician, dated 5/28/18,
showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
– The resident was readmitted to the facility from the hospital and the resident had
decided to receive hospice services;
– On 5/30/18, at 3:00 P.M., the physician initialed the fax which indicated the order was
approved.
Review of the resident’s care plan updated on 9/10/18, showed:
– No hospice care plan.
Review of the physician’s orders [REDACTED].
– No order for hospice.
2. Review of Resident #1’s admission MDS, dated [DATE], showed:
– No cognitive impairment;
– Extensive assistance of one staff for ADLs;
– No scheduled pain medications and received as needed pain medication (PRN);
– No non-medication interventions for pain and no indication that pain effects sleep;
– Non-injury fall.
Review of the resident’s POS, dated (MONTH) (YEAR), showed:
– [MEDICATION NAME] (narcotic pain medication) [MEDICATION NAME] (application of a
medicine or drug through the skin) patch change every 72 hours, 12 micrograms (MCG)/HR
(hour); start date 10/17/18, no diagnosis listed;
– [MEDICATION NAME] (narcotic pain medication) oral tablet 5/325 milligrams (mg), give one
tablet orally every four hours as needed; start date 10/17/18, no diagnosis listed.
Review of the Resident Care Guidelines/Messages, updated on 10/31/18, a tool used to
determine care needs for the resident, showed:
– No interventions for pain control.
Review of the resident’s hospital discharge instructions, dated 10/17/18, showed the
resident had a nondisplaced fracture (the bone cracks either part or all of the way
through, but does move and maintains its proper alignment) of left clavicle (collarbone is
a long bone that serves as a strut between the shoulder blade and the sternum or
breastbone), and nondisplaced fracture of proximal phalanx of left middle finger from a
fall.
Review of the resident’s current care plan updated on 10/26/18, showed:
– Recent clavicle fracture with interventions that included to ensure the resident wears
the sling (most clavicle fractures can be treated by wearing a sling to keep the arm and
shoulder from moving while the bone heals).
– The care plan did not identify a problem of pain with interventions for pain control.
During an interview on 10/31/18, at 11:10 A.M., the resident said:
– He/she lived in the facility’s apartments prior to the recent fall;
– He/she has a history of falls and the recent fall resulted in a clavicle and finger
fracture;
– He/she is receiving pain medication and the pain to his/her left shoulder has not yet
improved since the injury;
– The pain to his/her shoulder has affected his/her sleep and appetite;
– He/she rated the shoulder pain a 4 thru 7 on a pain scale (a tool that doctors use to
help assess a person’s pain) of 1 to 10 most days.
During an interview on 10/31/18, at 11:16 A.M., Nurse Aide (NA) A said:
– Resident #1 frequently reports shoulder discomfort.
3. Review of Resident #53’s quarterly MDS dated [DATE], showed:
– A Brief Interview for Mental Status (BIMS) score of three, which indicated the resident
did not make his/her own decisions;
– Limited assist of one staff for bed mobility, transfers, and toileting;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
– Extensive assist of one staff for hygiene and bathing;
– Not steady, only able to stabilize with staff assistance for moving from seated to
standing position, walking, turning around, moving on and off toilet, surface to surface
transfers between bed and chair or wheelchair;
– Diagnoses included: [MEDICAL CONDITION], high blood pressure, dementia, pain and weight
loss.
Review of the hospice initial care plan, dated 10/22/18, showed:
– Admit to hospice;
– Start of care 10/22/18.
Review of the care plan last updated on 10/30/18, showed:
– No care plan for hospice.
Review of the October, (YEAR) physician’s orders [REDACTED].
– No order for hospice.
During an interview on 11/1/18, at 6:26 P.M., the Director of Nursing (DON) said:
– She expected hospice to be care planned when the resident was admitted to hospice.
4. Review of Resident #25’s quarterly MDS, dated [DATE], showed:
– A BIMS score of 15 which indicated the resident made his/her own decisions;
– Extensive assist of two or more staff for bed mobility, toileting, and hygiene;
– Total dependence of two or more staff for transfers;
– Only able to stabilize with staff assistance for surface to surface transfers between
bed and chair or wheelchair;
– Impairment of the lower extremities;
– Wheelchair;
– Diagnoses included: [MEDICAL CONDITION] (a debilitating disease that affected the brain,
spine, and central nervous system).
Review of the care plan last updated on 10/30/18, showed:
– Staff did not update the plan or develop a care plan with in depth approaches related to
three injuries to the face/forehead from staff hitting the resident with the mechanical
lift during transfers.
During an interview on 11/1/18, at 6:26 P.M., the DON said:
– She expected staff to care plan in depth approaches related to the three head injuries
the resident experienced from being hit in the face/forehead by staff when they
transferred the resident with the mechanical lift.
5. During an interview on 10/31/18, at 11:45 A.M., LPN A said:
– He/she recently administered narcotic pain medication to Resident #1 as he/she had
complaints of left shoulder pain;
– Resident #36 receives hospice services and it was unclear why his/her POS did not
include this order;
– A resident receiving hospice should have hospice a care plan;
– A resident receiving scheduled and PRN narcotic pain medication should have a care plan
to address his/her needs;
– The aides are to use the care guides located on the kiosk.
During an interview on 11/01/18, at 11:41 A.M., Certified Nurse Aide (CNA) A said:
– A resident’s care needs can be found in the kiosk.
During an interview on 11/1/18, at 11:45 A.M., NA B said:
– He/she is unaware of any tool that directs care needs for residents;
– He/she is aware of the care needs for each resident as other aides have verbally
informed him/her of the care needs for residents.
During an interview on 11/1/18, at 6:00 P.M., Registered Nurse (RN) A said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
– He/she is responsible for completing and submitting the MDS;
– He/she implements appropriate interventions on the care plan for residents and
responsibilities include writing these care plans and updating as needed;
– Resident #1 recently fractured his/her clavicle and finger and should have a care plan
related to pain control;
– Resident #36 is on hospice and he/she should have a care plan with interventions that
direct staff with care;
– The resident care guidelines are a tool for staff and should reflect the care plan;
– He/she was aware that several of the care guidelines require updating.
During an interview on 11/1/18, at 7:00 P.M., the Director of Nursing (DON) said:
– A care plan should be individualized and provide a picture of the resident, one should
be able to identify the resident from the care plan;
– The nurse is responsible for implementing immediate interventions when new problems are
identified;
– The MDS Coordinator is responsible for ensuring the care plans are individualized and
specific to the needs of the resident and are updated when changes occur and at least
quarterly;
– The resident care guidelines located in the kiosk are one of the tools that staff use to
direct cares, she was unaware that some of them have not been updated for over two years;
– A resident receiving hospice care should have a care plan for these services.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to ensure staff
provided care in accordance with professional standards of practice when staff failed to
notify the attending physician of a change in condition which resulted in hospitalization
of one of 18 sampled residents (Resident #24); and failed to obtain a physician’s order
for placement of residents on hospice which affected two sampled residents (Resident #53
and #37). The facility census was 77.
1. Review of the facility’s undated Change in a Resident’s Condition or Status policy
showed:
– The facility shall promptly notify the resident and or representative and his/her
attending physician of changes in the resident’s condition or status.
– The nurse supervisor or designee will notify the resident’s attending physician when
there is a significant change in the resident’s physical, mental, or psychosocial status,
there is a need to alter the resident’s treatment significantly (to commence a new form of
treatment), or when it is deemed necessary or appropriate in the best interest of the
resident.
– Unless otherwise instructed by the resident, the nurse supervisor will notify the
resident’s next of kin or representative when there is a significant change in the
resident’s physical, mental, or psychosocial status.
– Except for medical emergencies, notifications will be made within 24 to 48 hours of a
change occurring in the resident’s condition or status.
– The nurse supervisor and or designee will record in the residents’ medical record any

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
changes in the resident’s medical condition or status.
– If a significant change in the resident’s physical or mental condition occurs, a
comprehensive assessment of the resident’s condition will be conducted by the care plan
coordinator.
2. Review of Resident #24’s October, (YEAR) physician’s order sheet (POS) showed:
– [MEDICATION NAME] (used to treat allergies [REDACTED].
Review of a faxed physician’s order, dated [DATE], and written by Licensed Practical Nurse
(LPN) B showed:
– Has an order for [REDACTED].>- Due to Centers for Medicare Services (CMS) rules,
would you consider a dose reduction of this medication?
– The attending physician responded with no changes.
Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff, dated [DATE], showed:
– Long- and short-term memory problems;
– Extensive assist of two or more staff for bed mobility, transfers, locomotion on and off
the unit, dressing and toileting;
– Total dependence of one staff for bathing;
– Limited assist of one staff for eating;
– Not steady, only able to stabilize with staff assistance for surface to surface
transfers between bed and chair or wheelchair;
– Always incontinent of bladder and bowel;
– Mechanically altered, therapeutic diet;
– Weight- 138 pounds;
– [DIAGNOSES REDACTED].
Review of the care plan, updated [DATE], showed:
– Assisted to eat meals by spouse or staff;
– Advanced dementia, severe cognitive impairment, will not verbally respond to
conversation;
– At risk for dehydration.
Review of a nurse’s progress note, dated [DATE], at 5:32 P.M., showed:
– Spouse verbalized the resident had nasal drainage while assisted with noon meal;
– Day shift nurse notified physician for orders; awaiting orders.
Review of a fax to the Nurse Practitioner dated [DATE] showed:
– Resident noted to have clear nasal drainage, no cough, lung sounds diminished.
– Blood pressure (BP) ,[DATE], Pulse (P) 77, Respirations (R) 16, Temperature (T) 97.7,
and Oxygen saturation (level of oxygen in blood, O2 sat) 93% low normal.
Review of an updated fax to the Nurse Practitioner, dated [DATE], showed:
– BP ,[DATE], P 70, O2 sat 94% (normal), T 96.9, R 18 (normal) and unlabored;
– Spouse complained of nasal drainage and decreased appetite, green drainage from eyes but
no redness;
Review of a nurse’s progress note, dated [DATE], at 9:06 A.M., showed:
– Fax sent to Nurse Practitioner A per spouse request related to clear nasal drainage.
Review of the [DATE], fax to the Nurse Practitioner showed:
– The NP ordered to start [MEDICATION NAME] (used to treat allergic rhinitis, allergies
[REDACTED].
Review of a nurse’s progress note, dated [DATE], at 10:26 A.M., showed:
– New order: [MEDICATION NAME] 10 mg daily for 30 days then stop.
Observation and interview on [DATE], at 9:40 A.M., showed:
– The resident sat at nurses’ station in hall way asleep in wheelchair;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
– Spouse A sat with the resident and said the resident was very sleepy since adding
allergy medication.
– Said he/she was not eating now and normally ate well.
Observation and interview on [DATE], at 12:12 P.M., showed:
– The resident slept in wheelchair at dining room table;
– Spouse A attempted to assist the resident to eat lunch;
– The resident would not eat;
– Spouse A attempted to give the resident liquids but the liquid ran from the resident’s
mouth, and he/she was not able to drink;
– Spouse A said staff do not offer to assist the resident to eat when he/she was in the
facility and assisted the resident to eat.
– LPN B approached the resident but did not offer to assist the resident to eat.
Review of a nurse’s progress note, dated [DATE], at 2:11 A.M., showed:
– Primary Care Physician (PCP) faxed back stating [MEDICATION NAME] could be causing the
resident’s changes of not eating and sleeping all the time.
– The PCP asked that staff fax to him/her the physician’s order sheet (POS) so that the
[MEDICATION NAME] can be stopped.
– POS faxed and awaiting new order to discontinue these two medications.
Observation and interview on [DATE], at 11:28 A.M., showed:
– The resident’s spouse informed LPN B he/she was concerned about the resident; he/she was
sleepy and not eating again today.
– LPN B said resident’s spouse contacted the attending physician on [DATE], to get
medications changed.
– LPN B said he/she faxed the physician this morning ([DATE]) to get an order to
discontinue Novlog insulin.
– LPN B and the restorative aide told the spouse an order was needed to assist the
resident to eat.
– LPN B said an order was needed for speech therapy to evaluate the resident.
– LPN B said staff faxed the physician on [DATE], for orders because the spouse reported a
runny nose and they did not hear back from the physician.
– LPN B said staff faxed the physician again but the physician never responded with orders
until [DATE], seven days after the spouse reported the resident had a runny nose and no
staff followed up on the previous faxes.
– LPN B said, on [DATE], the physician ordered [MEDICATION NAME] (an over the counter
allergy medication).
– The resident had an order from [DATE] for [MEDICATION NAME] 10 mg daily, not a new
order.
– LPN B said he/she did not fax the physician on [DATE], about the resident’s increased
lethargy, inability to rouse the resident, and not eating or drinking that he/she
observed.
– He/she did notify the physician on [DATE], after learning that the spouse called the
physician on [DATE], about the resident’s lethargy and the resident not eating.
– The physician made monthly rounds already this month and had not seen the resident since
the increased lethargy began.
– Staff should have notified the physician of the resident’s change of condition but did
not until this morning ([DATE]).
– Spouse A would not allow staff to assist the resident to eat when he/she was assisting
the resident with a meal.
During an interview on [DATE], at 11:45 A.M., Spouse A said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
– The resident was not doing well.
– After he/she contacted the physician on [DATE], medication changes were made but he/she
did not know what medications were changed.
– The resident had a temperature this morning of 98.8 which was high for the resident;
his/her normal temperature was 97.6 and he/she was worried about the increased
temperature.
– Spouse A appeared teary eyed as he/she said he/she contacted the resident’s family
member to come to the facility.
– He/she said he/she did not know what else to do.
Observation showed on [DATE], at 12:30 P.M., showed:
– The resident’s room door was closed and family said they did not want to be bothered by
anyone.
Review of a fax to Nurse Practitioner (NP) A, dated [DATE], at 12:55 P.M., showed:
– Resident continued to decline;
– Not eating well for staff or spouse;
– Difficult to get medication administered;
– Blood Pressure-,[DATE], Pulse-95, Respirations-18, Temperature-97, oxygen saturation-
95%, lungs clear but diminished, no nasal drainage, no strong urine odor, no cough or
behaviors or falls;
– Consumed less than 5% of breakfast, blood sugar check 89 mg/dl (low);
– NP A ordered urine by straight catheter if needed, blood work- CMP (chemistry levels),
CBC (complete blood count to determine infection, [MEDICAL CONDITION]), TSH ([MEDICAL
CONDITION] levels), and Hgb A1C (blood sugar level) this week, STAT (immediately);
– Stop [MEDICATION NAME] if not already off of medication.
Observation and interview on [DATE], at 1:30 P.M., LPN B did and said:
– He/she drew blood work for labs and collected a urine specimen via a straight catheter
(sterile tube inserted into the bladder to drain urine for a specimen and then removed) as
ordered by the physician.
– Blood and urine sent to the lab at the hospital for evaluation.
Record review of a nurse’s progress note written by LPN B and dated [DATE], at 4:11 P.M.,
showed:
– Resident continued to eat poorly for staff and spouse, continued to sleep more than
usual, resident is not lethargic, blood sugar level this morning was 79 mg/dl, consumed
less than 5% of breakfast, blood sugar level after breakfast was 87 mg/dl, Blood
Pressure-,[DATE], Pulse-95, Respirations-18, T-97, oxygen saturation-95%, lungs clear but
diminished, no nasal drainage, no strong urine odor, no cough or behaviors or falls;
– Spoke with Spouse A and informed him/her that the physician was notified of the
resident’s status;
– Spoke with family member and informed family member that at family’s request the
resident could be sent to the hospital for evaluation;
– Family member did not want resident poked and prodded;
– Hospice discussed and ordered by PCP;
– Orders received for stat lab work.
Review of a nurse’s progress note written by LPN C and dated [DATE], at 5:35 P.M., showed:
– NP A called and gave verbal orders to send the resident to the emergency room for
evaluation and treatment of [REDACTED].
– Spouse A and family member notified;
– Transported to the hospital by non-emergent ambulance.
Review of a telephone order, dated [DATE], at 5:20 P.M., showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
– Sent to hospital for evaluation and treatment.
Review of critical lab values, dated [DATE], at 6:14 P.M., showed:
– Sodium level 168 (critical), normal range ,[DATE] MEQ/L (milliequivilents/liter);
– Chloride level 132 (high), normal range ,[DATE] MEQ/L.
During an interview on [DATE], at 10.37 A.M., the Director of Nursing (DON) said:
– The PCP should be notified of any change of condition.
During an interview on [DATE], at 5:43 P.M., the MDS Coordinator said:
– Staff usually told her if there was a change in condition of a resident and she would
assess and add to the care plan.
– Changes should be care planned immediately.
– Changes in condition are discussed every morning in the morning meetings.
3. The facility did not provide a policy related to following physicians’ orders.
4. Review of Resident #53’s quarterly MDS, dated [DATE], showed:
– A Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident did
not make daily decisions;
– [DIAGNOSES REDACTED].
Review of October, (YEAR), POS showed:
– No order for admit to hospice for end of life care.
Review of the care plan, updated [DATE], showed:
– Hospice not care planned.
Review of the Hospice Interdisciplinary Initial Care Plan/Physicians’ Orders, dated
[DATE], showed:
– Start of care date [DATE].
During an interview on [DATE], at 2:52 P.M., LPN B said:
– The resident expired the evening of [DATE].
5. Review of Resident #37’s admission MDS, dated [DATE], showed:
– A BIMS score of 13 which indicated supervision needed in daily decision making;
– Oxygen, indwelling catheter;
– [DIAGNOSES REDACTED].
Review of the care plan, dated [DATE], showed:
– Hospice.
Review of the October, (YEAR), POS showed:
– No order for admit to hospice.
During an interview on [DATE], at 6:26 P.M., the DON said:
– An order should be written when a resident was placed on hospice.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to ensure staff
provided complete perineal care to three of 18 sampled residents (Resident #37, #60, and
#72) and cleaned back to front during perineal care which affected one resident (Resident
#70), with a [DIAGNOSES REDACTED]. The facility census was 77.
1. Review of the facility’s Perineal Care policy, dated October, 2010, showed:
– Purpose: To provide cleanliness and comfort to the resident, to prevent infection and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
skin irritation, and to observe the resident’s skin condition;
– Wash hands and apply gloves;
– Wipe perineal area front to back;
– Separate the large skin folds and wash front to back; if the resident had an indwelling
catheter, gently wash the juncture of the tubing from the urinary opening down the
catheter three inches; gently rinse and dry area;
– Continue to wash the perineum moving from inside outward to and including thighs,
alternating from side to side, and using downward [MEDICAL CONDITION];
– Rinse perineum thoroughly and dry skin;
– Turn the resident and wash the rectal area thoroughly, wiping from base of large skin
folds and extending over the buttocks;
– Rinse thoroughly and dry skin;
– Remove gloves and wash hands.
2. Review of Resident #37’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 9/7/18, showed:
– A Brief Interview for Mental Status (BIMS) score of 13 which indicated supervision
needed for daily decision making;
– Extensive assist of two or more staff for bed mobility and hygiene;
– Total dependence on two or more staff for toileting;
– Indwelling urinary catheter;
– Frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the care plan, dated 9/17/18, showed:
– Provide perineal care after each incontinent episode.
Review of the Resident Care Guidelines/Messages (used by direct care staff to determine
type of care needed), dated 10/12/18, showed:
– Catheter;
– Used bedpan;
– Assist of one staff for hygiene;
– Extensive assist of two staff for bed mobility.
Observation and interview on 10/31/18, at 12:52 P.M., Certified Nurse Aide (CNA) G and CNA
H did and said:
– Provided perineal and catheter care to the resident;
– Both CNAs washed their hands and applied gloves;
– Front perineal care and catheter care provided in the correct manner;
– Neither CNA turned the resident nor washed the resident’s rectal area, thighs, or
buttocks;
– CNA G and CNA H said they should wash all areas of the skin and perineal area during
perineal and catheter care, but they did not.
3. Review of the quarterly MDS, dated [DATE], for Resident #60 showed:
– A BIMS score of three which indicated severe cognitive impairment, did not make own
daily decisions;
– Extensive assist of two or more staff for bed mobility, toileting, and hygiene;
– Frequently incontinent of bladder and bowel.
Review of the care plan, dated updated 10/11/18, showed:
– Alteration in urinary continence related to increasing incontinence of bladder without
potential for improvement;
– Provide prompt incontinence care;
– Assist with toileting upon rising, before meals, prior to laying resident down, and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265715

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SUNNYVIEW NURSING HOME & APARTMENTS

STREET ADDRESS, CITY, STATE, ZIP

1311 E 28TH STREET
TRENTON, MO 64683

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
check regularly during the night.
Observation and interview on 10/31/18, at 10:01 A.M., CNA G and CNA H did and said:
– CNA H used 14 wipes to wipe front to back the rectal area and fecal material was noted
to each wipe;
– CNA H changed gloves and washed his/her hands;
– CNA G rolled the resident to the other side;
– CNA H used one wipe and wiped front to back the rectal area and fecal material was noted
to the wipe;
– CNA H asked the resident, Do you feel clean?
– The resident did not answer the CNA’s question.
– CNA G told CNA H to stop cleaning the resident even though there was fecal material on
the last wipe used;
– CNA H did not wash the resident’s right buttock;
– CNA H said he/she should have washed all area of the perineum soiled with urine or fecal
material;
– Said he/she should have cleansed the rectal area until it was without fecal material but
he/she did not.
4. Review of Resident #72’s quarterly MDS, showed staff assessed the resident as follows:
– Severe cognitive impairment;
– Occasional incontinence of bladder and required assistance of one staff for personal
hygiene and dressing.
Review of the resident’s care plan, updated 10/2/18, showed:
– [DIAGNOSES REDACTED].
– Problem: Resident has dementia and is in facility for generalized weakness and cognitive
impairment;
– Approach: Incontinent of bladder at times, wears adult briefs, and assist resident as
needed.
Observation on 10/31/18, at 10:10 A.M., showed CNA C and CNA D did the following:
– Assisted the resident onto the toilet, and removed clothing soaked with urine and loose
stool;
– Staff assisted the resident to stand and CNA C stood behind the resident, wiping large
amounts of loose stool from the rectal area;
– CNA C moved to the front of the resident, did not change soiled gloves, wiped down each
groin area once, wiped down in the inner perineal fold once, and did not open and clean
between the perineal folds;
– CNA C did not clean between thighs, sides of thighs and hips, supra pe