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Complaint Investigation

Sunnycrest Manor

September 2, 2025 · Dubuque, IA · 2375 Roosevelt Street
Citations 1
CMS Rating 3/5
Beds 77
Provider ID 165556
Healthcare Facility
Sunnycrest Manor
Dubuque, IA  ·  View full profile →
Inspection Summary

Sunnycrest Manor in Dubuque, IA — inspection on September 2, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During a phone interview on 9/2/2025 at 10:17 a.m., Staff A reported during the evening meal on July 29, the resident shoveled food into his mouth.

Dietary took awhile getting the resident chicken his family had left for him the day before, and that upset the resident.

Staff reminded him to slow down, but the resident refused to listen.

When Staff A took the resident's chicken and cut it up into bite size pieces to prevent choking.

That angered the resident.

When the resident completed his meal, Staff A removed him from the table.

The resident yelled at Staff A as he pushed his wheelchair towards the elevator.

Staff A revealed the resident's behavior frustrated him and he removed the resident's processor.

Staff A put the processor on once they were in the elevator.

Staff A told the resident he needed to calm down, and had been eating too fast.

Staff A thought removing the processor would calm the resident down. He replaced it after less than a minute.

Staff A reported the facility terminated his employment due to his decision to remove the resident's processor.

Observation during the noon meal on 9/2/2025 revealed staff sat with the resident and provided constant cues and reminders to eat slowly, eat one bite at a time and take a drink in between bites.

The resident had episodes of coughing and staff asked him to take one bite at a time. On 9/2/2025 at 1:00 p.m., the resident sat in his room in a wheel chair.

The resident said Staff A was pretty good, and some staff were fired because they did not perform as they should.

When asked if Staff A ever removed his processor, the resident stated Yes, when he gave me a shower.

When asked if Staff A ever removed his processor after dinner, the resident stated Yes, I had chicken left. He put it back on. I guess he was tired of hearing me complaining.

The facility Abuse and Crime Prevention, Identification, Investigation and Reporting policy revised 11/2022 included:All residents have the right to be free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, acts of personal degradation, and any physical or chemical restraint not required to treat the resident's medical symptoms.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Dubuque, IA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Sunnycrest Manor or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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