Sunrise Point Health and Rehabilitation Center

Inspectors wroteBased on interview, and record review, the facility failed to protect the residents' right to be free from abuse and neglect by not ensuring staff utilized a mechanical lift for transfer of resident #1 resulting in a leg fracture, for 1 of 9 residents reviewed for transfers with a mechanical lift, out of a total sample of 10 residents, (#1). On 10/16/25 at approximately 2:40 PM, the facility failed to ensure nursing staff followed resident #1's plan of care for safe transfers resulting in serious injury and pain of the physically impaired resident during a transfer from wheelchair to bed. Two certified nursing assistants (CNAs) failed to follow resident #1's care plan which required her to be transferred using a mechanical lift with assistance of two staff. The two CNAs transferred the resident from her wheelchair by manually lifting the resident and pivoting her to the bed. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a safe environment to prevent an accident resulting in leg fracture during resident transfer, for 1 of 9 residents reviewed for use of mechanical lifts, of a total sample of 10 residents, (#1). On 10/16/25 at approximately 2:40 PM, the facility failed to ensure nursing staff followed resident #1's plan of care for safe transfers resulting in serious injury and avoidable pain of a physically impaired resident during a transfer from wheelchair to bed. Two certified nursing assistants (CNAs) failed to follow resident #1's care plan which required her to be transferred using a mechanical lift with assistance of two staff. The two CNAs transferred the resident from her wheelchair by manually lifting her to an upright position and pivoting her to the bed. [...]

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of abuse made by a resident within the required timeframe and failed to report and investigate an allegation of abuse made by a resident to the state agency (SA) for 2 of 6 residents reviewed for abuse, of a total sample of 15 residents, (#4, and #10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 38 residents, (#47).

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident's rights to choose their preferred bathing preferences for 1 of 3 residents reviewed for choices, of a total sample of 38 residents, (#81).

Inspectors wroteBased on interview and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level 1 evaluation for 3 of 5 residents reviewed for PASARR, of a total sample of 38 residents, (#15, #46 & #55).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow accepted standards of practice to prevent cross-contamination during wound care for 1 of 2 residents reviewed for pressure ulcers, of a total sample of 38 residents, (#350).

Inspectors wroteBased on interview, and record review, the facility failed to notify the physician of an acute (requires immediate care), significant change of condition for 1 of 3 residents reviewed for Quality of Care and Treatment, of a total sample of 3 residents, (#1).

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident's wishes related to health care treatments and procedures at the end of life were accurately recorded and readily available to nursing staff. As a result, the nursing staff failed to honor an Advance Directive that reflected the decision to withhold Cardiopulmonary Resuscitation (CPR) for 1 of 2 residents reviewed for CPR, of a total sample of 6 residents, (#1). These failures contributed to resident #1 receiving CPR against his wish for a natural, dignified death. There was likelihood resident #1 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE], resident #1's sister/Healthcare Proxy signed a State of Florida Do Not Resuscitate Order (DNRO) and placed her brother in Hospice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by failing to provide necessary care and services to prevent falls with major injuries and failed to develop and revise fall management approaches to mitigate the fall risk for 1 of 6 residents reviewed for falls of a total sample of 6 residents, (#4). These failures contributed to falls with major injury for resident #4 who required hospitalization, surgery, and rehabilitation for hip fracture. Resident #4 suffered excruciating pain, and was placed at risk blood clots, infection, pneumonia and decline in function. Resident #4 was a physically and severely cognitively impaired resident identified at high risk for falls. The resident sustained 11 falls in the past 10 months. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide effective fall management approaches and increased supervision for physically and cognitively impaired residents to avoid falls with major injury for 1 of 6 residents reviewed for falls, (#4). Resident #4 was a physically and severely cognitively impaired resident identified at high risk for falls. The resident sustained 11 falls in the past 10 months. On [DATE], he sustained a fall that resulted in a fracture of his left femur (hip bone) that required hospitalization and surgical repair. The resident returned from the hospital on [DATE] and fell two more times, on the day of readmission and again on [DATE]. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow the process for a verbal physician order for chest x-ray for 1 of 3 residents reviewed for diagnostic services out of a total sample of 5 residents, (#4). On [DATE] at 8 PM, the facility failed to obtain radiology diagnostic services for a resident with increased cough, 3 days post-surgery for fractured hip. A verbal order was given by the Advance Practice Registered Nurse (APRN) which was not entered into the electronic record and not processed by the nurse. On [DATE], the resident experienced acute respiratory distress and was transferred to the hospital where he died two days later of pneumonia. The facility's failure to process and implement a verbal order to obtain diagnostic services for resident #4's respiratory decline resulted in Immediate Jeopardy starting on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to identify, monitor and treat pressure injuries for 1 of 3 residents reviewed for pressure ulcers, of a total sample of 35 residents, (#48). The facility's failure to evaluate alterations in skin integrity and implement appropriate treatments timely resulted in actual harm. Resident #48 was identified with 2 new facility acquired unstageable pressure ulcer/injury by the surveyor from 4/6-4/7/21. The resident had 1 unstageable pressure ulcer/injury to his left heel and 1 on left inner ankle. The facility failed to identify wounds at an early stage and failed to initiate timely treatment and preventive measures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care for 1 of 4 dependent residents of a total sample of 35 residents, (#28).

Inspectors wroteBased on observation and interview, the facility failed to follow proper thawing procedures to prevent the potential of food borne illness when preparing frozen chicken.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safe functioning of resident beds for 1 of 35 total sampled residents, (#4).