Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunrise Health & Rehabilitation Center during CMS and state inspections, most recent first.
Food service safety standards were not followed in the main kitchen. Several male staff with facial hair were observed without beard covers, and one staff member’s mustache remained uncovered after he put on a beard cover. Surveyors also found plates with food particles and worn food contact surfaces, dented cans of tomato soup in dry storage, and a high-temp dish machine that repeatedly failed to reach required rinse and wash temperatures.
Two residents had inaccurate MDS coding. One resident’s MDS was marked as using bed rails under restraints and alarms even though the MDS coordinator said the facility does not use restraints. Another resident’s MDS was coded as receiving IV fluids during the lookback period, but the LPN said the resident did not have IV fluids during that time.
Failure to apply ordered palm protectors for a resident with severe cognitive impairment and bilateral hand contractures. The resident had an order and care plan for bilateral palm protectors every shift, and OT recommended splints in place, but repeated observations found the resident in bed without the protectors, which were instead in a dresser drawer. Staff interviews confirmed the splints were not on the resident at the time observed.
Failure to Address Weight Loss and Nutritional Interventions: Three residents with significant nutrition concerns had incomplete or missing documentation and follow-through on ordered supplements and weight-loss monitoring. One resident with poor intake and pain had an untouched breakfast, stated he would accept shakes, but had no documented house supplement order; another resident with ESRD, malnutrition, and a wound had supplement orders that were not continued after hospitalization and a one-time Magic Cup order that was not followed up; a third resident with ESRD and malnutrition had significant weight loss that was not addressed in the RD note.
A resident with a Midline IV for IV antibiotics and treatment of sepsis, pneumonia, MRSA, and a complicated UTI had a transparent dressing left in place far beyond the ordered weekly change schedule. Surveyors observed the dressing still dated from the original insertion, with old dried blood present, and record review plus staff interviews confirmed the dressing remained unchanged through transfer to the hospital and readmission until survey intervention.
A facility failed to follow physician oxygen orders for several residents, with oxygen concentrator settings observed above or below ordered rates, and one resident receiving oxygen without a physician order in place. During an oral inhalation treatment, an LPN administered the medication without first obtaining respiratory rate, BP, oxygen saturation, or lung sounds, and only later returned to complete parts of the assessment.
Incomplete and inaccurate dialysis communication and weight documentation: Two residents receiving dialysis had missing pre- and post-treatment weights, missing blood sugar results, and incomplete fluid removal entries on communication forms. The forms also showed mismatches between recorded weight changes and the amount of fluid removed. Staff stated CNAs obtained the weights and nurses entered them into the record, and staff acknowledged the missing documentation and discrepancies when reviewed.
Code status was not documented in the physician's orders for one resident whose chart was reviewed. The resident had diagnoses including DM2, peripheral neuropathy, and PVD, and had intact cognition per the MDS. An LPN/Unit Manager stated staff check the EHR and care plan for code status, but it should be in the physician's orders; the order was added after surveyor intervention.
Bathroom call lights were not maintained in a working, reachable manner for two residents. One resident had moderate cognitive impairment, multiple chronic conditions, and a care plan calling for a reachable call light due to fall risk; the bathroom call light was tied to a grab bar. Another resident was cognitively impaired with confusion, needed limited assistance with toileting and transfers, and also had a care plan requiring a working, reachable call light; the bathroom call light was likewise tied to a grab bar on repeated observations.
The facility failed to maintain resident dignity during dining and care, as several residents were served meals in disposable dining ware despite not being on isolation, and a CNA stood over a resident while feeding her. Additionally, a resident reported being left in soiled conditions, experiencing disrespectful communication, and having her dietary preferences ignored, indicating a lack of adherence to the facility's policies on dignity and respect.
A resident with severe cognitive impairment and multiple health conditions was not provided necessary assistance with eating, leading to untouched meal trays for extended periods. Observations and staff interviews revealed inconsistencies in the level of assistance provided, despite documentation indicating the resident required total assistance with most meals.
Two residents experienced significant weight loss due to the facility's failure to monitor and address their nutritional needs. One resident, with severe cognitive impairment, did not receive prescribed nutritional supplements despite significant weight loss. Another resident, with dementia, lost 26 pounds in a month without weekly weight monitoring as ordered. The facility's policies on nutritional management and weight monitoring were not effectively implemented, leading to inadequate responses to significant weight changes.
A resident with muscle wasting and diabetes experienced delays in receiving prescribed pain medication, leading to inadequate pain management. Despite orders for Oxycodone every 8 hours, the medication was often administered 2-3 hours late, as confirmed by audit reports and resident complaints. The facility's pain management policy was not followed, resulting in a deficiency.
Two residents in an LTC facility experienced dissatisfaction with meals due to the facility's failure to accommodate their food preferences. One resident, with underweight and muscle wasting, frequently received meals she disliked, while another, with chronic kidney disease, was not provided with Hispanic dishes he preferred. The registered dietitian did not effectively document or communicate these preferences, leading to meals that did not align with the residents' needs.
A resident with multiple health conditions was on a fluid restriction of 1000 ml per day, but the LTC facility failed to communicate and document this order effectively. The resident, who speaks Spanish, was not informed about the restriction, and staff were unaware or did not document the fluid intake properly. Observations showed the resident received more fluids than allowed, and the MAR and TAR records were not updated, indicating a deficiency in care and communication.
A resident with multiple diagnoses, including paraplegia and quadriplegia, developed a stage III sacral wound due to the facility's failure to assess and identify the pressure ulcer in a timely manner. Despite being at moderate risk for pressure ulcers, the resident's sacral area was not documented or assessed by nursing staff until eleven days after admission. The facility's policy on pressure injury prevention was not followed, leading to the deficiency.
Food Service Safety Deficiencies in Main Kitchen
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional food service safety standards in the main kitchen. During a kitchen tour, several male staff were observed with facial hair and were not wearing beard covers; after being alerted, one staff member put on a beard cover but did not cover his mustache, and the surveyor had to explain that beard covers were to cover all facial hair. Two plates in the plate warmer had food particles on them and showed signs of wear and excessive use on the food contact surface. Two 50-ounce cans of tomato soup in the dry stock room had dents on the bottom. The high-temperature dishwashing machine was run three times but did not reach required temperatures, with the rinse cycle reaching 175 degrees Fahrenheit instead of 180 degrees and the wash cycle reaching 125 degrees Fahrenheit instead of 150-165 degrees. The Administrator was informed of these findings during an interview.
Incorrect MDS Coding for Restraints and IV Fluids
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to correctly complete MDS assessments for 2 of 35 sampled residents. One resident was admitted with diagnoses including cerebral infarction, type 2 diabetes mellitus, and COPD; the quarterly MDS showed a BIMS score of 11 indicating moderate cognitive impairment, but Section P was coded as using bed rails for restraints and alarms. The MDS Coordinator stated this was an error because the facility does not use restraints. Another resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, acquired absence of the left leg above the knee, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety; the quarterly MDS showed a BIMS score of 6 indicating severe cognitive impairment, but Section K was coded as receiving IV fluids during the 7-day lookback period. The MDS Coordinator stated hydration was triggered because the MDS was coded as receiving IV fluids, but the resident did not have IV fluids during that lookback period.
Failure to Apply Ordered Palm Protectors for Resident with Hand Contractures
Penalty
Summary
The facility failed to provide splints/protectors to assist in preventing contractures for Resident #15, who was admitted with diagnoses of dementia, depression, and right-hand contracture. The MDS showed the resident’s cognitive status was severely impaired. The physician’s orders included bilateral hand palm protectors every shift for skin integrity, and the care plan addressed contracture prevention and management with split-type palm protectors for both hands, therapy referral as needed, and application and removal of splints as scheduled. Occupational therapy evaluated the resident and documented bilateral upper extremity hand contractures, recommending the use of splints in place. During multiple observations, Resident #15 was found in bed without the bilateral palm hand protectors on either hand, and the hands were noted to be very contracted. On each observation, the palm protectors were located in the resident’s top dresser drawer rather than being on the resident. No staff were present during the observations. In interviews, the Assistant Director of Rehab stated daily staff were responsible for placing the splints on residents and that audits were conducted to ensure staff did so. A CNA stated that Rehab or she was responsible for placing the palm protectors on Resident #15 and confirmed that they were not on the resident that day.
Failure to Address Weight Loss and Nutritional Interventions
Penalty
Summary
The facility failed to address weight loss in a timely manner and failed to provide nutritional interventions for three residents reviewed for nutrition. One resident with anemia, depression, moderate cognitive impairment, and significant weight loss was observed eating little to nothing at breakfast, stated pain prevented him from eating, and later said he was not very hungry but would eat ice cream and drink shakes if offered. The record showed a care plan for significant weight loss related to poor intake and use of an appetite stimulant, but the weights log did not document the amount consumed, and staff confirmed there was no record of a house supplement order for him despite the resident stating he would accept shakes. A second resident with cirrhosis of the liver, protein-calorie malnutrition, pressure ulcer, muscle wasting and atrophy, ESRD on dialysis, ascites, and fluid overload had a fluid restriction order that included Juven with liquid protein and water amounts at specific times. However, the physician's orders later did not include any nutritional supplement orders. The resident stated he had tried a Magic Cup once and did not receive it again, and he denied ever receiving or trying Juven. Staff stated the resident had been prescribed a generic wound supplement packet because Juven was not available, but after the resident returned from the hospital it was not restarted, and the Magic Cup order had been written as a one-time order and was not followed up. A third resident with diabetes, ESRD on dialysis, protein-calorie malnutrition, and moderate cognitive impairment had significant weight loss documented as 15.9 pounds, or 7.2%, in 16 days and 20.3 pounds, or 9.2%, in 21 days. The nutrition admission assessment stated the goal was gradual weight loss and that the RD would monitor dry weight, but the last nutrition note reviewed did not address the significant weight loss. The RD stated that significant weight loss should be addressed within a day or two and acknowledged there was no documentation of the weight loss in the record.
Outdated Midline IV Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to provide timely care for a resident with a Midline IV catheter by not changing the transparent dressing as ordered. The resident had multiple diagnoses including atherosclerotic heart disease, systolic congestive heart failure, chronic kidney disease, COPD, Parkinson's disease with dyskinesia, and moderate cognitive impairment with a BIMS score of 9. The physician's order required the Midline IV transparent dressing to be changed weekly on Monday night shift and as needed, and the care plan directed staff to observe and change the dressing as scheduled and PRN while monitoring for signs of infection or leakage. Observation on 02/23/26 showed the resident's Midline IV dressing was still dated Wednesday 02/11 @ 9 AM, and a small amount of old, dried blood was noted in the base of the tubing. A second observation later that day showed the same dated dressing and the same dried blood. Record review showed the resident had received IV medications including micafungin, vancomycin, and cefepime for sepsis, pneumonia, MRSA, and a complicated UTI. The nursing progress notes documented that the Midline was re-inserted on 02/11/26 by IV access, and the resident was transferred to the hospital on 02/14/26 for chest pain and later re-admitted on 02/18/26 with the same Midline IV dressing still in place. Further review of the MAR, nursing progress notes, and TAR did not show that the original Midline IV transparent dressing had been changed after the 02/11/26 insertion date, leaving it in place for 13 days. Staff interviews confirmed the resident returned from the hospital with the same dressing and that it had not been changed until 02/23/26, the first day of survey after surveyor intervention. The DON acknowledged that the Midline IV transparent dressing should have been changed in a timely manner according to the physician's written orders.
Oxygen orders not followed and inhalation treatment given without required assessments
Penalty
Summary
The facility failed to follow physicians’ oxygen orders for multiple residents receiving oxygen therapy. Resident #38, who had critical illness myopathy and COPD with acute exacerbation and was ordered oxygen concentrator with humidifier at 2 liters per minute, was observed receiving oxygen at 1.5 liters per minute on two separate observations. Resident #229, admitted with pulmonary candidiasis and COPD with acute exacerbation and ordered oxygen at 3 liters per minute, was observed receiving oxygen at 2.5 liters per minute, and the resident stated her oxygen was always set at 2 liters per minute. Resident #108, who had respiratory failure with hypoxia and severe cognitive impairment, was ordered oxygen at 2 liters per minute but was observed receiving 3 liters per minute on two occasions. Resident #228, admitted with COPD, respiratory disorders, obstructive sleep apnea, shortness of breath, and other diagnoses, had a physician order for oxygen at 3 liters per minute via nasal cannula. The resident was observed receiving oxygen at 2 liters per minute, 2.5 liters per minute, and 2.5 liters per minute on different observations. Staff acknowledged the order for 3 liters per minute and confirmed the observed settings were not accurate. The resident stated he could not reach the concentrator and did not touch it. The report also noted that the facility’s oxygen therapy policy required oxygen to be adjusted according to doctor’s orders. The facility also failed to obtain a physician order for oxygen therapy for Resident #49. The resident was observed receiving oxygen at 2 liters via oxygen tank, but the record did not contain an order for oxygen therapy administration after readmission. Nursing notes documented oxygen use and humidification, and staff stated the resident had been on oxygen since prior admissions and had been placed back on continuous oxygen after a trial without it, yet staff acknowledged there had never been a physician order in place. In addition, during medication administration observation for Resident #54, staff administered an oral inhalation medication without first obtaining respiratory rate, blood pressure, oxygen saturation, or lung auscultation, and only later returned to obtain oxygen saturation and lung sounds. Staff interviews indicated that they were expected to assess lung sounds and vital signs before and after inhalation treatment, but the observed treatment was given without those assessments.
Incomplete and inaccurate dialysis communication and weight documentation
Penalty
Summary
The facility failed to ensure dialysis communication sheets were filled out accurately and completely for 2 of 3 residents reviewed for dialysis services, including a resident with diabetes, end stage renal disease on dialysis, and a left below-knee amputation, and another resident with end stage renal disease on dialysis, anorexia, and protein-calorie malnutrition. The facility policy stated weights should be recorded at the time obtained, and the contract with the dialysis company required communication forms to include the most recent vital signs and current weights, with the dialysis center entering the total amount of fluid removed. The communication form also noted that the floor nurse was to report the post weight promptly to dialysis. For the resident with a BIMS score of 10, the record showed multiple missing pre-weights and post-weights in the electronic record, along with missing blood sugar results on several dialysis communication forms. The forms also lacked pre-weights on some dates and did not document total fluids removed on others. In addition, the documented fluid removal amounts did not match the difference between the recorded pre- and post-dialysis weights on several occasions, including instances where the weight change was greater than the amount of fluid removed that was documented, and one instance where the resident gained weight but a fluid loss was recorded. For the resident with a BIMS score of 13, the record also showed missing pre-weights and post-weights in the electronic record and missing pre-weights on multiple dialysis communication forms. The forms contained discrepancies between the recorded weight differences and the documented amount of fluid removed on several dates. Staff interviews confirmed that CNAs obtained the before-and-after dialysis weights and nurses entered the information into the record, and staff acknowledged the missing documentation and discrepancies when the forms were reviewed.
Code Status Not Documented in Physician Orders
Penalty
Summary
The facility failed to document the code status in the physician's orders for 1 of 35 sampled residents, Resident #6. The facility policy titled, Communication of Code Status, stated that when an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record, including the Order Section of Point Click Care, with examples such as Full Code, Do Not Resuscitate, Do Not Intubate, and Do Not Hospitalize. On 02/24/26 at 10:22 AM, review of the Physician Orders for Resident #6 did not reveal a code status order. Resident #6 was admitted with diagnoses including Type 2 Diabetes Mellitus, Other Idiopathic Peripheral Autonomic Neuropathy, and Peripheral Vascular Disease, and the quarterly MDS documented a BIMS score of 14, indicating intact cognition. On 02/25/26 at 9:50 AM, an LPN and Unit Manager stated that staff check the EHR and care plan for code status, and that the code status should be in the Physician's Orders; if it is not there, they check the care plan. The order was added after surveyor intervention.
Bathroom Call Lights Not Maintained in Working Reach
Penalty
Summary
The facility failed to maintain working call lights in the bathrooms for 2 of 35 residents, Resident #112 and Resident #225. Resident #112’s quarterly MDS documented a BIMS score of 09, indicating moderate cognitive impairment, along with partial/moderate assistance needed for transfers, the ability to walk short distances independently and up to 150 feet with assistance, and frequent bowel and bladder incontinence. The resident’s diagnoses included anemia, hypertension, heart failure, renal insufficiency, diabetes mellitus, hip fracture, malnutrition, chronic lung disease, pulmonary fibrosis, immunodeficiency, muscle wasting and atrophy, muscle weakness, dependence on renal dialysis, and adjustment disorder with depressed mood. The care plan identified fall risk related to gait and balance problems and impaired mobility and included interventions to keep the call light within reach and maintain a working and reachable call light in a safe environment. Resident #112’s bathroom call light was observed tied around the grab bar to the right side of the commode. Resident #225’s baseline care plan described the resident as cognitively impaired with confusion and needing limited assistance with bed mobility, transfers, locomotion, and toileting. The resident’s care plans identified ADL self-care deficits and fall risk related to limited mobility, sequelae of CVA, cerebral ischemia, muscle wasting and atrophy, and ESRD, with interventions to keep the call light within reach and maintain a working and reachable call light in a safe environment. Resident #225’s bathroom call light was observed tied around the grab bar to the left side of the commode on two separate observations. During interview, the RN stated the resident could use the call light but could not use the bathroom independently and required one-person assistance to the toilet.
Failure to Maintain Resident Dignity During Dining and Care
Penalty
Summary
The facility failed to treat residents with dignity during dining observations, as evidenced by the use of disposable dining ware for residents who were no longer on isolation. Residents #101, #176, and #412 were observed being served meals in Styrofoam containers with plastic utensils, despite not being on isolation. Staff interviews revealed that the kitchen staff had not updated the dining ware for these residents after they were taken off isolation, indicating a lapse in communication and adherence to the facility's policy on promoting resident dignity. Additionally, Resident #162 was observed being fed by a CNA who stood over her, despite a chair being available to sit at eye level, which is against the facility's policy for maintaining dignity during mealtimes. The CNA's actions were noted to be disrespectful, as she referred to the resident as "a feeder" in front of her. This behavior demonstrates a lack of adherence to the facility's guidelines on treating residents with respect and dignity during meals. Resident #135 reported multiple instances of neglect and disrespect, including being left in soiled conditions for extended periods, staff entering her room without permission, and being spoken to in a disrespectful manner. She also expressed dissatisfaction with the lack of communication regarding her dietary preferences and the use of rough paper towels for personal hygiene. These incidents highlight a broader issue of inadequate care and communication, contributing to the residents' loss of dignity and respect.
Failure to Assist Resident with Severe Cognitive Impairment in Eating
Penalty
Summary
The facility failed to provide necessary assistance with feeding for a resident with severe cognitive impairment and other health conditions, including Type 2 Diabetes, Heart Failure, and Muscle Wasting. The resident, who was admitted with a Brief Interview of Mental Status (BIMS) score indicating severe cognitive impairment, required set-up and clean-up assistance with eating as per the Minimum Data Set (MDS). Observations revealed that the resident's meals were left untouched for extended periods without staff assistance. On two separate occasions, the resident's meal trays were observed to be 100% untouched for 30 minutes or more, indicating a lack of timely assistance from staff. Interviews with staff confirmed that the resident needed assistance with all meals, yet documentation showed inconsistencies in the level of assistance provided. The Activities of Daily Living (ADL) task records indicated varying levels of assistance, from total dependence to independent eating, which contradicted staff statements and observations. The MDS Coordinator confirmed that the resident required total assistance with most meals, highlighting a discrepancy between documented care needs and actual care provided. This failure to provide necessary feeding assistance compromised the resident's nutritional intake and care quality.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of two residents, leading to significant weight loss and potential malnutrition. Resident #162, who was admitted with diagnoses including protein-calorie malnutrition and severe cognitive impairment, experienced a significant weight loss of 5.7% over a period from June to August. Despite having a physician's order for nutritional supplements if meal intake was less than 50%, Resident #162 did not receive any supplements in July. The Registered Dietitian (RD) did not document the estimated caloric and protein needs due to missing height information and failed to make additional nutritional recommendations despite the noted weight loss. Resident #98, admitted with unspecified protein-calorie malnutrition and dementia, also experienced a significant weight loss of 26 pounds (13.27%) in one month. The resident's weight was not documented for four weeks, despite a physician's order for weekly weights. The RD acknowledged that the significant weight loss was not addressed in a timely manner and that the care plan was not updated until August, despite the resident's refusal to be weighed being documented only in early August. Both cases highlight a failure in the facility's processes for monitoring and addressing significant weight changes and nutritional needs. The facility's policies on nutritional management and weight monitoring were not effectively implemented, as evidenced by the lack of timely interventions and documentation. The RDs involved did not adequately respond to the significant weight losses, and there was a lack of communication and documentation regarding the residents' refusal to be weighed and the need for nutritional interventions.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, leading to a deficiency in care. The resident, who was cognitively intact and had diagnoses of muscle wasting, type 2 diabetes, and muscle weakness, reported that his pain medication was consistently administered late. Despite having a physician's order for Oxycodone to be given every 8 hours, the medication was often delayed by 2 to 3 hours, as confirmed by the medication administration audit report. This delay in medication administration was corroborated by the resident's complaints of increased pain and inability to sleep due to the lack of timely pain relief. Interviews with the resident and staff revealed discrepancies in the administration of pain medication. The resident expressed dissatisfaction with the timing of his medication, stating that it was not given on time, which affected his pain management. The Director of Nursing acknowledged that pain medication is typically administered within an hour before or after the scheduled time, yet the audit report showed significant delays. This inconsistency in medication administration did not align with the facility's pain management policy, which emphasized the importance of anticipating the resident's need for pain relief and responding immediately to complaints of pain.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodates resident preferences and appealing options for two residents, leading to a deficiency in nutritional management. Resident #88, who was admitted with diagnoses including underweight and muscle wasting, expressed dissatisfaction with the meals provided, specifically disliking egg salad, which was frequently served. Despite being assessed by a registered dietitian, Resident #88's food preferences were not adequately documented or communicated, resulting in meals that did not align with her preferences. Observations showed that Resident #88 often refused the meals served and opted for alternatives like a tuna sandwich and fruit, indicating a lack of effective communication and documentation of her dietary preferences. Resident #172, who was readmitted with multiple diagnoses including chronic kidney disease and protein-calorie malnutrition, also experienced issues with meal preferences. Despite having a good cognitive function and speaking Spanish, Resident #172 was not provided with meals that matched his Hispanic food preferences. The meal tickets and activity calendar were in English, which he did not understand, leading to confusion and dissatisfaction with the meals served. The registered dietitian, who spoke Spanish, did not effectively communicate with Resident #172 about his food preferences, resulting in meals that did not meet his cultural and personal preferences. Both residents experienced a lack of personalized meal options that considered their individual preferences and dietary needs. The facility's failure to adequately assess, document, and communicate these preferences contributed to the deficiency. The registered dietitian's attempts to gather information were insufficient, and there was a lack of follow-through in updating the nutrition management system to reflect the residents' preferences, leading to ongoing dissatisfaction with the meals provided.
Failure to Communicate and Document Fluid Restriction
Penalty
Summary
The facility failed to effectively communicate and educate staff and a resident regarding a medically prescribed fluid restriction. Resident #172, who was readmitted with multiple diagnoses including Type 2 Diabetes Mellitus, End Stage Renal Disease, and Kidney Transplant Failure, was on a fluid restriction of 1000 ml per day as per physician's orders. However, the facility did not ensure that this restriction was communicated to the resident or consistently documented by the staff. The resident, who speaks Spanish and has minimal understanding of English, was not informed about the fluid restriction or the allowable amount of liquids per shift. Observations and interviews revealed that the resident was provided with more fluids than allowed, and staff were unaware of the fluid restriction. The resident's meal trays and bedside contained more fluids than prescribed, and staff, including CNAs and activities personnel, were not informed about the fluid restriction. The MAR and TAR records for the resident showed X symbols, indicating that the fluid restriction order had not been acknowledged or documented by the nursing staff. Interviews with various staff members, including the RD, CNAs, and the Director of Activities, confirmed a lack of communication and documentation regarding the fluid restriction. The staff did not document the amount of fluids provided to the resident, and there was a misunderstanding about the necessity of documenting the fluid restriction as a physician order. The facility's failure to communicate and document the fluid restriction order led to the resident consuming more fluids than prescribed, highlighting a significant deficiency in the facility's care and communication processes.
Failure to Timely Identify and Manage Pressure Ulcer
Penalty
Summary
The facility failed to assess and identify a pressure ulcer in a timely manner for a resident, leading to the development of a stage III sacral wound. The resident, who was admitted with multiple diagnoses including paraplegia and quadriplegia, was at moderate risk for pressure ulcers as indicated by a Braden Scale score of 13. Despite this, the facility's nursing staff did not document any assessment of the resident's sacral area until eleven days after admission, when the wound was finally discovered. Interviews with staff revealed that the resident was totally dependent on care and required assistance for all activities of daily living. Certified Nursing Assistants (CNAs) reported repositioning the resident every two hours and performing regular skin checks, yet no issues were noted in the sacral area during this time. The resident's Primary Care Physician and Advanced Registered Nurse Practitioner (ARNP) for wound care both acknowledged that preventative skin measures should have been implemented upon admission, but these were not adequately documented or executed by the facility. The Director of Nursing (DON) confirmed that the sacral wound was not identified or documented by the nursing staff until it had progressed to a stage III ulcer. The facility's failure to promptly assess and manage the resident's skin condition, as well as to notify the resident's representative of the change, contributed to the deficiency. This oversight occurred despite the facility's policy on pressure injury prevention and management, which mandates systematic assessment and intervention to prevent such occurrences.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 404 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sunrise
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regents Park Of Sunrise | 0.9 mi | ★★★★★ | 0 | 0 |
| Springtree Rehabilitation & Health Care Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Nspire Healthcare Tamarac | 2 mi | ★★★★★ | 29 | 0 |
| Tamarac Center For Rehabilitation And Healing | 2.8 mi | ★★★★★ | 0 | 0 |
| Nspire Healthcare Plantation | 3.5 mi | ★★★★★ | 14 | 0 |
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