Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunrise Point Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who required a mechanical lift for transfers due to significant physical impairments was manually lifted and pivoted by two CNAs, contrary to her care plan. During the transfer, the resident suffered a leg fracture and experienced severe pain, which was not promptly reported or assessed by staff, including an LPN who delayed evaluation for several hours. The staff involved were aware of the resident's transfer requirements but chose to disregard them, resulting in substantiated neglect and serious injury.
Two CNAs manually transferred a resident with hemiplegia and other significant medical conditions, disregarding the care plan that required a mechanical lift with two staff. During the transfer, the resident suffered a fractured tibia and experienced increased pain and functional decline. The incident was not reported to nursing staff, and there were delays in obtaining appropriate medical evaluation and follow-up.
The facility failed to report and investigate abuse allegations made by two residents within the required timeframe. A resident reported being smacked by a CNA, but the incident was not investigated until days later. Another resident filed grievances about rough handling by a CNA, which were not reported or thoroughly investigated. The facility did not adhere to its policies on abuse reporting and investigation, resulting in a deficiency.
A facility failed to conduct a medication self-administration assessment for a resident with severe cognitive impairment, who was found with an unsecured Afrin nasal spray on her bedside table. The resident, admitted with multiple diagnoses, used the nasal spray without a physician's order or a completed self-administration evaluation. The LPN and DON confirmed the absence of necessary assessments and orders, contrary to the facility's policy requiring interdisciplinary team approval for self-administration.
A resident with end-stage renal disease and other conditions, who was cognitively intact, expressed a preference for showers three times a week. However, the facility failed to honor this preference, providing only three showers over 29 days, with most instances being bed baths. The ADON confirmed the resident's care plan indicated a preference for showers, which was not adhered to, violating the resident's rights.
The facility failed to conduct accurate PASARR evaluations for three residents, leading to deficiencies in documenting mental disorders and intellectual disabilities. One resident with schizophrenia and another with multiple mental health diagnoses had incomplete PASARR documentation. A third resident's PASARR did not reflect her bipolar and depressive disorders. The DON acknowledged these inaccuracies, which were not corrected in a timely manner.
A resident with an unstageable pressure ulcer did not receive proper infection control during wound care. The North Wing UM placed supplies on an unsanitized bedside table without a barrier and failed to perform hand hygiene after removing soiled dressings. The DON confirmed these actions were against facility policy, which requires a clean field and hand hygiene before and after glove use.
A resident's Do Not Resuscitate Order (DNRO) was not properly processed into the Electronic Medical Record (EMR) or placed in the Code Status binder, leading to the resident receiving CPR against their wishes. The DNRO, signed by the resident's sister/Healthcare Proxy and the physician, was received by the South Court Unit Manager (UM) from the Hospice nurse but was incorrectly placed in the Hospice chart instead of the Code Status binder. This error resulted in nursing staff being unaware of the DNRO during an emergency, causing the initiation of CPR and potential severe consequences for the resident.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
Staff failed to protect a resident's right to be free from abuse and neglect by not following the resident's care plan for safe transfers. The resident, who had hemiplegia, hemiparesis, obesity, chronic lower back pain, and muscle weakness, was dependent on staff for transfers and required the use of a mechanical lift with assistance from two staff members. Despite this, two CNAs manually lifted and pivoted the resident from her wheelchair to her bed, disregarding the care plan and the presence of a mechanical lift sling already under the resident. During the manual transfer, the resident complained of severe pain in her left leg and was lowered to the floor. The CNAs then lifted her from the floor and placed her in bed without using the mechanical lift. The resident continued to express extreme pain, but neither CNA reported the incident or the resident's complaints to a nurse. The resident later informed another CNA of her pain, who reported it multiple times to an LPN, but the LPN did not assess the resident until nearly seven hours later. An X-ray performed the following day revealed a fractured tibia. The facility's investigation confirmed that the CNAs were aware of the resident's transfer requirements and chose to ignore them. The LPN also failed to respond promptly to the resident's complaints of pain. The actions and inactions of the CNAs and the LPN resulted in a serious injury to the resident and constituted neglect, as defined by the facility's policy. The incident placed not only the affected resident but also other residents requiring mechanical lifts at risk for serious harm.
Removal Plan
- Resident was assessed by the nurse due to her complaint of pain in left lower extremity, provider was notified and order received for diagnostic imaging.
- X-ray was performed and results were received which showed a proximal tibia fracture with mild displacement.
- Resident's physician was notified of the abnormal X-ray results and orders were received for a leg immobilizer and an outpatient orthopedic physician consult.
- A knee immobilizer was placed to resident's left leg as ordered.
- Resident and roommate were interviewed by the former DON and reported that resident was transferred without the use of the mechanical lift by two CNAs.
- The facility initiated an investigation.
- The ADON began education on identifying resident's transfer status, safe transfers and skills validation.
- An Ad Hoc QAPI meeting was held with the facility Administrator, Director of Nursing and Medical Director to review the incident including physician orders obtained related to the resident's fracture. Resident's individualized plan of care including outpatient orthopedic consult and leg immobilizer deemed appropriate by the Medical Director. Discussed staff training to be conducted as a result of incident.
- The CNA who assisted the assigned CNA performed a reenactment of the incident and provided a statement which included information that the two CNAs had knowledge of resident's transfer status and subsequent disregard by performing a stand and pivot transfer. Resident's care plan and Kardex indicated she required two person assistance with the use of mechanical lift for transfers.
- Each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected.
- As part of the investigation process, residents were interviewed by the Social Services Director to determine if there were additional concerns of abuse or neglect with no findings.
- The facility held an ad hoc QAPI meeting to review the progress of education and competency completion as well as quality reviews. The committee conducted a root cause analysis which determined the assigned CNA made an independent decision, chose to ignore her prior education and did not follow the resident's plan of care for safe transfers. The ad hoc QAPI committee including the Medical Director approved the recommendations.
- Resident was seen by the provider. Her pain regime was reviewed and adjusted. The facility scheduled an orthopedic appointment as per the physician order.
- The former DON discussed transfer options to the hospital with resident.
- The former DON spoke to the resident and resident voiced wanting to go to the hospital.
- Resident was sent to the emergency room for evaluation due to uncontrolled pain related to the fracture. The resident returned to the facility.
- Resident's provider was contacted, and pain regimen was reviewed and adjusted.
- Nursing staff were educated on change in condition to include but not limited to accidents resulting in injury, offering resident to be transferred to higher level of care for further evaluation if serious injury, escalation to chain of command via nurse supervisor and/or DON if resident concern is not addressed, following resident care plan/Kardex, safe resident handing, mechanical lift usage and competencies. The remaining nursing staff members to receive education prior to next shift worked.
- Facility staff were educated on abuse, neglect and exploitation by the Administrator, Staff Development Coordinator and Nurse Managers. The remaining staff members to receive education prior to next shift worked.
- Ad Hoc QAPI meetings were completed with Medical Director, Administrator, and former DON where incident, abuse and neglect, use of mechanical lifts, transfer competencies, updating care plans/Kardex, change in condition, pain management and following care plans/Kardex were discussed. No recommended changes were made to the performance improvement plan.
Failure to Follow Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when two CNAs failed to follow a resident's care plan, which required the use of a mechanical lift with two staff for all transfers. Instead, the CNAs manually lifted the resident from her wheelchair to her bed using a stand and pivot technique. During the transfer, the resident immediately complained of severe pain in her left leg and was subsequently lowered to the floor. The CNAs then manually lifted her from the floor and placed her in bed, but did not report the incident or the resident's pain to the nurse. The resident involved had a history of hemiplegia and hemiparesis following a stroke, obesity, chronic back pain, and muscle weakness, and was dependent on staff for all transfers. Her care plan and Kardex clearly indicated the need for a mechanical lift with two staff. Following the improper transfer, the resident experienced increased pain and was later found to have sustained a left proximal tibia fracture with mild displacement, as confirmed by X-ray. The resident's pain complaints increased significantly after the incident, and her functional status and mood declined, as documented in subsequent assessments. Both CNAs involved were unaware or disregarded the resident's transfer requirements, and neither reported the incident or the resident's pain to nursing staff. The resident did not receive immediate hospital evaluation for her injury, and there were delays in obtaining appropriate orthopedic follow-up. The failure to follow the resident's care plan for safe transfers resulted in a serious injury and avoidable pain, and placed other residents requiring mechanical lifts at risk for harm.
Removal Plan
- Resident was assessed by the nurse due to her complaint of pain in left lower extremity, provider was notified and order received for diagnostic imaging.
- Resident and roommate were interviewed by former DON and reported that resident was transferred without the use of the mechanical lift by two CNAs.
- The CNAs who were noted as failing to follow resident's plan of care correctly for use of mechanical lift were immediately suspended.
- The ADON began education on identifying resident's transfer status, safe transfers and skills validation.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility Administrator, Director of Nursing and Medical Director to review the incident and training to be conducted as result of incident.
- The CNA who assisted the assigned CNA performed a reenactment of the incident and provided a statement which included information that the two CNAs had knowledge of resident's transfer status and subsequently disregarded this information by performing a stand and pivot transfer. Resident's care plan and Kardex indicated she required a two person assist with the use of mechanical lift for transfers.
- Each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected.
- The facility held an ad hoc QAPI meeting to review the progress of education and competency completion as well as quality reviews. The committee conducted a root cause analysis which determined the assigned CNA made an independent decision, chose to ignore her prior education/training and did not follow the resident's plan of care for safe transfers. The ad hoc QAPI committee including the Medical Director approved the recommendations.
- The nursing staff were educated on change in condition to include but not limited to accidents resulting in injury, offering the resident to be transferred to higher level of care for further evaluation if serious injury, escalation to chain of command via nurse supervisor and/or DON if resident concern is not addressed, following resident care plan/Kardex, safe resident handing, mechanical lift usage and competencies. The remaining nursing staff members would receive education prior to next shift worked.
- Ad Hoc QAPI meetings were completed with Medical Director, Administrator, and former DON where incident, abuse and neglect, use of mechanical lifts, transfer competencies, updating care plans/Kardex, change in condition, pain management and following care plans/Kardex were discussed. No recommended changes were made to the performance improvement plan.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report and investigate allegations of abuse made by two residents within the required timeframe. Resident #4, who was cognitively intact and dependent on staff for various activities, reported an incident on 12/26/24 where a CNA allegedly smacked his hand. Despite the incident being witnessed by RN A and LPN B, it was not reported as an abuse allegation until 12/31/24. The facility's Administrator and DON did not initiate an investigation on the day of the incident, as they perceived it as a behavioral issue due to the resident's history, rather than a potential abuse case. Resident #10, also cognitively intact and dependent on staff, filed grievances in October 2024 regarding rough handling by a CNA. The grievance filed on 10/31/24 described the CNA as very rough, causing the resident to cry out. However, this grievance was not reported to the state agency, and the facility did not conduct a thorough investigation. The Social Services Director, who handled the grievances, did not consider the incident as abuse, and the DON's corrective actions were not documented. The facility's policies on abuse, neglect, and exploitation require immediate reporting and investigation of such allegations. However, in both cases, the facility failed to adhere to these policies, resulting in a lack of timely reporting and investigation of the abuse allegations. The facility's failure to report and investigate these incidents within the required timeframe constitutes a deficiency in their handling of abuse allegations.
Failure to Conduct Medication Self-Administration Assessment
Penalty
Summary
The facility failed to conduct a medication self-administration assessment for a resident who was observed with an unsecured Afrin nasal spray on her bedside table. The resident, who was severely cognitively impaired with a Brief Interview for Mental Status score of 00 out of 15, was admitted with diagnoses including cerebral infarction, unspecified glaucoma, asthma, and shortness of breath. Despite her cognitive impairment, the resident reported using the nasal spray because her nose got stuffy sometimes. Upon review, it was found that there was no physician's order for the Afrin nasal spray, and the resident had not completed a self-administration evaluation. The LPN confirmed the absence of a physician's order and the lack of a self-administration assessment. The Director of Nursing stated that a self-administration assessment should be completed to ensure the resident could safely self-administer medication. The facility's policy requires that the interdisciplinary team determine which medications may be self-administered safely, which was not adhered to in this case.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to choose their preferred bathing method, which is a violation of resident self-determination rights. The resident, who was admitted with diagnoses including end-stage renal disease, type II diabetes, heart failure, and dependence on renal dialysis, was cognitively intact and expressed a preference for showers three times a week in the evening. Despite this, the resident received only three showers over a 29-day period, with the majority of bathing instances being bed baths, contrary to her stated preference. The resident expressed dissatisfaction with the lack of showers, noting that her hair was not clean and had only been washed once since admission. The Assistant Director of Nursing confirmed that the resident's care plan and Kardex indicated a preference for showers, yet this preference was not honored. The facility's policy stated that residents should be provided showers as per their request, but this was not adhered to in the case of this resident. The ADON acknowledged the discrepancy and the importance of respecting the resident's bathing preferences, confirming that the resident's choices were not honored as required by the facility's policy.
Failure to Conduct Accurate PASARR Evaluations
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASARR) level 1 evaluation for three residents, leading to deficiencies in the assessment and documentation of mental disorders or intellectual disabilities. Resident #46 was admitted with diagnoses including anxiety and schizophrenia, and was on antipsychotic medications. However, the PASARR documentation did not reflect these diagnoses, as it was marked with 'N/A' for mental illness, indicating a lack of proper evaluation and documentation. Resident #15 had multiple diagnoses, including schizoaffective disorder, dementia, and intellectual disabilities, and was on various psychotropic medications. The PASARR documentation for this resident was incomplete, missing critical information about mental illness and intellectual disorders. The Director of Nursing (DON) acknowledged the inaccuracies in the PASARR and confirmed that the resident should have triggered a Level 2 screening, which was not initially done. Resident #55 was admitted with bipolar disorder and major depressive disorder, but the PASARR documentation did not list these diagnoses. The DON confirmed that the PASARR was inaccurate and should have been updated. The facility's policy required coordination with the PASARR program to ensure accurate assessments, but this was not adhered to, resulting in the deficiencies noted in the report.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to accepted standards of practice for infection prevention and control during wound care for a resident with an unstageable pressure ulcer. The resident, who was admitted from an acute care hospital, had multiple diagnoses including dementia, seizures, hypertension, heart failure, acute kidney failure, and a urinary tract infection. The wound care physician's orders required daily treatment of the resident's sacral wound, which included cleansing, drying, and applying specific dressings. However, during an observation, the North Wing Unit Manager (UM) placed treatment supplies on the resident's bedside table without cleaning or sanitizing it, nor did she use a barrier drape. Additionally, after removing the soiled dressing, the UM failed to perform hand hygiene before donning new gloves to continue the wound care. The Director of Nursing (DON) and Regional Nurse expressed concern upon learning of the infection control breaches. The DON confirmed that the UM should have sanitized the table and performed hand hygiene after removing the soiled dressing. The UM, who was new to the facility, was unaware of the facility's policy and procedures regarding wound care. The facility's policy for clean dressing changes and hand hygiene clearly outlined the need for setting up a clean field and performing hand hygiene before and after glove use, which were not followed in this instance.
Failure to Accurately Record and Make Available Resident's DNRO
Penalty
Summary
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. This resulted in the nursing staff failing to honor an Advance Directive that reflected the decision to withhold Cardiopulmonary Resuscitation (CPR) for a resident who had clearly expressed the wish to not receive CPR. Despite the resident having a State of Florida Do Not Resuscitate Order (DNRO) signed by the resident's sister/Healthcare Proxy and the physician, the DNRO form was not scanned into the Electronic Medical Record (EMR) or placed in the Code Status binder as per facility policy. This failure led to the resident receiving CPR against their wishes, resulting in potential severe pain, broken bones, organ damage, and a prolonged dying process. The sequence of events leading to the deficiency included the DNRO form being received by the South Court Unit Manager (UM) from the Hospice nurse but not being correctly processed into the EMR and Code Status binder. The UM acknowledged the error in placing the DNRO form in the Hospice chart instead of the Code Status binder, where nursing staff could readily access it in case of an emergency. Despite the clear directive from the resident's sister and the physician's order for DNR, the failure to have the DNRO readily available in the Code Status binder led to confusion among the nursing staff when the resident was found unresponsive, resulting in CPR being initiated against the resident's wishes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rockledge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockledge Healthcare & Rehabilitation Center | 0.3 mi | ★★★★★ | 0 | 0 |
| The Terrace At Courtenay Springs | 2.9 mi | ★★★★★ | 5 | 0 |
| Space Coast Healthcare And Rehabilitation Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Merritt Island | 4.6 mi | ★★★★★ | 0 | 0 |
| Viera Healthcare And Rehabilitation Center | 6.3 mi | ★★★★★ | 7 | 0 |
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