Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Sunnyside Care Center during CMS and state inspections, most recent first.
A dependent, cognitively impaired resident with hemiplegia and contractures was being transferred by two NAs using a full‑body mechanical lift with a medium sling when the resident fell from the sling, sustaining a scalp laceration with hematoma, a tiny SAH, and a right elbow skin tear with soft tissue swelling. Staff placed the sling with the top several inches below the shoulders and the bottom under the resident’s buttocks, contrary to expectations that it extend from the shoulders to below the tailbone, and one NA reported double‑looping the upper sling straps on the lift bar. Both NAs heard a popping or adjusting sound from the sling during the lift, visually rechecked the loops, then continued the transfer; as the lift was moved away from the bed and the resident’s feet were swung off the mattress, the sling rotated and the resident fell out of the top right side while his legs remained in the sling. Interviews with the DON, RN, and lift manufacturer’s representative confirmed that only one correctly selected loop per side should be attached and that improper sling positioning and/or loop attachment could allow a resident to fall, and the facility’s investigation concluded the cause was inconclusive but may have involved human error.
A resident with severe cognitive impairment, MDRO, a G-tube, a suprapubic catheter, and a head wound was on Enhanced Barrier Precautions (EBP) requiring gown and gloves for high-contact care, device care, and wound care, as indicated by the care plan, facility policy, and a CDC EBP sign on the door. Surveyors observed a PTA and a NA transferring the resident with a full body lift without gown or gloves, and later two NAs performing high-contact care (rolling, checking a brief, boosting in bed, and positioning with boots, wedge, and pillows) wearing only gloves and no gowns. An RN administered medications via G-tube after entering the room without PPE and used only gloves, and another RN performed wound care on the resident’s head, initially handling the old dressing without gloves and then exiting the room without hand hygiene. In interviews, NAs and RNs described expectations to use gowns and gloves for residents on EBP and acknowledged they had not followed or had misunderstood these requirements.
A resident with multiple sclerosis and persistent pain was prescribed and administered oxycodone without being provided education or informed consent regarding the risks and benefits of opioid use. Staff and leadership confirmed that the required education was not completed, despite facility policy mandating such education for high-risk medications.
A resident with hemiparesis and multiple sclerosis, who required extensive assistance and used a motorized wheelchair, was observed with a seatbelt fastened around her waist that she could not remove independently. Staff confirmed the seatbelt was used to prevent falls, but there was no assessment, physician order, or care plan documentation identifying the seatbelt as a restraint, despite facility policy requiring such assessment.
A resident's MDS assessment was inaccurately coded, recording only one fall without injury when documentation showed two unwitnessed falls occurred during the assessment period. The acting DON confirmed the discrepancy, and facility policy requires accurate completion and attestation of MDS entries.
Two residents at high risk for falls did not receive adequate supervision or safe handling as required by their care plans and facility policy. One resident was routinely transported while seated on a four-wheeled walker, contrary to manufacturer warnings, and another resident's walker was repeatedly left out of reach despite a history of falls and care plan interventions. Staff interviews confirmed these unsafe practices and lack of awareness regarding proper procedures.
Two residents with grab bars on their beds did not receive comprehensive assessments or have alternatives attempted prior to the use of bed rails. Staff and residents confirmed that grab bars were installed without documented evaluation of safety, alternatives, or compatibility, and care plans did not reflect their use. Facility policy requiring assessment and proper installation was not followed, resulting in a deficiency.
Improper Mechanical Lift Sling Use Leads to Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement safe mechanical lift transfer practices for a dependent resident, resulting in a fall from a full‑body lift. The resident had a history of CVA with hemiplegia, severe cognitive impairment, expressive aphasia, contractures of multiple extremities, and was dependent on staff for all ADLs and transfers, using a wheelchair for mobility. The care plan directed staff to transfer the resident with a Hoyer‑type full body mechanical lift using a medium sling, with assist of two staff, and to use safe transfer techniques and caution during transfers to prevent striking body parts on hard surfaces. The resident was assessed as a moderate fall risk related to poor communication/comprehension, unawareness of safety needs, and impaired mobility. On the day of the incident, two NAs assisted the resident with a transfer from bed to wheelchair after a bath. A medium cream‑colored sling with dark tan trim was placed under the resident. One NA reported positioning the top of the sling approximately five inches below the resident’s shoulders so that the bottom of the sling covered his bottom, and then crisscrossing the sling between his legs. This placement was later contrasted with the manufacturer’s and facility expectations that the top of the sling be at shoulder level and the bottom approximately two inches below the tailbone so the resident would not sit on the sling. The NAs attached the sling loops to the lift bar; one NA described placing the short black upper loop on the bar and then placing the longer tan loop on top of the black loop (double‑looping), while the other NA described attaching the lower long tan loops and the upper short black loops, using the same color and length on each side. Both NAs reported hearing a “pop” or adjustment sound from the sling while the resident was being raised and stated they stopped and visually rechecked the loops, believing all were attached. The resident was then lifted off the bed with his feet still on the mattress while the lift was pulled back from the bed. One NA moved to the foot of the bed, swung the resident’s feet off the mattress, and supported them as they came off the edge. As the lift was moved away, the sling rotated so that the resident’s back faced the lift and his front faced the window. One NA reported seeing the resident’s weight shift and then observed him fall out of the top right side of the sling, with his upper body and head striking the floor while his legs remained in the sling. The resident sustained a laceration and hematoma to the posterior scalp and a right elbow skin tear with prominent soft tissue swelling, and imaging showed a tiny subarachnoid hemorrhage about the left frontal lobe and contusion/laceration over the right parietal/occipital area without fracture. Interviews with the DON, an RN, and the lift manufacturer’s representative confirmed that correct practice required the sling to be positioned with the top at the shoulders, the bottom below the tailbone, and only one loop of the same color and length attached on each side, and that incorrect sling placement and/or loop attachment could allow a resident to fall from the sling. The facility’s investigation could not conclusively determine the exact mechanism of the fall but acknowledged that human error related to sling placement and/or loop attachment may have contributed.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for a resident on EBP with indwelling devices and an open wound. The resident had multiple diagnoses including CVA, neurogenic bladder, MDRO, aphasia, and had a G-tube and suprapubic catheter. The care plan and facility EBP policy required staff to use gown and gloves for high-contact resident care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care (urinary catheter, feeding tube), and wound care. An EBP sign from CDC was posted on the resident’s door, instructing that everyone must clean their hands before entering and when leaving the room, and that providers and staff must wear gloves and gown for high-contact resident care activities. Surveyors observed multiple instances where staff did not follow these EBP and hand hygiene requirements. A PTA and a nursing assistant transferred the resident from wheelchair to bed using a full body lift without donning gown or gloves, despite the EBP sign and PPE cart at the door. Later, two nursing assistants entered and provided high-contact care, including rolling the resident, checking the brief, boosting the resident in bed, and applying pressure-relieving boots, wedge, and pillows. They wore gloves but did not wear gowns as required for high-contact care under EBP. Although they removed gloves and sanitized their hands before leaving, the lack of gowns during these high-contact activities was inconsistent with the posted EBP instructions and facility policy. Additional observations showed registered nurses also failed to comply with EBP and hand hygiene requirements. One RN entered the room without gown or gloves to administer medications via G-tube, only applying gloves after entering and raising the resident’s shirt to access the tube, without using a gown as required for device care. Another RN entered without gown or gloves, removed and replaced a dressing on the back of the resident’s head, and handled wound care supplies; she initially handled the old dressing without gloves, then applied clean gloves to place a new dressing and wrap, and exited the room without washing or sanitizing her hands. In interviews, multiple staff, including nursing assistants and RNs, acknowledged that gowns and gloves were expected for high-contact care and device care for residents on EBP, and some admitted they had not followed these requirements or had misunderstood when gowns were required, despite the EBP sign and facility policy.
Failure to Provide Informed Consent and Education on Opioid Medication
Penalty
Summary
The facility failed to obtain informed consent and provide education to a resident or their representative regarding the risks and benefits of opioid medication use. The resident, who had intact cognition and diagnoses including anemia, hemiparesis, and multiple sclerosis, was experiencing persistent pain and was prescribed oxycodone as part of their pain management regimen. Documentation showed that the resident received oxycodone on several occasions, but there was no evidence in the medical record that education about the risks and benefits of the opioid medication was provided to the resident or their representative. Interviews with the resident, nursing staff, the acting DON, and the pharmacist consultant confirmed that no education regarding the risks and benefits of the opioid medication had been conducted prior to administration. The facility's policy on high-risk medications required that residents and/or their representatives be educated on the use and risks/benefits of such medications, including opioids. Despite this policy, the process in place only ensured education for psychotropic medications, not opioids, resulting in the deficiency.
Failure to Assess and Document Use of Wheelchair Seatbelt as a Restraint
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess the use of a restrictive device as a potential restraint for a resident with intact cognition and diagnoses including anemia, hemiparesis, and multiple sclerosis. The resident required extensive assistance with activities of daily living, used a wheelchair for mobility, and had a high risk for falls. Despite documentation in the Minimum Data Set, Care Area Assessment, and care plan indicating no use of restraints, observations revealed the resident was consistently seated in a motorized wheelchair with a seatbelt fastened around her waist. The resident was unable to remove the seatbelt independently and stated it made movement difficult, while staff confirmed the seatbelt was used to prevent her from sliding or falling out of the wheelchair. Interviews with nursing staff and the acting director of nursing confirmed that the seatbelt restricted the resident's movement and that she could not remove it herself, meeting the facility's own definition of a physical restraint. However, there was no evidence in the medical record of a restraint assessment, physician order, or care plan documentation regarding the seatbelt's use as a restraint. The facility's policy required assessment of any device that could be considered a restraint, but this was not completed for the resident in question.
Inaccurate MDS Coding of Resident Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in an incorrect assessment record. According to the CMS RAI 3.0 User's Manual, Section J1800 and J1900 require that all falls since the last assessment be documented, including the number and whether injuries occurred. For the resident in question, the quarterly MDS indicated only one fall without injury since the last assessment. However, a review of the resident's progress notes revealed two unwitnessed falls without injury during the relevant period. During an interview, the acting DON confirmed that there were two falls and acknowledged that the MDS should have been coded to reflect both incidents. Facility policy requires accurate and comprehensive assessment documentation, with staff attesting to the accuracy of their entries.
Failure to Prevent Accident Hazards and Ensure Safe Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that accident hazards were minimized and that adequate supervision and assistance were provided to prevent accidents for two residents identified as being at high risk for falls. One resident, who was cognitively intact and had diagnoses including heart failure, arthritis, and chronic obstructive pulmonary disease, required supervision or assistance for mobility and transfers. Despite being assessed as high risk for falls and having a care plan specifying the need for safe transfer and supervision, this resident was observed being transported by a nursing assistant while seated on a four-wheeled walker, which was used as a transportation device against manufacturer warnings. The nursing assistant admitted to routinely transporting the resident in this manner and was unaware that this practice was unsafe and not permitted. Another resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, had a history of multiple falls in the facility. The resident's care plan included specific interventions such as ensuring the walker was within reach at all times to prevent self-transfers and falls. However, during multiple observations, the resident's walker was found out of reach, positioned several feet away from the resident while seated in a recliner. Staff interviews confirmed that the walker should have been within reach, and the resident was at continued risk for falls due to this oversight. Facility policies required individualized fall risk assessments and implementation of care plan interventions to minimize fall risk, as well as safe handling and transfer procedures. Despite these policies, the facility did not consistently implement or monitor the required interventions for residents at high risk for falls, resulting in unsafe practices and failure to provide adequate supervision and accident prevention.
Failure to Assess and Attempt Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess and attempt alternatives prior to the use of bed rails for two residents who were observed to have grab bars installed on their beds. Both residents were cognitively intact and had varying degrees of independence with activities of daily living, but their care plans did not identify the presence of grab bars. Documentation in their medical records lacked a comprehensive assessment regarding the appropriate use of bed rails, safety measurements, and any attempted alternatives before the installation of the bed rails. Observations revealed that both residents had double-sized standard beds with black grab bars attached, which were used to assist with positioning and transfers. Interviews with the residents indicated that the grab bars were either brought in by family members or were present when the residents arrived at the facility. Neither resident was aware of any staff assessment of the grab bars. Staff interviews confirmed that the usual practice was to obtain a consent form for bed rail use and review it annually, but staff were not aware of any alternatives being tried prior to installation. The acting DON confirmed that the facility had not completed assessments of the grab bars and did not have the manufacturer's instructions for the devices in use. The facility's policy required a person-centered approach, including the assessment of alternatives, evaluation of risks such as entrapment, and assurance of correct installation and maintenance. However, these steps were not documented or completed for the two residents, resulting in a deficiency related to the use of bed rails without comprehensive assessment and consideration of alternatives.
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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 Lake Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Essentia Health Oak Crossing | 10.8 mi | ★★★★★ | 8 | 0 |
| Emmanuel Nursing Home | 11.3 mi | ★★★★★ | 9 | 1 |
| Viking Manor Nursing Home | 17.2 mi | ★★★★★ | 0 | 0 |
| Frazee Care Center | 19.5 mi | ★★★★★ | 6 | 0 |
| Pelican Valley Health Center | 21.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.