Sunrise Point Health And Rehabilitation Center

jeopardy to resident health or safety

Kardex indicated she required two person assistance with the use of mechanical lift for transfers. *On 10/18/25 through 10-19-25, each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected. *On 10/19/25 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. *On 10/19/25, 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. *On 10/20/25, resident #1 was seen by the provider.

Her pain regime was reviewed and adjusted.

The facility scheduled an orthopedic appointment for 10/24/25 as per the physician order. *On 10/20/25, the former DON discussed transfer options to the hospital with resident #1. *On 10/21/25, the former DON spoke to the resident and resident voiced wanting to go to the hospital. *On 10/21/25, resident #1 was sent to the emergency room for evaluation due to uncontrolled pain related to the fracture.

The resident returned to the facility. *On 10/21/25, resident #1's provider was contacted, and pain regimen was reviewed and adjusted. *On 10/17/25 through 10/21/25, the 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. As of 10/21/25, 77 out of 92 nursing staff received education, (84%), The remaining 15 total nursing staff members to receive education prior to next shift worked. *On 10/17/25 through 10/21/25, facility staff were educated on abuse, neglect and exploitation by the Administrator, Staff Development Coordinator and Nurse Managers. As of 10/21/25, 111 out of 128 staff members received education, (86%).

The remaining 17 total staff members to receive education prior to next shift worked. *Ad Hoc QAPI meetings were completed 10/20/25 and 10/21/25 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.

From 10/29/25 to 10/30/25, interviews were conducted with 18 staff members representing all shifts (1 Registered Nurse, 4 LPNs, 9 CNAs, 1 dietary, 2 environmental services and 1 activity aide/CNA).

Staff interviews revealed they were knowledgeable of identifying abuse and neglect, following a resident's plan of care, safe handling of resident and who to report any violations or suspected violation.

The resident sample was expanded during the survey to include five additional residents.

Observations, interviews, and record reviews conducted revealed no concerns related to abuse and neglect, care plans and transfer status for residents #6 through #10.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunrise Point Health and Rehabilitation Center

1775 Huntington Lane Rockledge, FL 32955

SUMMARY STATEMENT OF DEFICIENCIES