Inspection Report
Plan of Correction
Deficiencies: 0
Sep 30, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility will be certified in compliance effective September 24, 2025, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 2
Sep 11, 2025
Visit Reason
The inspection was an annual recertification survey conducted from September 8 to September 11, 2025, to assess compliance with federal regulations.
Findings
The facility was found deficient in ensuring a safe environment free of accident hazards, specifically related to safe transfer techniques for Resident #46, and in infection prevention and control practices, including hand hygiene for staff.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement safe transfer techniques for Resident #46, resulting in pain and improper use of mechanical lift devices. | Level D |
| Failure to provide proper hand hygiene after resident care for Resident #9, including improper use and removal of personal protective equipment. | Level D |
Report Facts
Residents present: 67
Dates of survey: September 8 to September 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Healthcare Administrator | Submitted the Plan of Correction |
| Staff E | Certified Medication Aide (CMA) | Involved in deficient transfer technique with Resident #46 |
| Staff F | CNA in training | Involved in deficient transfer technique with Resident #46 |
| Staff H | Certified Nursing Assistant (CNA) | Failed to perform proper hand hygiene after resident care |
| Staff I | Registered Nurse, Unit Manager | Reported hand hygiene deficiencies |
| Staff C | Registered Nurse (RN) | Observed resident transfer issues |
| Staff D | CNA | Reported resident transfer difficulties |
| Director of Nursing | Director of Nursing (DON) | Provided statements on transfer practices and conducted staff education |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 16, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective October 16, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 3
Sep 26, 2024
Visit Reason
The inspection was conducted as an annual recertification survey of Sunrise Retirement Community from September 23, 2024 to September 26, 2024.
Findings
The facility failed to meet professional standards in medication administration and pharmacy services, including failure to ensure timely medication delivery, proper destruction of controlled substances, and accurate resident records. Deficiencies were noted in the care plans and documentation for residents #5 and #36, with issues related to medication availability, weight monitoring, and record accuracy.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure staff followed physicians' orders for medications for resident #5, including timely delivery and administration of furosemide and rivastigmine patches. | SS=D |
| Facility failed to properly monitor and store controlled substances for residents #36 and #5, including failure to destroy discontinued medications and document destruction accurately. | SS=D |
| Facility failed to maintain accurate and complete resident records for resident #5, including medication changes and documentation of adverse reactions. | SS=D |
Report Facts
Census: 70
Medication orders not given: 5
Medication orders not given: 3
Medication tablets destroyed: 21
Medication tablets delivered: 30
Medication tablets delivered: 14
Medication tablets destroyed: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 19, 2024
Visit Reason
A complaint investigation for complaint #120168-C and facility reported incidents #120543-I, #121495-I was conducted from July 18, 2024 through July 19, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaint #120168-C and facility reported incidents #120543-I and #121495-I; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 4, 2024
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Sunrise Retirement Community Nursing Home is in substantial compliance based on acceptance of the credible allegation of substantial compliance and the submitted Plan of Correction. The facility will be certified in compliance effective December 28, 2023.
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 6
Nov 30, 2023
Visit Reason
The facility underwent an annual recertification survey conducted from November 27, 2023 to November 30, 2023 to assess compliance with federal regulations for long term care facilities.
Findings
The survey identified multiple deficiencies including failure to maintain clean and safe equipment, incomplete comprehensive care plans regarding medication monitoring, improper respiratory care related to oxygen tubing, insufficient nursing staff response to call lights, medication administration errors, and inadequate food service hygiene practices.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide residents clean and in good repair equipment for 1 of 6 residents reviewed (Resident #29) due to a torn wheelchair headrest. | SS=D |
| Failed to provide a comprehensive care plan that adequately reflected residents' medications and monitoring for 3 of 6 residents reviewed (Residents #2, #57, and #58). | SS=D |
| Failed to change and label oxygen tubing for 1 of 2 residents reviewed (Resident #118). | SS=D |
| Failed to provide sufficient nursing staff to assure residents' safety by not responding to call lights in a timely manner (less than 15 minutes) for 1 of 8 residents reviewed (Resident #10). | SS=D |
| Failed to properly administer medications for 1 of 16 residents reviewed (Resident #58) by administering incorrect doses of sliding scale insulin. | SS=D |
| Failed to prepare food in accordance with professional standards when a dietary staff member served food without completing hand hygiene prior to or during meal service. | SS=E |
Report Facts
Call light response delays: 8
Medication administration errors: 2
Medication doses: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Healthcare Administrator | Signed the inspection report and plan of correction |
| Staff F | Certified Nurse Aide | Reported on wheelchair headrest condition and reporting procedures |
| Staff G | Certified Nurse Aide | Reported on wheelchair repair procedures and communication |
| Staff H | Licensed Practical Nurse | Reported on headrest tear awareness and replacement procedures |
| Staff D | Registered Nurse Manager | Provided information on care plan expectations and wheelchair headrest replacement |
| Staff L | Registered Nurse | Reported on oxygen tubing change orders |
| Staff A | Certified Nurse Assistant | Reported on call light response expectations and pager system |
| Staff B | Registered Nurse | Reported on call light response expectations |
| Staff C | Dietary Aide | Observed serving food without proper hand hygiene |
| Director of Nursing | Provided multiple statements on facility policies and expectations regarding care plans, oxygen tubing, call light response, and medication administration |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 31, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on October 31, 2022, related to regulatory compliance.
Findings
The facility was certified in compliance effective October 23, 2022, based on acceptance of a credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Renewal
Census: 69
Deficiencies: 5
Sep 22, 2022
Visit Reason
The inspection was a facility recertification survey conducted from 09/19/22 to 09/22/22 to assess compliance with federal regulations for Sunrise Retirement Community.
Findings
The facility was found deficient in completing a discharge Minimum Data Set (MDS) assessment for one sampled resident, and in food safety practices including lack of soap and paper towels at a kitchen handwashing sink, presence of outdated leftovers, unclean steam table, and juice machine with juice drainage.
Severity Breakdown
SS=F: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to complete a discharge Minimum Data Set (MDS) assessment for one sampled resident. | — |
| Failed to ensure availability of soap and paper towels at a handwashing sink in the kitchen. | SS=F |
| Observed outdated leftovers in the walk-in cooler. | SS=F |
| Staff placed prepared food on a dirty steam table that was not cleaned before use. | SS=F |
| Juice machine had juice draining down the front of it. | SS=F |
Report Facts
Census: 69
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Administrator | Confirmed discharge MDS assessment was not done and signed the plan of correction |
| Staff D | Nurse Manager | Interviewed regarding the missed discharge MDS assessment |
| Director of Nursing | Explained Nurse Managers' responsibility for discharge MDS assessments and impact of non-completion | |
| Certified Dietary Manager | CDM | Observed soap dispenser empty and discarded outdated food |
| Registered Dietitian | Stated soap should have been replaced promptly | |
| Staff C | Dietary Aide | Stated she cleaned the kitchen including steam table and juice machine after meals |
Inspection Report
Plan of Correction
Deficiencies: 0
May 31, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective May 24, 2022.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
May 5, 2022
Visit Reason
The inspection was conducted related to the investigation of a facility reported incident #104345-I from April 27, 2022 to May 5, 2022, which was substantiated.
Findings
The facility failed to ensure adequate supervision for Resident #4 who required two-person assistance with a full-body mechanical lift during transfers. One staff member admitted to transferring the resident with only one person, violating facility policy and safety protocols.
Complaint Details
The facility reported incident #104345 was substantiated. The investigation included staff interviews and review of policies. One staff member admitted to improper transfer technique and was suspended pending further investigation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents, specifically Resident #4 was transferred with one staff member instead of two as required. | SS=D |
Report Facts
Census: 63
Dates of investigation: Investigation conducted from April 27, 2022 to May 5, 2022
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 9
May 20, 2021
Visit Reason
Annual health survey of Sunrise Retirement Community conducted to assess compliance with federal regulations including care standards, infection control, medication management, and food service.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for weekly weights, inadequate pressure ulcer treatment, improper perineal care leading to UTI risk, lack of CPAP machine cleaning, failure to monitor INR for a resident on anticoagulants resulting in hospitalization, failure to limit PRN psychotropic drug use, improper food portioning for special diets, unsafe food handling practices, and lapses in infection control practices during personal care, wound care, and medication administration.
Severity Breakdown
SS=D: 6
SS=E: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to follow physician's orders for weekly weights for Resident #6. | SS=D |
| Failed to provide pressure reduction devices per wound nurse recommendation and physician order for Resident #5 with pressure ulcers. | SS=D |
| Failed to provide perineal care to prevent urinary tract infection for Resident #5. | SS=D |
| Failed to provide cleaning and maintenance of CPAP machine for Resident #38. | SS=D |
| Failed to monitor INR for Resident #50 on anticoagulants, resulting in critical INR and hospitalization. | SS=D |
| Failed to limit PRN psychotropic drug use to 14 days or document rationale for extension for Resident #5. | SS=D |
| Failed to serve appropriate portions of mechanical soft and pureed diets to residents in Bernstein unit. | SS=E |
| Failed to prepare and serve food in accordance with professional food service safety standards, including improper glove use and bare hand contact. | SS=E |
| Failed to provide appropriate infection control practices during personal care, wound care, and medication administration for multiple residents. | SS=E |
Report Facts
Residents on mechanical soft diet: 6
Residents on pureed diet: 6
INR value: 8
INR value: 1.6
INR value: 6.9
Pressure ulcer measurement: 4
Pressure ulcer measurement: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Unit Manager | Stated order for weekly weights was not followed; confirmed CPAP cleaning policy; stated expectation for following physician orders |
| Staff D | Licensed Practical Nurse (LPN) | Observed improper perineal care; assisted resident with morning care without placing prescribed boot |
| Staff F | Certified Nursing Assistant (CNA) | Assisted resident with morning care; observed during perineal care |
| Staff H | Registered Nurse (RN) Unit Manager | Confirmed missed INR test for Resident #50; described new INR monitoring process |
| Staff I | Registered Nurse (RN) | Changed dressing on Resident #50; attempted INR test with difficulty |
| Staff A | Dietary Aide | Served inappropriate portions of pureed pork and baked potato |
| Staff G | Cook | Prepared pureed foods with improper glove use and hand hygiene |
| Staff M | Licensed Practical Nurse (LPN) | Dropped medication box on floor and did not sanitize before use |
| Staff N | Certified Nursing Assistant (CNA) | Provided incontinence care without changing gloves or sanitizing hands |
| Staff O | Licensed Practical Nurse (LPN) | Handled wound care supplies placed on floor and did not follow infection control practices |
| Staff C | Certified Nursing Assistant (CNA) | Handled soiled linens improperly during resident care |
| Staff B | Licensed Practical Nurse (LPN) | Handled bread with bare hands during food preparation |
| Staff D | Licensed Practical Nurse (LPN) | Handled eye drop bag improperly during medication administration |
Inspection Report
Abbreviated Survey
Census: 52
Deficiencies: 0
Feb 3, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 2/2 to 2/3/2021.
Findings
The facility was found in compliance with CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Census: 50
Deficiencies: 1
Dec 30, 2020
Visit Reason
A focused COVID-19 infection survey was conducted to assess the facility's compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found not in compliance with infection prevention and control requirements related to COVID-19. A deficiency was cited regarding failure to wear proper personal protective equipment and incomplete infection control practices.
Deficiencies (1)
| Description |
|---|
| Staff failed to wear proper personal protective equipment during a resident room visit involving isolation procedures. |
Report Facts
Total residents: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Healthcare Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Abbreviated Survey
Census: 50
Deficiencies: 2
Dec 30, 2020
Visit Reason
A focused COVID-19 infection survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation and infection control.
Findings
The facility failed to ensure all staff wore appropriate personal protective equipment when caring for a resident on isolation precautions and failed to adequately screen all staff for COVID-19 symptoms and temperature before working with residents.
Deficiencies (2)
| Description |
|---|
| Failure to ensure all staff wore appropriate personal protective equipment when caring for a resident in isolation precautions. |
| Failure to assure all staff were adequately screened for signs and symptoms of COVID-19 before working with residents. |
Report Facts
Total residents: 50
Staff screening entries reviewed: 46
Staff entries missing temperature: 10
Staff entries missing symptom indication: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Healthcare Administrator | Named in the plan of correction |
Inspection Report
Abbreviated Survey
Census: 50
Deficiencies: 1
Nov 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals ending 11/3/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility failed to ensure non-facility staff wore personal protective equipment (PPE) properly while working with a resident when less than six feet away, specifically Staff A was observed not wearing a face mask appropriately while assisting Resident #7. The resident had cognitive and hearing impairments requiring staff to sometimes pull down masks to communicate.
Deficiencies (1)
| Description |
|---|
| Failure to ensure non-facility staff wore PPE while working with a resident within six feet, specifically Staff A not wearing a face mask properly. |
Report Facts
Total residents: 50
Residents reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Home Health Care Aide | Observed not wearing face mask properly while assisting Resident #7 |
| Staff B | Registered Nurse (RN) | Provided statements about PPE expectations for Staff A |
| Staff C | Certified Nurses' Aide (CNA) | Reported never seeing Staff A without a face mask |
| Staff D | Reported never seeing Staff A without a face mask | |
| Staff E | Licensed Practical Nurse (LPN) | Reported Staff A did not wear a shield but always a mask |
| Chris Schenkelberg | Administrator | Signed the report and provided statements about Staff A's mask use |
| Director of Nursing (DON) | Director of Nursing | Explained facility did not employ Staff A and discussed mask policies |
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 1
Sep 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals ending on 09/30/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found out of compliance with infection control practices to prevent the spread of COVID-19. Observations, record reviews, and interviews revealed failures in infection control practices including improper screening, inadequate isolation of symptomatic residents, and staff not following proper mask and hygiene protocols. The facility reported seven residents and 14 staff members diagnosed with COVID-19.
Deficiencies (1)
| Description |
|---|
| Failure to implement appropriate infection control practices and screening to prevent the spread of COVID-19, including improper resident isolation and staff mask use. |
Report Facts
Total residents: 57
Census: 56
Residents diagnosed with COVID-19: 7
Staff diagnosed with COVID-19: 14
Date survey completed: Sep 30, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Observed adjusting mask improperly and sanitizing hands after handling dirty dishes |
| Staff G | Dietary Aide | Reported kiosk symptom screening procedures |
| Staff E | Housekeeping | Reported kiosk symptom screening procedures |
| Staff I | Certified Nurses' Aide (CNA) | Observed giving new staff a tour with improper mask use |
| Staff J | Observed wearing mask improperly and sanitizing hands after handling resident's toy | |
| Staff L | Certified Nurses' Aide (CNA) | Observed wearing N95 mask and face shield improperly, lowering mask below nose and mouth |
| Director of Nursing | Director of Nursing (DON) | Reported additional staff member tested positive for COVID-19 |
| Administrator | Reported COVID-19 cases and infection control challenges | |
| Staff B | Licensed Practical Nurse (LPN) | Reported resident returned to floor with bad cough |
| Staff F | Certified Nurses' Aide (CNA) | Reported working with resident before illness and mask use issues |
| Staff K | Unit Manager | Reported resident testing and staff positive COVID-19 cases |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Jun 30, 2020
Visit Reason
An investigation of Complaint #91629-C was conducted ending on June 30, 2020, to assess quality of care concerns at Sunrise Retirement Community.
Findings
The facility failed to provide adequate assessment for dehydration and failed to notify the physician and family of a change in condition in a timely manner for one resident. The complaint was substantiated with detailed findings of inadequate nursing assessments and delayed physician notification leading to resident decline and hospitalization.
Complaint Details
Complaint #91629-C was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate assessment for dehydration and timely notification to physician and family for Resident #1. | SS=D |
Report Facts
Census: 60
Medication dosages: 5
Medication dosages: 10
Medication dosages: 125
Medication dosages: 150
Medication dosages: 0.25
Medication dosages: 0.5
Sodium level: 180
BUN level: 112
Creatinine level: 3.7
Temperature: 97.8
Heart rate: 63
Respirations: 26
Blood pressure: 83
Blood pressure: 65
Oxygen saturation: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Schenkelberg | Administrator | Signed the report and plan of correction |
| Staff B RN | Registered Nurse | Interviewed regarding resident condition and communication with physician |
| Director of Nursing | Director of Nursing | Interviewed regarding nursing assessments and expectations |
Inspection Report
Routine
Census: 60
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 60
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