Sutton Park Center for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Sutton Park Center for Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Jan 28, 2026

  Based on observation and interview conducted during the recertification survey and abbreviated surveys (686919, 2690393) from 01/20/2026 to 01/28/2026, the facility did not maintain a homelike environment for two of four (third and sixth floor) nursing units, and a tub room on the 4th floor. Specifically, 1) resident rooms # 302 a-b, 307 a-d, 315 a-d, 316 a-d were not personalized, lacked adequate visitor seating, 2) fifteen resident rooms (602, 603, 604, 605, 606, 607, 608, 609, 610, 611, 614, 616, 617, 619, and 620) were observed stark and bare without personalization; and 15 resident rooms (603, 604b, 605a, 606a-b, 609a, 610, 606 a-b, 607a-d, 609a, 610, 616a-d, 617a, 618b, 619a-b, and 620) did not contain a chair for resident/visitor use; and 3) the tub room on the 4th floor, had window… […]

• No harm, potential for more than minimal, patternF684Jan 28, 2026

  Based on observation, interview, and record review conducted during the recertification and abbreviated (2569922) surveys from 01/20/2026 to 01/28/2026, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one (1) of seven (7) residents (Resident # 51) reviewed for Activities of Daily Living and one (1) of one (1) residents (Resident #158) reviewed for non-pressure skin conditions. Specifically, 1) Resident #158 did not have their daily wound dressing changed for 7 days and did not receive treatment according to the physician order. 2) Resident # 51 dislocated their hip and did not have an orthopedic follow-up as recommended in the hospital discharge summary. […]

• No harm, potential for more than minimal, isolatedF609Jan 28, 2026

  Based on observation, interview, and record review conducted during the recertification and abbreviated (2569922) surveys from 01/20/2026 to 01/28/2026, the facility did not ensure that all alleged injuries of unknown origin, were reported to the State Agency for one (1) of seven (7) residents. (Resident #51) reviewed for abuse. Specifically, Resident #51 had an x-ray that confirmed the dislocation of the right femoral head (top of long bone in the thigh) prosthesis (hip replacement). The 01/18/2025 Accident/Incident Report documented the date, location, and time of occurrence as unknown, and there was no documented evidence that the injury of unknown origin was reported to the State Agency. […]

• No harm, potential for more than minimal, isolatedF610Jan 28, 2026

  Based on observation, interview, and record review during the recertification and abbreviated (2569922) surveys from 01/20/2026 to 01/28/2026, the facility did not ensure a thorough and complete investigation was done to rule out abuse, neglect, or mistreatment for one (1) of seven (7) residents (Resident # 51), reviewed for abuse. Specifically, Resident # 51 had their right hip replacement dislocated, and the facility did not thoroughly investigate to determine if the care plan was followed when determining a root cause analysis for the dislocated hip. […]

• No harm, potential for more than minimal, isolatedF686Jan 28, 2026

  Based on observation, record review and interview during the recertification survey from 01/20/2026 to 01/28/2026, the facility did not ensure residents received necessary treatment and services consistent with professional standards of practice, to prevent new pressure ulcers from developing and/or promote healing of pressure ulcers for two (2) of eight (8) Residents (Resident #125 and #94) reviewed for pressure ulcers. 1) Specifically, Resident #125 who had Stage 4 pressure ulcers to their right hip and sacrum and was at high risk for further development of pressure ulcers, was observed on multiple occasions without physician-ordered bilateral heel boots in place and/or their heels were not offloaded while in bed. […]