Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunset Home during CMS and state inspections, most recent first.
A resident with cognitive impairment was subjected to aggressive handling by a CNA, witnessed by multiple staff who reported the actions as inappropriate and distressing. The facility failed to conduct a thorough abuse investigation by not interviewing all witnesses and allowed the accused CNA to return to work before the investigation was complete, resulting in an Immediate Jeopardy finding.
A resident with dementia and limited communication abilities was forcibly moved down a hallway by a CNA, despite her resistance and care plan instructions to avoid physical contact. Multiple staff witnessed the incident, noting the CNA's anger and inappropriate language. The event caused the resident to appear scared and traumatized, and was later substantiated as abuse after further investigation.
The facility did not ensure that CNA staff received the required 12 hours of annual in-service education, including abuse and dementia training. Documentation was lacking to confirm completion of these trainings, and leadership acknowledged uncertainty and absence of proof for the required education, potentially affecting all residents.
A resident was found with a large, unexplained bruise on the left mid-back, which was observed by an LPN and reported to the DON. Despite facility policy requiring immediate reporting of injuries of unknown origin, the incident was not reported to the state agency, as confirmed by both the DON and the administrator.
A resident was found with a large, unexplained bruise on the left mid back, which was reported by an LPN to the DON. Despite facility policy requiring prompt and thorough investigation of injuries of unknown origin, no investigation was initiated or documented. Both the DON and Administrator acknowledged that an investigation should have occurred but did not.
A resident developed a stage 4 pressure ulcer due to the facility's failure to follow physician orders and implement pressure-relieving interventions. The resident, with multiple health issues and moderate cognitive impairment, was dependent on staff for mobility. Despite care plan directives, wound care was inconsistently documented, and staff reported supply shortages. The ulcer worsened, becoming infected and painful, with staff and the resident's power of attorney noting inadequate repositioning and care practices.
A resident with Type 2 Diabetes Mellitus received incorrect insulin for 45 days due to a transcription error, leading to hypoglycemic episodes requiring glucagon injections. The facility failed to administer the correct insulin as per the physician's order, and the error was discovered after the resident's blood sugar levels fluctuated significantly.
A resident with multiple health conditions experienced a medication error involving insulin, which was not communicated to the family or physician. The resident's blood sugar levels dropped significantly, but the NP was not notified at the time. The facility lacked a specific policy for notifying family and physicians of such incidents.
A resident with multiple serious health conditions was admitted to the facility, but vital signs were not recorded until four days later, and required assessments were delayed. The DON confirmed the lapse, noting that documentation often remains on paper and is not entered into the system promptly.
A resident with multiple health conditions, including diabetes, was sent home with the wrong insulin during a home visit. The error occurred when an LPN gave the resident an insulin syringe from the medication cart, which was not intended for her. The facility lacked a policy on medication storage, and the error was discovered when the resident was contacted and advised not to take the insulin.
The facility failed to maintain a sanitary environment, leading to a cockroach infestation in the kitchen and dining areas. Despite regular pest control treatments, live and dead cockroaches were observed, and staff reported seeing them on resident trays and in dining areas. The issue persisted due to food trays left overnight, contributing to the infestation, affecting all 96 residents.
The facility failed to provide adequate supervision and assistance to residents at risk for falls and those needing dining help. Observations showed a resident left unsupervised in a wheelchair and CNAs eating instead of assisting residents. There was also a lack of documentation for meal intakes and incontinence care, affecting residents with significant weight loss, frequent incontinence, and high fall risk.
The facility failed to monitor and document the chemical dishwasher's sanitizer concentration and did not label opened freezer food items with dates. Additionally, cool down temperatures for soups prepared and stored in the freezer were not recorded, contrary to facility policy. These deficiencies could potentially affect all 87 residents.
The facility failed to ensure proper respiratory care for four residents by not dating oxygen tubing and humidification bottles, and not storing oxygen tubing in a bag when not in use. Observations revealed undated and improperly stored equipment for residents receiving oxygen therapy, contrary to the facility's policy. The DON confirmed the requirement for dating and proper storage.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters. Despite the policy requiring gowns and gloves during high-contact care to prevent MDRO spread, no EBP signs or PPE were observed during a facility tour. Residents and staff confirmed the absence of PPE use during catheter care. The ADON admitted to not ensuring EBP implementation, leading to a lack of infection prevention measures for at-risk residents.
The facility failed to ensure call lights were within reach for three residents, including one with severe cognitive impairment and another dependent on care. Observations revealed call lights placed out of reach, confirmed by staff, compromising residents' ability to request assistance.
A resident with range of motion limitations did not have a physician-ordered hand splint applied as required. Observations showed the resident's hand in a tight contracture without the splint, and the care plan did not address the need for the splint. Facility staff confirmed the splint was not regularly applied, and there was no documentation of its use or refusals.
A resident with dementia and a history of falls was left unsupervised in the lobby, leading to a fall outside the building. Despite being high risk for falls, the resident exited the facility by following an employee through a door before the alarm sounded. The receptionist saw the resident slip out and called the nursing office, but the resident had already fallen by the time help arrived.
A facility failed to cover a resident's urinary catheter drainage bag with a privacy bag as required by their Catheter Care Procedure. The resident, who has a supra pubic urinary catheter, was observed twice with the catheter bag unsecured to the bottom of his wheelchair without a privacy bag. An LPN confirmed the deficiency, acknowledging the requirement for a privacy bag but was unsure why it was not in place.
A facility failed to follow a physician's order for daily weight monitoring for a resident receiving dialysis. Despite a policy requiring daily weights, the resident, who has End Stage Renal Disease and Heart Failure, was not weighed on multiple occasions. The resident confirmed the inconsistency, and the DON acknowledged the oversight.
The facility failed to justify the use of antipsychotic medications for two residents with dementia, as required by its policy. One resident had no documented behaviors justifying Risperidone use, and no psychotropic assessment was completed since the previous year. Another resident's care plan showed no behaviors warranting antipsychotic medication, and a pharmacy recommendation for dose reduction was denied without rationale. Staff confirmed the lack of behaviors justifying medication use, highlighting the facility's non-compliance with its policy.
A resident's Health Care Power of Attorney raised multiple concerns about the resident's care, including foot treatment and CNA access to medical records. Despite reporting these issues to the facility's administrator, the grievances were neither documented nor addressed, as confirmed by the administrator, who admitted to neglecting the concerns.
The facility failed to document wound care and provide thickened liquids as ordered for three residents. A resident did not receive consistent wound care, with missing documentation on multiple dates, and two residents requiring thickened liquids were given regular water instead. The DON and staff confirmed these deficiencies.
A facility failed to obtain timely physician orders and document weekly assessments for a resident's pressure ulcer. The ulcer was identified, but treatment orders were delayed by a week, and no further wound measurements were documented. The DON confirmed the lack of documentation and was unsure why the physician was not notified or why treatment was delayed.
Staff failed to immediately notify the Administrator of possible abuse involving a resident with multiple diagnoses, including sepsis and a left ankle fracture. The resident reported that a CNA yelled and was rough during a transfer, causing pain. The LPN did not immediately inform the Administrator, as required by the facility's policy, leading to a delay in addressing the incident.
A resident with severely impaired cognition and a history of wandering eloped from her unit through an open double door, passed through an alarmed door, and was found on a stairway landing. The resident, diagnosed with Dementia and a history of falls, was independently propelling her wheelchair prior to the incident. The care plan did not reflect her increased elopement risk. Staff members did not respond to the door alarms, citing they did not hear them, and there were discrepancies in staff accounts regarding alarm handling. The investigation revealed gaps in staff communication and awareness of the door alarm system, as well as inconsistencies in staff responses during the search for the resident.
A resident developed a severe UTI and sepsis due to the facility's failure to notify the physician of significant changes in the resident's condition. Despite documented abnormal urinary symptoms, the LPN did not inform the physician, leading to delayed treatment and hospitalization.
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with Alzheimer's Disease, depression, and hypertension, who was rarely or never understood according to her MDS. On the day of the incident, the resident became verbally aggressive and was observed by multiple staff members to be resisting redirection away from a door. A certified nurse aide (CNA) intervened by forcefully hooking her arm under the resident's arm, turning her around, and walking her down the hallway despite the resident's resistance. Several staff members reported that the CNA appeared angry, used inappropriate language, and that the resident was dragged down the hallway while fighting and yelling. Witnesses, including a registered nurse (RN), a licensed practical nurse (LPN), and another CNA, expressed discomfort with the CNA's actions and described the interaction as aggressive and inappropriate. Despite these observations and statements, the facility's initial abuse investigation was incomplete. The CNA involved was suspended immediately after the incident but was allowed to return to work after the investigation was deemed unsubstantiated. The administrator confirmed that not all witnesses present during the incident were interviewed, including a CNA who directly intervened and took over care of the resident. Additionally, other staff members present on the hallway at the time were not interviewed as part of the initial investigation. The administrator admitted to not being concerned due to a lack of prior issues with the CNA, which contributed to the incomplete investigation. The facility's failure to follow its own abuse and neglect policy, which requires a thorough investigation including interviews with all relevant staff and witnesses, resulted in the CNA returning to work with the resident and other residents before the investigation was properly completed. This failure to protect the resident from further potential abuse and to conduct a comprehensive investigation led to an Immediate Jeopardy finding by surveyors.
Removal Plan
- Administrator, DON, and ADON reviewed Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating.
- Staff were educated on Abuse Prevention Policy by DON and ADON.
- Staff not working dayshift were called by Administrator, DON, and ADON and were given education via phone of Abuse Prevention policy.
- Remainder of the staff not working or reached by phone will be required to receive the education prior to working their next shift by DON and/or ADON or designee and will be required to sign the education sign-in sheet.
- An Emergency QAPI (Quality Assurance Performance Improvement) discussion was held with Medical Director, Administrator, DON, ADON and Social Service Director to review the investigation findings and conclusion and review the QA audit tools for ongoing audit plan. QA Audit for thorough investigation will be conducted with each allegation investigation. These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality assurance meeting.
- Administrator and DON will meet monthly to review all audit findings and discuss, if any, possible further training/education or policy review changes need to occur.
- R1's Care Plan was updated with at risk for abuse/harm and interventions by Social Service Director.
Forcible Handling of Resident with Dementia Results in Substantiated Abuse
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, depression, and hypertension, who was rarely or never understood and had a care plan indicating a need for personal space and minimal physical contact, was forcibly moved down a hallway against her will by a certified nurse aide (CNA). The resident was exhibiting combative behaviors and was near a door at the end of the hallway when a registered nurse (RN) attempted to redirect her. The CNA intervened by hooking her arm under the resident's arm and physically moving her, despite the resident's resistance and vocal objections. Multiple staff interviews confirmed that the CNA was visibly angry and used inappropriate language during the incident, stating, "we aint doing this sh*t today," before forcibly moving the resident. Other staff, including an LPN and another CNA, witnessed the event and expressed discomfort with the CNA's actions, describing the resident as being dragged while fighting and yelling. The resident was described as acting scared and traumatized following the incident, and staff noted that she followed another CNA around for the rest of the night. The facility's initial abuse investigation deemed the allegation unfounded, but after further staff interviews and review, the incident was substantiated as abuse. The facility's policy prohibits abuse, including the willful infliction of injury or unreasonable confinement, and requires interventions that respect residents' needs and behaviors. The failure to follow the resident's care plan and the use of force resulted in psychosocial harm, as evidenced by the resident's subsequent behavior and staff observations.
Removal Plan
- Administrator, Director of Nursing, and Assistant Director of Nursing reviewed Abuse Policy and intervening and reporting with quiz; Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout with all on duty staff in person. All staff not working at the time were reached by phone and were educated. Any staff who were not reachable will not be able to clock in for their next shift until DON or ADON provide the education and handouts.
- The Abuse policy and intervening and reporting with quiz, Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout specific to intervention of preventing abuse and recognizing stress and burnout in co-workers and intervening was added to the orientation packet for new staff.
- An emergency QAPI (Quality Assurance and Performance Improvement) discussion was held with the Medical Director, Administrator, DON, ADON, and Social Service Director to review the investigation findings and conclusion and review the QA audit tools for ongoing audit plan. QA Audit will be conducted of 5 residents and 5 staff per month by DON, ADON, Social Services Director and/or designees about Abuse, Stress, and Burnout and concerns regarding any cares. These audit tools will be reported monthly on the QAPI scorecard and reported at the QA meeting.
- All residents with Alzheimer's Disease/Dementia were reviewed for At Risk for Abuse/Harm and any identified, care plan was added and/or updated by Social Services Director.
- Administrator and Director of Nursing will meet monthly to review all audit findings for discussion for need, if any, for further training/education and/or policy review changes.
Failure to Provide Required In-Service Education for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of annual in-service education, including abuse and dementia training. Review of facility records and interviews revealed that while some CNAs attended abuse training sessions during Town Hall meetings, there was no documentation to confirm that all CNAs completed the mandated 12 hours of in-service education. Additionally, there was no evidence of dementia training being provided to CNAs within the past one and a half years. Interviews with the Director of Nursing (DON) and the Administrator confirmed uncertainty regarding the completion and documentation of required training for CNAs. The Administrator acknowledged the absence of proof for the 12 hours of annual in-service education and the lack of dementia training. This deficiency has the potential to affect all 88 residents residing in the facility.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the state agency as required by its Abuse and Neglect Policy. A resident was observed by an LPN to have a large, circular red/purple bruise approximately six inches in diameter on the left mid-back during a transfer to a stretcher. The LPN noted that the resident had been on Eliquis, a blood thinning medication, which had been placed on hold, and that there were no recent falls other than one that occurred two to three weeks prior, which the nurse did not believe was related to the bruise. The LPN reported the bruise to the Director of Nursing (DON), stating that the bruise appeared overnight and its cause was unknown. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the state agency, the incident was not reported. Both the DON and the facility administrator confirmed that the injury was not reported to the state agency, acknowledging that it should have been. The facility's records did not contain documentation of the required report for this incident.
Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation following the discovery of a bruise of unknown origin on one of three residents reviewed for bruises. According to the facility's Abuse and Neglect Policy, any injury of unknown source should be promptly and thoroughly investigated, including reviewing the resident's medical record, interviewing relevant staff, witnesses, the resident (if appropriate), and documenting the results. In this case, a large circular red/purple bruise was observed on a resident's left mid back by an LPN during a transfer to a stretcher. The LPN reported the bruise to the Director of Nursing (DON), noting that the resident was on Eliquis, a blood thinner that had been placed on hold, and that there were no recent falls other than one that occurred two to three weeks prior. The LPN stated the bruise appeared overnight and could not be explained. Despite the policy requirements and the report made to the DON, no investigation was initiated or documented regarding the bruise of unknown origin. Both the DON and the facility Administrator confirmed that an investigation should have been started but was not. The lack of investigation meant that the facility did not follow its own policy for responding to injuries of unknown origin, as required for potential abuse or neglect cases.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident, resulting in a facility-acquired stage 4 pressure ulcer on the coccyx that became infected and caused pain. The resident, who had multiple diagnoses including spinal stenosis, hypertension, and chronic kidney disease, was admitted with a moderate cognitive impairment and was dependent on staff for mobility and toileting. The care plan indicated the need for specific interventions to prevent skin breakdown, including turning the resident every two hours and avoiding positioning on the coccyx. Despite these care plan directives, the facility did not consistently follow the physician's orders for wound care and pressure relief. The resident's treatment records showed multiple instances where wound care was not documented as completed, and staff interviews confirmed that supplies were often unavailable, leading to missed treatments. The resident's condition worsened over time, with the pressure ulcer progressing from a stage 2 to a stage 4, accompanied by infection and a foul odor. The nurse practitioner noted that the wound care was not being performed as ordered, and the resident was not being repositioned adequately, contributing to the deterioration of the wound. Interviews with staff and the resident's power of attorney revealed systemic issues in the facility's care practices, including inadequate turning and repositioning of residents and frequent shortages of necessary wound care supplies. The resident's power of attorney observed that the resident was often left lying on her back, contrary to care plan instructions, and expressed concerns about the quality of care on the floor where the resident was housed. The facility's administrator acknowledged that the treatment administration records indicated non-compliance with the prescribed care, and the nurse practitioner emphasized that better care could have minimized the severity of the wound.
Medication Error Leads to Hypoglycemic Episodes
Penalty
Summary
The facility failed to accurately transcribe a physician's order and administer the correct insulin to a resident, leading to significant medication errors. The resident, who has a history of Type 2 Diabetes Mellitus and other serious health conditions, was prescribed Insulin Aspart for sliding scale use and Lantus SoloStar for daily use. However, the order was incorrectly transcribed, resulting in the administration of Insulin Glargine-yfgn, a long-acting insulin, instead of the prescribed short-acting insulin for sliding scale use. This error persisted for 45 days, during which the resident experienced two episodes of hypoglycemia, requiring emergency glucagon injections. The resident's blood sugar levels dropped significantly, reaching as low as 37 and 44, without timely notification to the physician. The incorrect insulin administration was discovered after the resident's blood sugar levels continued to fluctuate, prompting a review by the Nurse Practitioner, who identified the transcription error. Interviews with facility staff revealed that the error originated from an incorrect transcription by an agency LPN, which was not caught due to a lack of checks in place to verify medication orders. The Director of Nursing and other staff members acknowledged the mistake and its duration, highlighting the absence of a system to ensure the accuracy of medication orders. The pharmacist also noted that the unusual order should have been questioned, emphasizing the seriousness of hypoglycemia, especially in elderly patients.
Failure to Notify Family and Physician of Medication Error and Change in Condition
Penalty
Summary
The facility failed to notify a resident's family and physician of a medication error and a significant change in condition. A resident, who is a male with multiple diagnoses including Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease, and Chronic Kidney Disease, experienced a medication error involving insulin. The error occurred when an agency LPN incorrectly changed the resident's insulin medication from a short-acting insulin, Fiasp, to an incorrect insulin, Glargine-yfgn, which the resident received from November 4, 2024, to December 19, 2024. This error was not communicated to the resident's Power of Attorney, as confirmed by the facility's Administrator. Additionally, the resident's blood sugar levels were significantly low, with a reading of 24, and later increased to the 200 range. Despite this significant change in condition, the Nurse Practitioner was not notified at the time of the incident. The Nurse Practitioner only became aware of the blood sugar drop upon reviewing the medical records later. The Director of Nursing acknowledged the error in insulin administration and the lack of notification to the physician and family, and the Administrator admitted there was no specific policy in place for such notifications.
Failure to Timely Record Vitals and Assessments for New Admission
Penalty
Summary
The facility failed to conduct timely vital sign checks and assessments for a resident, identified as R3, upon admission. R3, a male with multiple serious health conditions including malignant neoplasms, embolism, thrombocytopenia, and chronic heart failure, was admitted to the facility. However, the first recorded vital signs were not documented until four days after admission, which is a significant delay. The Director of Nursing (DON) confirmed the absence of recorded vitals and acknowledged that the nurses often document on paper, which may not always be transferred to the electronic system. Additionally, the required assessments for R3, such as the Elopement Evaluation, Skin Check, and Fall Risk Evaluation, were not completed until several days post-admission, contrary to the facility's protocol. The Administrator could not find any policy clearly defining when vitals should be taken, and the DON stated that vitals should be recorded every shift for the first three days to establish a baseline. This lack of timely assessments and documentation represents a deficiency in the facility's adherence to its own protocols for new admissions.
Medication Error During Resident Home Visit
Penalty
Summary
The facility failed to ensure the correct medication was sent with a resident during a home visit, leading to a medication error. The resident, a female with multiple diagnoses including diabetes, was sent home with the wrong insulin. The facility's policy on administering medications requires that medications be administered safely and as prescribed, and that residents leaving the facility temporarily should be given the correct medications for their absence. However, during the resident's home visit, the wrong insulin was sent with her, and she was later contacted and advised not to take it. The incident occurred when the unit coordinator prepared the resident's medications, but left the floor before the resident departed. A previous LPN then gave the resident the insulin syringe that was in the medication cart, which was not intended for her. The Director of Nursing confirmed that no insulin was supposed to be sent with the resident, and the administrator acknowledged the lack of a policy on medication storage. The facility was unable to identify whose insulin was mistakenly given to the resident.
Cockroach Infestation in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen and dining areas, resulting in a cockroach infestation. The facility's Sanitation policy, dated November 2022, mandates that all food service areas be kept clean and free from insects. Despite this, multiple pest control service slips and invoices from November 2024 to February 2025 document repeated treatments for cockroaches in various areas of the facility, including the kitchen, dining halls, and basement. Observations and interviews with staff confirmed the presence of live and dead cockroaches in these areas, indicating an ongoing issue. On February 10, 2025, a Certified Nursing Assistant (CNA) reported seeing cockroaches on resident trays in the fourth-floor dining room, and a live cockroach was observed beneath the sink and counter in the same area. The counter, which had a broken lid on a container of bread and stored clean silverware, was identified as a location where cockroaches were seen. A Dietary Assistant also reported seeing live cockroaches in the main dining room, particularly under the juice machine, and noted that the issue had persisted for several months despite regular pest control treatments. The Director of Housekeeping confirmed that housekeeping cleans the dining rooms three times a day, but food trays left overnight contribute to the infestation. The Dietary Manager acknowledged the presence of cockroaches and stated that a deep clean was conducted six months prior, but the problem persists. The facility's Administrator confirmed ongoing pest control visits but was unsure if the source of the infestation had been identified. The report indicates that the infestation has the potential to affect all 96 residents residing in the facility.
Inadequate Supervision and Documentation in Resident Care
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for residents at risk for falls and those requiring dining assistance. Observations revealed that a resident with a history of falls was left unsupervised and slouched in her wheelchair, unable to reposition herself. Despite the presence of several CNAs in the dining room, they were observed eating and not attending to the residents, including those who needed help with meals. This lack of supervision and assistance was evident as residents consumed minimal portions of their meals without encouragement or support from the staff. The facility's policies require CNAs to document meal and fluid intakes, as well as episodes of incontinence, to monitor residents' health and well-being. However, the report indicates that there was no documentation of meal intakes or incontinence care for the residents reviewed. This lack of documentation was confirmed by the Assistant Director of Nursing, who acknowledged that CNAs were not recording these details in the residents' medical records, either on paper or electronically. The report highlights specific deficiencies in the care provided to three residents. One resident experienced significant weight loss over a month, another was frequently incontinent and required extensive assistance with eating, and the third was at high risk for falls. Despite these needs, the facility failed to provide the necessary care and documentation, as evidenced by the lack of recorded meal intakes and incontinence episodes, and the inadequate supervision during mealtimes.
Deficiencies in Food Safety Practices and Documentation
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of the chemical dishwasher's sanitizer concentration, as well as the labeling and dating of opened freezer food items. The Dietary Manager, identified as V7, conducted a test on the dishwasher's chemical level and stated that sanitation checks should be completed twice daily. However, the facility's Dish Machine-PPM Sanitizer Record log for September and October 2024 showed multiple instances where these checks were not completed, indicating a lapse in adherence to the facility's policy. Additionally, opened bags of frozen food items such as french fries, onion rings, pork fritters, and chicken strips were found in the walk-in freezer without labels indicating the date opened or a use-by date, contrary to the facility's policy. Furthermore, the facility did not record cool down temperatures for soups prepared ahead and stored in the freezer, which is a requirement according to the facility's Food Preparation and Service policy. The Dietary Manager, V7, confirmed that various soups made in October were stored in the freezer without documentation of their cool down temperatures. The cook, V9, admitted to not considering the need for cool down logs for these soups. This oversight in documentation and monitoring of food safety practices has the potential to affect all 87 residents residing in the facility.
Failure to Properly Date and Store Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for four residents by not adhering to the established protocol for oxygen tubing and humidification bottles. Specifically, the oxygen tubing and humidification bottles for residents were not dated, and the oxygen tubing was not stored in a bag when not in use. This was observed in four residents who were part of a sample of 36 reviewed for respiratory care. The facility's policy requires that oxygen tubing and masks be changed every seven days and as needed, and that they be dated and stored properly. For instance, one resident's nasal cannula oxygen tubing was found on the floor, undated, and unbagged, with the humidification bottle also undated. Another resident was observed with oxygen flowing at three liters per nasal cannula, with both the tubing and humidification bottle undated. Similar issues were noted with two other residents, where the oxygen tubing was not labeled with the date and was not stored in a bag when not in use. The Director of Nursing confirmed that all oxygen tubing and humidifier bottles should be dated and stored in plastic bags when not in use.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters, affecting 10 out of 10 residents reviewed for EBP in a sample of 36. The facility's EBP policy requires the use of gowns and gloves during high-contact resident care activities to prevent the spread of multi-drug resistant organisms (MDROs). However, during a facility tour, it was observed that no EBP signs were posted on any resident's door, and no personal protective equipment (PPE) was available inside or outside the rooms of residents who required EBP. Interviews with residents and staff confirmed that staff did not wear gowns or other PPE when providing catheter care. Specific residents, such as those with indwelling urinary catheters, were not placed on EBP despite being identified as needing such precautions. The Assistant Director of Nursing (ADON) and Infection Preventionist admitted to not ensuring the implementation of EBP for residents who required it. The ADON acknowledged the lack of monitoring to ensure EBP signs were posted, PPE was available, and staff were following the EBP protocols. This oversight led to a failure in implementing necessary infection prevention measures for residents at increased risk.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three residents, leading to a deficiency in accommodating their needs. Resident 37, who is severely cognitively impaired and at high risk for falls, was observed lying in bed with the call light placed on top of her side table, out of reach. This was confirmed by a CNA who acknowledged that the call light was not accessible to the resident. Resident 30, who has severe cognitive impairment and requires assistance for daily activities, was found sitting in a wheelchair without a call light in reach. The call light was clipped to a recliner, and the resident expressed unawareness of its location. Additionally, Resident 64, who is dependent on care, was observed in a high back wheelchair with the call light hanging over a bedside table, out of reach. The resident reported that the call light is often inaccessible, and a CNA confirmed that it should be attached to the resident or the wheelchair. The Director of Nursing stated that call lights should always be within reach.
Failure to Implement Physician-Ordered Hand Splint for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered hand splint was in place daily for a resident with limitations in range of motion. The resident, identified as R73, had a physician's order to wear a left upper extremity splint during daytime hours, which was not consistently followed. Observations revealed that the resident's left hand was in a tight fist contracture without the splint, and the resident's care plan did not address the limitations in range of motion or the use of the splint. Interviews with the resident's Power of Attorney and facility staff confirmed that the splint was not regularly applied, and there was no documentation of the splint's use or any refusals by the resident. The facility's Rehabilitation/Restorative Programs policy requires that residents be evaluated for individual status and potential rehabilitation/restorative programs upon admission or onset of a decline in activities of daily living. However, the resident's care plan was not updated to reflect the need for the splint, and the Director of Nursing was unaware of the order. Additionally, the restorative care logs and behavior management program did not document the administration or refusals of the splint, indicating a lack of communication and documentation regarding the resident's care needs.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to adequately supervise a resident with dementia and a history of falls, leading to an incident where the resident fell outside the building. The resident, who has multiple diagnoses including dementia, anxiety, Parkinson's disease, and a history of falls, was left unsupervised in the facility lobby. The resident's care plan indicated a high risk for falls due to impaired cognition, poor safety awareness, and other factors. Despite these risks, the resident was left unattended in the lobby while staff gathered other residents for an outdoor activity. On the day of the incident, the resident managed to exit the building by following an employee through a door before the alarm could sound. The receptionist observed the resident slipping out and notified the nursing office, but by the time the Director of Nursing arrived, the resident had already fallen off the curb outside. The activity aide confirmed that the resident was left in the lobby without supervision, which was not unusual for the resident's behavior, as she was known to be strong-willed and act independently.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter drainage bag was covered for a resident with a supra pubic urinary catheter. The facility's Catheter Care Procedure requires that the catheter drainage bag be inside a cloth dignity bag and that the catheter tubing and dignity bag do not touch the floor. However, observations revealed that the resident's catheter bag was secured to the bottom of his wheelchair without a privacy bag covering it. This was confirmed on two separate occasions, once when the resident was in his room and once when he was sitting across from the nursing station. An Agency Licensed Practical Nurse verified the absence of the privacy bag and acknowledged that the resident should have had one, but was unsure why it was missing.
Failure to Follow Daily Weight Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to adhere to a physician's order for daily weight monitoring for a resident receiving dialysis, identified as R45. The facility's policy mandates daily weighing of residents undergoing hemodialysis, with any significant weight increase to be reported. R45, who has diagnoses including End Stage Renal Disease and Heart Failure, was admitted with a physician's order to be weighed daily and to notify the physician if there was a weight increase of more than five pounds over three days. However, R45's weight records show multiple instances where daily weights were not recorded, specifically on 15 different dates. The resident confirmed that daily weighing was not consistently performed, and the Director of Nursing acknowledged the failure to follow the order for daily weights.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to document behaviors and diagnoses to justify the use of antipsychotic medications, perform psychotropic assessments quarterly, and perform gradual dose reductions of scheduled antipsychotic medications for two residents diagnosed with dementia. The facility's policy requires that psychotropic medications be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. However, for one resident, there was no evidence of a psychotropic drug assessment since September of the previous year, and no attempt at a gradual dose reduction was made within the last year. The resident was observed to have no behaviors justifying the use of Risperidone, with the only noted behavior being wandering. Another resident was prescribed Risperidone for dementia with behaviors related to Lewy Body Dementia, but the care plan documented no behaviors warranting the use of antipsychotic medication. The resident's behavior management program tracking sheets showed no behaviors from June through September, with only two instances of repetitive verbalizations in October. Despite a pharmacy recommendation for a gradual dose reduction, it was denied by the nurse practitioner without documented clinical rationale. Interviews with facility staff, including CNAs and the Director of Nursing, confirmed that the residents did not exhibit behaviors that justified the continued use of antipsychotic medications. The Director of Nursing acknowledged the lack of psychotropic drug assessments and the absence of a clinical rationale for not attempting a gradual dose reduction. The facility's failure to adhere to its policy and regulatory requirements resulted in the inappropriate use of antipsychotic medications for these residents.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to document and address a grievance for one resident, identified as R3, out of three reviewed for resolution of grievances in a sample of seven. The facility's Grievance/Concern Policy outlines that department directors are responsible for following up on concerns and ensuring appropriate resolution, with Social Services maintaining a log of grievances. However, the facility's grievance log showed no entries for several months, indicating a lack of documentation and follow-up on grievances. R3's Health Care Power of Attorney, identified as V5, reported having multiple concerns regarding R3's care, including issues with foot treatment, liquid intake, and CNA access to electronic medical records. V5 communicated these concerns to the facility's administrator, V1, on two occasions, but V1 admitted to not documenting or addressing these grievances. V1 acknowledged the oversight, stating that she "dropped the ball" on addressing V5's concerns.
Failure to Document Wound Care and Provide Thickened Liquids
Penalty
Summary
The facility failed to complete wound assessment documentation and perform wound care for a resident, identified as R4, and did not provide thickened water between meals for two other residents, R3 and R7. R4, who is cognitively intact with a BIMS score of 15 out of 15, had physician orders for Silvadene cream and a specific wound care regimen for a skin abrasion on the right knee. However, the Treatment Administration Record lacked documentation of these treatments on multiple dates, and there was no description or measurement of the wound in R4's medical record. R4 expressed that treatments were inconsistent and dependent on staff availability, and the Director of Nursing confirmed the absence of necessary documentation. Additionally, the facility did not adhere to physician orders for thickened liquids for residents R3 and R7, who required nectar-thick liquids due to swallowing difficulties. R3's Health Care Power of Attorney reported finding regular water at R3's bedside on multiple occasions, and a CNA confirmed having to replace regular water with thickened water after being alerted by R3's family. Similarly, R7 was found with a pitcher of unthickened water, which was confirmed by a registered nurse as inappropriate given R7's need for thickened liquids.
Failure to Obtain Timely Treatment Orders for Pressure Ulcer
Penalty
Summary
The facility failed to obtain timely physician orders for the treatment of a pressure ulcer and did not document weekly assessments for a resident's pressure ulcer. The facility's Skin Care/Ulcers policy requires documentation of all skin ulcers and physician-ordered treatments. However, a resident's pressure ulcer on the left heel was identified on 7/23/24, but there was no documentation of physician notification or treatment orders at that time. The resident's Treatment Administration Record indicated that treatment orders were not initiated until 7/30/24, a week after the ulcer was first noted. Additionally, the facility did not document any further wound measurements or assessments after the initial discovery of the ulcer. The Director of Nursing confirmed the lack of documentation and was unsure why the physician was not notified or why treatment was delayed. Furthermore, there were no nurse's notes explaining why the treatment was not completed on 7/30/24 and 7/31/24, as indicated by the Treatment Administration Record. This lack of documentation and delay in treatment represents a failure to adhere to the facility's policy and provide appropriate care for the resident's pressure ulcer.
Failure to Immediately Report Suspected Abuse
Penalty
Summary
Staff failed to immediately notify the Administrator of possible abuse involving a resident who was admitted for short-term rehab with diagnoses including sepsis, left ankle fracture, hypertension, and type 2 diabetes mellitus. The incident occurred when a Certified Nursing Assistant (CNA) allegedly yelled at the resident and was rough during a transfer, causing pain to the resident's left foot. The resident reported the incident to a Licensed Practical Nurse (LPN), who did not immediately inform the Administrator as required by the facility's Abuse and Neglect Policy. Instead, the LPN intended to report the incident but was interrupted by a phone call from the resident's Nurse Practitioner, who had already been informed by the resident. The LPN then reported the incident to the Unit Coordinator, who subsequently sent the CNA home after taking a statement. The facility's policy mandates that any suspected abuse, allegations of abuse, or incidents of abuse must be reported to the Administrator immediately. Despite attending an in-service on abuse reporting, the LPN did not follow this protocol. The Administrator was eventually informed of the incident by the Nurse Practitioner and took action to remove the CNA from the facility. The delay in reporting the incident to the Administrator constitutes a failure to adhere to the facility's abuse reporting procedures, as outlined in their policy dated July 2023.
Supervision and Response Deficiency in Resident Elopement Incident
Penalty
Summary
The report details a significant deficiency in a nursing home's supervision and response to a resident with severely impaired cognition and a history of wandering. The resident, identified as R1, eloped from her unit through an open double door that is normally closed, passed through an alarmed door leading to a stairway, and was found on a landing after descending 8 steps. R1, an elderly individual with diagnoses including Dementia, History of Falls with Fractures, and other medical conditions, was observed independently propelling her wheelchair and interacting with peers and staff prior to the elopement. Despite being known as a wanderer and requiring substantial assistance with transfers, R1's care plan had not been updated to reflect her increased risk for elopement. The facility's failure to provide adequate supervision to prevent R1's elopement was compounded by staff members' lack of response to door alarms at the time of the incident. Staff members reported not hearing the alarm sound when R1 exited through the alarmed door, and there were discrepancies in staff accounts regarding the handling of door alarms. The investigation following R1's elopement revealed gaps in staff communication and awareness of the facility's door alarm system. Additionally, the report highlighted inconsistencies in staff responses and actions during the search for R1, indicating a breakdown in communication and coordination among team members.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident (R4), resulting in a severe urinary tract infection (UTI), sepsis, and a five-day hospitalization. R4 was admitted to the facility with multiple diagnoses, including a history of UTIs and urinary retention. On two occasions, the Licensed Practical Nurse (LPN) documented abnormal urinary symptoms, including foul odor and mucus discharge, but did not notify the physician or nurse practitioner of these changes. This lack of communication led to a delay in treatment for R4's UTI, which subsequently worsened into sepsis and metabolic encephalopathy. R4's family member (V27) noticed a decline in R4's condition and attempted to communicate concerns to the staff, who dismissed them. On the day R4 was sent to the hospital, V27 observed that R4 was unresponsive and had a limp head, prompting V27 to insist on hospital transfer. The Director of Nursing (DON) confirmed that there was no documented evidence of physician notification regarding R4's abnormal urine symptoms, which should have been reported according to the facility's policy. The Nurse Practitioner (NP) stated that there was no record of being notified about R4's symptoms, and had they been informed, they would have ordered a urinalysis and started antibiotic treatment. The failure to notify the physician of R4's significant change in condition led to a severe UTI and sepsis, resulting in R4's hospitalization. The facility's policy mandates timely notification of the physician for significant changes in a resident's condition, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 102 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Quincy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Home | 1.6 mi | — | 1 | 0 |
| Blessing Hospital Snu | 1.6 mi | — | 0 | 0 |
| Quincy Healthcare & Sr Living | 1.9 mi | — | 0 | 0 |
| Maple Lawn Nursing Home | 11.5 mi | — | 22 | 0 |
| Luther Manor Retirement & Nursing Center | 12.9 mi | — | 36 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sunset Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.