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 Rehabilitation And Health Care during CMS and state inspections, most recent first.
A resident's primary care physician was changed to the facility's Medical Director without notifying the resident or their representative, despite facility policy requiring resident choice and notification. Interviews and record review confirmed that neither verbal nor written notice was provided regarding the change.
A resident with impaired cognition and poor safety awareness, dependent on a wheelchair, was given an open cup of hot coffee without a lid and without adequate supervision. While self-propelling in the hallway, the resident spilled the coffee onto his lap, resulting in a second-degree burn. Staff interviews confirmed awareness of the resident's safety risks, and the facility lacked a policy for hot beverage supervision at the time of the incident.
Two residents experienced falls without proper post-fall assessments, injury identification, or thorough investigation by nursing staff. In both cases, required neurological checks, documentation, and notifications to physicians and family were not completed per policy. Care plans were not promptly updated with new interventions, and staff were not informed of changes, resulting in inadequate supervision and failure to prevent further incidents.
A resident reported to a RN that two CNAs had hurt her with washcloths. The RN documented the allegation and informed the DON hours later, but the DON did not report the incident to the Administrator. Both the Administrator and Interim Administrator confirmed they were not notified of the allegation, resulting in a failure to follow the facility's abuse reporting policy.
A resident with intact cognition reported that a CNA placed a sock in her mouth, but the facility's investigation was incomplete. The Administrator only interviewed the resident and two CNAs involved, did not obtain formal statements, failed to assess the resident for injury, and did not involve Social Services, contrary to facility policy.
A facility failed to perform ongoing clinical assessments for a resident with multiple acute medical conditions, including COPD and a recent cerebrovascular infarction. Despite the facility's policy requiring documentation every shift for new admissions, no assessments were recorded for two days. The resident was eventually transferred back to the hospital due to decreased oxygen levels and altered mental status.
A resident with dysphasia was admitted to a facility with a physician-ordered pureed diet and nectar thick liquids. Despite this, the resident was served a meal with whole bread, diced meat, and regular consistency fluids, leading to choking. The resident's granddaughter, who is also their POA, reported the incident to an LPN, who confirmed the dietary error.
The facility's kitchen was found to be unsanitary, with significant buildup of dust, grease, and food debris. Food items were improperly labeled and dated, leading to confusion about their freshness and safety. Additionally, the facility failed to adhere to proper food cooling and thawing procedures, with inconsistencies in the Food Cooling Log and issues with leaking substances in the walk-in freezer and refrigerator.
A facility failed to align a resident's Physician Orders with their POLST form regarding CPR code status. The Physician Orders listed the resident as 'Full Code,' while the POLST indicated 'DNR' with selective treatment. The Assistant Director of Nursing admitted to missing this inconsistency.
The facility failed to implement dietary recommendations and physician orders for two residents, leading to significant weight loss and inadequate nutritional monitoring. One resident experienced a 15.03% weight loss over six months without receiving prescribed supplements, while another resident's weekly weights were not recorded as ordered. These deficiencies indicate lapses in communication and adherence to policies.
The facility failed to date oxygen tubing, place oxygen signs on doors, and change nebulizer equipment weekly for residents receiving oxygen therapy. A resident with heart failure had undated tubing and no sign on the door, while another with obesity and hypertension had similar issues. A third resident's nebulizer mask was not changed for over a month. The DON confirmed the policy requires weekly changes and proper dating.
A facility failed to attempt a Gradual Dose Reduction (GDR) of Olanzapine for a resident with Bipolar Disorder, despite the resident showing no episodes of paranoid thoughts/behaviors over nine months. The facility's policy requires GDRs to be attempted at least twice a year unless clinically contraindicated. The Assistant Director of Nursing confirmed no GDR was attempted in the past year, and it was unclear why the new psychiatric service did not attempt a reduction.
The facility failed to follow infection control protocols during incontinence care and wound management for two residents. A resident received incontinent care without staff changing gloves or performing hand hygiene. Another resident with multiple wounds was not placed under Enhanced Barrier Precautions, and staff did not wear gowns during wound care, contrary to facility policy.
A resident was found unresponsive in a facility without documented Advanced Directives, resulting in staff failing to perform CPR. Despite the resident's expressed wish to be resuscitated, the absence of documentation led to inaction. The facility's policies on Advanced Directives were not followed, and staff were unclear about their responsibilities, leading to an Immediate Jeopardy situation.
A resident at high risk for pressure ulcers did not receive necessary interventions, such as repositioning and heel protection, leading to the deterioration of heel ulcers. The facility failed to conduct required assessments and treatments, resulting in the progression of the ulcers to more severe stages. Staff were unaware of the resident's condition, and no care plan was developed, highlighting significant lapses in care and communication.
A facility failed to provide adequate urinary catheter care for a resident, as required by their policy. The resident's records showed that catheter care was missed on 80 shifts, and observations revealed a crusty substance at the catheter site. Staff interviews confirmed the site often appeared dirty, indicating a lack of adherence to care protocols.
A resident with a UTI did not receive scheduled doses of Primaxin 500 mg IV due to a failure in obtaining the medication from the pharmacy. The facility's administrator confirmed that the pharmacy did not deliver the antibiotics because of an internal issue, leading to missed doses.
A resident with a UTI did not receive scheduled doses of the prescribed IV antibiotic Primaxin 500 mg on three occasions. The facility's Medication Error Policy mandates reporting and documentation of such errors, but the resident missed doses, which was later confirmed by the resident and the facility administrator.
A resident with a history of sexual aggression was inadequately supervised, resulting in multiple incidents of sexual and physical abuse against other residents. Despite the care plan requiring one-on-one supervision, the resident was left unsupervised, leading to inappropriate contact with several residents, some of whom were severely cognitively impaired. Staff were unaware of the supervision requirements, and no behavior tracking or intervention plan was in place.
A facility failed to implement its abuse prevention policies, resulting in unreported resident-to-resident abuse. A cognitively impaired resident engaged in non-consensual sexual activities with others, but staff did not report these incidents to authorities. The Administrator did not ensure compliance with reporting procedures, leading to ongoing abuse and regulatory non-compliance.
A facility failed to implement its abuse policies, resulting in a resident with a history of sexual aggression having unsupervised access to other residents, leading to multiple incidents of abuse. Despite documented needs for one-on-one supervision, the facility did not provide adequate monitoring or interventions. Staff did not thoroughly investigate or document the allegations, nor did they submit a final report to the State Agency within the required timeframe, allowing the abuse to continue.
The facility failed to protect resident privacy by not addressing the wandering behaviors of two residents, leading to frequent intrusions into other residents' rooms. Despite R8's care plan lacking strategies for his wandering and R38's plan only including general goals, both residents repeatedly entered others' rooms, causing distress. A CNA confirmed these behaviors, indicating a lack of effective interventions to uphold residents' rights to privacy.
Two residents experienced discomfort due to non-functional above-bed lighting and increased room humidity. The lights lacked pull strings, preventing them from being turned off, and a window was left partially open, causing humidity issues. Staff interviews revealed that maintenance was not informed due to a lack of work order submission.
Failure to Notify Resident and Representative of Physician Change
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician by changing the resident's primary care physician without notifying the resident or their representative. According to the facility's Resident Rights Policy, residents are entitled to autonomy and choice regarding their care, including the selection of their physician. The resident was admitted with a specific primary care physician, but the facility switched the resident's physician to the facility's newly hired Medical Director in May 2025. This change was documented in the electronic health record, which showed that the new physician continued to provide care in the following months. Interviews with the resident's family member and representative confirmed that neither was notified, verbally or in writing, about the change in physician. The Assistant Director of Nursing and the Administrator both verified that there was no documentation of notification to the resident or their representative regarding the physician change. The Administrator also stated that the decision to switch all residents to the new Medical Director was made by the facility after the Medical Director was hired.
Failure to Supervise Resident Handling Hot Beverage Resulting in Burn
Penalty
Summary
The facility failed to provide adequate supervision to a resident with moderately impaired cognition and poor safety awareness while handling a hot beverage. The resident, who has a history of chronic medical conditions including COPD, seizures, TIA, cerebral infarction, and unspecified dementia, was given coffee by kitchen staff in an open cup without a lid. The resident, who is dependent on a wheelchair for mobility and requires assistance with transfers and mobility, attempted to self-propel his wheelchair while holding the cup. This resulted in the resident spilling the hot coffee onto his lap, causing burns to his right thigh and knee. Staff interviews confirmed that the resident was frequently seen with coffee and that staff were aware of his impaired safety awareness and cognition. Prior to the incident, the facility did not have a policy regarding the use and supervision of hot beverages. The care plan for the resident did not include interventions such as providing a cup with a lid or staff assistance when handling hot beverages. Multiple staff members, including the CNA, LPN, and DON, expressed concerns about the resident's ability to safely handle hot beverages, noting that he often tilted his cup in his lap while moving in his wheelchair. The lack of a hot beverage policy and failure to implement appropriate supervision or safety measures directly contributed to the resident sustaining a second-degree burn.
Failure to Conduct Post-Fall Assessments and Implement Interventions
Penalty
Summary
The facility failed to follow its own policies and procedures regarding post-fall assessments, injury identification, incident investigation, and implementation of interventions for two residents who experienced falls. In one case, a resident with severe cognitive impairment and multiple medical conditions was found on the floor after an unwitnessed fall. The nursing staff did not conduct a full body assessment prior to moving the resident, and neurological checks were not performed as required by policy. Documentation was incomplete, with missing records of pain assessments, medication administration, and timely notification of the resident's power of attorney and physician. The care plan was not updated promptly to reflect new interventions for skin integrity or fall prevention, and pain management orders from the hospital were not reconciled in the medical record. In another instance, a resident with a history of behavioral issues and recent hospitalization for sepsis experienced a change of plane, interpreted by staff as intentional behavior rather than a fall. As a result, no post-fall assessment, risk management incident report, or follow-up assessments were conducted. The physician and family were not notified, and the event was not documented in the resident's record. Staff interviews revealed a lack of awareness and understanding of the need to document and investigate such incidents, regardless of perceived intent. The facility's investigation into these incidents was limited to direct care staff interviews and did not include a thorough root cause analysis. Staff were not informed of new interventions implemented after the falls, and there was a lack of communication regarding changes to care plans. The deficiencies identified include failure to provide adequate supervision, failure to assess and document post-fall injuries, failure to notify responsible parties, and failure to update care plans and implement interventions to prevent further incidents.
Failure to Report Alleged Abuse to Administrator
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the Administrator as required by its own abuse prevention policy. According to the facility's policy, any employee or agent who becomes aware of abuse or neglect must immediately report the matter to the Administrator or their designee. In this case, a resident reported to a Registered Nurse that two CNAs had hurt her with washcloths. The nurse documented the allegation and reported it to the Director of Nursing (DON) hours later. However, the DON did not report the incident to the Administrator, and both the Administrator and Interim Administrator confirmed they were not informed of the allegation. The failure to report the incident to the appropriate authority resulted in noncompliance with the facility's abuse reporting policy.
Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with diagnoses including cerebral palsy, hypothyroidism, and cerebrovascular disease, who was cognitively intact at the time of the incident. The resident reported to a case manager that a staff member had placed a sock in her mouth. Upon being notified, the Administrator spoke with the resident, who initially denied that the staff member physically placed the sock in her mouth, but later changed her account to confirm the physical act. Despite the facility's policy requiring a comprehensive investigation, including interviews with all relevant staff and residents, formal written statements, assessment for injury by nursing, and a trauma-informed care assessment by Social Services, these steps were not completed. The Administrator only spoke with the resident and the two staff members involved, without obtaining formal statements or conducting broader interviews. No assessment for injury or trauma was performed, and Social Services was not involved in the investigation process. The Administrator acknowledged that the investigation was lacking and did not follow the facility's established procedures for abuse allegations. The failure to conduct a thorough investigation and to document appropriate actions as outlined in the facility's policy resulted in a deficiency related to the facility's response to an alleged violation of resident rights.
Failure to Document Ongoing Clinical Assessments
Penalty
Summary
The facility failed to perform ongoing clinical assessments for a resident experiencing an acute medical condition. The resident, who was admitted to the facility with a history of COPD, asthma, diabetes mellitus, chronic kidney disease, and a recent cerebrovascular infarction, was not assessed or documented on for two days following their admission. The facility's policy requires documentation every shift for new admissions, but no nursing assessments or progress notes were recorded for the resident on 2/6/2025 and 2/7/2025. The resident was admitted to the facility from the hospital with symptoms including decreased appetite, shortness of breath, and wheezing, and was placed on a pureed diet with nectar thick consistency due to speech difficulties. Despite these conditions, the facility did not document any skilled care assessments during the critical period leading up to the resident's transfer back to the hospital due to decreased oxygen levels, altered mental status, and elevated temperature. The Director of Nurses confirmed the lack of documentation and acknowledged that the nurses were not performing necessary assessments.
Failure to Provide Correct Textured Diet to Resident with Dysphasia
Penalty
Summary
The facility failed to provide the correct textured diet to a resident with a documented diagnosis of dysphasia. The resident, who had a history of cerebral infarction, dysphasia, aphasia, diabetes mellitus, chronic kidney disease, and influenza A, was admitted to the facility following a hospital stay where they were placed on a pureed diet with nectar thick consistency liquids. Upon admission to the facility, the resident's physician order sheet and diet order form both specified a pureed diet with nectar thick liquids. However, shortly after the resident's admission, their granddaughter, who is also their power of attorney, observed that the resident was served a meal tray that did not comply with the prescribed diet. The tray contained whole white bread with diced meat and shredded cheese, along with regular consistency cranberry juice and water. The resident began consuming the incorrect meal and subsequently choked. The granddaughter reported the incident to a Licensed Practical Nurse, who confirmed that the resident had been given the wrong diet and fluids, acknowledging the error upon reviewing the resident's medical records.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by observations of significant buildup of dust, grease, and food debris in various areas of the kitchen. The pass-through window over the steam table wells, the microwave, and storage bins containing flour, sugar, brown sugar, and oats were all found to be dirty and unlabeled. Food carts and kitchen equipment such as burners, ovens, and convection ovens were also observed to have old food splatters and grease buildup. The Dietary Manager acknowledged the need for extensive cleaning. Additionally, the facility did not properly label and date food items in storage, leading to confusion about the freshness and safety of the food. The walk-in refrigerator contained several food items with unclear labeling, including pans of barbeque pork, Swiss steak, and puddings, as well as various dairy products and condiments without open dates. Some items were found to be past their expiration dates, and others were covered in mold. The Dietary Manager admitted that the labeling system was not being followed correctly. The facility also failed to adhere to proper food cooling and thawing procedures. The Food Cooling Log showed inconsistencies and inaccuracies, with identical start times and temperatures recorded for different food items, suggesting a lack of proper monitoring. A case of supplements was found thawing in the refrigerator without a thaw date, indicating a lack of awareness of the required procedures. Furthermore, the walk-in freezer and refrigerator had issues with leaking substances, which were not adequately addressed, posing a risk of contamination to stored food items.
Discrepancy in CPR Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's Physician Orders matched their Practitioner Order for Life-Sustaining Treatment (POLST) regarding Cardio-Pulmonary Resuscitation (CPR) code status. Specifically, for one resident reviewed for Advanced Directives, the Physician Orders indicated a 'Full Code' status, while the POLST form, signed by the resident's Power of Attorney, Medical Director, and Care Plan Coordinator, documented a 'Do Not Resuscitate' (DNR) status with selective treatment only. The Assistant Director of Nursing acknowledged the discrepancy, stating responsibility for ensuring the Physician Orders align with the POLST form, and admitted to missing the inconsistency in the resident's November Physician Orders.
Failure to Implement Dietary Recommendations and Monitor Nutritional Status
Penalty
Summary
The facility failed to adhere to a dietician's recommendations and physician orders regarding nutritional supplements for two residents, leading to deficiencies in their care. Resident R66 experienced a significant weight loss of 15.03% over six months, from 153 pounds in May 2024 to 130 pounds in November 2024. Despite the dietician's recommendations for Med Pass supplements to address this weight loss, these orders were not processed by the nursing staff. The dietary recommendations were delayed in being sent to the physician due to the dietary manager's absence, and once signed by the physician, they were not implemented by the nursing staff. Additionally, Resident R43, who was admitted with a gastric tube and diagnoses of dehydration, severe protein-calorie malnutrition, and hypernatremia, did not have their weekly weights recorded as ordered by the physician. The facility's records show only one weight recorded for October 2024, despite the requirement for weekly weight monitoring. The Director of Nursing and Assistant Director of Nursing confirmed the lack of documentation for R43's weekly weights, indicating a failure to monitor the resident's nutritional status adequately. These deficiencies highlight a breakdown in communication and process within the facility, where dietary recommendations and physician orders were not effectively communicated or implemented. The absence of a care plan for R66's unplanned weight loss and the failure to conduct weekly weight assessments for R43 demonstrate lapses in the facility's adherence to its own policies and procedures for monitoring and addressing residents' nutritional needs.
Failure to Comply with Oxygen and Nebulizer Equipment Management
Penalty
Summary
The facility failed to adhere to its Oxygen Administration Policy by not dating oxygen tubing, not placing oxygen signs on resident doors, and not changing nebulizer facemasks and tubing weekly for three residents receiving oxygen therapy. Resident R5, who has diagnoses including congestive heart failure and diabetes, was observed with undated oxygen tubing and no oxygen sign on the door. The tubing was last documented as changed over a week prior. Similarly, Resident R56, with conditions such as morbid obesity and hypertension, was found with undated oxygen tubing and no sign on the door, with no documentation of the last tubing change. Both residents were confirmed by an LPN to be on oxygen without the required signage. Resident R34, who has an order for Albuterol nebulizer treatment, was found using a nebulizer facemask dated over a month prior, contrary to the policy of weekly changes. The Director of Nursing confirmed that the equipment should be changed weekly and dated accordingly. These observations indicate a failure to comply with the facility's policy on oxygen and nebulizer equipment management, potentially impacting the quality of care provided to the residents.
Failure to Attempt Gradual Dose Reduction of Olanzapine
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) of Olanzapine for a resident diagnosed with Bipolar Disorder, who was being monitored for paranoid thoughts/behaviors. Despite the facility's policy requiring GDRs to be attempted at least twice a year unless clinically contraindicated, the resident had not experienced any episodes of paranoid thoughts/behaviors over a nine-month period, as documented in behavior tracking sheets. The resident's psychiatric note indicated that a GDR was clinically contraindicated at the time, yet the facility did not attempt a reduction in the past year. The Assistant Director of Nursing confirmed that the resident had not undergone a GDR of Olanzapine in the last twelve months. The facility had recently started with a new psychiatric service, but it was unclear why a reduction was not attempted in October. The facility's failure to attempt a GDR as per their policy led to the deficiency noted in the report.
Infection Control Deficiencies in Incontinence and Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during the provision of incontinent care and the implementation of Enhanced Barrier Precautions (EBP) for two residents. For one resident, identified as R5, the facility's staff did not change gloves or perform hand hygiene while providing incontinent care. This resident, who was admitted with conditions including morbid obesity and heart failure, was dependent on staff for toileting and occasionally incontinent of bowel and bladder. During an observation, a Certified Nursing Assistant (CNA) removed a soiled brief and cleaned the resident without changing gloves or sanitizing hands, contrary to the facility's incontinence care policy. Another resident, identified as R56, was not placed under Enhanced Barrier Precautions despite having multiple wounds, including a full-thickness abdominal wound and wounds on both ankles. The resident's care plan required daily dressing changes, yet staff did not wear gowns during wound care, and there was no PPE or signage indicating EBP outside the resident's room. The Wound Physician and Wound Nurse both failed to wear gowns while assessing and dressing the wounds, which is a requirement under the facility's EBP policy for residents with open wounds. The Assistant Director of Nursing confirmed that the staff did not follow the EBP protocol for R56, as they were unaware that all wounds required such precautions. This lack of adherence to infection control measures highlights a significant deficiency in the facility's implementation of its own policies, potentially increasing the risk of cross-contamination and infection spread among residents.
Failure to Document Advanced Directives Leads to Critical Incident
Penalty
Summary
The facility failed to formulate and document Advanced Directives for five out of six residents reviewed, leading to a critical incident involving a resident who was found unresponsive. The resident, who had no documented Advanced Directives, was not provided CPR by the staff, despite the absence of a Do Not Resuscitate (DNR) order. The resident's family later confirmed that the resident had expressed a desire to be resuscitated, which was not honored due to the lack of documentation. The facility's policies require that upon admission, residents are informed of their rights to accept or refuse medical treatment and to formulate an advance directive. However, this process was not completed for several residents, including the one who passed away without receiving CPR. The staff involved were unaware of the resident's code status due to incomplete documentation, resulting in a failure to initiate life-saving measures. Interviews with staff revealed a lack of understanding and communication regarding the responsibility for documenting and acting upon Advanced Directives. The admitting nurse did not complete the necessary documentation, and the nurse who found the resident unresponsive did not perform CPR, citing the absence of Advanced Directives in the resident's chart. This oversight led to an Immediate Jeopardy situation, highlighting significant gaps in the facility's adherence to its own policies and procedures.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to adhere to its own policies regarding pressure ulcer prevention and care, resulting in the deterioration of a resident's heel pressure ulcers. The resident, identified as R7, was at high risk for pressure ulcers according to the Braden Scale assessments conducted in March 2024. Despite this, the facility did not implement necessary interventions such as providing a pressure-relieving cushion, turning and repositioning the resident every two hours, or using heel protectors. Furthermore, the facility did not conduct the required weekly Braden Scale assessments or daily skin checks, as evidenced by missing documentation in the resident's medical records. The facility's Treatment Administration Records (TARs) and Physician's Order Sheets (POSs) indicated that R7 did not receive daily skin checks on 24 occasions and weekly skin documentation was only completed once between March and July 2024. Additionally, the physician-ordered skin prep treatment for R7's heels was not administered 82 times during this period. The facility also failed to document the turning and repositioning of R7 every two hours as ordered by the physician. These lapses in care contributed to the progression of R7's heel pressure ulcers from stage one to an unstageable ulcer on the right heel and a stage three ulcer on the left heel. Observations and interviews further highlighted the facility's deficiencies. On multiple occasions, R7 was found lying in bed without heel protection or dressings on the pressure ulcers, and staff were unaware of the resident's treatment needs. The hospice nurse reported that R7 was not being turned or repositioned by facility staff, and the Assistant Director of Nursing and Care Plan Coordinator were unaware of R7's pressure ulcers. The lack of communication and documentation resulted in the absence of a pressure ulcer care plan and appropriate interventions for R7, ultimately leading to the deterioration of the resident's condition.
Failure to Provide Adequate Urinary Catheter Care
Penalty
Summary
The facility failed to maintain proper urinary catheter care for a resident, identified as R7, who was part of a sample of 13 residents reviewed for urinary catheter care. The facility's policy, dated 10-7-22, outlines the necessity of providing catheter care every shift to prevent catheter-associated urinary tract infections. However, R7's Treatment Administration Records (TARs) from 5-16-24 to 7-31-24 indicate that catheter care was not provided on 80 shifts during this period. This lack of care was confirmed by the facility administrator. Observations and interviews further highlighted the deficiency. On 7-27-24, R7 was observed with a crusty brown substance at the catheter insertion site, indicating inadequate cleaning. A hospice nurse and a certified nursing assistant both reported that R7's catheter site often appeared dirty and uncleaned, with dried yellowish drainage. These observations and statements corroborate the failure to adhere to the facility's catheter care policy, resulting in inadequate care for R7.
Failure to Administer Scheduled IV Antibiotics
Penalty
Summary
The facility failed to provide scheduled IV antibiotics to a resident diagnosed with a urinary tract infection. The physician's order required Primaxin 500 mg IV to be administered every six hours. However, the medication administration records show that the resident did not receive the scheduled doses on three occasions. The resident confirmed missing several doses and was informed by the staff that the antibiotics were not delivered from the pharmacy. The facility administrator acknowledged the issue, stating that the pharmacy failed to send the IV antibiotics due to an internal issue with their system, resulting in the missed doses.
Failure to Administer Prescribed IV Antibiotic
Penalty
Summary
The facility failed to administer a physician-ordered intravenous antibiotic to a resident diagnosed with a urinary tract infection. The resident, identified as R8, was prescribed Primaxin 500 mg IV every six hours to treat an infection caused by Extended B-Lactamase E. Coli. However, the medication administration records indicate that the scheduled doses on July 23, 2024, at 2:00 AM, 8:00 AM, and 2:00 PM were not administered. The facility's Medication Error Policy requires nursing personnel to report and document any medication errors, including notifying the attending physician and the resident's power of attorney. Despite this policy, the resident missed several doses of the prescribed antibiotic, as confirmed by the resident and the facility administrator. This oversight was identified during a review of the resident's medication administration records and was acknowledged by the facility administrator, who completed a medication error report.
Failure to Supervise Resident Leads to Multiple Abuse Incidents
Penalty
Summary
The facility failed to adequately supervise a resident with a history of sexual aggression, leading to multiple incidents of resident-to-resident sexual and physical abuse. The resident, who was diagnosed with sexual aggression, dementia with behavioral disturbances, anxiety, and major depression disorder, was not provided with the one-on-one supervision as outlined in their care plan. This lack of supervision allowed the resident to engage in inappropriate sexual contact with several other residents, some of whom were severely cognitively impaired and unable to consent or defend themselves. The incidents involved the aggressive resident sexually assaulting three residents on multiple occasions, groping another resident, and physically assaulting yet another. Despite the care plan specifying the need for constant supervision and behavioral interventions, these measures were not implemented or tracked effectively. Staff interviews revealed that the aggressive resident had been left unsupervised, and there was a lack of awareness among staff about the resident's history and care plan requirements. The facility's failure to implement and monitor the necessary interventions and supervision led to an Immediate Jeopardy situation. The staff, including the administrator, were unaware of the resident's need for one-on-one supervision, and there was no behavior tracking or intervention plan in place to address the resident's inappropriate behaviors. This oversight resulted in repeated incidents of abuse, highlighting significant lapses in the facility's abuse prevention and resident supervision protocols.
Removal Plan
- V1 is no longer employed by the facility.
- R1 was placed on one-on-one staff supervision at all times to prevent recurrence.
- An audit tool was developed and implemented to ensure all staff provide one-on-one staff supervision to R1 indefinitely and is being reviewed by V2 daily to ensure compliance.
- R1's care plan was reviewed and updated with behavioral interventions to address R1's sexually aggressive behaviors towards other residents.
- The IDT met to discuss discharge planning for R1 to a more appropriate setting.
- All staff were in-serviced on the facility's Abuse Policy and providing adequate supervision of residents to prevent further abuse by V7 (Corporate Manager).
- Department supervisors conducted an abuse assessment on all residents to screen all residents for potential abuse, concerns, or incidences.
- V20 (Administrator-In-Training) submitted initial abuse reports for R1, R2, R5, R6, R10, and R11 to the state agency.
- V13 (Social Service Director) completed assessments to address psychosocial needs of R1, R2, R5, R6, R10, and R11.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program policies and procedures, resulting in the failure to identify and report resident-to-resident suspected crimes and abuse immediately to the appropriate authorities. This deficiency involved six residents who were subjected to further criminal sexual and physical assault by another resident. The facility's policy required immediate reporting of any potential or alleged mistreatment, exploitation, neglect, and abuse to a supervisor and the Administrator, as well as contacting the police in cases of physical sexual contact. However, these protocols were not followed, leading to an Immediate Jeopardy situation. The incidents involved a resident who was severely cognitively impaired and engaged in non-consensual sexual activities with other residents. Staff members, including CNAs and LPNs, witnessed or were informed of these incidents but failed to report them to the police, the residents' families, or the state agency. The Administrator, who was responsible for ensuring compliance with the abuse policy, did not take appropriate action to investigate or report these incidents. As a result, the affected residents continued to be exposed to the perpetrator, who admitted to engaging in sexual activities with multiple residents. Interviews with staff and residents revealed a lack of awareness and confusion about the reporting process and the identity of the Abuse Coordinator. Several staff members did not know who to report the incidents to, and there was no documentation of investigations or notifications to the relevant authorities. The facility's failure to follow its abuse policy and ensure staff were informed and trained on reporting procedures contributed to the ongoing abuse and the facility's non-compliance with regulatory requirements.
Removal Plan
- V1 is no longer employed by the facility.
- A mandatory All-Staff meeting was held by V7 (Corporate Manager) to educate staff on the Abuse Program and to ensure all staff are informed of who the Abuse Coordinator is and the process for reporting allegations of abuse. Those staff, including agency staff, not in attendance at this training will be in-serviced by a department head prior to their next scheduled shift.
- V20 (Administrator-In-Training) submitted initial abuse reports for R1, R2, R5, R6, R10, and R11 to the State Agency.
- V20 notified R1, R2, R5, R6, R10, and R11's family representatives of all allegations of abuse.
- V20 notified the police of all allegations of abuse of R1, R2, R5, R6, R10, and R11.
Failure to Implement Abuse Policies Leads to Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policies and procedures effectively, resulting in multiple incidents of sexual and physical abuse by a resident with a history of sexual aggression and severe cognitive impairment. The resident, identified as R1, had unsupervised access to other residents, leading to repeated assaults on several residents, including R2, R5, R6, R10, and R11. Despite R1's documented history of sexual inappropriateness and the need for one-on-one supervision, the facility did not provide adequate monitoring or interventions to prevent further abuse. The facility's staff, including the administrator and director of nursing, did not thoroughly investigate the allegations of abuse or implement measures to ensure the safety and supervision of residents during the investigation. Reports of R1's inappropriate behavior were not properly documented or addressed, and the facility failed to submit a final report of the investigation to the State Agency within the required five working days. This lack of action allowed R1 to continue having unsupervised access to other residents, exacerbating the risk of further abuse. Interviews with staff and residents revealed a pattern of neglect in addressing R1's behavior. Staff members were aware of R1's actions but did not take appropriate steps to separate R1 from other residents or increase supervision. The facility's failure to act on these reports and implement effective interventions contributed to the ongoing risk and occurrence of abuse, resulting in an Immediate Jeopardy situation.
Removal Plan
- V1 is no longer employed by the facility.
- R1 was placed on one-on-one staff supervision at all times to prevent recurrence.
- An audit tool was developed and implemented to ensure all staff provide one-on-one staff supervision to R1 indefinitely and is being reviewed by V2 daily to ensure compliance.
- R1's care plan was reviewed and updated with behavioral interventions to address R1's sexually aggressive behaviors towards other residents.
- The IDT met to discuss discharge planning for R1 to a more appropriate setting.
- A mandatory All-Staff meeting was held by V7 (Corporate Manager) to educate staff on the Abuse Program and to ensure all staff are informed of who the Abuse Coordinator is and the process for thoroughly investigating all allegations of abuse, protecting residents from abuse while the investigation is underway, and reporting to IDPH with a five-day final report. Those staff, including agency staff, not in attendance at this training will be in-serviced by a department head prior to their next scheduled shift.
- V20 (Administrator-In-Training) submitted final abuse reports for R1, R2, R5, R6, R10, and R11 to the State Agency.
- Department supervisors conducted an abuse assessment on all residents to screen all residents for potential abuse, concerns, or incidences.
- V13 (Social Service Director) completed assessments to address psychosocial needs of R1, R2, R5, R6, R10, and R11.
Failure to Address Wandering Behaviors Infringes on Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by not adequately addressing the wandering behaviors of two residents, identified as R8 and R38. R8's care plan did not include any strategies to manage his wandering behavior, while R38's care plan acknowledged impaired cognition and wandering due to Lewy Body Dementia but only included general goals of supervision and redirection. This lack of specific interventions led to multiple incidents where these residents entered the rooms of other residents, infringing on their privacy. Several residents reported frequent and unwanted intrusions by R8 and R38. For instance, R3 experienced an intrusion by R8, who entered his room and bathroom, despite R3's protests. Similarly, R4, R46, and R47 expressed discomfort and frustration over R8 and R38 entering their rooms uninvited, with R46 noting that R8 entered his room about ten times a day. A CNA confirmed that both R8 and R38 were known to wander into other residents' rooms, and staff attempted to redirect them when possible. These incidents highlight the facility's failure to implement effective measures to protect residents' rights to privacy and a homelike environment as outlined in their Residents' Rights policy.
Failure to Maintain Comfortable and Homelike Environment
Penalty
Summary
The facility failed to ensure that the above-bed lighting was in working condition and that room temperatures were kept at comfortable levels for two residents. During an observation, it was noted that both residents' above-bed lights were missing pull strings, making it impossible for them to turn the lights on or off. One resident expressed difficulty sleeping due to the lights being on all night. Additionally, the window in their room was found to be unlocked and partially open, allowing outside air to enter and causing increased humidity and discomfort. Interviews with staff revealed that the maintenance director was unaware of the issue because a maintenance work order slip had not been filled out. The administrator-in-training acknowledged the problem and indicated that new switches were needed for the lights. A CNA confirmed that the lights had been on continuously, even during the night, due to the missing pull strings. The facility's failure to address these issues resulted in an environment that was not safe, clean, comfortable, or homelike, as required by their Residents' Rights policy.
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 50 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Graham Hospital | 0.3 mi | — | 9 | 0 |
| Renaissance Care Center | 1.5 mi | — | 1 | 0 |
| Loft Rehab & Nursing Of Canton | 2.7 mi | — | 1 | 0 |
| Clayberg, The | 9.5 mi | — | 0 | 0 |
| Farmington Village Nrsg | 9.5 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.