Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunset Lake Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors observed dietary staff using unsanitary practices, including using a cut glove stored in a back pocket without proper cleaning, applying hand sanitizer to the glove instead of cleaning it, and performing hand hygiene for less than the required time. Staff also used the dishwashing sink for handwashing and demonstrated a lack of understanding of proper hand hygiene standards.
Two residents with severe cognitive and physical impairments did not receive necessary assistance with hygiene, dressing, and incontinence care. Staff were observed leaving one resident in food-stained clothing and soiled bedding for extended periods, while another resident's family member had to change a saturated brief after staff failed to respond to repeated requests for help. Documentation and interviews confirmed that required ADL support was not provided.
Two residents with documented preferences for music, religious services, and group activities were not consistently offered or assisted to participate in these activities, despite care plans and facility policy requiring individualized engagement. Both residents were frequently observed alone in their rooms without access to preferred activities, and activity logs showed minimal participation or one-on-one engagement.
A resident with a history of falls and cognitive impairment experienced multiple unwitnessed and witnessed falls over several months, despite various care plan interventions. The resident was housed in a room far from the nurses' station, left unsupervised, and exposed to environmental hazards such as a broken fan on the floor. Staff were aware of the frequent falls and cognitive issues but did not implement increased supervision or frequent checks, and safety equipment was not consistently used.
Multiple residents reported prolonged wait times for call light responses, with some waiting up to an hour for assistance and experiencing discomfort or unmet care needs. Staff interviews confirmed expectations for prompt response, but residents consistently cited staffing shortages as the reason for delays. Documentation of call light audits was withheld from surveyors by the administrator.
Staff did not follow infection prevention protocols for two residents with PICC lines, failing to change dressings as ordered and lacking proper documentation of dressing changes. Additionally, staff providing care to a resident on enhanced barrier precautions did not wear required PPE, such as gowns, during high-contact care activities, despite being aware of the protocols and signage. The DON acknowledged that PPE supply location may have contributed to staff non-compliance.
A newly admitted resident with diabetes, a recent fall, and a history of wounds did not receive a resident-centered baseline care plan within 48 hours of admission. The baseline care plan incorrectly documented no wounds, as a full skin assessment was not performed due to the resident's refusal to remove dressings. Staff and family later identified and addressed wounds that were not initially care planned, and the DON acknowledged the care plan's lack of resident-specific information.
A resident with left-sided contracture and hemiplegia did not consistently receive prescribed splinting for the hand and knee, as required by physician orders. Observations showed the resident was often without the necessary splints, and when applied, the hand splint was frequently positioned incorrectly. Staff interviews revealed confusion about the orders and inconsistent knowledge of proper application, and there were no written instructions available for staff. This resulted in a failure to provide appropriate care to maintain or improve the resident's range of motion.
During an emergency evacuation for a hurricane, a facility failed to protect residents from neglect, resulting in serious harm. Residents were transported without necessary medications, food, or hydration, and staff support was inadequate. The facility's emergency plan was not effectively implemented, leading to widespread neglect and immediate jeopardy to residents' health and safety.
During an emergency evacuation due to a hurricane, the facility failed to ensure the safety and proper care of residents, resulting in serious harm. A resident with fractures was laid across bus seats, causing severe pain; another wheelchair-bound resident sustained an ankle fracture during improper transport; and an oxygen-dependent resident experienced respiratory distress due to lack of a CPAP machine. The facility's emergency plan was not effectively implemented, and necessary medications were not provided.
The facility failed to effectively utilize resources and implement an emergency plan during a hurricane evacuation, resulting in serious harm to residents. A resident suffered fractures due to improper transport, another was evacuated without necessary medical equipment, and many residents missed medications. The facility lacked contingency plans and adequate staff training, leading to a chaotic evacuation process.
The facility failed to implement corrective actions for deficiencies in staff training and competency during an emergency evacuation ahead of a hurricane. Inadequate transportation and lack of nursing staff on transport vehicles led to multiple residents suffering harm, including severe pain, fractures, and respiratory distress. The facility's Emergency Preparedness Plan was not effectively implemented, and no corrective actions were discussed in QAPI meetings following the incident.
The facility's assessment was incomplete, lacking input from listed contributors, including key staff and a resident. Interviews revealed that the Activities Director, Director of Housekeeping, and others were unaware of the assessment process. Additionally, the assessment did not document how staff were informed about the Comprehensive Emergency Management Plan (CEMP), as confirmed by the Administrator.
A facility failed to ensure that three nurses were trained and competent in checking the function of wander alert bands, leading to a resident with cognitive impairment being found outside the facility. The resident was wearing a wander alert bracelet, but staff only checked its placement, not its functionality. Documentation showed inaccurate records of functionality checks, and there was no training or competency documentation for the staff involved.
A resident was injured during an evacuation when therapy staff physically lifted them off a bus without a mechanical lift, resulting in a fracture. The facility failed to report the incident to the appropriate authorities as required by state law.
Improper Sanitation and Food Handling Practices Observed in Kitchen
Penalty
Summary
Multiple instances of improper sanitation and food handling practices were observed in the facility's kitchen. Dietary staff were seen using a cut-resistant glove that was stored in a back pocket and not sanitized before use, with hand sanitizer being applied to the glove instead of proper cleaning. Staff also performed hand hygiene for less than the required duration, with some using the 3-compartment sink intended for dishwashing rather than the designated handwashing sink. These actions were directly observed during food preparation and after handling garbage. Interviews with dietary staff revealed a lack of understanding regarding the correct handwashing duration, with one staff member stating that 10 seconds was sufficient. The culinary manager acknowledged that the use of hand sanitizer on gloves and improper handwashing practices were not in accordance with professional standards and facility policy. The observations and staff interviews indicate that the facility failed to ensure food was prepared and handled in accordance with professional standards for food service safety.
Failure to Provide Adequate ADL Support and Hygiene
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living (ADLs) for two residents who required substantial help due to severe cognitive and physical impairments. One resident, admitted with diagnoses including stroke, hemiplegia, aphasia, and muscle weakness, was observed multiple times over two days wearing the same food-stained blouse and lying in soiled bedding. Staff were seen attempting to feed the resident while she was not fully alert, resulting in food spilling onto her clothing and bedding, which were not changed afterward. Incontinence care was provided without changing the soiled linens, and staff admitted unfamiliarity with the residents due to being assigned to a different unit. Another resident with severe dementia, pneumonia, spinal fracture, and atrial fibrillation was found by his daughter in a completely soaked incontinent brief, which she had to change herself after multiple unsuccessful attempts to get staff assistance. The resident was also observed wearing the same shirt over several days, with documentation indicating no staff assistance was provided for dressing or toileting, despite care plans identifying a need for hands-on help. Staff interviews revealed a lack of knowledge about the residents' care needs, with some staff stating they did not usually work in the assigned hallway and were unsure if residents' clothing or bedding had been changed. Documentation and direct observations confirmed that both residents did not receive necessary hygiene, dressing, and incontinence care as required by their conditions and care plans. The facility's failure to provide appropriate ADL support resulted in residents remaining in soiled clothing and bedding, and in one case, a family member having to intervene to address basic care needs.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of two residents, as required by their own policy and federal regulations. Both residents had documented preferences and care plan interventions indicating the importance of activities such as music, religious services, group events, and social interaction. Despite these documented needs, observations over several days showed that both residents spent extended periods in their rooms, often in bed, with no music, television, or engagement in preferred activities. Activity calendars indicated that relevant group activities were scheduled, but the residents were not consistently offered assistance to attend or participate. One resident, with a history of major depressive disorder and moderately impaired cognitive skills, expressed a strong interest in music, religious activities, and group events. However, he reported that staff did not routinely invite him to activities or assist him in getting out of bed, and he was observed missing several activities he had identified as important. Documentation showed limited participation in activities over a period of weeks, with only a few conversation visits and minimal engagement in group or preferred activities. The second resident, who was on hospice and had severe cognitive impairment, primarily spoke Polish and required assistance and cues to participate in activities. Her care plan noted a preference for music and religious activities, but she was observed alone in her room with the television off during scheduled activities. Activity logs indicated infrequent and brief one-on-one visits, and no group activity participation was documented in the previous month. Staff interviews confirmed language barriers and limited engagement, despite the resident's expressed preferences for certain activities.
Failure to Provide Adequate Supervision and Safe Environment for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision to prevent multiple falls for a resident with a significant history of falls and cognitive impairment. The resident, who had previously been hospitalized for multiple falls following a craniotomy, continued to experience frequent unwitnessed and witnessed falls after admission to the facility. Despite the implementation of various care plan interventions such as reminders to use the call light, placement of signs, medication reviews, and environmental adjustments, the resident sustained 14 falls over several months. Many of these falls were unwitnessed, and the interventions did not include increased supervision or frequent checks, even though the resident was known to be non-compliant with safety reminders and had memory deficits. Observations revealed that the resident was housed in a room located at the far end of the hallway, away from the nurses' station and staff visibility, and was often left unsupervised. The resident did not participate in therapy sessions, group activities, or supervised outdoor time, and typically remained in the room with a roommate. Environmental hazards, such as a broken fan on the floor, were present in the resident's room for several days and were not removed despite being identified as a tripping hazard. Additionally, safety equipment such as fall mats and side rails were not consistently in use, and required signage was missing from the room. Interviews with staff confirmed awareness of the resident's frequent falls and cognitive challenges, but no interventions to increase supervision were implemented until after the survey observations. Staff acknowledged that the resident was not listed for frequent checks and that the room location was not optimal for monitoring. The DON confirmed that interventions had not been effective in preventing falls and that incident reporting for the resident's falls had ceased. The lack of increased supervision and failure to address environmental hazards contributed to the ongoing risk and occurrence of falls for the resident.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and observations. Several residents reported extended wait times for call light responses, with some waiting 15 to 60 minutes for assistance. One resident described being left on a bedpan for over an hour, resulting in numbness and discomfort, while another reported having to keep a partially filled urinal at the bedside due to delayed staff response. Residents consistently stated that staff told them the facility was short-staffed, and that call light response times varied depending on the day and staff present. Photographic evidence was obtained to support these claims. Staff interviews confirmed that call lights should be answered within 3 to 5 minutes, and the DON stated that the facility staffs based on census and acuity, never going below certain staffing thresholds. Despite this, residents continued to experience delays. The DON also indicated that all staff, including non-nursing departments, are expected to answer call lights, and that call light audits and ambassador rounds are conducted. However, when surveyors requested documentation of these audits, the administrator withheld the forms, stating the survey team was not permitted access.
Failure to Follow Infection Control Protocols for PICC Lines and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols for residents with peripherally inserted central catheters (PICCs) and those on enhanced barrier precautions (EBP). For one resident with a PICC line, the dressing was not changed as ordered, with the dressing remaining in place since hospital admission and not being changed by facility staff, despite ongoing intravenous antibiotic administration. Documentation indicated the dressing had been changed, but the nurse later admitted this was not accurate. The Director of Nursing confirmed that the facility policy requires dressing changes every 5-7 days, and that documentation should not be completed before the task is performed. Another resident with a PICC line for antibiotic infusion also did not have dressing changes documented as required by physician orders. Observation revealed the dressing was outdated, and the Unit Manager stated she could not determine when it was last changed due to lack of documentation. The Unit Manager subsequently changed the dressing and implemented a plan to perform all PICC dressing changes on the same day to avoid confusion, but prior to this, the required infection control interventions were not followed. Additionally, staff did not adhere to EBP protocols for a resident with a suprapubic catheter and multiple chronic wounds. Staff were observed providing high-contact care activities, such as toileting, dressing, and transferring the resident, without donning the required gown, despite EBP signage and available PPE supplies. Both the CNA and LPN involved acknowledged they did not wear gowns as required. The DON noted that staff had been educated on EBP but recognized that the location of PPE supplies may have contributed to non-compliance.
Failure to Develop and Communicate Resident-Centered Baseline Care Plan
Penalty
Summary
The facility failed to develop and communicate a resident-centered baseline care plan to address the immediate needs of a newly admitted resident within 48 hours of admission, as required by policy. The resident, who had a history of a recent fall, adjustment disorder, type 2 diabetes, and congestive heart failure, was admitted with intact cognition and no skin conditions noted on the initial evaluation. However, the baseline care plan incorrectly indicated that the resident did not have any wounds, despite the presence of dressings on the coccyx and bilateral heels. Staff interviews revealed that the admitting nurse did not perform a full skin assessment due to the resident's refusal to remove hospital dressings after a long commute, and documented 'no wounds' on the baseline care plan because the form did not allow for additional comments. Further review showed that the resident and family expressed concerns about the lack of preparation for the resident's diabetic dietary needs and wound care. The wound care nurse later identified and treated wounds on the coccyx and heels, including a deep tissue injury and excoriation, which were not initially care planned. Staff interviews confirmed that the baseline care plan was not updated to reflect the resident's actual condition, and the DON acknowledged the limitation of the form and the need for resident-specific care planning, particularly regarding wounds.
Failure to Provide Proper Splint Application and ROM Care
Penalty
Summary
A deficiency was identified when a resident with a history of left hand contracture, hemiplegia, hemiparesis, and left knee stiffness did not receive appropriate care and services to maintain or improve range of motion (ROM) as ordered. Physician orders specified the use of a knee extension splint for the left knee and a resting hand splint for the left hand, with clear instructions on application times and monitoring of skin integrity. Despite these orders, multiple observations revealed that the resident was frequently not wearing the prescribed splints, and when the hand splint was applied, it was often done incorrectly, with the hand roll positioned at the wrist instead of the palm. Staff interviews indicated a lack of awareness and understanding regarding the resident's splint orders. Some staff members were unaware of the need for a knee splint, and others did not know the current status of the orders. The Director of Therapy confirmed that staff are instructed and demonstrated on how to apply the devices, but there were no written instructions or photos available for this resident. The Director of Therapy also noted that the resident experienced discomfort with the leg splint, but the physician's order remained active and was not updated until therapy was completed. Documentation review showed that the CNA Kardex included instructions for both splints, yet these were not consistently followed. Observations over several days confirmed repeated failures to apply the splints as ordered, and when applied, the devices were not positioned correctly. This lack of adherence to physician orders and improper application of splints contributed to the facility's failure to provide appropriate care and services to prevent a decline in the resident's range of motion.
Neglect During Emergency Evacuation
Penalty
Summary
The facility failed to protect residents from neglect during an emergency evacuation ahead of a major hurricane. The evacuation involved 112 residents, with 96 traveling approximately 197 miles over eight hours to two receiving facilities. During this transfer, the facility neglected to ensure that residents received necessary medications, food, or hydration, and failed to provide adequate staff support during transport. This resulted in several residents suffering serious harm, including a resident with multiple fractures who was improperly laid across two seats on a bus without access to pain medication, and another resident who sustained an open ankle fracture when being carried off the bus. The facility's Comprehensive Emergency Management Plan (CEMP) was not effectively implemented, as evidenced by the lack of contingency planning for transportation and the failure to ensure staff accompanied residents during the evacuation. The plan required that medications travel with residents and that staff remain with them throughout the evacuation process, but these protocols were not followed. The facility's contracted transport companies were unable to provide the necessary equipment, such as mechanical lifts, and the facility did not have a backup plan in place. As a result, residents were transported inappropriately, and many did not receive their prescribed medications, including insulin, antibiotics, and pain management drugs. Interviews with staff and residents revealed a chaotic evacuation process, with insufficient staff to provide care and administer medications. Residents reported being left without food, water, or necessary medical equipment, such as CPAP machines and oxygen, leading to severe health complications. The facility's administration failed to ensure that the evacuation was conducted safely and in accordance with the CEMP, resulting in widespread neglect and immediate jeopardy to the residents' health and safety.
Inadequate Emergency Evacuation Procedures Lead to Resident Harm
Penalty
Summary
The facility failed to ensure the safety and proper care of residents during an emergency evacuation due to a hurricane. This deficiency affected all 112 residents evacuated, with specific incidents involving three residents who suffered due to inadequate transportation and supervision. The facility did not have appropriate processes in place to manage the evacuation, resulting in serious harm to the residents. One resident with multiple fractures and a neck brace was inappropriately laid across two seats on a coach bus for a long journey, causing severe pain. Another resident, who was wheelchair-bound and required a full body mechanical lift, was improperly transported on a coach bus and sustained an open ankle fracture when staff physically carried her off the bus. Additionally, a resident who was oxygen-dependent and required a CPAP machine was laid flat on a mattress on the floor, leading to respiratory distress and an emergency hospital transfer. The facility's emergency plan was not effectively implemented, as evidenced by the lack of appropriate transportation and medical equipment for the residents. The Medical Director was not consulted about the safety of transporting certain residents, and there was a failure to ensure that residents received their necessary medications during the evacuation. The Administrator acknowledged the challenges faced during the evacuation but did not identify any concerns warranting discussion in the Quality Assurance and Performance Improvement (QAPI) program.
Inadequate Emergency Evacuation Planning and Execution
Penalty
Summary
The facility's administration failed to effectively utilize its resources to prevent the neglect of residents during an emergency evacuation ahead of a category 3 hurricane. The facility did not develop and implement an effective emergency plan, including contingency planning for evacuation transportation, nor did it adequately train and verify the competency of staff to respond to natural disasters. This resulted in avoidable serious harm to several residents and created a likelihood of serious injury to many others during the evacuation process. Resident #19 suffered multiple fractures and excruciating pain when staff inappropriately laid her across two seats for a long transport. Resident #7, who required a full body mechanical lift for transfers, was evacuated in a coach bus instead of necessary transportation equipped with a lift, resulting in a fractured ankle when she was physically carried off the bus. Resident #9, who had Chronic Obstructive Pulmonary Disease and required a CPAP machine, was evacuated without it and was improperly laid flat, leading to her becoming unresponsive and requiring emergency hospital transfer. The facility's emergency plan lacked contingency planning for when contracted transport companies could not fulfill their agreements. Staff interviews revealed a lack of training and preparedness, with many staff members driving their own vehicles to the receiving facility instead of accompanying residents on transport. The Administrator was unable to provide documentation of staff assignments or care provided during the evacuation, and there was no evidence of staff or resident training prior to hurricane season. The chaotic evacuation process resulted in residents missing medications, experiencing distress, and suffering from inadequate care during transport.
Deficient Emergency Evacuation Procedures During Hurricane
Penalty
Summary
The facility failed to implement corrective actions for identified quality deficiencies related to staff training and competency in responding to natural disasters, which led to the neglect of residents during an emergency evacuation ahead of a category 3 hurricane. The facility did not ensure appropriate transportation for wheelchair and stretcher-bound residents and failed to staff each transport vehicle with nursing staff to ensure residents' safety, provision of care, and administration of necessary medications. This resulted in multiple residents suffering harm during the evacuation process. One resident with multiple fractures was inappropriately laid across two seats for approximately 197 miles and seven hours during transport, causing severe pain. Another resident, who required a mechanical lift for transfers, was evacuated in a coach bus without a lift, resulting in a fractured ankle when staff physically carried her off the bus. A third resident with Chronic Obstructive Pulmonary Disease was not evacuated with her CPAP machine and was improperly laid flat, leading to serious harm and an emergency hospital transfer. The facility's failure to have an effective Quality Assurance and Performance Improvement program to identify and address these deficiencies created a likelihood of serious harm, injury, or death for other residents. The facility's Emergency Preparedness Plan was not effectively implemented, as evidenced by the lack of staff training on the evacuation process and the absence of nursing staff on transport vehicles to provide necessary care. The Administrator was unaware of the residents not receiving care, food, hydration, or medications during the evacuation, and no corrective actions were discussed in the facility's QAPI meetings following the incident.
Incomplete Facility Assessment and Lack of Staff Involvement
Penalty
Summary
The facility failed to ensure a comprehensive and complete Facility Assessment, which is necessary to determine the resources required for competent resident care during regular operations and emergencies. The assessment, last updated on January 11, 2024, listed several staff members and a resident as contributors. However, interviews revealed that the Activities Director, Director of Housekeeping, Assistant Director of Housekeeping, and Admissions Director were not familiar with the assessment and did not participate in its development. Additionally, the resident mentioned as a contributor stated she had no involvement or awareness of the planning process. Furthermore, the assessment lacked documentation on how staff were informed about the Comprehensive Emergency Management Plan (CEMP). The Administrator confirmed that the current assessment did not include instructions for staff regarding the CEMP.
Failure to Ensure Competency in Wander Alert Device Functionality
Penalty
Summary
The facility failed to ensure that three of five sampled nurses were trained and competent in checking the function of wander alert bands, which are designed to alert staff when a resident leaves a designated safe area. This deficiency was identified through observations, record reviews, and interviews. Specifically, Resident #16, who was at high risk for elopement due to cognitive impairment, was found outside the facility despite wearing a wander alert bracelet. The bracelet was supposed to be checked every shift for placement and functionality, but the investigation revealed that the bracelet was sounding when the resident was brought back inside, indicating a failure in monitoring its function. Further investigation showed that Registered Nurse Staff N and Staff HH were not aware of how to check the functionality of the wander alert bracelets, only verifying their placement. Documentation showed that these staff members had inaccurately recorded that they had checked the function of the bracelets. The Assistant Director of Nursing confirmed there was no documentation of training or competency for these staff members regarding the wander alert devices. Additionally, the Director of Nursing admitted that the facility lacked a policy and procedure for checking the function of the wander alert bracelets.
Failure to Report Resident Injury During Evacuation
Penalty
Summary
The facility failed to immediately report an alleged violation involving neglect for a resident who was injured during an evacuation ahead of a hurricane. The incident occurred when the facility had to evacuate residents due to an impending hurricane, and the available transportation did not have the necessary mechanical lifts for wheelchair-bound residents. As a result, the resident, who required a full body mechanical lift for transfers, was physically lifted by therapy staff from the receiving facility, leading to an injury when the resident's foot came in contact with the ground. The facility Administrator initiated an investigation into the incident but did not report the injury, which resulted in a fracture, to the State Survey Agency and Adult Protective Services as required by state law. The Administrator acknowledged that the resident did not evacuate on a stretcher transportation due to space constraints and confirmed that the injury occurred during the physical transfer off the bus. Despite recognizing the incident as an accident, the Administrator did not classify it as a reportable event, thus failing to comply with mandatory reporting requirements.
What surveyors are citing around you — mapped
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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 94 citations issued within 25 miles in the last 12 months — including the 6 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Venice
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capri Health And Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Advinia Care At Venice | 1.9 mi | ★★★★★ | 0 | 0 |
| Village On The Isle | 2.8 mi | ★★★★★ | 0 | 0 |
| Aviata At Venice | 3 mi | ★★★★★ | 6 | 0 |
| Venice Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 0 | 0 |
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