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 Home Inc during CMS and state inspections, most recent first.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services, with the current dietary manager lacking certification and only recently starting relevant coursework. Administrative staff confirmed the absence of certification, and the facility could not provide a policy for qualified dietary managers, resulting in noncompliance for all residents receiving meals from the kitchen.
A CNA wore a protective gown and gloves in the hallway while assisting a resident and handling facility equipment, removing the PPE only after leaving the resident care area, contrary to the facility's EBP policy. The facility also did not have a properly implemented infection monitoring surveillance plan in place until recently, resulting in lapses in infection identification and control.
Surveyors found expired bisacodyl suppositories and aspirin/diphenhydramine tablets in the medication room, as well as an opened, undated glargine insulin pen on a nurse treatment cart. Nursing and administrative staff confirmed that medications should be checked for expiration and insulin pens dated when opened, as per facility policy. The failure to remove expired medications and properly date the insulin pen resulted in a deficiency.
Nursing staff conducted blood glucose testing and administered insulin injections to two residents in the dining room in the presence of other residents, staff, and visitors. One resident expressed discomfort about the procedure, and staff confirmed that such practices occurred in communal areas, despite facility policy requiring care to be provided in a manner that maintains resident dignity and privacy.
A resident with left-sided hemiplegia and a history of falls was transported to the facility in a regular wheelchair without proper support, resulting in repeated sliding and the need for frequent repositioning. During the transport, the transportation aide became frustrated and verbally abusive, yelling and cursing at the resident. The incident was documented in the grievance log, but there was no evidence of a formal investigation or reporting to the state agency as required by facility policy.
A resident with significant mobility impairments reported being verbally abused by a transportation aide during a van ride, including being yelled at and cursed at for sliding out of a wheelchair. The incident was documented in the grievance log and acknowledged by the aide, but staff did not immediately report the allegation to the administrator or state agency as required by policy, resulting in a failure to investigate the abuse allegation.
A resident with left-sided hemiplegia and a history of falls reported being verbally abused by a transportation aide during a van ride to the facility, including being yelled at and cursed for sliding out of a wheelchair. The facility documented the complaint and the aide's admission of frustration but did not conduct a thorough investigation or report the allegation to the state agency, as required by policy.
A resident with dementia and a left heel pressure ulcer did not have the required wound dressing applied after a morning shower and before a wound clinic appointment. Staff transferred and assisted the resident without a dressing in place, and a new dressing was only applied after consulting with the wound clinic. The facility could not provide a policy for pressure ulcer treatment.
A resident with a neurogenic bladder, indwelling catheter, and multiple comorbidities did not receive the physician-ordered daily fluid intake, as staff failed to monitor and document intake as required. Dietary and nursing staff were unclear about their responsibilities, and the facility lacked a urinary tract infection prevention policy, resulting in the resident being placed at risk for ongoing UTIs.
A resident with heart failure, chronic kidney disease, diabetes, and a neurogenic bladder did not receive the physician-ordered daily fluid intake, as staff failed to monitor and document intake as directed in the care plan. Staff interviews revealed confusion about responsibility for tracking fluids, and the facility lacked a urinary tract infection prevention policy. This resulted in the resident not receiving the required fluids, with recent hospitalizations for dehydration and urinary tract infection.
A consultant pharmacist did not notify the DON or physician about a resident's blood pressure not being monitored as ordered while the resident continued to receive losartan. The resident, with a history of hypertension, TIA, and anemia, had an active order requiring blood pressure checks before medication administration, but only received weekly monitoring. Facility policy required the pharmacist to review and communicate medication regimen issues monthly, but this was not done.
A resident with hypertension, TIA, and anemia received losartan without staff consistently monitoring blood pressure as ordered by the physician. Staff only checked blood pressure weekly, despite orders to hold the medication if certain parameters were not met, resulting in a failure to follow physician orders and facility policy.
A resident with severe cognitive impairment was forced to go to bed by two CNAs despite his protests, leading to agitation and physical resistance. The resident, who had a history of cognitive decline and required assistance for daily activities, was found with multiple bruises following the incident. The facility failed to respect the resident's right to choose and maintain his dignity, resulting in psychosocial impairment and decreased quality of life.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager to oversee the food and nutrition services for all 39 residents. During an observation in the kitchen, it was found that the staff member acting as the dietary manager had only recently started and was not certified, though she had begun coursework to become a Certified Dietary Manager. Administrative staff confirmed that the current dietary manager was not certified. Additionally, the facility was unable to provide a policy regarding qualified dietary managers. These actions resulted in the facility not meeting the requirement to have a certified dietary manager responsible for the nutritional needs of the residents.
Failure to Follow PPE Protocols and Maintain Infection Surveillance
Penalty
Summary
Certified Nurse Aide (CNA) M was observed wearing a yellow protective gown and gloves while pushing a resident in a wheelchair to the dining room and then opening a closet, all while still wearing the PPE. CNA M stated that the gown was worn in the hallway so the surveyor would recognize her in it. The PPE was removed only after entering the service hall next to the dining room, rather than before exiting the resident's room as required by facility policy. This practice was not in accordance with the facility's Enhanced Barrier Precautions (EBP) policy, which specifies that PPE should be discarded before leaving a resident's room to prevent the spread of infection. Additionally, the facility failed to maintain an effective infection monitoring surveillance plan prior to January 2025. The infection tracking system was not correctly implemented until that time, as verified by the Administrative Nurse. This lapse meant that the facility did not have a consistent method for identifying, reporting, investigating, and controlling infections and communicable diseases for all individuals in the facility, as required by their Infection Prevention and Control Program.
Expired Medications and Undated Insulin Pen Found During Survey
Penalty
Summary
Surveyors observed that expired medications, including bisacodyl suppositories with an expiration date of November 2024 and a container of aspirin/diphenhydramine tablets expired December 2024, were present in the facility's medication room. Additionally, an opened glargine insulin pen on the nurse treatment cart was found to be undated. Licensed nursing staff confirmed the presence of expired medications and acknowledged that the insulin pen should have been dated when opened. Administrative staff verified that facility policy requires staff to date insulin pens upon opening and to check expiration dates when transferring medications from the medication room to the medication cart for administration. The facility's policy also mandates weekly audits of medication inventories to ensure all medications are properly dated and not expired. Despite these protocols, expired medications remained accessible and an insulin pen was not dated, resulting in a deficiency related to medication storage and labeling.
Insulin Administration in Dining Room Compromises Resident Dignity
Penalty
Summary
Licensed nursing staff performed blood glucose testing and administered insulin injections to two residents in the facility's dining room while other residents, staff, and visitors were present. One resident verbally expressed discomfort about needles during the procedure, and insulin was injected at the dining table in view of others. Another resident received insulin at a table with two other residents and a visitor present. These actions were observed by surveyors during meal times. Interviews with nursing staff confirmed that insulin administration and blood sugar checks were sometimes performed in the dining room, and staff indicated that residents could receive these procedures privately if they wished. The facility's policy stated that care should be provided in a manner that maintains and enhances each resident's dignity and respect. However, the observed practice did not ensure privacy or dignity for the residents involved, as required by facility policy.
Failure to Prevent Verbal Abuse During Resident Transport
Penalty
Summary
A resident with a history of cerebral infarction resulting in left-sided hemiplegia, cerebral edema, and muscle weakness was admitted to the facility and required total assistance for mobility, including the use of a mechanical lift and a specialized Broda chair to prevent sliding. During transport to the facility via the facility van, the resident was placed in a regular wheelchair without a pommel, which did not adequately prevent him from sliding forward. The transportation aide had to stop multiple times to reposition the resident, who repeatedly slid out of the wheelchair during the trip. During the transport, the resident reported being verbally abused by the transportation aide, who became frustrated and yelled and cursed at him for sliding out of the wheelchair. The resident stated that he was told, in explicit language, that the aide was tired of stopping to reposition him. The aide later acknowledged feeling angry and frustrated during the transport but denied cursing. The incident was documented in the facility's grievance log, and the resident also informed his family about the treatment he received during the ride. The facility's records indicated that the previous facility did not communicate the resident's risk of sliding forward, and the transportation aide was not provided with this information. The facility's policy required that all allegations of abuse be reported and investigated, but there was no evidence that the incident was reported to the state agency or that a formal investigation was conducted at the time. The only documentation available was the grievance log and the aide's statement.
Failure to Report Allegation of Verbal Abuse During Resident Transport
Penalty
Summary
A deficiency occurred when staff failed to immediately report an allegation of verbal abuse made by a resident against a transportation aide to the facility administrator and the state agency. The resident, who had a history of stroke with left-sided hemiplegia, cerebral edema, and muscle weakness, was dependent on staff for mobility and required a specialized wheelchair to prevent sliding. Upon admission, the resident reported being yelled at and cursed at by the transportation aide during the van ride to the facility, particularly after repeatedly sliding out of the wheelchair due to his physical limitations. The incident was documented in the facility's grievance log, where the resident described the aide's use of profanity and expressed distress over being blamed for something he could not control. The transportation aide acknowledged feeling frustrated during the transport and confirmed that she had to stop multiple times to reposition the resident, eventually requiring assistance from facility staff. However, there was no evidence that the allegation of verbal abuse was reported to the administrator or the state agency as required by facility policy. Facility records, including the grievance log and witness statements, confirmed the resident's complaint and the aide's account of the incident. Despite the facility's policy mandating immediate reporting and investigation of all abuse allegations, the required notifications and investigation were not completed. This failure to follow protocol placed the resident at risk for ongoing abuse or mistreatment.
Failure to Investigate Allegation of Verbal Abuse During Resident Transport
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse made by a newly admitted resident. The resident, who had a history of cerebral infarction resulting in left-sided hemiplegia, cerebral edema, and muscle weakness, was dependent on staff for mobility and required a specialized wheelchair to prevent sliding. Upon admission, the resident reported being verbally abused by a transportation aide during the van ride to the facility, stating that the aide yelled and cursed at him multiple times because he kept sliding out of his wheelchair. The resident also informed his family about the incident. Documentation in the facility's grievance log confirmed the resident's complaint, and a witness statement from the transportation aide acknowledged frustration during the transport but denied cursing. The aide described having to stop several times to reposition the resident and eventually required assistance from facility staff. Despite the resident's report and the aide's admission of frustration, the facility's only documented response was to educate the aide on abuse, neglect, and exploitation. There was no evidence of a thorough investigation, witness interviews, or a written report as required by the facility's abuse policy. Administrative staff later verified that the allegation was not reported to the state agency and that no formal investigation was conducted. The only documentation available was the grievance log entry and the aide's note. The facility's policy mandates immediate reporting and investigation of all abuse allegations, including obtaining witness statements and filing a written report, which was not followed in this case.
Failure to Maintain Pressure Ulcer Dressing on Resident's Heel
Penalty
Summary
A resident with dementia and a history of left hip fracture was identified as having an open pressure ulcer (PU) on her left heel. The resident required moderate to maximum staff assistance for activities such as bathing and dressing. Physician orders directed staff to dress the left heel wound with saline-moistened promogram prisma followed by a mepilex border dressing. The resident's care plan also instructed staff to monitor and document the wound's size, depth, granulation, and healing progress, and to notify the physician as needed. On the day of the incident, after the resident's early morning shower and prior to a scheduled wound clinic appointment, staff observed that the resident's left heel PU was not covered with any dressing as ordered. The resident was transferred multiple times and participated in activities without a dressing on the wound. Staff only applied a new dressing after consulting with the wound clinic later that morning. Interviews confirmed that open wounds should be covered at all times unless otherwise ordered by a physician. The facility was unable to provide a policy for pressure ulcer treatment.
Failure to Ensure Physician-Ordered Fluid Intake and UTI Prevention
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including heart failure, neuromuscular dysfunction of the bladder, diabetes mellitus, chronic kidney disease, and a neurogenic bladder with an indwelling catheter, did not receive the physician-ordered daily fluid intake of two quarts (1920 cc) of water. The resident's care plan directed staff to monitor and document intake and output, and to report signs or symptoms of urinary tract infection to the physician. However, review of the electronic medical record showed that the resident's fluid intake consistently fell short of the ordered amount over a period of several weeks. Interviews with dietary and nursing staff revealed confusion and lack of awareness regarding responsibility for tracking fluid intake, with dietary staff stating they were not keeping track of anyone's fluid intake and nursing staff unaware of the specific fluid order for the resident. Additionally, the facility was unable to provide a urinary tract infection prevention policy. These actions and inactions resulted in the resident not receiving the prescribed fluid intake, placing them at risk for ongoing urinary tract infections.
Failure to Provide Physician-Ordered Fluid Intake for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including heart failure, chronic kidney disease, diabetes mellitus, neurogenic bladder, and a history of urinary tract infections, received the physician-ordered daily fluid intake of two quarts (1920 cc) of water. The resident's care plan directed staff to monitor and document intake and output, and to report signs or symptoms of urinary tract infection to the physician. Despite these directives, review of the electronic medical record showed that the resident did not consistently receive the ordered amount of fluids over a period of several weeks. The resident had recently returned from the hospital with diagnoses of acute and chronic renal failure, dehydration, and a urinary tract infection, and subsequently required another hospitalization for a urinary tract infection. Interviews with dietary and nursing staff revealed confusion and lack of awareness regarding responsibility for tracking fluid intake, with dietary staff stating they were not currently monitoring anyone's fluid intake and nursing staff unaware of the specific fluid order for the resident. The facility was unable to provide a urinary tract infection prevention policy, and the existing hydration policy only generally stated that residents at risk for dehydration should receive appropriate interventions. These failures resulted in the resident not receiving the physician-ordered fluid intake, placing the resident at risk for ongoing dehydration and urinary tract infections.
Consultant Pharmacist Failed to Report Lack of Blood Pressure Monitoring
Penalty
Summary
The facility's consultant pharmacist did not notify the director of nursing or the physician regarding the lack of blood pressure monitoring for a resident who had an active order for losartan, a blood pressure medication. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 100 mmHg or diastolic less than 60 mmHg, and required monitoring to assess the medication's effectiveness. Despite this, the resident's blood pressure was only documented weekly over a period of several months, while the order and medication administration remained unchanged. The resident involved had diagnoses of hypertension, transient cerebral ischemic attack, and anemia, and was receiving multiple medications including an antihypertensive, antidepressant, diuretic, and opioid. The resident's care plan directed staff to consult with a pharmacist as needed and to monitor and report adverse reactions to medication therapy. The facility's policy required the consultant pharmacist to review medication regimens monthly and communicate findings and recommendations to the physician and care team. However, the consultant pharmacist failed to report the lack of required blood pressure monitoring, as confirmed by the administrative nurse.
Failure to Monitor Blood Pressure as Ordered During Antihypertensive Administration
Penalty
Summary
Staff failed to monitor a resident's blood pressure as ordered by the physician to assess the effectiveness and safety of her antihypertensive medication, losartan. The physician's order specified that losartan should be held if the resident's systolic blood pressure was less than 100 mmHg or diastolic blood pressure was less than 60 mmHg. Despite this, staff only obtained the resident's blood pressure weekly over several months, while the order remained active and the medication continued to be administered. The resident had diagnoses of hypertension, transient cerebral ischemic attack, and anemia, and was receiving multiple medications including an antihypertensive, antidepressant, diuretic, and opioid. The facility's policy required medications to be administered as ordered and for staff to monitor residents' responses to medications. However, staff did not consistently check blood pressure with each administration of losartan as required, resulting in a failure to follow physician orders and facility policy.
Resident's Rights Violated During Forced Bedtime Transfer
Penalty
Summary
The facility failed to uphold a resident's right to choose and respect his wishes, leading to a situation where the resident was forced to go to bed against his will. On the evening of December 5th, two CNAs attempted to transfer the resident from his wheelchair to his bed despite his protests. The resident, who had a history of cognitive decline and required assistance for daily activities, became agitated and resistant during the transfer, resulting in a physical struggle. The CNAs reported that their primary concern was preventing the resident from falling, but the situation escalated, causing the resident to become combative. The resident's medical records indicated he had severe cognitive impairment and required assistance for most activities, except eating. Despite this, the care plan noted that he was alert and able to communicate his needs, although he required cues for care. During the incident, the resident's oxygen was reportedly off, and he was short of breath, which may have contributed to his confusion and agitation. The CNAs involved claimed they were trying to ensure the resident's safety by putting on his oxygen, but their actions were perceived as coercive by another CNA who intervened. Following the incident, the resident was found to have multiple bruises on his hands and arms, which he could not recall how they occurred. The bruising was documented over several days, and the resident's representative expressed concern about the situation, noting that the resident did not typically go to bed early due to breathing difficulties when lying down. The facility's policy on resident rights emphasizes the importance of respecting residents' choices and ensuring their dignity, which was not upheld in this case, leading to psychosocial impairment and a decrease in the resident's quality of life.
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 43 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 Concordia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Villa | 14.2 mi | ★★★★★ | 14 | 0 |
| The Nicol Home | 17 mi | ★★★★★ | 0 | 0 |
| Belleville Healthcare And Rehabilitation Center | 17 mi | ★★★★★ | 17 | 0 |
| Mitchell County Hospital Health Systems Ltcu | 24.6 mi | ★★★★★ | 0 | 0 |
| Hilltop Lodge Health And Rehabilitation Center | 24.7 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sunset Home Inc.
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 July 2026) and official state health department websites.