Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a high risk for elopement exited the facility undetected and was later found by a nearby business with a fractured arm. Despite protocols requiring door alarms and supervision, a service entry/exit door lacked an alarm and a key was accessible, allowing the resident to leave. Staff did not hear any alarms, and the resident was not located during initial searches, resulting in the resident sustaining an injury outside the facility.
Kitchen Sanitation and Food Storage Deficiencies: Staff failed to keep the kitchen and food storage areas sanitary. Observations showed sticky, dirty floors; food debris; dust and grease on vents and racks; peeling paint and black residue on cabinets and walls; expired milk in the refrigerator; and food stored on the freezer floor with open, undated items and ice/water present. The dishwasher sanitization log had multiple blank entries, and a dietary aide did not know how to check sanitizer levels or the required PPM.
RN coverage was not maintained for at least 8 consecutive hours a day, 7 days a week. PBJ staffing data and facility staffing sheets showed multiple days in Jan, Feb, and Mar 2025 with no RN hours or no RN coverage, and the Administrator acknowledged awareness of the requirement and the days and weekends when no RN was in the building.
Daily staffing sheets were not posted with the hours scheduled for both LPN and non-licensed nursing staff, and the posting was blocked from public view by a decorative tree in the lobby. The Administrator stated the sheets should be visible to the public but was unaware they also needed to include the number of hours worked for licensed and unlicensed nursing staff.
Insulin pens for two residents were found open, undated, and not properly labeled in the med cart. An LPN confirmed the pens should be dated when opened, and the DON and Administrator stated the same. The facility’s policy and manufacturer instructions required insulin pens to be assigned to individual residents, labeled, dated when opened, and discarded after 28 days.
Failure to Clarify Digoxin Hold Parameters: A CMT prepared digoxin for a resident with CHF, a cognitive deficit, and long-term anticoagulant use even though the resident’s HR was 54 bpm. The CMT did not notify the nurse, stated there was no parameter for that dose, and said the nurse would decide what was best. The DON and Administrator stated the CMT should notify the charge nurse if a medication needed to be held, and an LPN said the nurse would double check the order.
The facility failed to conduct competency assessments for nurse aides as required by their facility assessment, affecting all residents. Seven randomly selected nurse aides did not have competency assessments completed at hire and every 6 months thereafter. The Director of Nursing and Administrator were unaware of the facility assessment's requirement for these assessments.
The facility did not have a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days a week, as required. On certain days, no RN was present for a 24-hour period. The Administrator mentioned a pending waiver application for RN coverage and relied on staffing agencies and an on-call RN system. The facility admitted residents on Medicare services but lacked a policy for RN coverage.
The facility failed to maintain a sanitary kitchen environment and adhere to food safety standards. Observations revealed unsanitary conditions, improper handwashing, and inadequate use of sanitizer solutions. Temperature logs for refrigerators, freezers, and dishwashers were incomplete, and food temperatures were not consistently checked. Additionally, outdated and undated food items were found, and staff lacked proper training in food safety protocols.
The facility failed to maintain consistent code status documentation for two residents, leading to discrepancies between physician orders, paper records, and visual indicators. Staff relied on stickers and charts for code status, resulting in confusion. The Social Services Director and other staff were unaware of the mismatches, which were later acknowledged by the Administrator and DON.
The facility did not follow its policy to conduct NA registry checks before hiring staff, affecting three out of five sampled employees, including a DA, an NA, and the DON. The administrator confirmed that these checks are required for all staff before employment, but they were not completed as expected.
The facility failed to provide written transfer notices to two residents when they were transferred to hospitals. One resident, with no cognitive impairment, was hospitalized after a fall, while another, with moderate cognitive impairment, was admitted for pneumonia. Interviews revealed that transfer forms were not completed as required, and the Social Services Director and Administrator confirmed the oversight.
The facility failed to provide and document a bed hold policy notice for two residents during hospital transfers, despite the policy requiring notification upon admission and transfer. One resident, with no cognitive impairment, was hospitalized after a fall, while another, with moderate cognitive impairment, was hospitalized for pneumonia. The Social Services Director and Administrator acknowledged the oversight, highlighting a deficiency in policy adherence.
The facility failed to provide complete and individualized care plans for residents, missing key diagnoses and activity preferences. A resident's care plan lacked provisions for PTSD, oxygen use, and COPD, while others did not address activity preferences, leading to dissatisfaction with available activities. Staff were unaware of certain resident needs, and activity tracking was insufficient.
The facility failed to update care plans and conduct quarterly meetings, affecting residents' care. A resident's care plan did not reflect discontinued use of weighted utensils, and two residents were not involved in care plan meetings. The DON admitted no meetings had been held since April 2023.
The facility failed to provide meaningful activities for several residents, leading to a deficiency in meeting their individual needs. Residents expressed dissatisfaction with the lack of interesting activities and inadequate communication about scheduled events. Observations confirmed that activities were not consistently offered, and residents were not adequately reminded or assisted to attend them. The Activity Director admitted to not tracking activities with each resident, and the Director of Nursing acknowledged the deficiency, noting that the Activity Director had other tasks that limited their ability to conduct more activities.
The facility failed to ensure proper CPAP administration and maintenance for two residents, lacking physician orders and proper cleaning protocols. One resident's CPAP mask was improperly stored, and another's equipment was undated, with open distilled water containers. Staff interviews revealed a lack of awareness about cleaning requirements and the need for physician orders.
The facility failed to assess residents for bed rail entrapment risks and did not obtain necessary physician's orders or informed consent before installation. This affected several residents, with missing assessments and documentation, indicating a systemic issue in safety protocols and communication.
The facility failed to ensure two nurse aides completed their training within four months of employment. Despite the requirement for nursing staff to have current certifications and for nurse aides to be enrolled in training within 120 days, one aide received certification late, and the other had no certification. Both aides missed classes, and the Administrator was unsure why they remained employed beyond the four-month period.
The facility failed to provide the required twelve hours of annual in-service education for nurse aides, did not conduct annual performance reviews, and lacked a system to track training hours. This affected five out of seven sampled CNAs and potentially impacted all staff and residents. The DON and Administrator were unaware of the deficiencies, and there was no policy for staff education.
The facility failed to serve food at safe and appetizing temperatures, as required by policy. Observations and interviews revealed that food temperatures were not checked before serving, resulting in residents receiving cold meals. Staff lacked training on proper temperature checking procedures.
The facility staff did not ensure that all shower hoses had a back flow preventer device, which is essential to prevent contamination of the potable water supply. An observation revealed that the shower hose in a specific shower room lacked this device, and the Maintenance Supervisor was unaware of the requirement.
The facility's pest control program was ineffective, with gnats in corridors and brown recluse spiders in a sprinkler riser room. Pest control logs lacked specific treatments for these pests. A resident returned from a family outing with a possible spider bite, leading to medical treatment. The facility's staff acknowledged the lack of targeted pest control measures for spiders.
The facility failed to provide the required 12 hours of annual in-service education for nurse aides, including necessary training in Dementia Care and other competencies. This affected several CNAs and potentially all staff and residents. The facility lacked a policy and tracking system for education, and the DON and Administrator were unaware of the deficiencies in training hours and competency requirements.
A facility failed to provide trauma-informed care to a resident with PTSD, lacking a care plan and behavioral interventions. The resident experienced anxiety and nightmares, but was not informed about professional mental health options. Staff interviews revealed reliance on a contracted office for behavioral health appointments and acknowledged the absence of a PTSD care plan.
Failure to Prevent Elopement and Injury of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a high risk for elopement was able to leave the facility without staff knowledge. The resident, who had diagnoses including dementia, Parkinson's disease, anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD, was assessed as a high elopement risk according to the facility's own assessment tool. Despite this, the resident was last seen by staff in the early morning hours and was later found by a nearby business lying on the ground, having sustained a fractured left arm. The resident was transported to the hospital for evaluation and treatment. The facility's elopement protocol required identification of residents at risk for elopement, use of door alarms, and regular testing of these alarms, as well as staff training on elopement procedures. On the day of the incident, staff did not hear any door alarms, and the resident was not located during initial searches of the building. Interviews and observations revealed that a service entry/exit door in the kitchen area did not have an alarm, and a key was left hanging by the door, which may have allowed the resident to exit undetected. Staff interviews indicated that the resident was last seen in the dining room and at the nurse's station, but there was a gap in supervision that allowed the resident to leave the secured unit. The resident was found outside the facility by a staff member who had joined the search after being notified of the missing resident. The resident was lying on the ground, wet, and complained of pain in the left arm. The incident report and interviews confirmed that the required supervision and environmental safeguards were not sufficient to prevent the resident's elopement and subsequent injury. The facility's failure to ensure all exit doors were properly alarmed and monitored contributed to the resident's ability to leave the premises unnoticed.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure food was stored in a sanitary manner and failed to maintain the kitchen in a sanitary manner. During observation of the kitchen, the floors were sticky and covered in dirt and debris, the area under the three-compartment sink had food debris, cabinets under the counter had peeling paint and black spots, the prep area and storage rack were dirty and dusty, the refrigerator handles were caked with a sticky substance, and the windows, walls, and dish room surfaces had food debris, dust, cobwebs, and black residue. An open gallon of milk was found in the refrigerator with an expiration date of 07/16/25. On a later observation, the same conditions remained, including a bottom refrigerator surface covered in liquid spatter and food debris, a vent behind the toaster oven caked in dust and grease, broken tiles at the kitchen exit door, sticky and dirty floors, dirty areas under the sink and prep table, dusty storage racks, peeling paint and black spots on cabinets, and black residue along the dish room drain and wall. In the walk-in freezer, a screwdriver was holding the door shut, the floor was covered in water and ice, a 20-pound turkey and two unopened boxes of link sausage were sitting on the floor, and open, undated bags of French fries, okra, and sausage patties were present with chunks of ice on the food and floor. The dry storage floor was also covered with a sticky substance, dirt, and debris. Record review showed the dishwasher sanitization log for July 2025 had multiple dates with no documentation that sanitizer levels were checked. During observation and interview, a dietary aide loaded and removed dishes from the dishwasher but did not check the sanitizer before running dishes and could not remember how to check it or state the required PPM. The dietary manager stated all staff should know how to check sanitizer, that it should be checked at every meal and recorded, and that there should be no blank spaces on the log. The maintenance supervisor said he was not aware of kitchen repairs needed and did not clean the vents, while the registered dietitian and administrator stated they expected the kitchen to be clean, in good repair, and food to be dated, stored properly, and expired food discarded.
RN Coverage Not Maintained 7 Days a Week
Penalty
Summary
The facility failed to ensure there was an RN providing services at least 8 consecutive hours a day, 7 days a week consistently for January, February, and March 2025, with a census of 23. Review of the PBJ Staffing Data Report showed no RN hours on multiple weekend days in January, February, and March 2025, and review of the facility staffing sheets also showed no RN coverage on multiple dates during those months. A staffing policy was requested but not provided. During an interview on 7/23/25 at 1:35 P.M., the Administrator stated she was aware of the regulation requiring RN coverage 8 hours a day, seven days a week, and was aware of days and weekends when there was no RN in the building.
Daily Staffing Sheets Not Properly Posted
Penalty
Summary
The facility failed to post the daily staffing sheets with the number of hours scheduled to work for both licensed and non-licensed nursing staff, and the posting was not kept in an area unobstructed from public view. The facility census was 23, and there was no policy regarding the posting of daily census and staffing sheets. On 7/22/25 at 2:15 P.M., observation showed the daily census and staffing sheets hung on a clipboard on a wall behind a decorative tall Christmas tree in the front lobby, which blocked the public from seeing the information. Review of the daily census and staffing sheets for June and July showed no staff hours posted for licensed or non-licensed staff. During interview on 7/22/25 at 3:10 P.M., the Administrator stated she knew the staffing and census sheets should be posted where the public could see them and that the Christmas tree would need to be moved, but she was unaware that the sheets also needed to include the number of hours worked for both licensed and unlicensed nursing staff.
Insulin pens were left open and undated in the medication cart
Penalty
Summary
The facility failed to accurately label insulin pens and to document when they were opened, as required for safe storage and administration of drugs and biologicals. The facility’s Diabetic Infection Control policy stated that multiple-dose insulin vials must be assigned to individual residents, labeled appropriately, and dated when opened. Manufacturer instructions for NovoLog FlexPen, Lantus SoloStar, and Humalog KwikPen each stated the pens should be thrown away after 28 days of use. For Resident #6, the July physician’s orders included NovoLog FlexPen insulin on a sliding scale and Lantus SoloStar 30 units at bedtime. During observation on 7/22/25, the Lantus pen and NovoLog FlexPen were found open, undated, and unlabeled in the medication cart. For Resident #9, the July physician’s order included Humalog insulin pen 5 units, and observation showed one insulin pen sitting on the top shelf of the medication cart outside its prescription box, open and not dated. LPN A stated that insulin pens should be labeled and dated when opened, and the DON and Administrator also stated that insulin pens are to be dated when opened.
Failure to Clarify Digoxin Hold Parameters
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for one resident who had CHF, was on long-term anticoagulants, and had a cognitive deficit. During medication preparation, a CMT checked the resident’s blood pressure at 138/60 and heart rate at 54 beats per minute while preparing digoxin. The CMT did not notify the nurse of the low heart rate and prepared the digoxin into a medication cup to give to the resident. During interview, the CMT stated there was no parameter for that dose of digoxin and said the resident received a different dose the next day that did have a parameter to not give the medication if the heart rate was below 60. The CMT also stated he/she would not notify the charge nurse and that the nurse would tell him/her what was best. An LPN stated that if a CMT needed to hold a medication, the CMT would notify the nurse, who would double check the order. The DON and Administrator stated that a CMT is to notify the charge nurse if a medication needed to be held, and the Administrator stated nurses are expected to question an order if parameters are not given on a medication that requires vital signs before administration.
Failure to Conduct Required Competency Assessments for Nurse Aides
Penalty
Summary
The facility failed to conduct competency assessments for nurse aides as required by their facility assessment, affecting all residents. Specifically, 7 randomly selected nurse aides did not have competency assessments completed at hire and every 6 months thereafter, as stipulated in the facility's assessment. The facility's assessment outlined that competencies such as person-centered care, activities of daily living, disaster procedures, infection control, medication administration, wound care, measurements, resident assessments and observations, care for residents with dementia, specialized care, and care for residents with mental and psychological disorders should be tested every 6 months and at hire for nursing staff. However, the facility did not provide a policy for competency and education, and the employee files reviewed showed no competency assessments for the year 2024 for any of the selected nurse aides. During an interview, the Director of Nursing (DON) and the Administrator revealed a lack of awareness regarding the facility assessment's requirement for competency assessments every 6 months and at hire. The DON stated that competency assessments were to be completed annually or more often as needed, particularly if there was a concern with care, such as a rise in urinary tract infections. The Administrator mentioned that most education was based on findings from the quarterly Quality Assurance meeting and believed that competency should be completed annually and as needed. Both were unaware of the specific requirements outlined in the facility assessment.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency was identified through interviews and record reviews, revealing that there was no RN present in the facility for a 24-hour period on specific dates in July and August. The facility census at the time was 33 residents. The Administrator stated that the facility had applied for a waiver for RN coverage but had not yet received approval from CMS. Despite this, the facility did not have a policy regarding RN coverage and relied on staffing agencies and an on-call RN system. The facility admitted residents on Medicare services, but the Administrator believed there was no care that required an RN on-site at all times.
Facility Fails to Maintain Sanitary Kitchen and Food Safety Standards
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by multiple observations of unsanitary conditions and improper food handling practices. Staff did not consistently wash their hands according to the facility's policy, often turning off faucets with bare hands after washing, and failed to use sanitizer solutions on kitchen surfaces. Additionally, the kitchen was observed to be in a state of disarray, with food debris on the floors, stove, and microwave, and improper storage of dishware and utensils. The facility also failed to ensure that refrigerator and freezer temperatures were checked and logged daily, with gaps in the temperature logs noted. Similarly, the dishwasher's temperature logs were incomplete, and the machine itself was found to be unclean. Staff were observed filling in logs retroactively, raising concerns about the accuracy of the recorded data. Furthermore, food temperatures were not consistently measured or logged during meal preparation and service, with staff failing to check temperatures before placing food on the steam table or serving it to residents. In addition to these deficiencies, the facility did not have policies in place for the proper dating and labeling of food items, leading to the presence of outdated and undated food products in storage. Staff interviews revealed a lack of training and understanding of proper food safety protocols, with some staff members admitting to not receiving adequate training or in-services from the dietary manager. The facility's failure to adhere to professional standards for food service safety poses a significant risk to the health and well-being of its residents.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to accurately reflect the residents' code status in their medical records, affecting two residents. For Resident #185, discrepancies were found between the physician's orders, which indicated a DNR status, and the paper medical record, which showed a full code status. The Social Services Director acknowledged the error and corrected the code status in the physician's orders after realizing the mismatch. Interviews with staff revealed that they relied on stickers on residents' doors and paper charts to determine code status, which led to confusion due to inconsistent documentation. Similarly, for Resident #28, the physician's orders indicated a DNR status, while the paper medical record and the resident's nameplate displayed a full code status. The Social Services Director was unaware of the physician's DNR order and believed the resident was a full code. Staff interviews highlighted reliance on visual indicators like stickers and paper charts for code status, which were inconsistent with the electronic records. The Administrator and Director of Nursing expected code status to be consistent across all records, but acknowledged the discrepancies for these two residents.
Failure to Conduct Required NA Registry Checks Before Hiring
Penalty
Summary
The facility failed to adhere to its written policy requiring a complete background check, including a check of the Nurses Aide (NA) registry, before hiring staff to work with residents. This deficiency was identified for three out of five sampled staff members. Specifically, the personnel files for a Dietary Aide (DA), a Nurses Aide (NA), and the Director of Nurses (DON) lacked evidence of completed NA registry checks prior to their employment. The facility's policy explicitly states that individuals with findings on the state nurse aide registry should not be employed. During interviews, the administrator confirmed that the Business Office Manager is responsible for conducting these checks and that all staff, regardless of their role, should be checked against the NA registry before their first day of employment. However, the checks were not completed as expected, leading to a breach of the facility's policy.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to provide written notice of transfer to two residents, Resident #13 and Resident #14, when they were transferred to local hospitals. Resident #13, who had no cognitive impairment and required substantial assistance with daily activities, was hospitalized after a fall and hip fracture. The resident reported not receiving written notice of the transfer, and there was no documentation of a transfer form in the resident's record. Similarly, Resident #14, who had moderate cognitive impairment and was dependent on staff for daily activities, was transferred to the hospital due to difficulty breathing and other critical symptoms. The resident was admitted for pneumonia, but again, there was no transfer form documented in the resident's record. Interviews with facility staff revealed that the Social Services Director typically completed transfer notices, but if a transfer occurred during weekends or after hours, the responsibility fell to the nurse on duty. It was acknowledged that sometimes the transfer forms were not completed. Both the Social Services Director and the Administrator confirmed that transfer forms should have been completed and provided to the residents and their guardians in a comprehensible language, and documented in the residents' charts. However, this procedure was not followed for Residents #13 and #14.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to document and provide a notice of bed hold policy to two residents, Resident #13 and Resident #14, when they were transferred to local hospitals. The facility's bed hold policy requires that all residents and guardians be notified of bed hold guidelines upon admission and at the time of transfer to the hospital. However, during interviews and record reviews, it was found that Resident #13, who had no cognitive impairment and required substantial assistance for daily activities, was not given a bed hold policy form when hospitalized after a fall and hip fracture. Similarly, Resident #14, who had moderate cognitive impairment and was dependent on staff for daily activities, was not provided with a bed hold policy form when transferred to the hospital for pneumonia. The Social Services Director acknowledged that the bed hold policy was signed upon admission but not completed again during hospital transfers. The Administrator confirmed that the bed hold policy form should have been completed and sent with each resident during hospitalization and expected it to be documented in the resident's chart. The lack of documentation and provision of the bed hold policy form during hospital transfers for these residents constitutes a deficiency in the facility's adherence to its own policy.
Deficiencies in Resident Care Plans and Activity Preferences
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. For Resident #30, the care plan did not include provisions for PTSD, use of oxygen, CPAP, or COPD, despite the resident's diagnoses and needs. Observations showed the resident experiencing symptoms such as shortness of breath, anxiety, and depression, and the resident reported not seeing a mental health professional. A CNA was unaware of the resident's PTSD, indicating a lack of communication and documentation. Resident #2's care plan did not address the resident's activity preferences, despite the resident expressing interest in activities such as bingo and jeopardy. The resident felt there were not enough activities to interest them, and there were no activity notes documented in the progress notes. Similarly, Resident #13's care plan addressed potential social isolation but did not include specific activity preferences, and the resident felt that activities were not geared towards men. Resident #20's care plan also lacked documentation of activity preferences, despite the resident expressing interest in outdoor activities and group participation. The Activity Director acknowledged not tracking activities with each resident and not offering specific activities geared towards men. The facility's Administrator and Director of Nursing expected care plans to include activity preferences and PTSD, but this was not reflected in the care plans reviewed.
Failure to Update Care Plans and Conduct Quarterly Meetings
Penalty
Summary
The facility failed to ensure that care plans were developed and updated in accordance with residents' specific conditions and needs. For one resident, the care plan did not reflect the discontinuation of weighted utensils, despite the resident no longer using them and having no current orders for them. Observations confirmed the resident was using regular silverware, and interviews with staff indicated a lack of awareness about the updated orders. The facility's policy required care plans to be updated with changes, but this was not adhered to. Additionally, the facility did not conduct quarterly care plan meetings for two residents. One resident, who had no cognitive impairment, expressed that they had never been invited to a care plan meeting and wished to participate in their care planning. Another resident, with severe cognitive impairment, was unaware of what a care plan was but expressed a desire to be involved in their care planning. The facility's policy required quarterly care plan meetings, but this was not followed. The Director of Nursing (DON) acknowledged responsibility for writing care plans and coordinating meetings but admitted that no care plan meetings had been held since their employment began in April 2023. This lack of adherence to care planning protocols and meeting schedules resulted in deficiencies affecting the quality of care for the residents involved.
Deficiency in Providing Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities for five of the twelve sampled residents, leading to a deficiency in meeting the individual needs of the residents. The activity policy outlined that activities should be planned and organized to meet the residents' needs, including a variety of activities such as spiritual, physical, emotional, cognitive, sensory, recreational, and work service-related activities. However, observations and interviews revealed that the facility did not adhere to this policy, as residents were not informed or invited to participate in activities, and there was a lack of an activity calendar in common areas or residents' rooms. Resident #17, with severe cognitive impairment, expressed that they did not participate in activities because they were not informed or invited, and the activities offered did not interest them. Similarly, Resident #21, with moderate cognitive impairment, enjoyed playing Bingo but desired more music activities and was not consistently informed about upcoming events. Resident #2, who had moderate cognitive impairment and mobility issues, also reported a lack of interesting activities and the absence of an activity calendar in their room. Observations confirmed that scheduled activities were not consistently offered, and residents were not adequately reminded or assisted to attend them. Resident #13, with intact cognition but dependent on a wheelchair, felt that activities were not geared towards men and lacked access to an activity schedule in their room. Resident #20, with moderate cognitive impairment and multiple health issues, expressed dissatisfaction with the limited activities and the lack of staff to offer individual activities. The Activity Director admitted to not tracking activities with each resident and not having a system for informing bed-bound residents about daily activities. The Director of Nursing acknowledged the deficiency, noting that the Activity Director had other tasks that limited their ability to conduct more activities, and expected more activities to be completed and calendars to be up-to-date.
Deficiencies in CPAP Administration and Maintenance
Penalty
Summary
The facility failed to ensure proper administration and maintenance of CPAP machines for two residents, leading to deficiencies in respiratory care. For one resident, there was no physician order for the use of the CPAP machine, nor were there orders for cleaning or changing the tubing and masks. Observations revealed that the CPAP mask was improperly stored in a gift bag, and there was condensation in the tubing. The resident reported that staff had cleaned the machine and tubing before, but not on a daily basis. For another resident, the facility did not label or date the CPAP machine's tubing and humidifier, and there were open, undated containers of distilled water. The resident's care plan indicated the use of CPAP at night, but the resident frequently refused staff assistance with placement. Observations showed condensation in the mask tubing, and the resident was unsure about the cleaning schedule of the machine. The resident mentioned that the mask and tubing were changed approximately once a month. Interviews with staff revealed a lack of awareness regarding the daily cleaning requirements for CPAP masks and the need for physician orders for CPAP use. The LPN stated that masks were not cleaned daily and were changed monthly. The DON confirmed that CPAP cleaning should follow the manufacturer's guidelines or be done weekly, and distilled water should be dated and used within 30 days of opening. The Charge Nurse was identified as responsible for the cleaning and care of CPAP machines.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility staff failed to properly assess residents for the risk of entrapment from bed rails before their installation. This deficiency was observed in four residents, where the facility did not ensure that the bed's dimensions were appropriate for the residents' size and weight. Additionally, the facility did not complete the required quarterly assessments for side rail and entrapment risks. The absence of these assessments was noted for Residents #20, #13, #14, and #21, indicating a systemic issue in the facility's adherence to safety protocols. Furthermore, the facility did not obtain the necessary physician's orders prior to the installation of bed rails for Residents #20, #13, and #14. Informed consent was also not obtained for Residents #13, #14, and #21. These lapses in protocol highlight a failure in communication and documentation processes within the facility. The lack of informed consent and physician's orders suggests that the facility did not adequately involve residents or their representatives in decisions regarding their care. The facility's policy on bed rails, which includes conducting regular inspections and ensuring compatibility of bed components, was not followed. Interviews with staff, including the Director of Nursing and the Administrator, revealed a lack of awareness and responsibility regarding the completion of entrapment assessments. Maintenance staff also indicated that they had not been involved in the installation or measurement of bed rails, mattresses, or bed frames, further underscoring the facility's failure to adhere to its own policies and procedures.
Failure to Ensure Timely Completion of Nurse Aide Training
Penalty
Summary
The facility failed to ensure that two nurse aides completed a nurse aide training program within four months of their employment, as required. The facility's assessment indicated that nursing staff must have current and verifiable licenses or certifications, and nurse aides should be enrolled in a Certified Nursing Assistant class within 120 days of hire. However, a review of employee files showed that Nurse Aide A, hired on July 6, 2023, did not have a competency evaluation and received certification on May 24, 2024, while Nurse Aide B, hired on March 14, 2024, also lacked a competency evaluation and had no certification issued. The Missouri CNA Registry confirmed that Nurse Aide A's certification was issued on May 24, 2024, and Nurse Aide B was not found in the registry. During an interview, the Administrator acknowledged that two nurse aides were working in the facility, with one certified in the last 90 days, and both were enrolled in online Certified Nurse Aide training. The Administrator was unsure if the Director of Nursing provided competency evaluations before nurse aides had contact with residents. It was noted that Nurse Aide A and B did not complete their classes within the four-month timeframe due to missed classes, and the Administrator was aware of this issue but unsure why the staff were still employed after four months.
Deficiency in Nurse Aide Education and Competency Tracking
Penalty
Summary
The facility failed to conduct at least twelve hours of nurse aide in-service education per year, did not provide annual individual performance reviews or evaluations for nurse aides, and did not implement a tracking system for monitoring training hours. This deficiency affected five out of seven sampled nurse aides and had the potential to impact all staff and residents. The facility's census was 33. The facility did not have a policy regarding staff education, and the review of the facility assessment indicated that competencies were to be tested every six months and at hire for nursing staff, which was not adhered to. During interviews, the Director of Nursing (DON) and the Administrator acknowledged the lack of a tracking system for education and hours of education. The DON was unaware that the facility assessment required competencies to be done every six months, and the Administrator was not aware that staff did not have the required 12 hours of education. The report highlighted that education is typically completed on paydays, and when a staff member misses a meeting, they must meet with the DON or Administrator one-on-one. However, there was no proof of education tracking or completion of required competencies for several CNAs.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature for four of twelve sampled residents. The facility's policy required hot foods to be at least 120 degrees Fahrenheit when served, but this standard was not consistently met. Residents reported that their food was often served cold, and observations confirmed that food temperatures were not checked before serving. During an observation in the kitchen, it was noted that food items were placed on the steam table without temperature checks. The staff member responsible for serving did not check the temperatures of the food on the steam table prior to serving lunch. Interviews with staff revealed a lack of training on proper food temperature checking procedures. The administrator confirmed that food temperatures should be checked before serving, but this was not done, leading to the deficiency.
Lack of Back Flow Preventer on Shower Hose
Penalty
Summary
The facility staff failed to ensure the presence of a back flow preventer device on all shower hoses, which is necessary to prevent toxins from contaminating the facility's potable water supply. During an observation, it was noted that the shower hose in the shower room across from room six lacked this device. In an interview conducted at the same time, the Maintenance Supervisor admitted to being unaware of the requirement for all shower hoses to have a back flow preventer device.
Ineffective Pest Control Program and Potential Spider Bite Incident
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of gnats in the corridors and brown recluse spiders in the sprinkler riser room. The pest control logs did not show any specific treatments for spiders or gnats. During an observation, the surveyor noted at least five living spiders and a dozen dead spiders in various stages of decay in the sprinkler riser room. The Maintenance Supervisor admitted there was no specific routine for spiders in their pest control program, and the Administrator confirmed that their pest control company did not specifically target spiders, acknowledging that general sprays are ineffective against brown recluse spiders. A resident returned from a weekend with family with a red, swollen, and scabbed area on the back of their right calf. The physician assessed the area and suggested it could be an abscess or a spider bite, prescribing Doxycycline and a topical treatment. The Director of Nursing and the Administrator discussed the incident, noting the resident had been away with family, and the physician was uncertain if it was a spider bite. The Administrator acknowledged the uncertainty of the source of the bite, given the resident's time away from the facility.
Deficiency in Nurse Aide Education and Competency Training
Penalty
Summary
The facility failed to conduct at least 12 hours of nurse aide in-service education per year, as required, and did not provide the necessary annual competency training in Dementia Care and other essential areas. This deficiency affected five out of seven sampled nurse aides and had the potential to impact all staff and residents, with the facility's census being 33. The facility did not have a policy for education, and there was no tracking system in place to monitor the completion of required training hours. The facility assessment indicated that competencies should be tested every six months and at the time of hire for nursing staff, covering various critical areas such as person-centered care, activities of daily living, infection control, and caring for residents with dementia. However, a review of employee files and education records showed that several CNAs had no education tracking, and some had not completed the required competencies for 2024. The education records that were available did not indicate the length of education, start, or end times, further highlighting the lack of a structured education program. During an interview, the DON and Administrator acknowledged the absence of a tracking system for education and hours of education. The DON was unaware of the facility assessment's requirements and the lack of sufficient education hours for staff. The Administrator also admitted to not knowing that the facility assessment required competencies to be completed every six months and at the time of hire. Education was typically conducted on paydays, but there was no system to ensure that all staff received the necessary training, especially if they missed scheduled meetings.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's Admission Minimum Data Set (MDS) indicated no cognitive loss and required setup assistance for Activities of Daily Living (ADLs). Despite having a diagnosis of PTSD, the facility did not have a policy on Trauma Informed Care, and the resident's medical record lacked behavior interventions, a psychiatric evaluation, or a care plan addressing the PTSD diagnosis. The resident expressed feelings of anxiety and distress, mentioning nightmares and a history of trauma, but reported that the facility had not provided any assistance for these issues. Interviews with facility staff revealed further deficiencies in care. The Social Service Director admitted to not arranging behavioral health appointments, relying instead on a contracted office to send a list of residents to be seen monthly. The Director of Nursing acknowledged the resident's PTSD diagnosis and stated that the care plan should have included this diagnosis. The resident was not informed about the option to see a professional for their mental health needs, contributing to their ongoing distress.
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 104 citations issued within 25 miles in the last 12 months — including the 5 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 Maysville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quail Run Health Care Center | 10.4 mi | ★★★★★ | 1 | 0 |
| Cameron Nursing Center | 11.7 mi | ★★★★★ | 2 | 0 |
| Daviess County Nursing And Rehabilitation | 20.1 mi | ★★★★★ | 0 | 0 |
| Abundant Acres Care And Rehab | 21.5 mi | ★★★★★ | 42 | 2 |
| Hill Crest Manor | 21.6 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 July 2026) and official state health department websites.