Average — CMS composite of the measures below.
A standard survey is most likely before around August 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.
Surveyors found multiple expired food items, including bread, tortillas, buns, and mayonnaise, in the kitchen's dry storage and walk-in refrigerator. Staff interviews confirmed knowledge of policies requiring expired foods to be discarded and regular checks to be performed, but these procedures were not effectively followed, resulting in expired items remaining in storage.
Three residents with severe cognitive impairment and multiple medical conditions were provided bed rails without documented attempts at alternatives, risk assessments, or informed consent. Staff interviews revealed inconsistent understanding of the facility's bed rail policy, and required steps such as interdisciplinary evaluation and proper documentation were not followed.
A resident with dementia and communication deficits was not served her meal or assisted with eating at the same time as others, resulting in visible distress and frustration. Staff did not engage with the resident during feeding, instead talking among themselves, and acknowledged that the delay and lack of interaction were not consistent with facility expectations for a dignified dining experience.
A medication cart was found to contain expired Artificial Tears prescribed to a resident with multiple chronic conditions, including dry eye syndrome. Staff interviews revealed that both shift nurses and the pharmacist were responsible for checking for expired medications, but the expired item was missed during routine checks, contrary to facility policy requiring proper labeling and removal of expired drugs.
A resident with a history of brain tumor and dementia, who had no prior elopement behaviors, was able to leave the facility unsupervised, access a vehicle, and was later found injured after a car accident. Staff discovered the resident missing during routine checks, and the facility's sign-out and monitoring procedures were not effectively followed, resulting in the resident's unsupervised exit and subsequent accident.
Expired Food Items Found in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen inspection, multiple perishable food items were found past their use-by or expiration dates, including a bag of white bread, tortillas, buns, and several bottles of mayonnaise. These items were located in the dry storage pantry and walk-in refrigerator, indicating a lapse in the facility's food storage and monitoring practices. Interviews with staff, including dietary staff, the DON, and the administrator, confirmed that all were aware of the policy requiring expired foods to be discarded immediately and that food items should be labeled with expiration dates. Staff described a check-off system and daily checks for expired foods, but the presence of expired items demonstrated that these procedures were not effectively implemented. Review of the facility's policy further supported that supervisors were responsible for ensuring expired foods were not present in storage areas.
Failure to Assess, Obtain Consent, and Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for three residents. Specifically, staff did not attempt appropriate alternatives before installing bed rails, did not assess the residents for safety risks or risk of entrapment, did not review the risks and benefits with the residents or their representatives, and did not obtain informed consent prior to installation. These failures were identified through observation, interviews, and record reviews for three residents with severe cognitive impairments and multiple medical diagnoses, including dementia, Alzheimer's disease, and communication deficits. For one resident, documentation showed the use of half rails for bed mobility and transfers, but there was no physician order, no assessment for side rail use, and no informed consent on file. The resident's representative was unaware of the bed rail installation and had not been consulted. Another resident was observed with half rails up on both sides of the bed, but there was no mention of bed rails in the care plan, no physician order, no assessment, and no informed consent documented. A third resident, also with severe cognitive impairment, had half rails in use for bed mobility and transferring, but again, there was no physician order, no assessment for entrapment risk, and no informed consent obtained. Interviews with staff revealed inconsistent understanding and application of the facility's bed rail policy. Some staff believed that consent was only needed in certain situations or that the signed restraint policy in the admission packet was sufficient. Others were unsure of the policy or relied on charge nurses to ensure proper documentation. The facility's policy required alternatives to be attempted, interdisciplinary evaluation, resident assessment, and informed consent before bed rail use, but these steps were not followed for the residents reviewed.
Failure to Provide Timely and Dignified Mealtime Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during mealtimes, as required by resident rights regulations. Observations revealed that the resident, who had diagnoses including dementia, cognitive communication deficit, and required assistance with eating following a fall, was not served her meal or provided assistance to eat at the same time as other residents at her table. On multiple occasions, the resident was observed waiting significantly longer than others for her food, displaying signs of distress such as rocking, moaning, and grunting. Staff acknowledged the delay and the resident's visible frustration, with one staff member apologizing for the wait and another noting that the resident was upset due to the delay. Further observations indicated that while assisting the resident with her meal, staff did not engage or communicate with her, instead conversing with each other. Interviews with staff confirmed that interaction with residents during feeding was important for their well-being, and that the delay in serving the resident was not typical but occurred during the survey process. Staff also stated that feeding two residents at once was acceptable as long as there was no cross-contamination, and that waiting 15-20 minutes for food while others were eating was excessive and not in line with facility expectations. The resident's care plan emphasized the need to monitor for nonverbal communication and to anticipate needs, especially given her cognitive and communication deficits. Despite this, the resident was left waiting for her meal and assistance, and staff did not provide the expected engagement during feeding. Facility policy also required a dignified dining experience, which was not upheld in this instance, as confirmed by both staff interviews and direct observations.
Expired Medication Found on Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards, specifically regarding expiration dates, as observed on one of four medication carts reviewed. During an observation, a resident's Artificial Tears (Natural Tears) with an expiration date of 08/2024 was found on the medication cart. The resident involved had multiple diagnoses, including chronic kidney disease, hypertensive heart failure, anxiety disorder, and dry eye syndrome, and was prescribed the Artificial Tears for dry eye syndrome. Interviews with staff, including an RN, the DON, and the Administrator, revealed that the expired medication had been missed during routine checks. The charge nurse was responsible for checking the medication cart each shift, and the pharmacist was responsible for monthly checks. The facility's policy required that all medications, including over-the-counter drugs, be labeled with expiration dates. Despite these procedures, the expired medication remained on the cart, indicating a lapse in adherence to established protocols.
Failure to Prevent Resident Elopement and Accident Due to Inadequate Supervision and Security
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. The resident, a male with a history of frontal lobe brain tumor, dementia, psychotic disorder, and alcohol dependence, was admitted with no documented wandering or elopement behaviors and had previously demonstrated normal cognition. However, on the night of the incident, the resident was able to leave the facility without signing out, access a nearby truck, and was subsequently involved in a motor vehicle accident, resulting in minor injuries and hospitalization. The facility's policies required residents to sign in and out when leaving or returning, and for staff to monitor residents by reviewing the sign-in/sign-out sheet and making routine checks. On the night of the incident, the resident was last seen by another resident around 11:00 PM, and was discovered missing during routine checks at approximately 10:15 PM. Staff searched the facility, reviewed the sign-out log, and, upon failing to locate the resident, initiated the missing resident protocol and notified administration and law enforcement. The resident was found several hours later by police, injured in a field after a car accident. Interviews with staff and review of records revealed that the resident did not have a history of elopement or wandering, and his care plan did not include interventions for such behaviors. The facility's process for re-entry after hours required residents to have a phone to call the nurses' station, but the resident did not have one. The incident led to the identification of Immediate Jeopardy due to the failure to prevent the resident's elopement and ensure adequate supervision, as well as the lack of effective monitoring and security measures to prevent such occurrences.
Removal Plan
- Facility will keep all exit doors secured at the facility with either a locking device or an alarm to protect residents. The locking devices will keep the doors locked, requiring anyone exiting the building to ask a staff member to temporarily override the locking mechanism. All staff are provided with the keypad override code. Staff will confirm the identity of the individual exiting the building, and ensure they are signed out if they are a resident. The exit doors that do not have locking devices are equipped with a loud, ongoing alarm that will alert staff that someone has passed through. Staff will confirm the identity of the individual that has passed through. Any exit door that is temporarily unsecured will be manned with a staff member continuously while unsecured.
- A doorbell is placed on each secured exit door to ensure residents and visitors who are outside have a way to alert staff to let them in. A sign will accompany the doorbell button on the door instructing those outside to push the doorbell button to enter.
- All staff will be in-serviced by Administration over the new exit-door security policy and the new doorbell policy. All present staff are in-serviced in-person; all staff not on shift have been in-serviced by phone. These policies and procedures will be part of new hire orientation ongoing.
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 24 citations issued within 25 miles in the last 12 months — including the 1 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 Clifton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Park Rehabilitation Health Care Center | 1.1 mi | ★★★★★ | 15 | 1 |
| Goodall Witcher Nursing Facility | 6.2 mi | — | 0 | 0 |
| The Hilltop On Main | 11.8 mi | ★★★★★ | 7 | 0 |
| Whitney Nursing And Rehabilitation Center | 19.6 mi | ★★★★★ | 2 | 0 |
| Hillside Medical Lodge | 25.6 mi | ★★★★★ | 8 | 0 |
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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.