Sunset Home

In the surveyor’s words

From the most serious findings on record at Sunset Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 5, 2022

  Based on observation, interview and record review the facility failed to provide adequate supervision, identify an elopement risk and implement safety measures and prevent one resident (Resident #1), who resided on the secure care unit, from eloping from the facility through an alarming door, and exiting from the building for approximately 18 hours with the temperature of 39 degrees Fahrenheit (F) and 14 mile per hour (MPH) wind gusts. Resident was found at a hotel 15.2 miles from the facility. The facility census was 39. The Administrator was notified on 5/3/22 at 2:09 P.M. of the Immediate Jeopardy (IJ) which began on 4/30/22. The IJ was removed on 5/5/22, as confirmed by surveyor onsite verification. […]

• Immediate jeopardy, isolatedF600Feb 24, 2022

  44993 Based on interview and record review, the facility failed to prevent the sexual abuse of two residents (Resident #2 and #3) when the facility did not put interventions in place to protect the residents from Resident #1, after he/she sexually abused Resident #2 on 2/1/22. He/she then sexually abused Resident #3 by fondling the resident's breasts on 2/20/22. The facility census was 41. The administrator was notified on 2/23/22 at 11:30 A.M. of an Immediate Jeopardy (IJ) which began on 2/20/22. […]

• Actual harm, isolatedF689Nov 5, 2025

  Based on observation, interview, and record review, the facility failed to prevent one of the three sampled residents, (Resident #1) from accidents and hazards when Resident #1 eloped from the facility and was found by a nearby business laying on the ground. The resident was transported to the hospital and found to have fractured in his/her left arm. The facility census was 29. Review of the facility's Elopement Protocol, dated April 2006 showed:Elopement, for the purpose of these guidelines is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety needs, and therefore at risk for injury outside the confines of the facility, has left the facility without knowledge of staff. […]

• No harm, potential for more than minimal, widespreadF812Jul 23, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 23.Review of the facility's Cleaning of Workspaces policy, dated May 2015 showed:-Walls, doors, vents and ceiling must be free from chipped and/or peeling paint and must be kept in good repair;-Walls, doors, vents and ceilings must be washed at least twice a year;-Heavily soiled surfaces must be cleaned more frequently;-Cabinets should be washed with detergent solution and warm water every week and more often if needed.Review of the facility's Storage of Food and Supplies, dated May 2025, showed:-Dry storage rooms must… […]

• No harm, potential for more than minimal, widespreadF726Aug 14, 2024

  Based on record review and interview, the facility failed to provide competency assessments in accordance with their facility assessment, when they failed to ensure 7 of 7 randomly selected nurse aides, had competency assessments at hire and every 6 months thereafter. This potentially effected all residents. The facility census was 33. The facility did not provide a policy for competency and education. Review of the Facility assessment dated [DATE] showed: -Competencies will be tested every 6 months and those indicated by star will be tested at hire, for nursing staff. […]