Sunset Home
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
resident is delusional and always thinks his/her sister, who has passed away is coming to pick him/her up.
The resident is easily redirected. He/She was not working the day Resident #1 eloped. They had an in-service and discussed the elopement, Resident #1 on 15-minute checks, all residents on two-hour visual safety checks, the additional alarms on the doors on the memory care unit. If unable to locate a resident, he/she would report it to the CN and then call Code Purple (missing resident). During an interview on 11/5/25 at 12:40 P.M., Dietary [NAME] A said:He/She only worked four days a week and was not working
the day Resident #1 eloped.He/She has never seen any resident go through the kitchen. During an
interview on 11/5/25 at 1:35 P.M., CNA B said:He/She worked on the North Hall and on the memory care unit.He/She was off the day the message went out for the Code Purple.When he/she arrived at the facility, he/she was informed of which resident was missing. He/She started driving around looking for Resident #1.He/She parked in the parking lot of the Dollar General and did not see anyone. He/She parked in the parking lot and went behind the building and found the resident on his/her side with his/her right arm under him/her trying to hold him/herself up. The resident was wearing a long-sleeved shirt, dark pants and tennis shoes. He/She did not recall the resident being covered in leaves. Where his/her body was touching ground was wet. The resident said he/she had been out with the girls, hit his/her head on a rock and his/her arm hurt. He/She covered the resident with his/her coat then removed blankets from his/her car and placed them on the resident. He/She called the facility and informed the CN Resident #1 had been found. The Police arrived and the ambulance arrived. The ambulance staff were aware the resident's left arm was hurting, and they did not obtain any vital signs from that side. He/She rode in the ambulance to the hospital with the resident. He/She informed the hospital staff about the resident's left arm hurting. The resident was settled in the hospital bed when he/she left the ER. They had a staff meeting that afternoon and discussed
the elopement, 15-minute checks, and two-hour visual safety checks on all residents, changing the doorknob on the kitchen door on the memory care unit and adding additional alarms. During an interview
on 11/5/25 a 2:08 P.M., Kitchen Aide A said:He/She has worked at the facility for a little over a month.A little
after 6:30 A.M., he/she was outside the deliver entrance door taking a break when he/she observed a figure walking past the propane tanks.He/She was not aware Resident #1 was missing at the time. Looking back, he/she thought that it very well could have been Resident #1 but not really for sure. they had a meeting that afternoon and were informed what to do if a resident went missing, also discussed changing the doorknob and the additional alarms. During an interview on 11/5/25 at 2:30 P.M., the Dietary Manager said:He/She had been in the position for about two weeks or maybe a month.He/She had no idea how Resident #1 eloped.Between 6:00 A.M. to 6:30 A.M., he/she opened the door to the dining room of the memory care unit. He/She had a conversation with the staff member working on the memory care unit and hung the menus then returned to the kitchen. Resident #1 was in the dining room at that time. He/She thought the door to the kitchen was shut but does not remember and also did not remember if it was locked or not.
He/She did not observe the resident going through the kitchen door, did not observe the resident in the hallway and did not hear the back delivery door open.They had an in-service that afternoon and discussed
the elopement, , changing the lock on the kitchen door, adding a doorbell and adding additional alarms.
Intake 2654580 Intake 2654882
Event ID:
Facility ID:
If continuation sheet
SUNSET HOME in MAYSVILLE, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MAYSVILLE, MO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SUNSET HOME or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.