Sunset Rehab: Fall Left Unreported After Nurse Judged It Behavior - IL
No assessment was done. No incident report was filed. The doctor wasn't called. The family wasn't called. The Director of Nursing wasn't told. The man's sister, who works at the same facility as a nurse, found out days later only because state inspectors started asking questions.
The resident, identified in inspection records as R3, had been admitted with a list of conditions that would give any nurse pause: schizophrenia, diabetes with neuropathy, congestive heart failure, COPD, depression, anxiety, traumatic brain injury, and limited physical mobility requiring a walker and standby assistance. He had been hospitalized for a fall just two days before, on October 22, 2025, and had returned to the facility the same day the dining room incident occurred, October 24, actively being treated for sepsis.
That afternoon, somewhere between 4:00 and 5:00 PM, R3 went down in the dining room. Two certified nursing aides, identified as V23 and V24, were there. So was V3, the licensed practical nurse on duty.
V3 left and never came back.
V23 later told inspectors that earlier that same day, while trying to take R3 to the shower, R3 had gone down on both knees. V23 said R3 liked to put himself on the floor and that she didn't think he was injured, but acknowledged the nurse who witnessed it, V3, never assessed him. Then came the dining room fall hours later. V24 told inspectors that R3 "fell and hit hard." She and V23 took his vital signs and checked on him themselves, because the nurse had already gone.
When inspectors interviewed V3 on October 30, she confirmed all of it. There was a change of plane in the dining room on October 24. She did not conduct a post-fall assessment. She did not file a Risk Management Incident report. She did not notify the physician. She did not notify the family. She did not do follow-up assessments. Her explanation: she considered it a behavior, not a fall.
She also said she didn't document R3's behaviors because, in her view, behaviors don't need to be documented.
V3 confirmed she knew R3 had just come back from the hospital that same day. She knew he was being treated for sepsis.
V5, the nurse who told inspectors she is R3's sister, said she was never informed that her brother had gone down on October 24. She found out during the inspection.
The Director of Nursing, V2, told inspectors she was also unaware the incident had occurred. After learning what V3 had told investigators, V2 offered the same framing: V3 had believed it was a behavior issue, not a fall. V2 noted that R3 can ambulate independently, though it isn't encouraged, and will sit on the floor when he wants to.
The administrator, V1, did not defend what happened. She agreed that a thorough investigation had not been conducted after R3's fall and that the incident should have been documented and reported so someone could have worked to identify the root cause.
R3's care plan, the document that exists precisely to guide staff decisions about a resident, noted his fall risk, his limited mobility, his history of putting himself on the floor, and the need to monitor for that behavior. It was a known pattern. It was written down. None of that translated into a nurse staying in the room after he hit the floor.
The inspection also flagged a separate failure involving another resident, R1, whose family was not informed of new fall precautions put in place after a fall, though the details of that case were not fully included in the portion of the report available.
The October 30 inspection was conducted in response to a complaint. Inspectors rated the harm level as minimal harm or potential for actual harm, affecting few residents.
R3 had come back from the hospital the morning of October 24 with a serious infection ravaging his body. That afternoon he hit the dining room floor hard enough that two aides felt the need to check his vitals. The nurse who saw it decided it was nothing worth writing down, and went on with her shift.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunset Rehabilitation and Health Care from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
Sunset Rehabilitation and Health Care in CANTON, IL was cited for violations during a health inspection on October 30, 2025.
The Director of Nursing wasn't told.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.