Sunset Rehabilitation And Health Care
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
not informed of the new interventions (frequent checks) put into place post Resident R1's fall.2. Resident R3 was admitted on [DATE REDACTED] with diagnoses of Schizophrenia, Diabetes Mellitus with Neuropathy, Urine Retention, Congestive Heart Failure, Osteoarthritis, COPD, Depression, Anxiety Disorder, and Traumatic Brain Injury.The current care plan documents Resident R3 has limited physical mobility related to weakness and deconditioning. Resident R3 can walk with a walker as tolerated with stand by assistance; behavior problem of fidgeting; resistive to Activities of Daily Living (ADL) cares; monitor for attention seeking behaviors and putting self on the floor.The Fall log documents Resident R3 sustained a fall on 10/22/25 with hospitalization.Resident R3's Progress Note documents Resident R3 was hospitalized on [DATE REDACTED] and returned to the facility on [DATE REDACTED].On 10/28/25 at 3:30 PM, V23 (Certified Nurse Aide/CNA) stated on 10/24/25 while trying to take Resident R3 to the shower, Resident R3 went down on both knees. V23 stated Resident R3 likes to put himself on the floor and I don't think he had an injury, but it wasn't assessed by the nurse (V3) who also witnessed the change of plane.10/28/25 at 3:45 PM, V24 (Certified Nurse Aide) stated Resident R3 fell and hit hard in the dining room on 10/24/25 between 4:00 PM-5:00 PM. V23 and V24 did the vital signs and assessed Resident R3 because V3 (Licensed Practical Nurse) left and never came back.On 10/30/25 at 11:00 AM, V3 (LPN) stated Resident R3 did have a change of plane in the dining room on 10/24/25 and a post fall assessment was not conducted, nor was a Risk Management Incident report initiated, the physician nor the family were notified and follow assessments were not conducted because she considered the change of plane to be intentional related to behaviors and not a fall. V3 stated she did not document Resident R3's behaviors because behaviors do not need to be documented. V3 stated she was aware that Resident R3 had returned from the hospital the same day and was actively undergoing treatment for Sepsis (a life-threatening medical emergency caused by your body's overwhelming response to an infection).On 10/29/25 at 9:11 AM, V5 (Licensed Practical Nurse/LPN) stated Resident R3 is her brother and was not notified that a change of plane occurred on 10/24/25.10/30/25 at 8:53 AM, V2 (Director of Nursing/DON) stated she was unaware Resident R3 had
a change of plane on 10/242/5. V2 stated Resident R3 can ambulate independently although it's not encouraged and will sit on the floor when he wants to. V2 stated after interviewing V3, V3 felt Resident R3's change of plane was a behavior issue and not a fall.On 10/30/25 at 1:45 PM, V1 (Administrator) agreed a thorough investigation had not been conducted after Resident R1's fall to determine the root cause. V1 stated Resident R3's change of plane should have been documented and reported so an investigation could have been conducted to assist in identifying
the root cause.
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Sunset Rehabilitation and Health Care in CANTON, IL 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 CANTON, IL, (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 Rehabilitation and Health Care or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.