Sunset Home

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

corrections on 10/17/25 at 9:04 AMThe Facility submitted the Abatement plan with corrections on 10/17/25 at 10:00 AMRegional Office submitted the Abatement plan with more corrections at 11:05 AMThe Facility submitted the Abatement plan with corrections at 11:21 AMThe Facility's Abatement plan was accepted on 10/17/25 at 11:43 AM.On 10/16/25 and 10/17/25 this surveyor confirmed through interview and record

review that the facility took the following steps to remove the immediacy1.On 10/16/25: V1 (Administrator),V2 (Director of Nursing) and V3 (Assistant Director of Nursing) reviewed Abuse Policy and intervening and reporting with quiz; Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout with all on duty staff in person. All staff not working on at the time were reached by phone and were educated. Any staff who were not reachable will not be able to clock in for their next shift until V2 (DON) or V3 (ADON) provide the education and handouts.2. The Abuse policy and intervening and reporting with quiz, Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout specific to intervention of preventing abuse and recognizing stress and burnout in co-workers and intervening was added to the orientation packet for new staff.3.On 10/16/25

An emergency QAPI (Quality Assurance and Performance Improvement) discussion was held with the Medical Director, V1 (Administrator),V2 (DON), V2 (ADON) and V32 (Social Service Director) to review the investigation findings and conclusion and review the QA audit tools for ongoing audit plan. QA Audit will be conducted of 5 residents and 5 staff per month by V2 (DON), V3 (ADON), V32 (Social Services Director) and/or designees about Abuse, Stress, and Burnout and concerns regarding any cares. These audit tools will be reported monthly on the QAPI scorecard and reported at the QA meeting; 4.On 10/17/25 All residents with Alzheimer's Disease/Dementia were reviewed for At Risk for Abuse/Harm and any identified, care plan was be added and/or updated by V32 (SSD) .5. V1 (Administrator) and V2 (Director of Nursing) will meet monthly to review all audit findings for discussion for need, if any, for further training/education and/or policy review changes.Completion date 10/17/25

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Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Home

418 Washington Street Quincy, IL 62301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Immediate jeopardy to resident health or safety

for thorough investigation will be conducted with each allegation investigation. These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality assurance meeting.6. V1 ( Administrator) and V2 (DON)will meet monthly to review all audit findings and discuss, if any, possible further training/education or policy review changes need to occur. 7. Resident R1's Care Plan was updated with at risk for abuse/harm and interventions by Social Service Director on 10/16/2025.Date of completion10/16/2025

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sunset Home

418 Washington Street Quincy, IL 62301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730

Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to ensure that Certified Nursing Assistant staff have had required 12 hours of in-service education. This failure has the potential to affect all 88 residents residing in the facility. Findings include: The facility policy titled, Abuse and Neglect, dated July 2023, documents not in its entirety, 3.) Aversion And Intervention of Abuse, a. Preventing resident abuse is a primary concern for Sunset Home. It is our goal to achieve and maintain an abuse free environment. B. Our abuse/intervention program may include but is not limited to: i. Conducting conflict resolution training classes for all staff. vii. Regularly scheduled in-service training programs designed to teach staff how to better understand the resident's abusive actions. Facility Town Hall meeting in-service sign in sheet for abuse training dated 3/13/25 documents V5, V6, V13, V15, and V16 (all Certified Nursing Assistants) attended, Town Hall meeting in-service sign in sheet for abuse training dated 4/17/25 documents V4, V5, V13, V17, V18, V19, V20, V21, V22, V23, V24, V25, V26, V27, and V28 (all Certified Nursing Assistants) attended, Town Hall meeting in-service sign in sheet for abuse training dated 9/18/25 documents V4, V5, V11, V12, V13, V14, V15, V19, V20, V21, V22, V23, V27, V29, V30, and V31 (all Certified Nursing Assistants) attended. On 10/15/25 at 1:10 PM V2 (Director of Nursing/DON) stated she is not sure about dementia training for the Certified Nursing Assistants/CNA, but the abuse training is done in the Town Hall meetings, and she (V2/DON) stated she does skills in-services on various topics at the monthly CNA meetings. On 10/15/25 at 1:15 PM V1 (Administrator) stated that she was not sure if there is proof that the CNAs (Certified Nursing Assistant) have had the required 12 hours of yearly in-servicing/education but will check with Human Resources. V1 also stated she does not think there has been any dementia training in

the one and half years she has been with the facility. On 10/15/25 at 2:20 PM V1 (Administrator) stated, I'm going to be honest with you we do not have any proof to show that the CNA (Certified Nursing Assistant) staff have had their 12 hours of training and unable to prove they all have had abuse and dementia training.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet