Sunset Home
SUNSET HOME in QUINCY, IL — inspection on October 17, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Training and Tips for Spotting Stress or Burnout with all on duty staff in person.
All staff not working
jeopardy to resident health or be able to clock in for their next shift until V2 (DON) or V3 (ADON) provide the education and safety 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
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
145800 10/17/2025
Sunset Home 418 Washington Street Quincy, IL 62301
and yelling, but she does that all the time.
She had been doing it all day. V3 stated that V4 (CNA)
jeopardy to resident health or help or needing help. (R1) had been having behaviors all day, it felt like (V4/CNA) just decided that safety (R1) was not going to be acting like that anymore. (V4/CNA) was visibly angry during this interaction.
V3 (RN) stated that at the time of the incident both she and V9 (LPN) felt that the interaction was not
stated that on 10/4/25 he heard a commotion and turned the corner to see R1 being dragged down the hallway while she was fighting and yelling. V8 stated that V4 stated here you take her. V8 stated he was able to hold his hand out to R1 and she took it calmly and was cooperative once let go.
That is not the way we should be treating a confused person. (V4/CNA) was noticeably upset and frustrated with (R1). R1 acted scared and followed me around all night. I for sure think she was traumatized by the whole thing even if she couldn't say it.
The Facility's Abuse Investigation dated 10/9/25 documents that on 10/4/25 V4 (CNA) was immediately suspended.
The Abuse Investigation dated 10/9/25 documents that the allegation was considered unsubstantiated as of 10/9/25 and V4 was allowed to return to work.The Facility's schedule documents that V4 (CNA) worked on 10/09/25 and 10/14/25. On 10/14/25 V4 (CNA) was the staff member responsible for R1's direct care. On 10/14/25 at 1:30 PM V1 (Administrator) confirmed that all statements from staff members on 10/4/25 indicated that V8 (CNA) was the staff member who took R1 from V4 (CNA) during the incident. V1 confirmed that she had not interviewed or spoken with V8 as of 10/14/25. I just haven't had problems with (V4/CNA) I wasn't that worried about it.
The facility's schedule for 10/4/25 documents that 3 staff members that were present on the hallway that incident took place on and V2 confirmed she has not interviewed them: V8 (CNA), V11 (CNA) and V12 (CNA).On 10/16/25 V1 (Administrator) provided an amended Abuse Investigation dated 10/15/25 that declared the abuse allegation on 10/4/25 as substantiated abuse.
The Facility's Resident Bedsheet census form dated 10/4/25 documents that 88 residents reside in the facility.Immediate Jeopardy Removal Plan:The Facility submitted it's original Abatement plan on 10/16/25 at 2:50 PMRegional Office returned the Abatement for corrections at 3:39 PMThe Facility submitted the Abatement plan with corrections on 10/16/25 at 3:42 PMRegional Office returned the Abatement plan for corrections on 10/17/25 at 9:04 AM.The Facility submitted the Abatement plan with corrections at 10:00 AMRegional Office returned the Abatement plan for corrections at 11:05 AMThe Facility submitted the Abatement plan at 11:21 AMRegional Office accepted the Abatement plan on 10/17/25 at 11:43 [NAME] 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 immediacy 1. On10/16/25 Administrator, DON, and ADON reviewed Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating.2. On 10/16/2025 staff were educated on Abuse Prevention Policy by V2 (DON) and V3 (ADON) 3. On 10/16/2025 Staff not working dayshift were called by (V1) Administrator, V2(DON), and V3 (ADON) were given education via phone of Abuse Prevention policy.4.
Remainder of the staff not working or reached by phone will be required to receive the education prior to working their next shift by V2 (DON) and/or V3 (ADON) or designee and will be required to sign the education sign-in sheet. 5. On 10/16/25 An Emergency QAPI (Quality Assurance Performance Improvement)discussion was held with Medical Director, V1(Administrator,)V2(DON), V3(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 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. 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
145800 10/17/2025
Sunset Home 418 Washington Street Quincy, IL 62301
residents residing in the facility.
Findings include: The facility policy titled, Abuse and Neglect, dated
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.