Inspection·May 21, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review staff failed to immediately notify the Administrator of possible abuse of one resident (R1) of three residents reviewed for abuse in the sample of three. Residents Affected - Few Findings include: The Abuse and Neglect Policy dated July 2023, documents It is the policy of (the facility) to provide each resident with an environment free from abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of resident property, exploitation and physical or chemical restraint not required to treat the residents' symptoms, as defined below. (The facility) shall follow the procedure for reporting and investigation of alleged resident abuse and neglect as outlined below, and in accordance with Skilled Nursing and Intermediate Care Facilities Code. The purpose and scope of this policy and procedure is to inform all individuals of the proper protocol for preventing, reporting, and investigating allegations of abuse and neglect, as specified in the corporate policy above. It is the responsibility of all employees, consultants, attending physicians, family members, visitors, etc., to immediately report any incident, suspected incident, or allegation of neglect or resident abuse, including, injuries of unknown origin, and theft or misappropriation of resident property to the administrator. b. Employees, consultants, and/or attending physicians must report any suspected abuse, allegations of abuse, or incidents of abuse to the administrator immediately. c. The administrator must be immediately notified of suspected abuse, allegations of abuse, or incidents of abuse. If such incidents occur or are discovered after hours, the administrator shall be contacted immediately. if the administrator is unavailable, contact the director of nursing services. The Initial Incident Report for R1 sent to the (State Agency) dated 5/11/24, documents that R1 was admitted to (The facility) on 5/7/24 for short term rehab. R1 has diagnoses of Sepsis, Left Ankle Fracture, Hypertension, and Type 2 Diabetes Mellitus. Today (5/11/24) V1/Administrator received a call from V5/R1's Nurse Practitioner. V5 stated that R1 was fearful of a Certified Nursing Assistant/CNA. R1 stated that the CNA had been yelling at R1 and was rough with R1 during a transfer and bumped R1's left foot causing R1 pain. V1 called the building and had the CNA sent home immediately. (The CNA was identified as V3) R1's MDS (Minimum Data Set) dated 5/13/24 documents a BIMS (Brief Interview for Mental Status) Score of 15/15, indicating cognition intact. On 5/20/24 at 10:38 AM, V8/Licensed Practical Nurse/LPN stated I was working days 6:00 AM to 4:30 PM on 5/11/24. That morning (V3/Certified Nursing Assistant) came to me and said that (R1) wanted some Tylenol for pain. I took the Tylenol to (R1). (R1) asked if I had time to talk to her. (R1) asked Didn't you hear (V3) yelling at me? I told (R1) that I did not hear that, but I did hear voices. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145800 Printed: 05/15/2026 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 145800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 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)