Health inspection·February 13, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on Observation, Interview and Record Review, the facility failed to ensure nursing assistants provided a resident at risk for falling with supervision, failed to provide residents with dining assistance, and failed to document meal and fluid intakes and episodes of incontinence for three of three residents (R1, R2, R3) reviewed for nursing care in the sample of four. Residents Affected - Few Findings include: The facility's Assistance with Meals policy, dated 3/2022, documents Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. All residents will be encouraged to eat in the dining room. Facility staff will serve resident trays and will help residents who require assistance with eating. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals; keeping interactions with other staff to a minimum while assisting residents with meals. The facility's Certified Nursing Assistant job description, dated 4/16/20, documents The primary purpose of your job position is to provide your assigned residents with routine daily nursing care procedures, and as may be directed by your supervisors. Record all entries on flow sheets, notes, charts, etc. (etcetera), in an informative and descriptive manner. Use the Care Plan to identify residents before serving meals, transferring, etc., as necessary. Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift. Maintain intake and output records as instructed. Keep incontinent residents clean and dry. Serve food trays. Assist with feeding as indicated (example; cutting foods, feeding, assist in dining room supervision, etc.). Assist residents with identifying food arrangements (example; informing residents with sight problems, what foods are on the tray, where it is located, if it is hot/cold, etc.). Record the residents' food/fluid intake. Report changes in the resident's eating habits. The facility's Behavioral Programs and Toileting Plans for Urinary incontinence policy, dated 10/2010, documents The purpose of this procedure is to provide guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for the resident with urinary incontinence. Monitor, record and evaluate information about the resident's bladder habits, and continence or incontinence, including: voiding patterns (frequency, volume, time, quality of stream, etc.); associated pain or discomfort; type of incontinence (stress, urge, mixed, overflow, functional, etc.); level of incontinence; and response to specific interventions. If the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. Page 1 of 5 145800 145800 02/13/2025 Sunset Home 418 Washington Street Quincy, IL 62301

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's current Care Plan, dated 1/30/25, documents R1 has diagnoses including but not limited to Glaucoma, Dry Eye Syndrome, Dysphagia and Muscle Weakness. This Care Plan documents I have vision impairment and require glasses. ADL (Activities of Daily Living) self care needs; Eating, (R1) requires set up assistance by one staff to eat. I am incontinent of bladder related to Impaired Mobility, Loss of peritoneal tone, Poor toileting habits. Staff manage my urinary incontinence, and I am able to alert them to my wants/needs. I have impaired skin integrity related to immobility and bowel and bladder incontinence. Monitor nutritional status. Serve diet as ordered, monitor intake and record. R1's Weight Summary, dated 2/11/25, documents R1's weight on 1/7/25 was 129.8 pounds. This same record documents R1's weight on 2/4/25 was 121.8 pounds, indicating R1 has suffered a six percent weight loss in one month. R2's current Care Plan, dated 11/13/24, documents I have impaired cognitive function/dementia or impaired thought processes related to Alzheimer's. ADL (Activities of Daily Living) self care needs; Eating, (R1) requires extensive assistance by one staff to eat. (R2) is approaching end of life. Family has decided to enroll him in (Hospice Program). He has a diagnosis of Alzheimer's Disease with calorie malnutrition. R2's Minimum Data Set assessment, dated 1/1/25, documents R2 has severe cognitive impairment and is frequently incontinent of bowel and bladder. R3's current Care Plan, dated 12/4/24, documents (R3) is incontinent of bladder (related to) Confusion, Dementia, Impaired Mobility, Loss of peritoneal tone. The resident uses disposable briefs. Change per schedule and PRN (as needed). Anticipate and meet the resident's needs. (R3) is High risk for falls related to Deconditioning, Gait/balance problems. (R3) has had an actual fall: 3/21/23 no injury, 3/31/23 no injury, 8/5/23 lowered to floor, 9/10/24 slid out of wheelchair, 9/13/24 fall no injury, 12/12/24 lowered to floor no injury, 1/12/25 lowered to floor no injury. On 2/10/25 at 12:05 PM, R3 was observed in the entry way to the fourth floor River-view dining room. R3 was slouched down in her wheelchair and appeared to have slid far enough that she could not reposition herself. R3 stated Can you help me? at which time V13 (Certified Nursing Assistant, CNA) was observed walking from the hallway into the dining room towards R3. At this same time V10, V11 and V12 (CNAs) were all observed sitting together, side by side at a table in the fourth floor dining room. V10 was eating a container with deli meat, crackers and cheese and was drinking a carbonated beverage. V10 confirmed she is a CNA who works in the facility and is not on break. V11 got up from the table at this time. V10 and V12 both stood from the table and began removing trays from the dining tables. Several residents remained in the dining room at this time including R1 and R2 who both were seated at the table where V10, V11 and V12 were just sitting. R1 was staring forward and took an occasional bite of his cake. Less than 25% of his noon meal had been consumed, approximately half of his cake and no more than two bites of a grilled sandwich were eaten. R1's vegetables and sides were untouched. R1 did not engage in conversation and was not observed being encouraged to eat any more than he had consumed. R2 was sitting at the other end of the table and was sleeping upright in his wheelchair. Less than 50% of his meal was eaten. R1 and R2's trays were both collected by 12:15 PM, without any further consumption or encouragement of consumption from staff. On 2/10/25 at 12:30 PM, V14 (Registered Nurse) confirmed that R3 does have a history of falling and has fallen from her wheelchair by sliding out of it before. V14 then stated Typically, CNA staff do not eat in the dining room during resident meals because they are in there to watch and assist residents. 145800 Page 2 of 5 145800 02/13/2025 Sunset Home 418 Washington Street Quincy, IL 62301

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/10/25 at 12:35 PM, V12 (CNA) stated If we (nursing assistants) do incontinence care or turning and positioning, we just put it on a paper. We don't chart in the computer. I guess the nurse enters that in the computer, I don't know. On 2/11/25 at 11:00 AM, V1 (Administrator) stated CNAs should not be eating in the dining room during resident mealtimes. They should be assisting residents and supervising the meal, especially not sitting all together. R1, R2 and R3's medical records do not document meal intake percentages, incontinence cares provided or incontinent urinary output recordings. On 2/11/25 at 1:30 PM, V3 (Assistant Director of Nursing) stated We do not have anywhere that we document meal intakes in R1, R2 or R3's records. (R2) falls asleep during meals a lot, so he sometimes just needs cues. I did see where (R1) just triggered this month for weight-loss. CNAs don't chart intakes of meals anywhere though. (R3) does fall from her wheelchair sometimes. It sounds like (nursing assistant) staff yesterday were not doing what they're supposed to be. The expectation of CNA's assisting at mealtimes is much more than what was being done. They should not all be sitting at the same table together when residents are in there for supervision and meal assistance. On 2/11/25 at 2:20 PM, V3 confirmed R1, R2 and R3 have not had bladder incontinent episodes documented in their medical records for the past two months. V3 stated I do not have documentation to show if (R1, R2 or R3) had any episodes of incontinence or output with urination. CNAs should be documenting the incontinent episodes so that they can prove it was done and taken care of. I don't have any other place for them to chart (besides paper) and we no longer have them chart in the computer. The last of the paper incontinence charting I can find is from October 2024. On 2/12/25 at 2:40 PM, V1 confirmed there is a lack in CNA charting and stated these are all things that are going to have to change. V1 stated There's no way to prove they (residents) are or are not receiving incontinence care if they are not documenting it. 145800 Page 3 of 5 145800 02/13/2025 Sunset Home 418 Washington Street Quincy, IL 62301

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on Observation, Interview and Record Review, the facility failed to keep the kitchen and resident dining areas free from cockroaches. This failure has the potential to affect all 96 residents residing in the facility. Findings include: The facility's Sanitation policy, dated 11/2022, documents The food service area is maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. All utensils, counter, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. The facility's Pest Control policy, dated 5/2008, documents Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The facility's pest control Service Slip/ Invoice, dated 11/6/24, documents the facility's kitchen and surrounding areas were treated for roaches (cockroach insects). The facility's pest control Service Slip/ Invoices, dated 12/27/24, 1/10/25, 1/24/25, documents on each of these dates' areas of the facility, including the kitchen, dining halls, interior walls and basement were treated for cockroaches. The facility's pest control Service Slip/ Invoice, dated 1/31/25, documents the facility's kitchen, ice machine and third and fourth floor dining hall areas were treated. This invoice documents Four river (dining hall) was showing a lot of roaches. The facility's pest control Service Slip/ Invoice, dated 2/7/25, documents the facility was treated in the basement and the kitchen for cockroaches. On 2/10/25 at 11:40 AM, V8 (Certified Nursing Assistant, CNA) stated she worked in the facility's fourth floor Riverside hall on 1/27/25 and saw cockroaches in the dining area. V8 stated I did see roaches on resident trays in the fourth floor dining room. The counter by the sink and the ice machine is where they seem to be. They (staff) will put trays up there and that is where the roaches were seen. One of the aides (unknown), told me the ice had roaches in the past too. I have heard there have been issues with roaches for a long time. On 2/10/25 at 12:15 PM, a live cockroach was observed crawling on the floor beneath the sink and counter in the Riverside fourth floor dining area. A non-living cockroach was observed on the microwave stand above the dining room's sink. At this time V10 (CNA) confirmed the insect on the floor was a live cockroach and stated They (pest control) usually come spray to treat them. I've seen maybe a couple lives ones today, but nothing big. At this time the counter near the sink and microwave contained a plastic container with loaves of bread inside. This container had a broken piece of lid which created an approximate three inch hole in the container's top lid. A resident tray was sitting on the counter with food under a warmed lid. This same counter also contained three column containers 145800 Page 4 of 5 145800 02/13/2025 Sunset Home 418 Washington Street Quincy, IL 62301

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many with holes in them which each stored forks, knives and spoons. V11 (CNA) confirmed that the silverware in the columns on this counter is clean and for resident use. On 2/10/25 at 12:45 PM, V15 (Dietary Assistant) stated I mostly work in the main dining room, outside of the kitchen area. I am not in the kitchen as much. I have seen roaches in the main dining room. This morning, I opened the cabinet under the juice machine and there were several live roaches. The only things stored in that cabinet is bags of sealed coffee. They (cockroaches) are usually less than an inch in size. I have killed larger ones myself too. This issue of roaches has been going on for several months. We get sprayed but it never seems to help or work fully. On 2/10/25 at 12:50 PM, V16 (Dietary Manager) confirmed the facility has cockroaches in the kitchen and dining areas. V16 stated They are better, but I still see them occasionally but it's usually just one or two. I have seen them on counters, and we wipe down the area and then I send a work order to maintenance when I see them. About six months ago we did a deep clean of the entire kitchen and food storage, one time. Then a new pest control company took over and it's gotten better since then, but not all the way gone. On 2/11/25 at 9:55 AM, V17 (Director of Housekeeping) confirmed the facility has had infestation issues with cockroaches. V17 stated Housekeeping cleans the dining rooms three times a day on each floor. But when they clean, they are not responsible for removing trays. That is dietary's responsibility. Roaches used to be found in all of the dining rooms. We still see them in dining room on fourth floor. Staff are leaving the food sitting on the counter overnight. No matter how much we clean, we still see them. Everything needs deep cleaned more often. Trays of food get left on the counter would be what's feeding the bugs. Dietary should be taking all the trays back, not leaving them in the dining area. There was a big tray with food and bowls from last night's supper or lunch on the counter this morning in the fourth floor dining room. Then in the sink there was about eight plates, some cups and bowls, all with food on them. When I lifted the tray this morning, there was one live roach and I killed it. I have seen them around the ice machine in the past, not today. On 2/11/25 at 11:00 AM, V1 (Administrator) confirmed the facility has been having pest control visits to address cockroaches in the facility's kitchen and dining areas. V1 stated The problem has gotten better but they are still present. They (pest control) just came last Friday but I am not sure if there has been further investigation as to the source or location of the infestation. A resident room roster dated 2/10/25 and provided by V3 (Assistant Director of nursing), documents there are 96 residents residing in the facility. 145800 Page 5 of 5