Health inspection·March 19, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete blood sugar had dropped. I was not notified when the incident happened. It is important I'm notified of a significant change when it happens instead of finding out about it later from reviewing medical records. On 3/19/25 at 1:02 PM, V1/Administrator stated that she does not have a specific policy about physician notification or family notification. V1 also stated (V4/NP) should have been told about (R1's) drop in blood sugar. Event ID: Facility ID: 145800 If continuation sheet Page 2 of 14 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 03/19/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to take vitals or do a resident's assessments in a timely manner for one resident of four residents (R3) reviewed for vitals and assessments in the sample of 9. Residents Affected - Few Findings include: The Admitting the Resident: Role of the Nursing Assistant dated 9/2013, documents The following information should be recorded in the resident's medical record: 4. The resident's vital signs. 5. The resident's height and weight. The admission Assessment and Follow Up: Role of the Nurse dated 9/2012, documents The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS (Minimum Data Set). 9. Conduct supplemental assessments following facility forms and protocol including a. Activity level; b. Pain assessment; c. Fall risk assessment; d. Neurological assessment; e. Skin assessment; f. Functional assessment ability to perform ADLs; and g. Behavioral assessment. The following information should be recorded in the resident's medical record: 3. Assessment data obtained during the procedure. R3's current computerized medical record documents R3 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses which included Secondary Malignant Neoplasm of Other Parts of Nervous System, Malignant Neoplasm of Right Kidney, Except Renal Pelvis, Acute Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity, Bilateral, Other Pulmonary Embolism without Acute Cor Pulmonale, Thrombocytopenia, Other Pancytopenia, Chronic Systolic (Congestive) Heart Failure, Cardiac Arrhythmia, Dehydration, Secondary Malignant Neoplasm of Bone, Shortness of Breath, Hyperlipidemia, Spondylosis without Myelopathy or Radiculopathy, Lumbar Region, Acute Embolism and Thrombosis of Deep Veins of Left Upper Extremity. R3's electronic Medical Record documents R3's assessments were done on 12/10/24 as follows: Elopement Evaluation at 6:41 AM, Braden Scale (Pressure Ulcer Risk) Evaluation at 2:24 PM, Skin Check at 2:26 PM, AIMS (Abnormal Involuntary Movement Scale) Evaluation at 3:17 PM, and Fall Risk Evaluation at 3:18 PM. R3's Weight and Vitals Summary dated 3/14/25 at 2:54 PM for 12/6/24 -12/20/24, documents the first vitals for R3 were recorded on 12/10/24 at 10:05 AM, four days after admission. On 3/13/24 at 1:33 PM V2/Director of Nursing/DON verified that R3 was admitted to the facility on [DATE] and there were no vitals recorded on the vitals log until 12/10/24. V2 stated I have no idea what happened. The vitals should have been taken and recorded. No idea why there are no vitals. The nurses are supposed to put them in the they put a lot on paper, and it doesn't always get recorded in the system. On 3/15/25 at 3:07 PM, V2/DON stated 'The assessments are the same for everybody. It doesn't matter if they are Private Pay, Medicare, or Medicaid. When a resident is first admitted vitals should be done every shift for at least the first three days to get a baseline. On 3/19/25 at 1:02 PM, V1/Administrator stated I can't find that any of the required assessments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 3 of 14 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 03/19/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm for (R3) were done when (R3) admitted on [DATE]. On 12/10/24 the Elopement Assessment, Skin Assessment, Fall Assessment, AIMS Assessment, and Braden Evaluation were all done but they should have been done sooner. V1 also stated I can't find a policy that clearly defines when vitals should be done. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 4 of 14 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 03/19/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow treatments as ordered by the physician and failed to implement pressure relieving interventions for one resident (R5) of four residents reviewed for pressure ulcers in the sample of nine. These failures resulted in R5 developing a facility acquired stage 4 pressure ulcer to her coccyx that became infected and caused R5 pain. Residents Affected - Few Findings include: The Prevention of Pressure Injuries policy dated 4/2020 documents The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Mobility/Repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. The Administering Medications policy not dated documents that medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (Medication Administration Record) space provided for that drug and dose. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 21. Topical medications used in treatments must be recorded on the resident's treatment record (TAR) (Treatment Administration Record). 28. If a medication error is noted to have occurred, immediately assess the resident for adverse reactions and notify the physician for any additional orders. Place the resident on the 24-hour report book, notify the POA (Power of Attorney) and fill out a medication error form and turn into the nursing office. R5's Face Sheet documents R5 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses which included Spinal Stenosis, Lumbar Region without Neurogenic Claudication, Prolapsed Uterus, Essential (Primary) Hypertension, Unspecified Urinary Incontinence, Vitamin D Deficiency, Other Abnormalities of Gait and Mobility, Chronic Diastolic (Congestive) Heart Failure, Weakness, and Chronic Kidney Disease, Stage Three. R5's Progress Notes dated 12/21/24 at 12:48 AM document that R5 passed away on 12/20/24. R5's Brief Interview for Mental Status/BIMS dated 11/20/24 documents a BIMS of 10 (moderate cognition). R5's MDS (Minimum Data Set) assessment dated [DATE] documents R5 required substantial assist for bed mobility, was dependent on staff for toileting and transfers, R5 had an indwelling urinary catheter, and R5 was always incontinent of bowel. R5's Care Plan dated 12/5/24 documents that R5 had impaired skin integrity related to Immobility and a Prolapsed Uterus and a Pressure Ulcer to the Coccyx dated 12/5/24. Interventions Administer treatments as ordered and monitor for effectiveness. Avoid positioning (R5) on coccyx. Follow facility policies/protocols for the prevention and treatment of skin breakdown. This same Care Plan documents R5 had ADL (activities of daily living) self-care needs, was dependent on staff for bed mobility, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 5 of 14 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 03/19/2025 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 0686 and required one staff to turn and reposition R5 in bed. Level of Harm - Actual harm R5's Nursing Note written by V2/Director of Nursing dated 9/18/24 at 3:00 PM, documents that R5 has two new pressure ulcers. Skin issue # (number) 1 is a stage one pressure injury on R5's left buttock that measures 0.7 cm/centimeters x 0.8 cm x 0.1 cm. Skin issue # 2 is a stage two pressure ulcer on R5's coccyx that measures 1.1 cm x 1 cm x 0.1 cm. There is no wound odor or tunneling on either wound. Residents Affected - Few R5's Physician Order dated 9/18/2024 documents Cleanse coccyx open area with NS (Normal Saline) and apply calcium alginate and (absorbent foam dressing) daily. Start date 9/18/2024. Cleanse open area to L (left) buttocks with NS and apply (moisture barrier ointment) TID (three times a day) and PRN (as needed). Start date 9/18/24. R5's Physician Order dated 10/19/2024 documents Cleanse coccyx and R (right) buttock open areas with NS and apply calcium alginate four x (by) four gauze and (absorbent foam dressing) daily until healed. Start date 10/19/24. R5's Braden Evaluation dated 11/20/24 at 3:52 PM, documents Sensory Perception: very limited. Moisture: Constantly moist. Activity: Chair fast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Probably inadequate. Braden score of 10 (High Risk). R5's Progress Notes written by V4/Nurse Practitioner/NP for 12/2/24 service, documents R5 is a [AGE] year-old female who is seen today due to worsening wound to the coccyx. Last week the on-call NP was paged with concerns for progression of the wound. The wound measures 2.5 cm/centimeters by 3.5 cm by 1.2 cm with tunneling, sloth, and foul odor (indicates infection). Orders were given for Santyl, calcium alginate and dressing, change daily. I (V4) am following up today. At my previous visit in early November, wounds to the coccyx and right buttocks were superficial without any slough tissue, depth, or tunneling. The area is painful for (R5). Wound care to coccyx: Cleanse with 1/4 (Diluted sodium hypochlorite solution) 0.125% (percent) solution. Apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked four X four gauze, ensuring packing extends through the tunneling. When removing old dressings, MUST be sure old gauze is removed!!! This dressing must be changed daily. Start Oxycodone 2.5 mg/milligrams oral daily; give 30 minutes prior to wound care in the AM. Turn every 2 (two) hours while in bed. (Pressure relieving) cushion at all times when in wheelchair. R5's Physician Order dated 12/3/2024 documents (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to coccyx topically one time a day for wound care. Cleanse wound with (Diluted sodium hypochlorite solution), apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked four X four gauze, ensure packing extends through tunneling. Upon removal make sure old gauze is removed. Dressing must be changed daily. Start date 12/4/24. Oxycodone HCI Oral Tablet 5 MG (milligrams) Give 0.5 tablet by mouth every night shift for wound prior to wound care. Start date 12/3/24. R5's Nursing Note written by V6/LPN dated 12/3/24 at 1:57 PM, documents Per (V4/Nurse Practitioner) on 12/3/24 at 1:00 PM: Orders for wound care as follows: Cleanse with 1/4 (Diluted sodium hypochlorite solution) 0.125% solution. Apply SANTYL to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked 4x4 gauze, ensuring packing extends through the tunneling. When removing old dressings, MUST be sure old gauze is removed!!! This dressing must be changed daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 6 of 14 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 03/19/2025 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 0686 Currently waiting on (Diluted sodium hypochlorite solution) from the pharmacy. Faxed pharmacy to ensure (Diluted sodium hypochlorite solution) is delivered tonight. Level of Harm - Actual harm Residents Affected - Few R5's Medication Administration Note written by V6/Licensed Practical Nurse/LPN dated 12/3/24 at 2:41 PM, documents (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % Apply to coccyx topically one time only for Wound care for 1 (one) Day 1 dose No supplies available from pharmacy at this time. R5's Physician Order dated 12/5/2024 documents (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to coccyx topically every day and night shift for wound care. Cleanse wound with (Diluted sodium hypochlorite solution), apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked four x four gauze, ensure packing extends through tunneling. Upon removal make sure old gauze is removed. Dressing must be changed daily. Start date 12/5/24. Turn every two hours while in bed, side to side, avoid laying on back. Must use pillows between knees. Every shift to prevent further breakdown. Start 12/5/24. R5's Progress Notes written by V4/NP for 12/13/24 service, documents that R5 is a [AGE] year-old female who is seen today for follow up wound care to the coccyx. Physical Exam Stage four, now with deep tissue injury to surrounding tissue at 12 O'clock. Wound bed: 2.5 cm x 3.5 cm x 1.2 cm with slough/foul odor (indicated in fection) and tunneling at 5-6 O'clock, approx. 3 of tunneling. Cleanse with 1/4 (Diluted sodium hypochlorite solution) 0.125% solution. Apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked 4 x 4 gauze, ensuring packing extends through the tunneling. When removing old dressings, MUST be sure old gauze is removed!!! Changed dressings twice daily. Turn every two hours while in bed, side to side, avoid laying on back. Must use pillows between knees to prevent further breakdown. R5's Medication Administration Note written by V17/Licensed Practical Nurse dated 12/17/24 at 4:52 AM, documents (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % Apply to coccyx topically every day and night shift for wound care Cleanse wound with (Diluted sodium hypochlorite solution), apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked 4x4 gauze, ensure packing extends through tunneling. Upon removal make sure old gauze is removed. Dressing must be changed daily. Unable to complete due to there being no (Diluted sodium hypochlorite solution) available to complete this treatment. R5's Skin Check dated 12/18/24 at 5:38 AM, documents that R5 has a Stage four Pressure Ulcer, full thickness skin and tissue loss on her right coccyx that was acquired in-house. R5 is unable to describe pain. R5 says It hurts during dressing change. Length 7 cm/centimeters, width 5.5 cm, depth 3 cm, with undermining and tunneling. Granulation 50 % (percent), slough 50 %, with purulent heavy exudate and moderate odor after cleansing. Skin issue 2, left breast Excoriation Pressure ulcer staging: Stage 2 Pressure ulcer/injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Length 6 cm, Width 1.3 cm, Depth 1.2 cm. Skin issue 3, Right medial forefoot, Eschar Pressure ulcer staging: Stage 2 Pressure ulcer/injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Other pain description: Unable to describe, says It hurts when doing dressing change. Length 1.5 cm, Width 1.6 cm, Depth 1.2 cm, Area 9.3 cm. R5's Treatment Administration Records/TAR for September 2024 through December 2024 documents Cleanse coccyx open area with NS (normal saline) and apply calcium alginate and (absorbent foam dressing) daily. This same TAR documents R5's treatment was not signed as being done on 9/22, 9/23, 9/24/24. Cleanse open area to L (left) buttocks with NS and apply (moisture barrier ointment) TID (three times (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 7 of 14 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 03/19/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few a day) and PRN (as needed) every shift for Wound care. This same TAR documents R5's treatment was not signed as being done on day shift 10/5, 10/20, 11/7, evening shift 9/20, 9/21, 9/24, 9/29, 11/6, 11/12, 11/26, 11/27, 11/28/24, and night shift 9/22, 9/23, and 9/24, 10/21, 10/23, 11/22, 11/24 Cleanse coccyx and R (right) buttock open area with NS and apply calcium alginate four x four gauze and (absorbent wound dressing) daily until healed. This same TAR documents R5's treatment was not signed as being done on 11/6, 11/22, and 11/24/24. (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to coccyx topically every day and night shift for wound care. Cleanse wound with (Diluted sodium hypochlorite solution), apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked 4 X 4 gauze, ensure packing extends through tunneling. Upon removal make sure old gauze is removed. Dressing must be changed daily. This same TAR documents R5's treatment was not signed as being done on days 12/10/24 and nights 12/11/24. Turn every 2 (two) hours while in bed, side to side, avoid laying on back. Must use pillows between knees. Every shift to prevent further breakdown. This same TAR documents R5's treatment was not signed as being done on the evening of 12/12/24. On 3/13/25 at 11:20 AM, V4/NP stated, I took care of (R5) for five years. For most of that time (R5) was stable with advanced Dementia. (R5) was up to activities then started having age related decline that led to her being bed bound. (R5) was not getting up at all at that time. (R5's) wound were caused by pressure. (R5's) wounds started out simple and treatments were ordered. From what I knew the treatments were working for (R5's) wounds and they were getting better. Then I was notified that I needed to look at (R5's) wound. I was totally floored by how huge it was. It was foul smelling and infected. It looked like there was also a deep tissue injury. I told (R5's) family that unfortunately this wound is bad, and we can't do surgery and all we can do is to try to manage pain and odor because the odor was so bad. We were doing symptom control until the end of (R5's) life. Once bed bound, (R5) should have been turned, and I should not have to explain it to staff and put that in the orders. It is nursing 101 that a resident should be turned and repositioned. (R5's) wound was nasty. I don't think (R5's) wound care was being done as ordered. I do the treatments at times and the supplies are not always available. I have had to request that they (the facility) get supplies that I have ordered. If treatments are not done as ordered the wound will get worse. On 3/13/25 at 4:51 PM V3/Previous MDS Coordinator stated There are a lot of reasons that (R5's) pressure ulcer got worse. (R5) was not turned like she should have been. The staff are not good about turning and repositioning the residents. (R5) had a small pressure ulcer that healed then (R5) got another one. The dressings were not changed like it should have been either because we would run out of supplies. On 3/14/25 at 11:34 AM, V16/R5's Power of Attorney/POA stated I came to the facility about once a week and talk to (R5) every day. (R5) had dementia but she knew what was going on. I went in more once (R5) was moved to the fourth floor from the first floor. The care just wasn't as good on the fourth floor. Most of the time (R5) was laying on her back. There was a sign in her room that (R5) was to be on her side. (V4/NP) made it known that (R5) should be on her side. I am putting the blame on the aids not all of them but some. (R5) had no use of her legs and could not move herself. (R5) was dependent on staff. I saw the wound and it was disgusting. I wish I had never seen it. It had a bad smell and was nasty. (V4/NP) had been brought in to take care of it. (V4) told me that inside the wound was bigger than the outside. It was on (R5's) lower back towards the buttock. On 3/15/25 at 1:23 PM, V12/LPN stated that she took care of R5. R5 did have a pressure ulcer that got worse and had a bad odor to it. There were times there were no supplies to do the dressing. R5 was supposed to be kept off her back while in bed but that didn't always happen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 8 of 14 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 03/19/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few On 3/15/25 at 1:36 PM, V13/LPN stated I am not at the facility often because I work as needed. The first time I saw the skin issue on (R5) it looked like a bruise. About a week later the area had opened and had a foul smell to it. On 3/15/25 at 3:59 PM, V15/Registered Nurse/RN stated (R5) had a pressure ulcer that got worse from laying on her back. The CNAs (Certified Nursing Assistants) don't turn the residents like they are supposed to. On 3/17/25 at 1:43 PM, V1/Administrator verified that according to R5's TAR, R5's dressings were not done daily as ordered. V1 stated If it is not marked it is not done. On 3/18/25 at 10:18 AM, V4/NP stated R5 was a high risk for developing a pressure ulcer but the severity of the wound did not need to happen. Better care would have minimalized the severity of it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 9 of 14 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 03/19/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to transcribe a physician's order accurately, administer the correct physician's ordered insulin for 45 days, and notify the physician once a residents' blood sugar dropped below normal parameters for one resident of three residents (R1) reviewed for significant medication errors in the sample of nine. These failures resulted in R1 experiencing hypoglycemia and lethargy on two occasions that required glucagon injections. Residents Affected - Few Findings include: The Administering Medications policy not dated documents that medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (Medication Administration Record) space provided for that drug and dose. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 21. Topical medications used in treatments must be recorded on the resident's treatment record (TAR) (Treatment Administration Record). 28. If a medication error is noted to have occurred, immediately assess the resident for adverse reactions and notify the physician for any additional orders. Place the resident on the 24-hour report book, notify the POA (Power of Attorney) and fill out a medication error form and turn into the nursing office. R1's current computerized medical record documents R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which include Type 2 Diabetes Mellitus without Complications, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Trifascicular Block, Occlusion and Stenosis of Unspecified Carotid Artery, Lymphoid Leukemia, Unspecified Not Having Achieved Remission, Hyperlipidemia, Essential (Primary) Hypertension, Presence of Cardiac Pacemaker, Acute Diastolic (Congestive) Heart Failure, and Chronic Kidney Disease, Stage 3. R1's Brief Interview for Mental Status/BIMS dated 12/25/24 documents a BIMS of 2 (cognitively impaired). R1's current Care Plan documents that R1 has Diabetes Mellitus. Interventions Diabetes medication as ordered by doctor. R1's Physician's Notes/Orders written by V31/R1's Physician dated 11/4/24, documents Subjective: Clarify Orders (Sliding scale insulin needs addressed as (V28/R1's Power of Attorney/POA) states (R1) is bottoming out. Prescription has been updated. Insulin Aspart, w (with)/Niacinamide, (Fiasp) 100 UNIT/ML Inject 6-8 units into the skin 3 (three) times daily after meals. Inject per sliding scale: 100-150 2 units, 151-199 4 units, 200-250 6 units, 251-400 8 units. Lantus SoloStar 100 UNIT/ML SOPN Injection-pen Inject 30 (thirty) units 3 ML into the skin daily. Plan: Follow up in 6 (six) months (around 5/4/2025). R1's Nursing Note written by V20/Agency Licensed Practical Nurse/LPN dated 11/4/24 at 1:25 PM documents (R1) returned from doctors' appointment with some new orders. Please see MAR (Medication Administration Record) for the orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 10 of 14 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 03/19/2025 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 0760 Level of Harm - Actual harm Residents Affected - Few R1's Medication Administration Record dated 11/1/24 - 12/19/24 documents Insulin Glargine-yfgn Subcutaneous Solution Pen Injector 100 UNIT/ML (Insulin Glargine-yfgn) Inject as per sliding scale. Start date 11/4/24 at 4:00 PM. R1's Nursing Note written by V25/Registered Nurse/RN dated 12/13/24 at 7:05 AM, documents Glucagon Emergency Injection Kit 1 (one) MG Inject 1 vial subcutaneously as needed for hypoglycemia. Blood sugar 44. R1's Medication Administration Note written by V3/LPN dated 12/18/24 at 7:52 AM, documents Glucagon Emergency Injection Kit 1 MG (milligram) Inject 1 vial subcutaneously as needed for hypoglycemia. R1's Nursing Note written by V3/LPN dated 12/18/24 at 7:54 AM, documents Blood sugar 37. Glucagon 1 mg given in left thigh. R1's Progress Notes written by V4/Nurse Practitioner/NP dated 12/19/25 at 4:35 PM documents (R1) is an [AGE] year-old male who is evaluated today for follow-up hypoglycemic episode. The nurse tells me (R1) required an injection of Glucagon again yesterday. Sugars are occasionally low in the morning. I reviewed (R1's) sugars and medication orders. I wrote previous orders about (R1's) sliding scale insulin although it appears these orders were not carried out when reviewing the MAR (Medication Administration Record). I also noted that the order for SSI (Sliding Scale Insulin) is entered as Basaglar, which is Glargine, which is incorrect. This is a long-acting insulin. STOP the incorrect order for sliding scale Basaglar. START insulin Aspart (Novolog) 100 units/ml and give according to the sliding scale. R1's Nursing Note written by V2/Director of Nursing/DON dated 12/19/24 at 2:37 PM, documents Clarified orders from (V4/NP) at this time. (V4) ordered to stop sliding scale of Basaglar which is (R1's) insulin Glargine-yfgn per insurance. (V4) is ok with using the current long-acting insulin. Start Aspart insulin which (R1) has Fiasp and (V4) is ok with continuing using that short acting insulin. R1's Medication Administration Record dated 12/19/24 - 12/31/24 documents Fiasp Flex Touch Subcutaneous Solution Pen- Injector 100 UNIT/ML (Insulin Aspart (with Niacinamide) Inject as per sliding scale. Start date 12/19/24 at 4:00 PM. R1's Progress Notes written by V4/NP for 12/16/24 service, documents, Labs reviewed. (R1) is awake and alert this morning. Labs show (R1's) sugar was 24 this morning. Glucometer read in the 50's. By late in the morning (R1) was in the 200 range. On call NP or myself was not notified of the Glucometer reading this morning. On 3/13/25 at 11:20 AM, V4/NP stated I was notified by nursing staff that (R1's) blood sugars had dropped for the second time in a week that required Glucagon to be given. It prompted a visit from me. I was like what is happening. I looked through the medical record and found the problem. I notified (V2/DON) that the incorrect insulin was being given. The order given on 11/4/24 was ordered by (V31/R1's Physician). I just looked the order up and the order from (V31) was correct. They were giving long-acting insulin as the sliding scale instead of the short acting and (R1) was bottoming out. I brought it to (V2/DON) to fix the order. (R1) didn't die but he was hypoglycemic, and I believe he bottomed out a couple of times and Glucagon needed to be used so I would say yes it did (R1) harm. I witnessed (R1) extremely lethargic from hypoglycemia. On 3/13/25 at 1:31 PM, V2/DON stated that R1's insulin order was changed on 11/4/24 and the new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 11 of 14 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 03/19/2025 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 0760 order got put in incorrectly. (V4/NP) asked me to check to see what happened. I found that the order was put in wrong. I don't remember how long it was wrong. It may have been a couple of weeks. Level of Harm - Actual harm Residents Affected - Few On 3/13/25 at 4:51 PM V3/Previous Minimum Data Set/MDS Coordinator stated (V4/NP) asked me to check to see what insulin (R1) was getting. I sent a picture to (V4) then took the bottle to (V4). (R1) was not getting the correct insulin. (R1) was supposed to be getting fast acting insulin for sliding scale but instead was getting a slow acting insulin. (V20/Agency LPN) put the order in wrong for (R1). (R1) got the wrong medication for over a month. I was working on 12/18/24 when R1's blood sugar dropped so low that he passed out and I had to give (R1) Glucagon. On 3/14/25 at 10:28 AM V2/DON stated (R1) had his insulin corrected on 12/19/25. (R1) took a sliding scale fast acting insulin and a slow acting insulin. (R1's) order was changed and when (V20/Agency LPN) made the change on 11-4-24, (V20) transcribed the order wrong and put in the wrong insulin order to the pharmacy and on (R1's) MAR. (R1) took the wrong insulin from 11/4/24 - 12/19/24. On 3/14/25 at 12:29 PM, V22/Pharmacist stated The insulin that was ordered on 11/4/25 for (R1) was a long-acting insulin. The insulin that (R1) should have got is completely different then what (R1) got. It was to be given before meals and that should have been questioned back to the doctor to see if that was correct because it is not usually given like that. That was not a normal order. Hypoglycemia is very serious, and you don't want that to happen. It could be very dangerous especially for the elderly. On 3/15/25 at 3:07 PM, V2/DON stated The pharmacy filled what we ordered for (R1) on 11/4/24 and that insulin was given until 12/19/24. Then on 12/19 (V4/NP) thought there was a problem with (R1's) insulin because (R1's) blood sugar had bottomed out. (V4) asked me to look into what was happening. I then realized that the wrong insulin had been ordered. (R1) was getting a slow acting insulin for sliding scale instead of the fast-acting insulin. (V4) doesn't usually give a verbal order. The order should have been double checked. On 3/18/25 at 1:23 PM, V1/Administrator stated, When that insulin order was put in for (R1) we (the facility) did not have checks in place to make sure the orders were correct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 12 of 14 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 03/19/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to send the correct medication on a home visit for one resident of three residents (R2) reviewed for home medications in the sample of 9. Findings include: The Administering Medications policy (not dated) documents Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. The Dispensing Medications to Residents on Leave/Pass dated 4/2007, documents The facility shall provide residents with necessary medication(s) when they leave the facility temporarily. 1. Residents who are away from the facility during medication passes will be given scheduled and essential PRN (as needed) medication(s) to take with them. They will only be given the amounts and dosages needed for the length of the anticipated absence. R2's current computerized medical record documents R2 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include Essential (Primary) Hypertension, Fibromyalgia, Spondylosis, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Unspecified Atrial Fibrillation, Hypertensive Chronic Kidney Disease, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and Peripheral Vascular Disease. R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 has a Brief Interview for Mental Status/BIMS of 15 (cognition intact). R2 requires set up help for eating, supervision for bed mobility, and is dependent on staff for transfers. R2's Care Plan documents I have Diabetes Mellitus. Intervention Administer diabetes medication as ordered by doctor. R2's Nursing Note written by V8/Unit Coordinator dated 12/21/24 at 10:49 AM, documents (R2) went out with family Noon meds and 7 PM med's sent with (R2). (R2) is planning to return around 7 PM this evening. On 3/13/25 at 10:56 AM, V1/Administrator stated that she remembers a conversation about R2 going on a home visit and having the wrong insulin with her. Either R2 or her family were called and told it was the wrong insulin and for R2 not to take it. V1 does not know whose medication it was or why R2 was given it. On 3/13/25 at 4:51 PM V3/Previous MDS Coordinator stated (R2) was going on a home visit and (V7/Unit Coordinator) got (R2's) medication ready to send with (R2). When it was time for (R2) to leave (V6/Previous Licensed Practical Nurse/LPN) gave the medication to (R2). Later (V7) said that (V6) gave (R2) the wrong insulin. (R2) and her family were called and told the insulin was wrong and not to take it. On 3/14/25 at 1:42 PM, V1 stated (V7/Previous Unit Coordinator) got (R2's) medication ready for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 13 of 14 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 03/19/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm (R2) to take on her home visit and had them in the medication cart. (V7) then left the floor. While (V7) was gone (R2) was ready to leave the facility. (V6/Previous LPN) gave (R2) the insulin syringe that was in the cart with (R2's) other med's that were ready. Then (V7) returned to the floor and (V6) told (V7) that (R2) had left with her insulin and medication. (V7) told (V6) that was not (R2's) insulin. V1 also stated I have no idea of whose insulin that was. I don't know who it would have been for. Residents Affected - Few On 3/14/25 at 1:50 PM, V2/Director of Nursing stated, There was no insulin that was supposed to go home with (R2). I don't know why the nurse had a syringe with insulin in it laying in the med cart. That shouldn't have happened. On 3/14/25 at 3:07 PM, R2 stated I went on a home visit on 12/21/24. I was gone from about 10:30 AM to 6:30 PM. Shortly after leaving the facility, I got a call and was told not to take the insulin the facility had sent with me because it was not my insulin. On 3/19/25 at 12:44 PM, V1/Administrator stated We do not have a policy on medication storage that I can find. I know the insulin should not have been left in the drawer like that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145800 If continuation sheet Page 14 of 14