Inspection·May 3, 2025

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, the facility failed to report an injury of unknown origin to the state agency for one of three residents (R1) reviewed for bruises in a sample of three. Residents Affected - Few Findings include: The facility's Abuse and Neglect Policy, dated 7/2023, documents Identifying and Recognizing signs and symptoms of abuse: a. The following are examples of actual abuse/neglect and signs and symptoms of abuse/neglect which should be promptly reported. This listing is not all inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, reported immediately. i. Signs of/actual physical abuse: 1. Welts or bruises. State Agencies: Purpose- to assure all serious bodily injuries and reasonably suspected crimes against resident's, resulting in serious bodily injuries, are reported to IDPH (Illinois Department of Public Health) immediately, all serious incidents and accidents, and allegations of abuse, including injuries of unknown sources, and reasonably suspicion of a crime against a resident are reported to IDPH in an appropriate fashion immediately with a final report sent to the department within five days. R1's Progress Note, dated 2/25/25 and signed by V4/LPN (Licensed Practical Nurse), documents During transfer from wheelchair to stretcher this nurse observed a large circular red/purple bruise to (R1's) left mid back. Emergency Medical Technicians were made aware that (R1) has been on Eliquis (blood thinning medication) but it was placed on hold per (V6/Nurse Practitioner) and that (R1) experienced no recent falls that this nurse was aware of other than the one on 2/7/25. This same progress note documented V4 notified V2/DON (Director of Nursing) of the bruise located to R1's left mid back. On 5/2/25 at 2:15PM V4/LPN stated she observed a large purplish/red bruise approximately six inches in diameter to R1's left mid back for the first time when sending R1 out to the hospital. V4 stated she was unable to measure the bruise to R1's back because R1 was being transferred out to the local hospital. V4 stated, I reported the bruise to (V2/Director of Nursing) because it had appeared overnight, and I did not know what caused it. I let (V2) know I did not believe it was due to (R1's) fall, because the fall had occurred two to three weeks prior to the bruise appearing. There was no rhyme or reason to the bruise appearing to (R1's) back. As of 5/2/25, the facility's reports to the local State Agency did not contain documentation of R1's 2/25/25 injury of unknown origin as being reported. On 5/2/25 at 2:28 PM V2/DON stated V4 did report R1's bruise (injury of unknown origin) to V2. V2 stated R1's injury of unknown origin was not reported to the local State Agency and should have been. (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 3 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 05/03/2025 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)