Health inspection·November 19, 2025

F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely toileting assistance and failed to honor a resident's dignity and self?determination for one (R53) of three residents reviewed for resident rights in a sample of 39. These failures resulted in R53 becoming incontinent of urine on multiple occasions and lying in her own urine for over two hours, which resulted in R53 experiencing embarrassment and disgust.Findings include:The facility's Certified Nursing Assistant job description reviewed 2/14/13, documents the primary purpose of your job description is to provide your assigned residents with routine daily nursing care procedures, and as may be directed by your supervisor. Record all entries on flow sheets, notes, charts, ect., in an informative and descriptive manner. Assist resident with bowel and bladder functions (i.e., take to bathroom, offer bed pan/urinal, portable commode, etc.). Maintain intake and output records as instructed. Keep residents dry (i.e., change gown, clothing, linen, etc., whenever it becomes wet or soiled). Keep incontinent residents clean and dry.R53's current care plan documents R53 will have reduced episodes of incontinence. This same care plan documents R53 requires assistance of two staff members for toileting.R53's Minimum Data Set (MDS) assessment dated [DATE] documents R53 requires two assist for toilet transfers.R53's medical record does not contain documentation of toileting R53, or if R53 is continent or incontinent when staff assist R53 with toileting.On 11/18/25 at 9:15 AM, R53 was sitting in her wheelchair in the hallway outside of the communal resident bathroom. On 11/18/2025 at 9:25 AM V9 (R53's Family Member) stated the facility does not have enough people to take the residents to the bathroom especially after breakfast in the morning. All the staff are in dining room, and nobody is on the floor to assist residents so by the time R53 can use the toilet she has already soiled herself. This upsets R53 a lot because she does not want to soil herself and understands she needs to use the restroom. V9 stated she has spoken with V1 (Administrator) several times who says, we are trying to get people trained, but nothing changes. Instead, they keep giving R53 medications to keep her quite because she gets upset about not receiving the correct care. Over the weekend they (facility staff) didn't put an adult brief on her at bedtime and when R53 woke up, she was wet and had to lay in urine for two hours before anyone helped her. On 11/18/25 at 9:45 AM, R53 stated The staff are not taking me to the bathroom. They tell me 'I'll take you in a minute.' I must wait 30 minutes to an hour normally to go to the restroom. This weekend the staff didn't put an adult brief on me, and I laid in bed for a couple of hours needing to go to the bathroom. I had my call light on, and I pounded on my bedside table with the call light, and nobody came. I don't pee the bed. I am not that person, but I couldn't help it, so I had to pee the bed and lay in my urine for over two hours. I was embarrassed and it was disgusting. On 11/18/25 at 11:00 AM, V22 (Ombudsman) stated V22 has had complaints of call lights not being answered and the lights are being turned off every right at 8:00 PM and after that the call lights are not answered. On 11/18/25 at 10:42 AM, V14 (CNA/Certified Nursing Page 1 of 2 145800 145800 11/19/2025 Sunset Home 418 Washington Street Quincy, IL 62301

F 0550 Level of Harm - Actual harm Residents Affected - Few Assistant) stated R53 lets us know when she needs to use the restroom. R53 will get someone or let us know. R53 is continent and only is incontinent if she must wait too long to use the restroom. V14 stated we do not have enough staff here to provide cares especially after breakfast. The past two weeks we have two aides after 2:00 PM. Thursday and Friday of last week it was only (V14) and V19 (CNA) as the only aides on the floor and it was very hard to get all the residents toileted and laid down in between meals. On 11/18/25 at 11:50 AM, V2 (Director of Nursing) stated that the facility does not have documentation whether a resident was continent or incontinent and they only paper document resident bowel movements. V2 stated we used to document in electronic charting but V1 (Administrator) prefers to document. V2 confirms she has no documentation of R53's toileting record. V2 further stated R53 will verbalize to staff when she needs to use the restroom and will wheel herself to the resident bathroom in the hallway and wait for assistance. V2 stated that staff is expected to answer call lights timely and assist residents with toileting. 145800 Page 2 of 2