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 (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 11/19/2025 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)