Health inspection·December 1, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/28/23 at 11:56 AM, V6, CNA, stated, I always stand when feeding residents because I move around so much. (R48) can actually feed himself. I feed him because he won't eat all his food. On 11/30/23 at 10:45 AM, V1, Administrator, stated, We don't have a policy or training stating that the staff have to be sitting when they feed residents. That's a requirement? At that time V17, Corporate Nurse Consultant, stated, The staff and resident have to be eye to eye when assisting with feeding. Event ID: Facility ID: 146016 If continuation sheet Page 2 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to give the appropriate notices for Medicare Part A for three (R23, R54 and R231) of three residents reviewed for Medical Part A Services in a sample of 34. Residents Affected - Few Findings include: R54's Medical Part A skilled services start date was 10/4/23 and last covered day was 10/23/23. R54 was not given the Advanced Beneficiary Notice/ABN or the Notice of Medicare Non-coverage/NOMNC. R23's Medical Part A skilled services start date was 7/14/23 and last covered day was 8/4/23. R54 was not given the ABN or the NOMNC. R231's Medical Part A skilled services start date was 11/17/23 and last covered day was 11/21/23. R54 was not given the ABN or the NOMNC. On 12/01/23 at 10:00 AM, V1, Administrator, stated, We don't have the ABN or NOMNC notices for (R54, R23, or R231). Social Services is responsible for them, but he just started, and these were prior to him starting in that position. On 12/01/23 at 10:42 AM, V1 stated, (R231) went back to the other facility; (R23) met max potential; and (R54) refused visits. We did not send any notices to these residents as they were missed to provide the documents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 3 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Face Sheet for R27 documents R27 was admitted to the facility on [DATE], with cumulative diagnoses logged as: Closed head injury, Facial laceration, Dilantin toxicity, Depression, Dementia, Vitamin B12 Deficiency, and Seizure Disorder. The facility initial OBRA (Omnibus Budget Reconciliation Act) Screen for R27, dated 11/4/2015, documents assessment completed and Screening indicated nursing facility services are appropriate. No PASRR (Preadmission Screening and Resident Review) was required at that time. The Physician/Prescriber Telephone Order, dated 11/10/2023, documents For Risperidone Add Dx (diagnosis) Schizoaffective Disorder. The Medical Record for R27 does not include a new screening or PASRR level II having been completed for R27 after the initiation of R27's antipsychotic medication or new diagnosis of Schizoaffective Disorder. On 11/28/23 at 10:00 AM, V15, SSD (Social Service Director), confirmed R27 was not re-screened after R27 received a new Mental Health diagnosis. On 11/29/23 at 10:15 AM, V1, Administrator, stated he didn't know residents needed to be re-screened for PASRR when an new Mental Health diagnosis was added. Based on interview and record review, the facility failed to obtain a new level II PASRR (Preadmision Screening and Resident Review) for a new diagnosis of serious mental illness for two residents (R27 and R50 ) out of four residents reviewed for PASRRs in a sample of 34. Findings include: 1. R50's medical record documents an admitting diagnosis of Dementia with behavioral disturbances, delusional disorder, and persistent mood affective disorder. R50s medical record, dated 11/13/23, documents a diagnosis of schizoaffective disorder. On 11/29/23 at 10:15 AM, V1, Administrator, verified R50 did not have a PASRR level II screening completed with the addition of his schizoaffective disorder, and stated, I don't know when the schizoaffective disorder was added. I know it was added after his admission because it's not on his admission paperwork. I didn't know they need to be re-screened for the the PASRR level II when they had a new diagnosis added. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 4 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Face Sheet for R70 documents R70 was admitted to the facility on [DATE] with the following diagnoses: Severe Bipolar Disorder with psychotic features, Neuro-cognitive Disorder with Lewy Bodies, and MDD (Major Depressive Disorder). Residents Affected - Few On [DATE], [DATE], and [DATE] between 9:00 AM and 3:00 PM, R70 was ambulating the facility unit independently with staggered gait and tremors at times, wandering in and out of other resident rooms, carrying stuffed animals, talking to himself, and sitting in the dining room. The PASRR Outcome Explanation Notice of Short Term Nursing Facility Approval for R70, documents, You are approved for short term nursing facility services. You do not require specialized services for your disability. Your Pre-admission Screening and Resident Review (PASRR) is complete. Short term nursing facility services are approved for the length of time listed on the Notice of PASRR Level II Outcome. The Notice of PASRR Level II Outcome for R70, dated [DATE], documents, Date of Determination: [DATE] and Date Short Term Approval Ends: [DATE]. R70's Medical Record does not include a new screening has been completed and the facility was unable to provide an further documentation. On [DATE] at 10:03 AM, V15, SSD (Social Service Director), confirmed R70's PASRR expired on [DATE], and R70 has not been re-screened. Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II (R22) and failed to obtain a new Level I Screening after expiration (R70) for two of four residents (R22 and R70) reviewed for PASARRs in the sample of 34. Findings include: 1. R22's Face Sheet documents R22's facility admission date as [DATE]. R22's Cumulative Diagnosis Log documents R22 with diagnoses to include but not limited to: Bipolar Disorder; Unspecified Psychosis; Depression; Panic Disorder; and Anxiety. R22's Omnibus Budget Reconciliation Act (OBRA) I-Initial Screen, dated [DATE], documents the following: There is a reasonable basis for suspecting developmental disability or mental illness with (R22); (R22) has a history of severe recurrent major depression with psychotic features; and (R22) has a history of a psychotic hospitalization. This same OBRA screening documents a Level II screening was needed, and it was not completed at the time, due to R22 discharging from the hospital prior to the screening being completed. As of [DATE], R22's medical record did not contain documentation that a Level II screening was completed. On [DATE] at 8:35 AM, V1 (Administrator) stated no Level II Screen could be provided for R22, and verified it should have been done. We are going to have to get him re-screened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 5 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0645 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 10:26 AM, V1 provided an updated Level I screen for R22, dated [DATE]. This Level I screening also documents a Level II screening must be conducted. V1 stated the Level II screening should have been done back in 2018. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 6 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a Comprehensive Care Plan for one (R45) of 19 residents reviewed for Care planning in the sample of 34. Findings include: The facility's Comprehensive Care Planning policy and procedure, revised 7/20/22, documents, It is the policy of (The Facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of the Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will described the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. Care Plan - Plan of care describing a need/problem, and indicating the approaches/interventions to be instituted to assist the Resident in maintaining/receiving care in relation to the need/problem. Program Plan - A structured program designed to change a specific need/problem. The Program Plan consists of, at minimum: a. Statement of the targeted problem/need. b. Goal stating the expected outcome of the reduction of the targeted problem. c. Interventions/approaches aimed at reducing the causative factors of the targeted problem. The Trauma Informed Care policy and procedure, dated 8/23/23, documents: The IDT will develop a resident centered care plan that will identify the stressor, triggers, clinical manifestations and interventions to mitigate against re-traumatization. The Elopement Prevention Policy, revised 10/06, documents: It is the policy of (The Facility) to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. The Interdisciplinary Team will initiate a plan of care for any resident determined high risk for elopement. Interventions of personal door alarm devices and monitoring will be initiated deemed necessary by the IDT and documented in the individual resident's plan of care. The Face Sheet for R45 documents R45 admitted to the facility on [DATE], with Cumulative Cumulative Diagnosis Log documenting R45 with the following diagnoses: PTSD (Post Traumatic Stress Disorder), Dementia with behavioral Disturbance, Depression, Anxiety, Sexual Reassignment, Mood Disorder, Psychotic Disorder, Neuro-Cognitive Disorder with Behavior Disturbance, Delusions, Hallucinations, Vascular Dementia, Psychosis, and Bipolar. On 11/28/23 through 11/30/23 between 9:00 AM and 3:00 PM, R45 was ambulating the unit with a wheeled walker, or sitting in the dinning room with furrowed brow and/or blank gaze. The Cognitive Assessment for R45, dated 11/14/23, documents R45 as severely impaired. The Elopement Evaluation for R45, dated 10/31/23, documents R45 is a High Risk for elopement. The current Care Plan for R45 does identify potential triggers or address R45's PTSD, and does not address R45's high risk for elopement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 7 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0656 On 11/30/23 at 11:43 AM, V15, SSD, confirmed R45's Care Plan does not include PTSD or Elopement risk. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 8 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident transferred out of bed for one (R9) of six residents reviewed for activities of daily living in a sample of 34. Residents Affected - Few Findings include: The Facility Assessment, dated 4/18/23, states, The purpose of the assessment is to determine what resources are necessary to care for residents. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The Reliant 600 RPL 600 User Manual, undated, documents, The weight limitation for the RPL600 is 600 pounds; troubleshooting- actuator fails to lift when button is pressed- boom actuator is in need of service, unit does not work properly and battery has been replaced and unit still does not work properly- check battery and replace if necessary, and contact mechanical lift facility for service. R9's MDS/Minimum Data Set, dated [DATE], documents transfer activity, chair/bed to chair transfer, toilet transfer, and sit to stand transfer did not occur for R9; dependant for dressing upper and lower, shower/bathing, toileting and footwear; dependant for chair/bed to chair transfer, and toilet; and chair/bed and toilet transfer not attempted due to medical condition or safety concerns; and no altered level of consciousness. R9's last documented weight was May 2023 at 352 pounds. R9's medical record documents R9 has morbid obesity. On 11/28, 11/29, 11/30, and 12/1/23, the mechanical lift on R9's hallway is a (brand name), which documents the max weight of 600 pounds on the lift. On 11/28/23 at 11:30 AM, 11/30/23 at 2:30 PM, and 12/1/23 at 1:30 PM, R9 was lying in bed, alert and oriented. On 11/28/23 at 11:30 AM, R9 stated V19, Certified Nurse Aid/CNA, asked Maintenance to look at the mechanical lift machine today. R9 also stated it takes two staff members to transfer her with (mechanical lift) and the mechanical lift does not always work to get her out of bed, so she has been staying in bed for the past three weeks, and she stated she would like to get out of bed and sit in her recliner (recliner in her room as she is in a room by herself). R9 stated the machine stalls when lifting her in the air, the emergency button has to be pushed, and she did not get up in her recliner a few times due this issue. On 11/28/23 at 11:35 AM, V19, Certified Nursing Assistant/CNA, verified the mechanical lift used on R9 is a (brand name mechanical lift), which documents the max weight of 600 pounds; the facility has two mechanical lifts on the main floor of the building, but a total of 3 mechanical lifts in the facility, and the last time V9 was weighed she was around 365 pounds. V19 also stated, The (mechanical) lift will not lift (R9) all the way out of bed even with the bed in the lowest position, (mechanical) lifts are located on hall P, A & C, and I tried to get the (mechanical) lift from another hall, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 9 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete but when I wanted it they were using it on A wing. At that same time, this surveyor observed the mechanical lift arm go up when the up button was pressed by V19, go down when the down button was pressed, and then V19 tried to have the mechanical lift arm go up again and it stalled out and would not go up (with or without weight on the mechanical lift arm) where the resident would be attached for transfer. V19 stated, This machine has a full battery charge so I don't know why it doesn't work right; Maintenance is supposed to look at this but it has been doing this for a while and they are aware, and I have two residents down here that use the mechanical lift. Event ID: Facility ID: 146016 If continuation sheet Page 10 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to ensure a resident had a device in place to prevent skin breakdown and prevent further contraction of a left hand contracture for one resident (R8) out of two resident reviewed for range of motion in a sample of 34. Findings include: The facility's Splint/Appliances policy revised 9/08 documents, A resident who has a contracture, or has a likelihood of developing a contracture, caused by a physical condition and requires further evaluation will be assessed by the Occupational Therapist for a splint/appliance as ordered by the resident's physician. 6. The Occupational Therapist will provide nursing with a schedule for the application and removal of the splint, subject to physician order. 7. The program will be identified on the resident's care plan including the problem, approaches and goals. R8's Occupational Therapy Plan of Care, dated 10/29/21, documents, Patient will utilize hand roll or palm protector for left upper extremity to prevent skin break down and for contracture prevention. R8's Occupational Therapy Plan of Care, dated 11/1/21, documents, Patient seated in wheelchair upon arrival to patient room. Patient did not have splint on and was unable to find splint in patient room. Rolled a towel up and had patient open left hand and grip the towel. Patient was educated on importance of maintaining splint positioning to reduce further contracture. R8's current care plan documents, Restorative Nursing Program- Splint or Brace. Problem/Need: Decreased mobility of left hand, increased potential of rigidity or joint. Resident will wear splint during specific time frames with no skin breakdown or discomfort thru the next review. Resident to wear resting hand splint 4 hours and as tolerated. To wear (soft splint) at night and when not wearing resting hand splint. On 11/28/23 at 10:32 AM, R8 was observed sitting in the dining room, with a contracture to his left hand. R8 was asked if he's able to open his left hand, and he stated, I can't open my hand, it's pretty much dead, but I can open it with my other hand. R8 opened his contracted left hand with his right hand. As R8 opened his contracted left hand, his fingernails on his contracted hand have grown past the tips of his finger, causing and indentation in his palm. At that time V2, Care Plan Coordinator (CPC) looked at R8's left hand and verified his fingernails were too long causing an indentation and stated, I'm not sure what's supposed to be in his hand, but I would imagine he should have a device for the contracture. On 11/28/23 at 10:47 AM, V2, CPC, and V8, Licensed Practical Nurse (LPN), reviewed R8's medical record and care plan. V2, CPC, verified R8's care plan documents the use of a splint for his left hand contracture and stated, I didn't know he had one. At that time V8, LPN, spoke up stating, I haven't seen him wear anything in a while. I thought they D/C'd (Discontinued) the hand splint. I don't think he has anything now. V8, CPC stated, We need to at least get his nails trimmed until we can get something for his hand. R8's Restorative Nursing Program Documentation, dated 11/16 through 12/15/23 documents R8 has refused to wear a splint every day on every shift including 11/28 and 1/29/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 11 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0688 On 11/28/23 and 11/29/23, multiple observations made throughout the day of R8 having a soft foam and rolled up washcloth in his contracted left palm. Level of Harm - Minimal harm or potential for actual harm On 11/30/23, several observations throughout the morning were made of R8 with no device in his left hand. Residents Affected - Few On 11/30/23 at 11:50 AM, R8 stated, They never put anything in my hand today. I don't know why. On 11/30/23 at 11:54 AM, V16,Certified Nursing Assistant (CNA), stated, I know (R8) used to have a (soft splint) we put is his hand, but I haven't seen it in a while. At best guess, it's probably been a couple of months. We haven't been able to find it. That's why he isn't wearing one. On 11/30/23 at 12:27 PM, V3 (CNA) reviewed the November/December 2023 restorative nursing program documentation and stated, Oh, we've been marking declined on his restorative nursing sheet because his (soft splint) is missing and we can't find it. I never asked him to wear it because it's been missing. V3, CNA, verified the CNAs have been documenting declined without asking R8 to wear his spilt, due to it missing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 12 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to screen and identify triggers for two of two residents (R45 and R62) reviewed for Trauma Informed Care in the sample of 34. Residents Affected - Few Findings include: The facility's undated Trauma Informed Care policy and procedure documents the purpose, To ensure that all residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to climate or mitigate triggers that may cause re-traumatization of the resident. Procedure: 1. Upon admission the Social Service Director (SSD) will review hospital discharge records and interview the resident or the resident's representative to determine any history of trauma. 2. The SSD will complete a Trauma Informed Care Screen to evaluate for any history of a traumatic experience that a resident may have had. The facility's undated Social Service Director Job Summary documents: The Social Service Director will assist in planning, developing, organizing, implementing and directing social service programs in accordance with current existing federal, state and local standards as well as our established policies and procedures in order to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis. 1. The Face Sheet for R45 documents R45 admitted to the facility on [DATE]. The Cumulative Diagnosis Log for R45 documents R45 with diagnoses of PTSD, Dementia with behavioral Disturbance, Depression, Sexual Reassignment, Mood Disorder, Psychotic Disorder, Neuro-Cognitive Disorder with Behavior Disturbance, Delusions, Hallucinations, Psychosis, and Bipolar. The Cognitive Assessment for R45, dated 11/4/23, documents R45 as severely impaired. The current Care Plan for R45 does not address R45's PTSD or list any potential triggers for PTSD. On 11/28/23, 11/29/23, and 11/30/23 between 9:00 AM and 3:00 PM, R45 was walking the unit hallway or sitting in the dining room with furrowed brow and/or blank gaze, or was lying in her bed with the lights out and her door closed. On 11/30/23 at 2:30 PM, V2 (Licensed Practical Nurse) stated V15, SSD (Social Service Director), would be the one who handles all the PTSD (Post Traumatic Stress Disorder) concerns. The Medical Record for R45 does not include a Trauma Informed Care Assessment having been completed for R45's PTSD. The current Care Plan for R45 does not address R45's PTSD or potential triggers. On 11/30/23 at 11:43 AM, V15, SSD, stated he does not know who the residents are with a diagnosis of PTSD, and does not do anything different for those residents than any other resident. V15, SSD, stated if a resident has PTSD it would be noted on their initial assessment. V15 confirmed R45 has not been assessed for Trauma Informed Care, and is unsure if there is something new he should be doing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 13 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0699 2. R62's Face Sheet documents R62 admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm R62's Cumulative Diagnosis Log documents R62 with a diagnosis of PTSD. R62's Cognitive Assessment, dated 10/5/23, documents R62 as cognitively intact. Residents Affected - Few R62's current Care Plan states, (R62) may display ineffective coping or overt behaviors due to PTSD diagnosis. Known psychosocial issues/behaviors attributed to PTSD diagnosis: self-isolation. This same Care Plan does not identify any personal triggers for R62's PTSD. On 11/30/23 at 2:30 PM, R62 was sitting up in bed in R62's bedroom. R62 stated, I have PTSD; I was raped by my great-grandfather as a child. I have nightmares about what my grandfather did to me. I don't like guys coming in here at night. I try to manage it myself and remember that they have other clients they are taking care of and that they are good people. I am just coping on my own. No one has talked to me about it (R62's PTSD diagnosis) here or asked what my triggers are. On 11/30/23 at 2:38 PM, V2 (Licensed Practical Nurse) stated V2 was not aware R62 had a PTSD diagnosis. V2 stated V15 (Social Service Director) would be the one who would handle that. On 11/30/23 at 3:02 PM, V15 stated V15 was not aware R62 had a PTSD diagnosis; V15 did not do any assessments or screenings for PTSD with R62, and that V15 would be the one responsible for doing so. As of 12/1/23, R62's medical record did not contain any assessments or screenings for PTSD for R62, and did not identify any triggers for R62's PTSD diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 14 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to obtain a Physician/Prescriber response to the Pharmacist's Medication Regimen Review/MRR for one of six residents (R22) reviewed for unnecessary medications in the sample of 34. Findings include: The facility's Medication Regimen Review Policy, dated January 2022, states, 6. The pharmacist will address copies of residents' MRRs to the Director of Nursing/DON and/or the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRRs. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the DON to act upon the recommendations contained in the MRR. 7.1 For those issues that require Physician/Prescriber intervention, facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has to be taken to address it. 7.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. 8. Facility should alert the Medical Record where MRRs are not addressed by the attending physician in a timely manner. 11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 days or 60 days per applicable regulation. R22's current Physician Order Sheet, dated 11/16/23-12/16/23, documents an order for Ziprasidone HCL (Hydrochloride) 40 mg/milligram Capsule. Take one capsule by mouth twice daily (BID) for Bipolar Disorder. This medication order has a start date of 7/8/22. R22's Medication Regimen Review Sheet documents, See report for any noted irregularities and/or recommendations for the following months: August; September; October; and November 2023. R22's Medication Regimen Review, dated 8/23/23; 9/25/23; 10/23/23; and 11/15/23 from V18 (Pharmacist) states, Comment: (R22) has received an antipsychotic, Ziprasidone 40 mg PO (by mouth) BID for Bipolar Disorder since July 2022 when it was reduced. Recommendation: Please attempt a gradual dose reduction (GDR) to Ziprasidone 20 mg po q (every) AM (morning) and 40 mg po q pm (evening). The section of the form titled Physician's Response is blank and does not contain documentation as to whether the recommendation was accepted or declined and does not contain a physician's signature. On 12/1/23 at 10:04 AM, V3 (Registered Nurse/Minimum Data Set Coordinator) stated no physician response to R22's August 2023-November 2023 MRRs could be provided, and stated there should be. On 12/1/23 at 1:15 PM, V2 (Licensed Practical Nurse) stated the facility is without a current Director of Nursing/DON, and the MRRs were being sent to the DON's electronic mail account. V2 stated V2 does not know why they were not previously acknowledged by a physician when the DON was in the building. V2 stated the MRRs should have been addressed by now. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 15 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. 2. The facility's Psychotropic Medication Policy, revised 11/28/17, states, 9. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. 10. Reductions shall be attempted at least twice in one year. 11. Nursing Administration will meet with the consultant Pharmacist on a monthly basis to discuss any resident who may need or is due for a possible medication reduction. 12. The consultant Pharmacist will request medication reductions as decided on a monthly basis. Recommendations will be printed and sent to the physician in a timely manner. The facility's Reduction of Psychotropic Medications Protocol, revised 8/22/18, states, Policy: Residents who must receive psychotropic medications are to be maintained at the safest, lowest dosage necessary to control the resident's condition. R22's current Physician Order Sheet, dated 11/16/23-12/16/23, documents an order for Ziprasidone HCL (Hydrochloride) 40 mg/milligram Capsule. Take one capsule by mouth twice daily (BID) for Bipolar Disorder. This medication order has a start date of 7/8/22. R22's Minimum Data Set Assessment, dated 7/28/23, documents R22 is taking an antipsychotic medication with the last attempted GDR/Gradual Dose Reduction on 6/28/22. R22's Medication Regimen Review Sheet documents, See report for any noted irregularities and/or recommendations for the following months: August; September; October; and November 2023. R22's Medication Regimen Review, dated 8/23/23; 9/25/23; 10/23/23; and 11/15/23 from V18 (Pharmacist) states, Comment: (R22) has received an antipsychotic, Ziprasidone 40 mg PO (by mouth) BID for Bipolar Disorder since July 2022 when it was reduced. Recommendation: Please attempt a gradual dose reduction (GDR) to Ziprasidone 20 mg po q (every) AM (morning) and 40 mg po q pm (evening). The section of the form titled Physician's Response is blank and does not contain documentation as to whether the recommendation was accepted or declined and does not contain a physician's signature. On 12/1/23 at 10:04 AM, V3 (Registered Nurse/Minimum Data Set Coordinator) verified no documentation could be provided to document a GDR for R22's antipsychotic medication, Ziprasidone, had been attempted since July 2022. Based on interview and record review, the facility failed to identify target behaviors and gain consent to warrant the use of antipsychotic medication for one resident (R50), and failed to attempt a gradual dose reduction for an antipsychotic medication for one resident (R22), out of five residents reviewed for unnecessary medications in a sample of 34. Findings include: 1. The facility's Psychotropic Medication policy, revised 11/28/17, documents, G. Use of Antipsychotic Drugs: 13. Antipsychotic's should not be used if one or more of the following is/are the only indication: a: Wandering. R50's medical record documents the following diagnosis: Dementia with agitation, delusional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 16 of 17 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 146016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Rehabilitation and Health Care 129 South 1st Avenue Canton, IL 61520 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 0758 disorder, mood disorder and schizoaffective disorder. Level of Harm - Minimal harm or potential for actual harm R50's Psychotropic Medication Consent -Antipsychotic, dated 8/13/20, documents, Medication: Seroquel. Medication dosage: 12.5 mg (milligrams) at bedtime. Medication used for these identified behaviors and diagnosis: Dementia and behavioral disturbances - exit seeking. Residents Affected - Few R50's behavior tracking sheet, dated 11/2023, documents, Psychotropic Medication: Seroquel. Diagnosis: Schizoaffective Disorder. Target Behavior: Wandering/Exit seeking. R50's current care plan documents, Resident requires use of psychotropic medication to manage mood and/or behavior issues. Class of drug: Anti Depressant, Antipsychotic. Related diagnosis: Depression, dementia with behavioral disturbances. Behaviors exhibited: Exit seeking. R50's physician order, dated 3/1/23, documents, Seroquel 25 mg tablet. Take 1/2 tablet (12.5mg) by mouth every other evening. Diagnosis: schizoaffective disorder. On 11/29/23 at 2:54 PM, V1, Administrator, stated, The targeted behavior for (R50's) behavior tracking is wandering/exit seeking, which is not an approved behavior for Seroquel. On 11/30/23 at 3:40 PM, V17, Corporate Nurse Consultant, stated, You can't have wandering /exit seeking as a targeted behavior for Seroquel. The consent and behavior tracking was supposed to be for his delusional disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 17 of 17