Inspection·March 19, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete No other nursing assessments or nursing progress notes are documented in R1's electronic medical record after of 2/5/25 at 10:32 A.M. until 2/7/25 at 4:37 P.M. On 3/18/2025 at 2:03 P.M., V2/Director of Nurses (DON) stated when a resident is admitted to the facility as a skilled level resident, facility staff are to document every shift, under the assessment tab in PCC (Point Click Care), a Skilled Documentation/Skilled Care Assessment form for each resident. At that time, V2/DON confirmed no skilled documentation form was present on R1's electronic medical record for 2/6/25 and 2/7/25. V2/DON stated, Just recently we realized the nurses weren't performing nursing assessments and documenting a resident's ongoing medical condition. We (V6/Assistant Director of Nurses and myself) have since educated all facility staff on this issue. At this time, V2 stated when a resident is transferred to the hospital, a complete nursing assessment is performed on a resident, and the results are documented in a resident's medical record via an E Interact Transfer Form. Event ID: Facility ID: 146016 If continuation sheet Page 2 of 4 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 03/19/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the correct textured diet to one of four residents (R1), a resident with a documented diagnosis of dysphasia, in a sample of four. FINDINGS INCLUDE: The (undated) facility policy, Therapeutic and Mechanically Altered Diets, directs staff, It is the policy of (facility) that therapeutic and mechanically altered diets are ordered by the physician and planned by the dietician. A therapeutic diet is a diet ordered to manage problematic health conditions. A mechanically altered diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake. Examples include soft diets, pureed foods and ground meat. Diets for residents that only take liquids that have been thickened are included in this definition. A physician's order is written for all diets including therapeutic and mechanically altered diets. R1's hospital Discharge Summary form, dated 02/05/2025, documents, admit date : [DATE]. Past medical history of COPD (Chronic Obstructive Pulmonary Disease), Asthma, Diabetes Mellitus, Chronic Kidney Disease presents to the ED (Emergency Department) with 1 to 2 days of decreased appetite, shortness of breath and wheezing. (R1) did test positive for Influenza A. On admission (R1) continued to be mostly nonverbal however did attempt to speak with family and speech was very garbled. (R1) does have slight right sided upper extremity weakness and significant right lower extremity weakness. Head CT (Computerized Tomography) was obtained which does show acute to subacute left occipital lobe and left anterior cerebral artery distribution cerebrovascular infarction. (R1) was evaluated by (Speech Therapy) and placed on a pureed diet with nectar thick consistency. R1's facility admission Record documents R1 was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Dysphasia, Aphasia, Diabetes Mellitus, Chronic Kidney Disease and Influenza A. R1's Physician Order Sheet, dated 02/05/2025, includes the following physician order: Low Concentrated Sweets diet. Pureed texture, Nectar thick (Liquids) consistency, for Dysphasia. R1's facility Diet Order Form, dated 02/05/2025 and signed by V6/Assistant Director of Nurses, documents, Pureed diet, Nectar thick liquids. On 3/18/2025 at 12:29 P.M., V8/R1's POA (Power of Attorney) stated she is R1's granddaughter and his POA. V8 stated she lived with (R1) and provided care for him. She called the ambulance on 1/30/25 due to R1 not moving and being unable to speak. R1 was admitted to local hospital with a stroke and was unable to speak clearly or swallow correctly. V8 stated the family made the decision to admit R1 to the facility as they were no longer able to care for (R1) and he required PT (Physical Therapy), OT (Occupational Therapy), and Speech Therapy. R1 was transferred to the facility on 2/5/25 around 10:30 in the morning and she and her boyfriend arrived around 11:00 AM that morning. Within an hour of her arrival, staff brought in a meal tray that consisted of two pieces of whole white bread with some diced meat and shredded cheese on top, applesauce, regular consistency cranberry juice and regular consistency water. V8 stated at that time, they were face timing with V7/R1's daughter. V8 stated R1 acted very thirsty and picked up the cranberry juice and began drinking. R1 then picked up the sandwich and began eating and swallowing, and immediately began choking. V8 stated her boyfriend put (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146016 If continuation sheet Page 3 of 4 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 03/19/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete his finger down R1's throat to dislodge the bolus of food. At that time, V7 noticed, via face time, R1's tray of food contained the wrong diet and wrong consistency of fluids. V8 grabbed R1's tray of food and went to the nurse's station and spoke with V9/Licensed Practical Nurse (LPN). V8 stated V9/LPN looked through R1's medical records and realized R1 had been provided the wrong diet and wrong consistency of fluids. On 3/18/20205 at 1:16 P.M., V9/Licensed Practical Nurse stated, When a resident is admitted , the transfer sheet contains a diet. I fill out a diet slip and hand it to someone in dietary. (R1) was on a pureed diet and thickened liquids. (R1) came to us very sick and had recently had a stroke. (R1) was admitted late morning (2/5/25). At lunchtime that day, his granddaughter (V8) brought his tray to me, and I knew right away (R1) had gotten the wrong diet. It wasn't pureed with thickened liquids, like it was supposed to be. (R1) had eaten some of the sandwich and had drunk quite a bit of the fluids. Event ID: Facility ID: 146016 If continuation sheet Page 4 of 4