Inspection·October 30, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Studies, Rhabdomyolysis, and Sciatica. R1's current care plan documents R1 has impaired cognitive function and thought process related to Dementia and impaired decision making, at risk for falls related to physical status and poor safety awareness and is dependent on staff for Activities of Daily Living. R1's Minimum Data Set (MDS), dated [DATE] section C0500, documents R1 had a Brief Interview for Mental Status (BIMS) score of 04 (severe cognitive impairment).V3's (Licensed Practical Nurse) Progress Notes, dated 10/24/25 at 9:34 PM (fall occurred between 3:30 PM and 4:00 PM), documents V3 was notified by CNA (V11, CNA/Certified Nurse Aide) that R1 was found lying on the floor next to her bed. R1 complained of mild pain to her right leg and was noted to have a scratch to the back of her right thigh with scant amounts of blood noted. Full body assessment completed, neuro checks initiated and were within normal limits, range of motion intact, moves all extremities without difficulty. Transferred resident from floor to her bed by mechanical lift. New treatment orders were to apply skin prep to area every shift until healed. V3's Progress Note, dated 10/24/25 at 4:55 PM (documented as a late entry on 10/26/25 at 8:38 PM), documents R1 had a new skin tear on her rear right thigh that measured 0.02 centimeters (CM) in length, 0.5 cm in depth and 0.01 cm in width. A film/membrane dressing with dry dressing applied.V11's (Licensed Practical Nurse) Progress Note, dated 10/25/25 at 7:15 AM, documents R1's right leg had decreased range of motion, pain from previous fall (10/24/25), physician was notified and an order for a stat x-ray of right hip and leg was obtained. At 9:03 AM, V11 cancelled the stat x-ray and sent R1 to the hospital via ambulance due to rotation of right leg, hematoma to right leg and swelling. At 11:57 AM, R1 returned to the facility with a diagnosis of right tibia and fibula (bones in the lower leg) fractures.The Emergency Department notes, dated 10/25/25, documents R1 sustained a right tibia and fibula fracture, a knee immobilizer was placed, Norco every six hours as needed for pain was ordered and a follow-up appointment with the Orthopedic Physician was scheduled for 10/27/25.The Electronic Health Record documents the Post Fall Assessment was conducted on 10/25/25 at 10:41 PM and on 10/26/25 at 1:41 PM. The record lacked documentation that post fall assessments and neurological checks were conducted per policy. A Fall Risk Assessment scored at an 11.0 was conducted on 10/24/25 at 12:13 PM, prior to R1's fall, and again on 10/25/25 at 5:01 PM which scored a 15.0 both scores indicate R1 was at high risk for falls.The Fall log documents R1 sustained an unwitnessed fall on 6/12/25, 9/30/25 and 10/24/25.R1's current Care Plan did not include new interventions related to skin integrity post fall on 10/24/25; new Safety/Fall interventions were not initiated post the 9/30/25 fall; Safety/Fall interventions were revised on 10/27/25 to include frequent checks from staff; and Pain interventions were revised on 10/29/25, 5 days after R1's fall, to include to administer pain medications as ordered.The Medication Administration Record (MAR) did not include that Acetaminophen was administered on 10/24/25 as reported by V3. R1 was administered Acetaminophen on 10/25/25 and 10/26/25 as ordered for pain management. The record lacked documentation the Norco (Narcotic for pain management) order from the Emergency Department on 10/25/25 was reconciled into the electronic medical record and made available for R1's pain management. The Medication Administration Record (MAR) documents on 10/27/25 the Orthopedic Physician ordered Norco to be administered every six hours as needed for pain. The MAR documents a Physician's order to complete a post-fall note every shift for the next three days was obtained on 10/7/25, 3 days post R1's fall. Neither the October 2025 Medication Administration Record nor the Treatment Administration Record indicated a new order for R1's skin tear was obtained or conducted post fall on 10/24/25.On 10/28/25 at 2:05 PM, V4 (Certified Nurse Aide) and 10/29/25 at 10:38 AM, V11 (Certified Nurse Aide) stated R1 was complaining of right leg pain and was bleeding from a cut on the back of her upper thigh post fall on 10/24/25. V4 stated upon notifying V3 (Licensed Practical Nurse) that R1 had fallen, V3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 10/30/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few instructed V4 to mechanically lift R1 back to bed without a nurse's assessment.On 10/29/25 at 11:45 AM, V20 (Primary Care Physician) stated the facility usually calls directly and V20 did receive a notification that R1 fell although there were no injuries or complaints sustained. No order for wound care was given due to no injuries reported. On 10/29/25 at 10:00 AM, V12 (Licensed Practical Nurse) stated when she notified V19 (R1's Power of Attorney) that R1 was being transferred to the hospital post fall, V19 stated he was unaware R1 had fallen and was not notified.On 10/29/25 at 11:24 AM, V19 (R1's Power of Attorney) stated the facility did not notify him on 10/24/24 regarding R1's fall, neither was a message left on his answering machine. The facility did notify him on 10/25/25 that R1 was going to the hospital due to a fall the previous night, was called again about the report of a fractured leg and then again when R1 returned to the facility from the Hospital.On 10/30/25 at 11:00 AM, V3 (Licensed Practical Nurse) stated she was working on another floor when notified about R1's fall by V11 (Certified Nurse Aide/CNA). V11 stated R1's fall was unwitnessed and there was a scratch of her leg. V3 told V11 she would assess R1 after she finished three other things. V3 then stated she was informed by V5 (Licensed Practical Nurse/LPN) that she laid eyes on R1 and was ok. V3 stated she instructed V5 to mechanically lift R1 back to bed and she had not conducted a full body assessment. V3 stated neuro checks were not completed per policy because she didn't have neurological deficits, although agreed per policy they should've been conducted. V3 stated it was a busy day and she was covering other floors. V3 had to stay after her shift to complete documentation. V3 stated she notified V20 (Primary Care Physician) and left a message for V19 (R1's Power of Attorney) but wasn't sure about the time of notifications or if the notifications were documented. V3 stated the unwitnessed fall protocol is to do a full body assessment and initiate neuro checks for 72 hours post fall, notify the physician, power of attorney and report it to the supervisor. Within the electronic medical record (EMR) there is a Risk Management section to enter the fall into. The entry into the Risk Management section generates post-fall assessments to be entered in the EHR's Progress Notes every shift. I gave (R1) Tylenol because that's what I do when someone falls. V3 was unable to state why the Tylenol administration was not documented. On 10/29/25 at 12:45 PM, V2 (DON/Director of Nursing) stated when a resident falls, the Nurse on duty is to assess the resident right away, before the resident can be moved or transferred to bed or wheelchair. If the Nurse assesses there is an injury requiring Emergency transport, the resident is not moved and will remain on the floor until the ambulance arrives. V2 stated her investigation concluded on 10/24/25 at 6:00 PM, V27 (Licensed Practical Nurse) came on shift and did a head-to-toe post-fall assessment.During interviews on 10/28/25 and 10/29/25, V4 (CNA), V10 (CNA), V11 (CNA) and V21 (CNA) were unaware that new intervention were care planned post R1's fall on 10/24/25 to prevent R1 from a repeat fall.On 10/30/25 at 1:45 PM, V1 (Administrator) agreed R1 did not have a full body assessment prior to being placed back to bed via mechanical lift post fall, post fall assessments and neurological checks were not conducted per policy, the record lacked documentation the Power of Attorney was notified of R1's fall, a thorough pain assessment nor the administration of Acetaminophen was documented as given per V3's interview, the pain medication prescribed by the Emergency Department Physician was not reconciled as an active order and available for use as needed, no order for wound care was given due to no injuries reported, the care plan did not include new interventions related to skin integrity post fall on 10/24/25; new Safety/Fall interventions were not initiated post the 9/30/25 fall; Safety/Fall interventions were revised on 10/27/25 to include frequent checks from staff, 3 days post fall; and Pain interventions were revised on 10/29/25, 5 days after R1's fall, to include to administer pain medications as ordered. V1 stated the investigation consisted of direct care staff interviews only. V1 was unaware that staff were (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 10/30/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete not informed of the new interventions (frequent checks) put into place post R1's fall.2. R3 was admitted on [DATE] with diagnoses of Schizophrenia, Diabetes Mellitus with Neuropathy, Urine Retention, Congestive Heart Failure, Osteoarthritis, COPD, Depression, Anxiety Disorder, and Traumatic Brain Injury.The current care plan documents R3 has limited physical mobility related to weakness and deconditioning. R3 can walk with a walker as tolerated with stand by assistance; behavior problem of fidgeting; resistive to Activities of Daily Living (ADL) cares; monitor for attention seeking behaviors and putting self on the floor.The Fall log documents R3 sustained a fall on 10/22/25 with hospitalization.R3's Progress Note documents R3 was hospitalized on [DATE] and returned to the facility on [DATE].On 10/28/25 at 3:30 PM, V23 (Certified Nurse Aide/CNA) stated on 10/24/25 while trying to take R3 to the shower, R3 went down on both knees. V23 stated R3 likes to put himself on the floor and I don't think he had an injury, but it wasn't assessed by the nurse (V3) who also witnessed the change of plane.10/28/25 at 3:45 PM, V24 (Certified Nurse Aide) stated R3 fell and hit hard in the dining room on 10/24/25 between 4:00 PM-5:00 PM. V23 and V24 did the vital signs and assessed R3 because V3 (Licensed Practical Nurse) left and never came back.On 10/30/25 at 11:00 AM, V3 (LPN) stated R3 did have a change of plane in the dining room on 10/24/25 and a post fall assessment was not conducted, nor was a Risk Management Incident report initiated, the physician nor the family were notified and follow assessments were not conducted because she considered the change of plane to be intentional related to behaviors and not a fall. V3 stated she did not document R3's behaviors because behaviors do not need to be documented. V3 stated she was aware that R3 had returned from the hospital the same day and was actively undergoing treatment for Sepsis (a life-threatening medical emergency caused by your body's overwhelming response to an infection).On 10/29/25 at 9:11 AM, V5 (Licensed Practical Nurse/LPN) stated R3 is her brother and was not notified that a change of plane occurred on 10/24/25.10/30/25 at 8:53 AM, V2 (Director of Nursing/DON) stated she was unaware R3 had a change of plane on 10/242/5. V2 stated R3 can ambulate independently although it's not encouraged and will sit on the floor when he wants to. V2 stated after interviewing V3, V3 felt R3's change of plane was a behavior issue and not a fall.On 10/30/25 at 1:45 PM, V1 (Administrator) agreed a thorough investigation had not been conducted after R1's fall to determine the root cause. V1 stated R3's change of plane should have been documented and reported so an investigation could have been conducted to assist in identifying the root cause. Event ID: Facility ID: 146016 If continuation sheet Page 4 of 4