Inspection·November 4, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review, the facility failed to adequately supervise a resident while handling a hot beverage and failed to have a policy regarding the use and supervision of hot beverages for one of three residents (R1) reviewed for accidents in the sample of three. These failures resulted in R1 sustaining a burn to the right thigh after spilling a hot beverage in his lap.This past noncompliance occurred on October 20, 2025 and was corrected the same day.Findings include: R1's admission Record documents R1's date of admission to the facility was 10/21/18, and his diagnoses on admission include Chronic Obstructive Pulmonary Disease, Seizures, Personal History of Transient Ischemic Attack, and Cerebral Infarction without Residual Deficits, and Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, or Anxiety. R1's Minimum Data Set Assessment, dated 9/5/25, documents R1 has moderately impaired cognition, requires a manual wheelchair for mobility, and is dependent with bathing, grooming, transfers, and mobility throughout the facility in his wheelchair. R1's care plan documents R1 can move self around the facility with supervision only, and prior to 10/20/25, had no intervention for a cup with lid for coffee. The facility's report to the local State Agency for R1, dated 10/20/25, documents R1 experienced a potential burn to bilateral thighs and R (right) knee after spilling coffee on his lap. R1's Final Report, dated 10/21/25, documents R1 inadvertently spilled his coffee onto his lap due to unsteadiness while attempting to self-propel in his wheelchair, Tx (treatment) orders to be followed and areas to be monitored for any new changes. (R1) to be seen by Facility Wound Dr (Doctor) during next rounds, and implemented a Hot Beverage Policy. R1's progress notes, dated 10/20/25 at 8:47am, document, Resident given coffee by kitchen staff without lid. Order received to apply Silvadene topically to bilateral thighs BID (twice a day) and PRN (as needed). Resident (R1) will no longer receive hot beverages without a lid, and a cup holder will be added to his wheelchair. R1's progress notes also document on 10/21/25 at 9:44am documents, Blisters have opened. Treatment orders have changed to apply nonadherent dressing and paper tape. R1's wound doctor note, Wound Assessment and Plan, dated 1/22/25, documents right thigh burn, second degree measuring 2.5cm (centimeter) in length, 3 cm in width, and 0.1cm in depth with peri wound showing maceration. On 10/31/25 at 10:55 am, R1 was noted to be lying on his back in bed with covers pulled up to his bare chest watching television. R1 was in no distress. When asked about spilling coffee R1 stated, I remember that. I burned myself. R1 pulled down blankets and points to two quarter sized pink areas on his inner right thigh and stated, That's what happened. R1 denies discomfort to site and could not remember if he uses a cup with a lid. On 10/31/25 at 11:07 am, V3 (Dietary Manager) stated the facility initiated a new Hot Beverage and Soup Policy after R1's incident with spilled coffee. On 10/31/25 at 1:30 pm, V1 (Administrator) stated R1 had spilled coffee in his lap on 10/20/25, when he tried to hold onto the cup and wheel his wheelchair down the hallway, spilling coffee on his lap, causing a burn to his right thigh area. V1 (Administrator) also verified the facility did not have a Hot Beverage Policy in place prior to (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: 146016 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 11/04/2025 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)