Sunset Home

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview the facility failed to thoroughly investigate an allegation of abuse for one resident (R1) and determined it unsubstantiated and failed to protect R1 from further abuse. This failure resulted in an Immediate Jeopardy Findings IncludeThe Immediate Jeopardy began on 10/09/25 at 6 AM when V4 (Certified Nurse Aide) was allowed to return back to work with all residents and specifically R1. On 10/16/25 at 9:30 AM V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 10/4/25 around 6:30 PM. While the Immediacy was removed on 10/16/25 the facility remains out of compliance at a severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of their removal plan. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (R1) was free from abuse of three residents reviewed for abuse in a total sample of nine. Based on V8's statement R1 acted scared and followed me around all night. I for sure think she was traumatized by the whole thing even if she couldn't say it., it can be determined that the reasonable person in this resident's position would have experienced psychosocial harm (e.g., embracement, humiliation, anxiety) as a result of this abuse. This failure resulted in an Immediate Jeopardy.

Inspectors wroteBased on interview and record review the facility failed to ensure that Certified Nursing Assistant staff have had required 12 hours of in-service education. This failure has the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the state agency for one of three residents (R1) reviewed for bruises in a sample of three.

Inspectors wroteBased on record review and interview, the facility failed to ensure a thorough investigation was completed following a bruise of unknown origin for one of three residents (R1) reviewed for bruises in a sample of three.

Inspectors wroteBased on interview and record review the facility failed to follow treatments as ordered by the physician and failed to implement pressure relieving interventions for one resident (R5) of four residents reviewed for pressure ulcers in the sample of nine. These failures resulted in R5 developing a facility acquired stage 4 pressure ulcer to her coccyx that became infected and caused R5 pain.

Inspectors wroteBased on interview and record review the facility failed to transcribe a physician's order accurately, administer the correct physician's ordered insulin for 45 days, and notify the physician once a residents' blood sugar dropped below normal parameters for one resident of three residents (R1) reviewed for significant medication errors in the sample of nine. These failures resulted in R1 experiencing hypoglycemia and lethargy on two occasions that required glucagon injections.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's family of a medication error and failed to notify the physician of a change in condition for one resident of three residents (R1) reviewed for insulin in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to take vitals or do a resident's assessments in a timely manner for one resident of four residents (R3) reviewed for vitals and assessments in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to send the correct medication on a home visit for one resident of three residents (R2) reviewed for home medications in the sample of 9.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to keep the kitchen and resident dining areas free from cockroaches. This failure has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure nursing assistants provided a resident at risk for falling with supervision, failed to provide residents with dining assistance, and failed to document meal and fluid intakes and episodes of incontinence for three of three residents (R1, R2, R3) reviewed for nursing care in the sample of four.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a chemical dishwasher was monitored for safe sanitizer concentration, failed to ensure opened bags of freezer kept food items were labeled with dates of opening, and failed to record cool down temperatures for soups that were prepared ahead and stored in the freezer for future use. This failure has the potential to affect all 87 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing and humidification bottles were dated and oxygen tubing was stored in a bag between uses for four of four residents (R64, R140, R147, and R290) reviewed for respiratory care in a sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters for 10 of 10 residents (R1, R6, R20, R29, R49, R50, R54, R73, R81, and R143) reviewed for EBP in the sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were placed within reach for three of 18 residents (R30, R37, and R64) reviewed for accommodation of needs in the sample of 36.

Inspectors wroteBased on Observation, Interview and Record review the facility failed to ensure a physician ordered hand splint was in place daily and a resident's limitations in range of motion were care planned for one of two residents (R73) reviewed for limitations in range of motion in the sample of 36.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to ensure a resident with a diagnosis of Dementia and a history of falling was adequately supervised to prevent a fall for one of three residents (R51) reviewed for Falls in the sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter drainage bag was covered for one of one resident (R6) reviewed for indwelling urinary catheters in a sample of 36.

Inspectors wroteBased on interview and record review the facility failed to follow a physician order for a daily weight for one of one resident (R45) reviewed for dialysis in the sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to document behaviors and diagnoses to justify the use of antipsychotic medications, perform psychotropic assessments quarterly, and perform gradual dose reductions of scheduled antipsychotic medications for two of three residents (R37 and R51) reviewed for the use of anti-psychotic medications with the diagnosis of Dementia in the sample of 36.

Inspectors wroteBased on record review and interview the facility failed to document and address a grievance for one resident (R3) of three reviewed for resolution of grievances in the sample of seven. Findings Include: The Facility's undated Grievance/Concern Policy documents the purpose of the policy is to provide an opportunity for residents and/or family to present concerns or grievance to the proper authorities at the facility and to receive responses to the issues raised. The Grievance/Concern policy documents, It is the responsibility of the Department Directors to follow-up on the concerns and to ensure appropriate resolution. A copy of Concerns Forms must be sent to the Administrator for signature. Complaints may be presented to any staff member who should then report the issue to his/her supervisor and/or Social Services as soon as possible. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete wound assessment documentation and perform wound care for (R4) and failed to provide thickened water in between meals for (R3 and R7) for three of three residents (R3, R4, and R7) reviewed for quality of care in the sample of seven. Findings Include: 1. The Facility's undated Skin Care Ulcers policy documents good skin care is important to maintain good health and prevent pressure areas. The integrity of skin should be maintained as the first line of defense against infections and pressure ulcers. Documentation will be done on all types of skin ulcers. Licensed staff and CNA will be responsible for providing nursing interventions for those residents with ulcers. Treatments for all ulcers will be ordered by the Physician. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain physician orders for treatment of a pressure ulcer wound in a timely manner and failed to document weekly pressure ulcer wound assessments for one of three residents (R3) reviewed for wounds in the sample of seven. Findings Include: The Facility's undated Skin Care/Ulcers policy documents Good skin care is important in order to maintain good health and prevent pressure area. The integrity of the skin should be maintained as the first line of defense against infections and pressure ulcers. Documentation will be done on all types of skin ulcers. The unit coordinator will document when and where the ulcer developed, and interventions used in the nursing notes. [...]

Inspectors wroteBased on interview and record review staff failed to immediately notify the Administrator of possible abuse of one resident (R1) of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to a resident with severely impaired cognition and a known wanderer, failed to respond to door alarms at the door and at the main alarm panel, and failed to thoroughly investigate an elopement for one of three residents (R1) reviewed for accidents in the sample of ten. These failures resulted in R1, a severely cognitively impaired resident with a diagnosis of Dementia, eloping from her unit through an open double door that is normally closed, approximately 80 feet, to an unoccupied area of the building, getting through an alarmed door that leads to a stairway and being found on a landing after descending 8 steps. R1's wheelchair was tipped backwards in front of her on the landing. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a significant change in condition for one of three residents (R4) reviewed for change in condition in the sample of ten. These failures resulted in R4 being diagnosed with a Severe Urinary Tract Infection (UTI), Sepsis, and being hospitalized for five days.

Inspectors wroteBased on record review and interview the facility failed to notify the physician of a resident's (R1's) significant decline in condition and of a resident (R2) not receiving a physician ordered IV (Intravenous) antibiotic medication for two of three residents (R1 and R2) reviewed for notification of changes in the sample of six.

Inspectors wroteFacility failures resulted in two deficient practices. A. Based on record review and interview the facility failed to document and assess for an underlying condition and seek medical treatment after a significant change in status for over 24 hours for one of three (R1) residents reviewed for timely care after a change in status in the sample of six. B. Based on record review and interview the facility the facility failed to perform a treatment to a diabetic heel ulcer as ordered by the physician for one of three residents (R2) reviewed for altered skin conditions in the sample of six.

Inspectors wroteBased on record reviews and interviews the facility failed to infuse a physician ordered IV (Intravenous) antibiotic as ordered for one of three residents (R2) reviewed for significant medication errors in the sample of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure disinfectant used on all food preparation surfaces and all dining room tables were within the proper concentration perimeters. This failure has the potential to affect all 94 residents within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for an indwelling urinary catheter, prophylactic antibiotic, the use of insulin, the use of an anticoagulant, and bowel/bladder incontinence for 6 of 22 residents (R8, R21, R27, R44, R45, R91) reviewed for care plans in the sample of 67.

Inspectors wroteBased on observation, interview, and record review, the facility failed to measure potential zones of entrapment for 54 of 54 residents (R1, R3, R4, R5, R7, R8, R10, R11, R19, R21, R23, R24, R25, R27, R28, R30, R36, R37, R38, R39, R40, R41, R43, R44, R45, R47, R52, R58, R59, R60, R61, R62, R64, R66, R68, R69, R70, R71, R76, R78, R79, R80, R82, R83, R85, R86, R87, R89, R91, R93, R95, R153, R154, R155) reviewed for siderails in the sample of 67.

Inspectors wroteBased on interview and record review the facility failed to allow choices for one resident (R79) of nineteen residents reviewed for choices in a total sample of 67. Findings Include: The undated Illinois Long-Term Care Ombudsman Resident's Rights booklet documents Your facility must be safe, clean, comfortable and homelike and You may keep or use your own property, R79's Progress Notes dated 11/07/23 at 1:29 PM documents (R79) wants own curtains that are Viking sport themed, and others taken down. Explained to him that due to regulations and privacy, etcetera this was not allowable. He did call his mother and she called me. I did check other staff to make sure I wasn't necessarily mistaken and then explained it to her about regulations but said she understood. I did go back and talk the (R79) again and this time said he understood. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to deliver cares in a dignified manner for one resident (R74) during a routine tour of the building in a total sample of 67. Findings Include: The Facility's undated Cell Phone Use Policy documents Employees may use cell phone/ electronic communication devices during lunch or break periods or as authorized in private space away from all patient care area and common work areas. Other than described, personal cell phones/electronic communication devices are to be turned off and stored during working hours and are not to be kept on person, in patient treatment areas or nursing stations unless authorized. On 11/16/23 at 10:30 AM V23 (Certified Nurse Aide) could be overheard speaking No, I told her to quit calling me about your business I don't want to be involved. [...]

Inspectors wroteBased on record review and interview the facility failed to formulate Advance Directives for one resident (R203) of 19 reviewed for Advanced Directives in a total sample of 67. Findings Include: The Facility's Statement of Facility Policy Regarding Advanced Directives and Life-Sustaining Treatment documents Federal law requires (this facility), as well as other health care facilities participating in certain federal programs, to distribute information regarding the right of adults to participate in medical treatment decisions. It is the policy of (the facility) to comply with Illinois court decisions and statutes regarding individual surrogate participation in medical treatment decisions and implementation of Advanced Directives. R203's medical record did not contain any information regarding whether the resident wished to be a full code or a do not resuscitate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's room was free of urine odors for one of one resident (R44) reviewed for ADL (Activities of Daily Living) in the sample of 67.

Inspectors wroteBased on interview and record review the facility failed to report one allegation of neglect for one resident (R79) of one reviewed for abuse in a total sample of 67. Findings Include: The Facility's undated Abuse and Neglect Policy documents It is the policy of (this facility) to provide each resident with an environment free from abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of resident property, exploitation and physical or chemical restraint not required to treat the residents' symptoms, as defined below. (This facility) shall follow the procedure for reporting and investigation of alleged resident abuse and neglect as outlined. The Facility's undated Abuse and Neglect Policy defines neglect refers to the failure to provide goods and/or services necessary to avoid physical harm, mental anguish, or mental illness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear gloves while cleansing a diabetic ulcer and perform hand hygiene during wound care for one of one resident (R47) reviewed for diabetic ulcers in the sample of 67.

Inspectors wroteBased on interview, observation, and record review the facility failed to document a diagnosis to warrant the use of an indwelling urinary catheter, ensure an indwelling urinary catheter drainage bag was kept below the level of the bladder and off of the floor, secure indwelling urinary catheter tubing, and complete a scheduled urinary catheter change for three of five residents (R27, R71, R91) reviewed for indwelling urinary catheters in the sample of 67.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a nebulizer mask and nebulizer tubing was dated and stored in a bag between uses for one of two residents (R40) reviewed for respiratory care in a sample of 67.

Inspectors wroteBased on interview and record review, the facility failed to develop a Dementia plan of care for one of three residents (R8) reviewed for Dementia in the sample of 67.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document a diagnosis and behaviors to warrant the use of an antipsychotic, ensure a resident was free of dual psychotropic medication therapy, obtain an informed consent for the use of a psychotropic, and obtain a stop physician order for a PRN (as needed) psychotropic medication for three of five residents (R28, R45, R79) reviewed for psychotropics in the sample of 67.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an opened multi-dose diabetic insulin pen was labeled with the date opened for one of 67 residents (R2) reviewed for storage and labeling of medications in a sample of 67.

Inspectors wroteBased on observation, interview and record review the facility failed to wash their hands and to transport linen in an effective manner to avoid contaminating items for three residents (R27, R38 and R91) in a total sample of 67. Findings Include: The Facility's undated Handwashing Policy documents This facility considers handwashing the primary means to prevent the spread of infections. The Facility's Handwashing Policy also documents All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, and visitors. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions. B. when hands are visibly soiled (hand washing with soap and water. C. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a fall prevention pressure alarm was in working order for one of four residents (R86) reviewed for falls in a sample of 29. This failure resulted in R86 sustaining a fall with a fractured left hip when R86's pressure alarm failed to sound and alert staff that R86 was ambulating without assistance.

Inspectors wroteBased on interview and record review the facility failed to complete a comprehensive care plan addressing Hospice care for one of one resident (R56) reviewed for hospice in a sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise care plans to address locations of pressure ulcers, pressure ulcer preventive measures or fall prevention interventions for two of 18 residents (R86, R87) reviewed for care plans in a sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to perform pressure ulcer risk assessments, accurately assess pressure wounds, develop, and implement individualized pressure ulcer prevention interventions based on pressure ulcer risk, or have a consistent method for tracking the improvement or decline of pressure ulcers for one of three residents (R86) reviewed for pressure ulcers in a sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident prescribed antipsychotic medications was assessed for clinical indications for use, appropriate diagnoses, and adverse target behaviors to warrant the use of antipsychotic medications for two of five residents (R49, R73) reviewed for unnecessary medications in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received the correct dosage of Keppra (anticonvulsant medication) and complete a medication error report for the 65 wrong dose administrations for one of 24 residents (R62) reviewed for medications in the sample of 29.