Health inspection·October 23, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few to impaired safety awareness, cognitive impairment due to dementia and at risk for falls due to history of falls, cognitive impairment and decreased strength and endurance.R2's Care Plan documented admission to this facility on 9/23/2025 and included diagnoses of dementia without behavioral disturbance, Diabetes type 2, history of traumatic brain injury, bipolar and major depressive disorder without psychotic features. R2's Care Plan documented on 9/23/2025, R2 has focused problem areas of new to facility, needs to adjust to new environment, needs assistance with activities of daily living, and at risk for falls due to history of falls and cognitive impairment. On 10/9/2025, R2's Care Plan was updated to include a new focused problem area of behaviors of wandering and physical aggressiveness towards other residents.On 10/20/2024 at 8:45am, V1 (Administrator) said R2 was recently admitted to this facility on 9/23/25 from a sister facility. V1 said R2 has dementia and has severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 4. V1 said nothing in R2's transfer paperwork documented any previous aggressive behavior and specifically documented R2 was non-aggressive but needed a more secure unit due to high elopement risk. V1 said the sister facility was not secure enough for R2's needs. V1 said R2's family agreed to R2 transferring to this facility and R2 was admitted to the dementia unit. V1 said since being admitted , R2 has not shown any aggressive behavior and has not been involved with any incidents or peer-to-peer altercations until 10/9/2025 when R2 hit R1. V1 said after the incident, R2 was placed on 1:1 supervision and moved to a different secured unit in the facility. V1 said R2 is doing well on the new unit and has not had any issues or aggressive behaviors. V1 said the incident between R1 and R2 was witnessed by V10 (Wound Care Nurse), V3 and V4 (both Certified Nursing Assistants/CNAs).On 10/20/2025 at 12:30pm, V3 said on 10/9/2025 around 2:00pm, she was in the hallway on the dementia unit. V3 said she could see R1 walking down the hallway and was by R2's bedroom doorway. V3 said R2 came out into the hallway and hit R1 on her right shoulder. V3 said R1 took a few steps then lost her balance, fell towards the wall and to the floor. V3 said she told V4 to go get the nurse while she stayed with R1 and R2 went and sat on his bed. On 10/20/2025 at 1:00pm, V4 said she also witnessed the same event. V4 said she was a few feet away from R1 and R2 when she saw R2 hit R1 on the shoulder. V4 said R1 took a few steps away, lost her balance, and fell to the floor. V4 said R2 went and sat down on his bed, and she ran to get the nurse (V10). V4 said when she returned, she asked R2 why he hit R1 and R2 answered, I thought she was going in my room. I was trying to keep her out of my room.On 10/20/2025 at 12:15pm, V10 said when she arrived, R1 was sitting on the floor in the hallway. V10 said R1 was not bleeding but she felt R1's right leg looked injured. V10 said she called 911 got R1 sent to the hospital where it was determined R1 had a broken right hip. V10 said R2 was immediately placed on 1:1 supervision and the next day was moved to a new unit. V10 said she had not seen any aggressive behavior or issues with R2 since he was admitted to this facility.Facility form titled Long-Term Care Facility-Serious Injury Incident and Communicable Disease Report dated 10/9/2025 documented under Detailed Incident Summary-Final: It was reported to Administrator by Wound Nurse of a resident-to-resident altercation. (R1) was walking by (R2's) room when (R2) stepped out and hit (R1) in the right side of her shoulder and face. (R1) fell on her left side. Residents were immediately separated, and (R1) was assessed by the nurse and transported to the hospital with a right hip fracture. (R2) was moved to the (name of behavioral unit) before (R1) returned to the facility. One on one supervision with (R2) was initiated immediately. Check ins with Social Services were also initiated. No further aggressive behaviors have been observed since the incident. Families, Police and MD were notified.Hospital records for R1 dated 10/9/2025 documented R1 presented to the emergency room via EMS (emergency medical service) for right hip pain. SNF (Skilled Nursing Facility) reports patient was pushed down, landed on right hip (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145135 If continuation sheet Page 2 of 3 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 145135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richland Nursing & Rehab 900 East Scott Street Olney, IL 62450 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 0600 Level of Harm - Actual harm with immediate pain with movement to RLE (right lower extremity) and unable to get up post fall. On arrival with RLE shortening and external rotation. These same hospital records documented on 10/10/2025, R1 underwent right hip fracture repair procedure where a right intramedullary rod was inserted to repair the fracture. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145135 If continuation sheet Page 3 of 3