Inspection·December 17, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concluded that the allegation was unsubstantiated, it appears that the reporting staff members are unreliable/inconsistent in their accounts and are not a reliable source of information as it relates to their interaction in this alleged occurrence. Staff interview attached to the reported incident indicated that three CNAs (V9, V10 and V12) all reported that they witnessed V11 (RN) hit resident and threw her in bed. 12/15/2023 at 12:54PM,V8 (LPN/Wound Care) said that a certified nurse assistant (CNA) reported to her that she saw the nurse hit a resident, picked her up and threw her in the bed, she received the same report from two other CNAs, she assessed the resident, there was no visible injury, but there was an abrasion on resident's back which she assumed is from the fall. V8 said that one of the CNAs later changed her story stating that she did not see the nurse hit the resident, she was just reporting what the other CNAs said. Review of medical record did not show any documented witnessed or unwitnessed fall for R1 the day of the incident. 12/15/2023 at 2:19PM, V9 (CNA) said that she was not assigned to R1 the day of the incident, they were passing dinner trays and she went to give resident her tray and noted her on the floor about 5:15PM and the resident's head was stuck at the back of a wheelchair. She went to get the assigned CNA and two of them could not get the resident out of the wheelchair so they called the nurse who is a male staff to help them, they finally unhooked resident from the wheelchair, the nurse was screaming at resident saying see what you made me do, I should slap you, and he slapped resident on her back. V9 added that they tried to stand resident up and the nurse grabbed resident and threw her in bed, then asked them to finish passing tray, clean up and come back to the resident. V9 stated that she has never changed her statement regarding the incident. 12/15/2023 2:32, V10 (CNA) said that she was the assigned CNA for R1 the day of the incident, around 5:15PM, another CNA told her that resident's head was stuck in a wheelchair, they tried for about five minutes to get her out but couldn't, they decided to get the nurse to help them and a third CNA came in. They finally released resident, she was sitting up and the nurse started yelling and screaming because they were all frustrated, he popped the resident on her back and was rough with her while putting her back in bed and pushed her again while she was in bed. They reported the incident, an investigator and the administrator spoke to her about the incident, and she never changed her story. 12/15/2023 4:16PM, V12 (CNA) said that R1 got her head stuck on a wheelchair, the nurse and two CNAs spent 10 to 15 minutes trying to get her out, she heard the nurse screaming loud, she went into the resident's room and saw the nurse pick up the resident and slammed her in bed, saying look what you make me do, and shoving her shoulder. V12 added that she did not notice any bruise on the resident because she was not assigned to her, she did not assess the resident and did not change her story regarding the incident at any time. At 3:19PM, V11 (RN) said that he was the floor nurse for 3 to 11pm and 11 to 7am on unit 3 the day R1 had an incident. R1 was walking around the unit with an unsteady gait and at risk for fall, he tried to redirect her but that was ineffective, the CNA took her to her room and 1 hour later he was called to come and help get resident off the floor. V 11 stated that it took them more than 25 minutes to unhook resident from the wheelchair, they put her in bed, he assessed resident and told the CNAs to clean her up and bring her out. V11 stated that he was very frustrated following the incident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 but denied hitting resident or being rough with her during transfer. Level of Harm - Minimal harm or potential for actual harm 12/15/2023 at 12:28PM, V1 (Administrator) said that she did not substantiate the abuse allegation because there were many inconsistencies with the eyewitness interviews, they changed their stories during follow up interview during the investigation. Residents Affected - Few Abuse policy dated 9/20 presented by V1 (administrator) stated in part, that the facility affirms the right of our residents to be free from abuse, neglect .and involuntary seclusion. The facility is committed to protecting our residents from abuse by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 3 of 3