Inspection·January 20, 2026

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by a staff member. This failure affects one (R2) of three residents reviewed for abuse in the sample list of 10. Findings:A facility investigation report dated December 9, 2025, at 7:13 PM, documents an alleged incident involving R2 and V13 (Certified Nursing Assistant (CNA)). According to the investigation report, R2 reached out and grabbed V13 (CNA's) head. V13 (CNA) immediately responded grabbing R2's hand and redirecting it away from V13's (CNA) head.The facility investigation file includes a witness statement dated December 9, 2025, documenting V12 (CNA) reported that around 7:00 PM on December 9, 2025, while she and V13 (CNA) were assisting R2 into bed, R2 grabbed V13 (CNA's) head. V12 (CNA) stated V13 (CNA) responded by striking R2's hand and telling R2 not to grab her head.The investigation file contains a statement dated December 9, 2025, from the alleged perpetrator V13 (CNA), documenting V13 (CNA) asked V12 (CNA) to assist with repositioning R2 in bed and R2 grabbed V13 (CNA's) head during the process. V13 (CNA) stated she removed R2's hand from her head.R2's Minimum Data Set (MDS) dated [DATE] documents R2 has severe cognitive impairment. R2 has a diagnosis of severe dementia with anxiety with behavioral disturbances.On 1/15/26 at 10:47 AM, R2 was observed lying flat on her back in bed with upper side rails in place. R2 was unable to respond to questions related to R2's severe cognitive impairment. R2's electronic medical record (EMR) contains a health status note dated 12/9/2025 documenting that a CNA reported an alleged incident occurring in R2's room during a transfer. This note documents R2 was assessed for injuries and vital signs were obtained. On 1/15/26 at 11:12 AM, V13, (CNA), stated she is no longer employed at the facility. V13 (CNA) acknowledged that an incident involving R2 occurred but reported that she does not recall the exact details. V13 (CNA) indicated that she does not wish to speak with this writer, expressing concern that doing so might incriminate her.On January 15, 2026, at 1:07 PM, V8 (Licensed Practical Nurse (LPN)), stated on the evening of December 9, 2025, V12 (CNA) approached her regarding a situation between R2 and V13 (CNA). V8 (LPN) reported that she advised V12 (CNA) that if the situation involved an allegation of abuse, the Administrator needed to be contacted immediately. V8 (LPN) stated she also called the Administrator and was instructed to place V13 (CNA) in the conference room until V1 (Administrator) could arrive at the facility to investigate the matter.On January 20, 2026, at 3:13 PM, V1, (Administrator/Abuse Coordinator), stated she investigated the incident between R2 and V13 (CNA). V1 reported that V13 (CNA) instinctively moved R2's hand away from her long hair and confirmed that there was no injury to R2. V1 (Administrator) agreed that all residents have the right to remain free from abuse while residing in the facility and stated, Absolutely 110% residents have the right to be free from physical abuse.The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy dated September 2022 states residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This (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: 145370 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 145370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sullivan Healthcare & Senior Living 11 Hawthorne Lane Sullivan, IL 61951 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)