Health inspection·September 27, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive person centered care plan for one resident (R1) of three residents reviewed for care plans in the sample list of three. Findings include: R1's undated Face Sheet documents R1's diagnoses as unspecified Psychosis not due to a substance or known physical condition, Non-traumatic Chronic Subdural Hemorrhage, unspecified Intracranial injury with loss of consciousness of unspecified duration, sequela, unspecified Mental Disorder due to known Physiological Condition, unspecified Mood. R1's Minimum Data Set (MDS) dated [DATE], documents R1 as moderate cognitive impairment and inattention and disorganized thinking. R1's Departmental Notes dated 7/27/23 at 9:48 PM, documents R1 was reported by north wing nurse that she was able to punch front door code and go outside. R1's Departmental Notes dated 8/15/23 at 10:00 AM, documents resident exited the front door of the facility to go to (a fast food restaurant), staff followed her (R1) out the door and assisted resident (R1) back into the building. R1's Departmental Notes dated 8/16/23 at 9:46 PM, documents resident (R1) exited out [NAME] door at 8:20 PM, found just off the patio. R1's Departmental Notes dated 9/13/23 at 8:43 AM, documents resident (R1) went outside door of facility. On 9/27/23 at 10:24 AM, V2 Director of Nursing (DON) stated R1 is absolutely a risk for elopement. V2 stated R1's care plan does not have elopement risk put in until 9/12/23. V2 stated an elopement screen risk was done on 7/15/23 but should have been re-done again. The facility's Care Plan Policy dated Revised April 2009, documents Care plans shall incorporate goals and objectives that lead to the resident ' s highest obtainable level of independence; goals and objectives are reviewed and/or revised: when there has been a significant change in the resident ' s condition; when the resident has been readmitted to the facility from a hospital/ rehabilitation stay; and at least quarterly. 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: 145416 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 145416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420 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)