Inspection·November 8, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to evaluate and obtain orders for self administration of medications for two (R6, R26) of two residents reviewed for self administration of medications from a total sample list of 31 residents. Residents Affected - Few Findings include: The facility provided Administering Medications Policy dated December 2012 documents that residents may only self-administer medication if the attending physician in conjunction with the interdisciplinary care planning team has determined that they have the decision making capacity to do so safely. The facility provided Self-Administration of Medications Policy dated December 2016 documents that the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident including a full and complete assessment of the resident's ability to self-administer medications. The staff and practitioner will document their findings of the assessment. R6's November 2023 Medication Administration Record documents orders for Spiriva 2.5 microgram inhaler, take two puffs daily and Symbicort 160-4.5 microgram inhaler, take two puffs daily. There is no order for a Combivent inhaler. On 11/7/23 at 8:35 AM, R6 stated that he used his Symbicort inhaler without supervision and that his Spiriva inhaler was not used because it was empty and that he could not recall how long it had been empty. R6 then pulled a Combivent inhaler out of his pocket and stated that he used it for emergencies. On 11/7/23 at 8:40 AM, V10 Licensed Practical Nurse stated that R6 doesn't have an order to self-administer his medications. We don't have a doctor's order and they are supposed to have one to keep medication in their rooms and to self-administer medication. R26's November 2023 Medication Administration Record documents orders for Trelegy-Ellipta 100-62.5-25 microgram inhaler, take two puffs daily. On 11/7/23 at 9:15 AM, R26 stated that he was keeping his Trelegy-Ellipta 100-62.5-25 inhaler at his bedside and that it has been lost since 11/5/23. I don't know where it went, and I haven't used it since Saturday. R26's November 2023 Medication Administration Record documents that Trelegy-Ellipta 100-62.5-25 microgram inhaler was not given on 11/5/23 and 11/7/23 and was administered on 11/6/23. On 11/7/23 at 10:23 AM, V10 Licensed Practical Nurse said that the documentation on 11/6/23 for the Trelegy-Ellipta 100-62.5-25 microgram inhaler was likely a documentation error. On 11/7/23 at 9:20 AM, V19 Licensed Practical Nurse stated that R26 doesn't have an order to self-administer medications and that an order is required to keep medication and self-administer at the bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 2 of 15 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 11/08/2023 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately code Minimum Data Set assessments for two (R50, R27) of 17 residents reviewed for assessments on the sample list of 31. Residents Affected - Few Findings include: 1. R50's Nursing Notes dated 9/06/2023 at 10:49 AM, documents R50 was discharged and medications including narcotics were sent with R50. R50's Discharge Minimum Data Set assessment dated [DATE] documents R50 was discharged to the hospital. On 11/8/23 at 3:00 PM, V18 Regional Nurse Consultant stated R50 was discharged to home not the hospital and that the Discharge Minimum Data Set assessment dated [DATE] was coded incorrectly. 2. R27's Minimum Data Set, dated [DATE] documents that R27 is on an antipsychotic medication. R27's August Medication Administration Record documents no anti-psychotic medications were ordered for R27. On 11/7/23 at 11:26 AM, V8 Minimum Data Set Coordinator stated, I must have mis-coded R27's Minimum Data Set. She has never been on an antipsychotic. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 3 of 15 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 11/08/2023 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a pressure relieving intervention (cushion) for one of three residents (R22) reviewed for pressure ulcers in the sample list of 31. Residents Affected - Few Findings Include: The facility's Prevention of Pressure Ulcers/Injuries policy with a revised date of July 2017 documents, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. This policy also documents, Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. R22's Face Sheet documents diagnoses including Pseudobulbar Affect, Vascular Dementia and Hypothyroidism. R22's Minimum Data Set (MDS) dated [DATE] documents R22 is at risk for developing pressure ulcers, has a pressure reducing device for the chair and documents R22's mobility devices as a walker and a wheelchair. R22's Skin Risk assessment dated [DATE] documents R22 is at risk for the development of pressure ulcers. R22's Care Plan dated 2/14/23 documents R22 has a pressure reducing cushion to the wheelchair. On 11/6/23 at 12:48 PM, R22 was in the dining room in R22's wheelchair and R22 did not have a cushion on the seat of R22's wheelchair. There was only the pressure alarm underneath of R22. On 11/7/23 at 2:02 PM, R22 was in R22's wheelchair wheeling R22's self in the hallway and R22 did not have a cushion in R22's wheelchair only the pressure alarm underneath R22. On 11/8/23 at 11:00 AM, V8 Minimum Data Set Nurse and V18 Regional Nurse confirmed that R22 is supposed to have a pressure relieving cushion in R22's wheelchair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 4 of 15 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 11/08/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide safe transport for one of three residents (R42) reviewed for accidents on the sample list of 31. Findings include: The facility's Operation Instructions for the shower chair with the model # SC9200 MS documents, Precautions: Exaggerated user movement in any direction or sitting on the edge of the seat may cause the chair to tip. This policy also documents, Safety/Maintenance Information: Make certain chair is assembled according to the enclosed instructions. R42's Face Sheet documents a diagnosis of Altered Mental Status, Morbid (Severe) Obesity and Weakness. R42's electronic medical record documents R42's weight on 11/5/23 was 246.6 pounds. R42's Minimum Data Set, dated [DATE] documents R42 has moderately impaired cognition, R42 does not walk and R42 is totally dependent on two staff for bathing. On 11/6/23 at 10:44 AM, R42 was being pushed down the hallway from R42's room to the shower room, approximately 35 feet, in a shower chair. The shower chair is being held together at the bottom rails by two rubber straps. On 11/8/23 at 9:49 AM, V18 Regional Nurse stated they should not transport residents in a shower chair. On 11/8/23 at 10:52 AM, an unknown resident was in the shower room in the same shower chair with the rubber strap across the bottom rails of the chair. On 11/8/23 at 11:03 AM, V19, CNA, stated that the reason the strap is on the bottom of the shower chair is because it's probably broken. On 11/8/23 at 12:01 PM, the shower chair was in the shower room and the manufacturers label on the bottom rail of the chair documented the model # SC9200 with a date of 11/11/2009. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 5 of 15 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 11/08/2023 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide oxygen per physician's orders for one of one resident (R42) reviewed for oxygen administration in the sample list of 31. Residents Affected - Few Findings include: The facility's Oxygen Administration policy with a revised date of October 2010 documents Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. This policy also documents, Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. R42's Physician Order dated November 2023 documents a diagnosis of Chronic Diastolic Congestive Heart Failure and documents an order for Oxygen at 2 liters per nasal cannula continually. R42's Minimum Data Set, dated [DATE] documents R42 uses oxygen. R42's Electronic Medication Administration Record dated November 2023 documents an order for Oxygen at 2 liters per nasal cannula with a start date of 8/31/23. On 11/6/23 at 10:20 AM, R42 was in the bed with oxygen on via a nasal cannula and the oxygen concentrator was set at 4 liters. On 11/7/23 at 9:15 AM, R42 was in R42's room in R42's wheelchair with the oxygen on via a nasal cannula. The oxygen concentrator was set on 4 liters. R42 stated that R42 thought it was supposed to be on 3 liters. At this same time V7 Registered Nurse confirmed the oxygen concentrator was set on 4 liters and stated V7 thought it was supposed to be set at 3 liters and proceeded to turn it down to 3 liters. On 11/7/23 at 2:09 PM, R42 was in R42's bed with the oxygen on via the nasal cannula and the oxygen concentrator was set on 4 liters again. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 6 of 15 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 11/08/2023 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)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to relieve pain by failing to provide pain medication as ordered for three (R9, R32, R47) of three residents reviewed for pain on the sample list of 31 residents. Residents Affected - Few Findings include: The facility Administering Medications Policy dated December 2012 documents that medication must be given as ordered including any required time frame. 1.) R9's undated diagnosis sheet documents Chronic Kidney Disease, Leg pain and Lymphedema. On 11/6/23 at 10:43 AM, R9 was sitting up in wheelchair and rubbing shoulder and hands stating that she was in pain. On 11/6/23 at 10:44 AM, R9 was sitting in a wheelchair in the dining room and stated, My pain patch ran out on Thursday, and they still haven't gotten it for me. I have been having a lot of pain. I have to get out of bed at night and sit up in my wheelchair to help with the pain, but I need my patch. R9's October and November Medication Administration Record documents an order for a Butrans 10 micrograms per hour pain patch to be administered weekly (Thursdays). On 11/7/23 at 1:14 PM, V7 Registered Nurse stated, (R9) should have had her patch weekly. She missed 12 days, from October 26 until November 6, 2023. On 11/6/23 at 3:00 PM, V7 Registered Nurse stated, The physician knows that we need R9's patches and we don't have them yet. We don't assess her for pain, according to our records. On 11/7/23 at 10:15 AM, V7 Registered Nurse stated that R9 received her patch last night it came in and was applied. On 11/7/23 at 10:30AM, R9 stated, I finally got my patch last night at 10:30 PM. I guess it helps, because getting up out of my chair to go to the bathroom was really hard without the medicine. On 11/7/23 at 2:00 PM, the box of R9's Butrans patches were dated as dispensed on 11/3/23 (Friday). 2.) R32's undated diagnosis sheet documents a primary diagnosis of Malignant Neoplasm of the Esophagus. R32's October and November Medication Administration record documents an order for Oxycodone -Acetaminophen 10-325 milligrams to be take every four hours for pain. On 11/7/23 at 1:25 PM, V7 Registered Nurse stated, R32 was out of his pain medication from Friday October 27, 2023, until Saturday, November 4, 2023. On 11/7/23 at 2:10 PM, R32 stated, I didn't have my pain medicine for a while. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 7 of 15 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 11/08/2023 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)

F 0697 Level of Harm - Minimal harm or potential for actual harm 3.) R47's undated diagnosis sheet documents a primary diagnosis of an unspecified fracture of the first cervical vertebrae. R47's November Medication Administration Record documents an order for Hydrocodone 10 milligrams/Acetaminophen 325 milligrams (Norco), one tablet as needed for pain every eight hours. Residents Affected - Few On 11/7/23 at 2:00 PM, R47 was wearing a cervical brace/collar and stated that his pain was currently a 6.5 of 10. On 11/7/23 at 1:20 PM, V7 Registered Nurse stated, R47 was out of Norco (pain medication) for 2 days. He was out of the medication on the evening of October 30th, then he was out of the medication all day on October 31st and then when I came back to work on the first of November, I pulled the dose from the emergency box. Staff don't like the pharmacy process for getting medications out of the box, so they don't do it isn't right. He was definitely in pain. On 11/7/23 at 2:00 PM, R47 stated, Yes, I was in pain. It isn't right. My friend with cancer didn't have his pain medicine either. On 11/6/23 at 3:00 PM, V7 Registered Nurse confirmed that R9, R32 and R47 all had delays in pain medication being administered as ordered, with conditions that cause them consistent pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 8 of 15 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 11/08/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to provide pain medication as ordered by the physician for two (R9 and R32) of two residents reviewed for pain on the sample list of 31 residents. Residents Affected - Few Findings include: The facility Administering Medications Policy dated 12/2012 documents that medication must be given as ordered, including any required time frame. 1.) R9's October and November Medication Administration Record documents an order for a Butrans 10 micrograms per hour transdermal pain patch to be administered weekly (Thursdays). On 11/6/23 at 10:44 AM, R9 was sitting in a wheelchair in the dining room and stated, My pain patch ran out on Thursday, and they still haven't gotten it for me. I have been having a lot of pain. I have to get out of bed at night and sit up in my wheelchair to help with the pain, but I need my patch. On 11/7/23 at 1:14 PM, V7 Registered Nurse stated, (R9) should have had her patch weekly. (R9) missed 12 days, from October 26 until November 6, 2023. On 11/6/23 at 3:20 PM, V22 Medical Director stated, I can tell you exactly when I got the fax from the facility and when we sent the order to the pharmacy. (The facility) requested (R9's) patch on 11/3/23 and it was ok'd by my partner. (R9) should have it by now. On 11/7/23 at 10:15 AM, V7 Registered Nurse stated, (R9) received her patch last night it came in and was applied. On 11/7/23 at 10:30AM, R9 stated, I finally got my patch last night at 10:30 PM. I guess it helps, because getting up out of my chair to go to the bathroom was really hard without the medicine. 2.) R32's October and November Medication Administration record documents an order for Oxycodone -Acetaminophen 10-325 milligrams to be take every four hours for pain. R32's October and November Medication Administration record documents that R32 did not receive Oxycodone-Acetaminophen 10-325 milligrams from October 27, 2023, through Saturday November 4, 2023. On 11/7/23 at 1:25 PM, V7 Registered Nurse stated, R32 was out of his pain medication from Friday October 27, 2023, through Saturday, November 4, 2023. He was in pain. On 11/7/23 at 2:10 PM, R32 stated, I didn't have my pain medicine for a while. On 11/6/23 at 3:20 PM, V22 Medical Director stated, The pain medication for R32 was requested on 11/1/23 and sent by my office to the pharmacy on the same day. My office and I are not the delay. The facility pharmacy is who they use, and they aren't open on weekends. I don't think that a nursing home pharmacy should be closed on the weekends. They need a backup or other plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 9 of 15 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 11/08/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/6/23 at 3:00 PM, V7 Registered Nurse confirmed that R9 and R32 had delays in pain medication being received in the facility causing them consistent pain. On 11/6/23 at 9:00 AM, V10 Licensed Practical Nurse stated, I think we only use (a local) pharmacy. I don't think that we have any other. We used to and it was so much better for the residents. I could just run out the door and get whatever the resident needed. On 11/7/23 at 1:14 PM, V7 Registered Nurse stated, I'm not aware of any back-up pharmacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 10 of 15 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 11/08/2023 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess the need for psychotropic medications and reassess the need for as needed antianxiety medication for three of five residents (R6, R22, R29) reviewed for unnecessary medications on the sample list of 31. Findings include: The facility's Antipsychotic Medication Use policy with a revised date of December 2016 documents, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Residents will not receive PRN (as needed) doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 1.) R22's Face Sheet documents diagnoses including Pseudobulbar Affect, Anxiety Disorder, Major Depressive Disorder and Vascular Dementia. R22's Electronic Medication Administration Record (EMAR) dated November 2023 documents orders for Venlafaxine HCL (Hydrochloride) ER (Extended Release) (antidepressant)150 mg (milligrams) one tablet everyday, Remeron (antidepressant) 15 mg at bedtime for an appetite stimulant with a start date of 9/7/23, Trazodone (antidepressant) 50 mg at bedtime with a start date of 10/20/23, Lorazepam (antianxiety) 0.5 mg every 8 hours as needed for anxiety with a start date of 4/25/23 and Haldol (antipsychotic) 0.5 mg twice a day with a start date of 10/17/23. This EMAR documents R22 has received all of the scheduled medications daily and received the as needed Lorazepam on 11/1/23, 11/2/23, two times on 11/4/23, on 11/5/23 and on 11/8/23. R22's Psychoactive Medication Quarterly Evaluation dated 11/3/23 documents this evaluation was for Ativan (Lorazepam) 0.5 mg three times a day scheduled, not as needed (prn). This assessment is not accurate and R22's medical record does not document an assessment for the as needed Ativan which R22 has had ordered since 4/25/23. R22's medical record does not contain any psychotropic medication assessment for the use of Venlafaxine or for Haldol. R22's medical record does not contain any justification for the use of the PRN antianxiety medication Lorazepam since being ordered on 4/25/23. On 11/8/23 at 12:14 PM, V18 Regional Nurse stated that V18 would expect psychotropic medication assessments to be completed and confirmed R22 was receiving an as needed antianxiety medication since 4/25/23. V18 stated V18 doesn't know why R22 is still on this medication. 2.) R6's Psychoactive Medication Quarterly Evaluation dated 10/13/23 documents R6 is receiving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 11 of 15 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 11/08/2023 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)

F 0758 Sertraline (antidepressant) 150 mg once a day for the diagnosis of Depression. Level of Harm - Minimal harm or potential for actual harm R6's November 2023 Medication Administration Record documents an order dated 10/25/23 for Sertraline 200 mg capsule, one capsule by mouth once a day. Residents Affected - Few R6's medical record does not include an assessment for the increase in dose of the Sertraline. On 11/8/23 at 2:00 PM, V18 stated the only assessment for R6's Sertraline was the assessment dated [DATE]. 3.) R29's physician order dated 9/28/23 documents an order for Lorazepam (anti-anxiety) 1 milligram every eight hours as needed. R29's progress note dated 10/31/23 at 5:04 PM, documents R29 was given one milligram of Lorazepam due to trying to bite, hit, and kick staff. R29's medical record does not include an assessment for the use of Lorazepam. On 11/8/23 at 2:30 PM, V18 Regional Nurse Consultant stated there was not an assessment for R29's use of Lorazepam. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 12 of 15 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 11/08/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility to prevent the potential for physical cross-contamination of food. This failure has the potential to affect all 49 residents in the facility. Residents Affected - Many Findings include: 1. On 11/6/2023 at 10:02 AM, two ice scoops were stored in a container located adjacent to the facility ice maker. One scoop was made of white plastic and the other scoop was clear plastic. Both scoops were heavily chipped on the leading edges and missing pieces of plastic up to a quarter of an inch in size. On 11/6/2023 at 12:16 PM, V3 (Dietary Manager) was using the white colored ice scoop from above to obtain ice from the ice maker for residents. On 11/07/2023 at 12:12 PM, the white ice scoop from above remained in the storage container. V3 was present and stated no (she doesn't know where the missing chips of plastic from the scoops are located). 2. On 11/6/2023 at 12:16 PM, a can opener was mounted on a food prep table in the kitchen. The opener was soiled with accumulations of metal shavings where the cutting blade makes contact with canned food items being opened. On 11/07/2023 at 12:20 PM, the can opener remained soiled with metal shavings. V3 was present and observed the can opener and stated it (the can opener) needs a new blade, and it needs washed. On 11/6/2023 at 12:02 PM, V3 reported the food prepared by the kitchen is available for all residents in the facility to consume. The facility's Long-Term Care Facility Application for Medicare and Medicaid (11/6/2023) documents 49 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 13 of 15 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 11/08/2023 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)

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure arbitration agreements provide for the selection of an arbitration venue convenient to both parties. This failure has the potential to affect five residents (R48, R102, R202, R204, R208) of five reviewed for arbitration agreements on the sample list of 31. Residents Affected - Some Findings include: The facility arbitration agreements signed by R48, R102, R202, R204, and R208 do not include any language providing for the selection of an arbitration venue convenient to both parties. The contract documents the arbitration will occur in the county where the facility is located. On 11/8/2023 at 10:39 AM, V4 (Business Office Manager) reported the facility arbitration agreement does not have the required language related to arbitration venue selection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 14 of 15 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 11/08/2023 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)

F 0909 Level of Harm - Minimal harm or potential for actual harm Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, interview, and record review the facility failed to assess a bed rail for areas of entrapment for one of one (R29) resident reviewed for bed rails on the sample list of 31. Residents Affected - Few Findings include: On 11/06/23 at 10:33 AM, R29 was lying in bed. There was a half side rail at the end of the bed. The gaps between the rails on the bed rail were greater than 4.5 inches. The gaps between the rail measured approximately 10 inches. V21 Caregiver stated the rail was added to the bed two weeks ago. R29's medical record did not contain a bed rail assessment to identify areas of entrapment. On 11/08/23 at 1:27 PM, V18 Regional Nurse Consultant stated that they did not have a bed rail assessment to identify areas of entrapment when the bed rail was placed on the bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 15 of 15