Health inspection·December 13, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to protect resident's dignity by failing to place a urinary catheter collection bag inside a covering or pouch. This failure affects two residents (R22 and R33) out of two reviewed for urinary catheters on the sample list of 26. Findings include: On 12/10/24 at 10:50 AM, R33's urinary catheter collection bag was positioned under his wheelchair without any covering, exposing approximately 400 cubic centimeters (cc's) of yellow colored urine inside the collection bag. On 12/10/24 at 10:55 AM, V2, Director of Nursing, shook her head no to indicate she did not like residents' catheter collection bags to be exposed and without a dignity pouch or bag. On 12/10/24 at 1:29 PM, V7, Private Caregiver for R22, stated it is about 50/50 whether the staff keep R22's urinary catheter collection bag covered. V7 stated there have been times when R22's family takes R22 out of the facility and she has had to run around the facility to look for a covering bag. On 12/10/24 at 1:50 PM, V1, Administrator, stated it is his expectation that residents would have their urinary catheter collection bags covered for dignity. The facility policy Quality of Life - Dignity dated 2001 documents each resident shall be cared for in a manner that promotes dignity, standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents by keeping urinary catheter bags covered. Page 1 of 20 145416 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to act on grievances from residents/family promptly, explain to residents how to file a grievance, inform residents where the survey book is located, and address lack of meal substitutes offered at mealtimes and not offering snacks at bedtime. This failure affects four of four residents (R3, R13, R21 and R25) reviewed for grievances in the sample list of 26. Residents Affected - Some Findings include: On 12/11/24 at 10:00 AM, R3, R13, R21, and R25, all stated they can complain but that's as far as it goes. The residents stated staff say they will look into their concerns but the residents can not tell anything has been done. The residents stated they do not know about filling out a grievance form and they do not fill out grievances. The residents stated V9 Activity Director takes the complaints but then after that they do not hear anything more about it. The residents stated staff do not pass out snacks at bedtime and when asked about it they are only offered peanut butter and jelly (PBJ). The residents stated there is no anytime menu that they can see. The residents stated staff offer PBJ, grilled cheese, and cereal in the morning. The residents stated they have told V9 how bad the food is but nothing has changed. The residents stated meals are usually late and cold and breakfast is supposed to come at 7:00 AM and does not, that 12:00 PM lunch is late, and 5:00 PM supper is late. The residents stated they can not get hamburgers or hot dogs, and the potatoes are not done, and the fries are always cold and not done. The residents stated they have no idea where the survey book is located. On 12/12/24 at 11:13 AM V9 stated V9 does not write down the concerns of residents on the sheet for the council meetings. V9 stated V9 had V1 Administrator and V2 Director of Nursing come to resident council meetings, but does not document resident concerns or document speaking with the manager for the concern area or document the outcome. On 12/12/24 at 11:16 AM, V5 Dietary Manager, stated they have an always available menu that was posted but not now. V5 stated resident dislikes are put in a dining log and appear on meal tickets. V5 stated if residents don't like something we offer a second choice or always available menu. V5 stated at lunch today they have an alternative that they can choose from that is left over from the day before. V5 stated if residents don't like that they can choose off the always available menu. V5 stated this has been a consistent issue and V5 has only been here a few weeks so a couple of cooks have been choosing to offer a grilled cheese and PBJ only instead of using the always available menu. V5 stated these are issues they are fixing as well: cold food, food not tasting good, and late meals. V5 stated since V5 has been here they have been keeping temperature logs and they are better and V5 is re-tempting food herself. V5 stated serving times have been better but breakfast was late because there was no staff to take trays to the residents. V5 stated snacks at night were not happening so she stays to make sure snacks are available. V5 stated the snack issue was just brought to her attention maybe three days ago by V6 Regional Dietary. On 12/12/24 at 1:13 PM, with difficulty, the survey book was found by the front door in the corner with the name of the binder covered up by decor, not readily visible. This survey book has the surveys in it with survey dates of only 2022, no other years present On 12/12/24 at 1:20 PM V1 was shown where the survey book was located, Christmas decor blocked the view of the survey book entirely. V1 verified that the survey book surveys were not up to date with 145416 Page 2 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0565 only 2022 surveys being present in the survey book. Level of Harm - Minimal harm or potential for actual harm The facility's undated Grievance Policy documents the residents have the right to file grievances and concerns either written or verbally. A staff member may file a grievance on behalf of a resident. Grievances should be directed to the Administrator (Grievance Official) of the facility. The Administrator will immediately begin to address the grievance upon receipt, immediately discuss the issue with the individual and advise of an appropriate time frame to address the issue. Residents Affected - Some 145416 Page 3 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 request a Preadmission Screening and Resident Review PASARR II Screening for (R26) who has a diagnosis of Schizoaffective Disorder and is receiving Antipsychotic medication. R26 is one of one resident reviewed for PASARR screening on a sample list of 26. Residents Affected - Few Findings Include: R26's Medical Diagnosis sheet dated 12/13/24 lists (R26's) Primary Medical Diagnosis for admission on [DATE] as Interstitial Pulmonary Disease. Included with the list of diagnoses is Schizoaffective Disorder with date of 9/2/2022. The Medical Diagnosis Sheet states under the column Classification for the Schizoaffective Disorder as During Stay. R26's PASARR (Preadmission Screening and Resident Review) Screen ,which is required for admission to the nursing facility, was completed on 8/8/2021 and documents (R26) did not need to be screened for a Level II screening. This PASARR screening was done when (R26) was a resident of a different nursing facility. On 12/12/24 at 12:50 PM (R26) was sitting at the dining room table talking and showing items to an imaginary person. (R26) stated Is this not beautiful, I just love it. ( R26) then responded Thank you I am glad you like it. (R26) continued to talk to the open area. R26's Physician's Order Sheet dated December 2024 documents (R26) takes the following medication for the diagnosis of Schizoaffective Disorder: Quetiapine Sulfate (Seroquel) (antipsychotic) tablets 25 mg (milligram) 1 tablet orally every day. The start date for this medication was 7/1/24. On 12/13/24 at 11:00 AM V3, [NAME] President Clinical Operations stated No I can not find a PASARR II for (R26). I guess the facility did not request one. R26's Care Plan dated 12/1/24 documents (R26) takes Psychotropic medications: Seroquel, Prozac and Trazodone to help (R26) with her depression and symptoms of Schizoaffective disease. On 12/13/24 at 11:00 AM V3, [NAME] President Clinical Operations confirmed the facility did not have a policy for admissions regarding PASARR screenings. 145416 Page 4 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document a discharge summary that includes a recapitulation of stay, a final summary of the resident's status, and a post discharge plan of care. This failure has the potential to affect one of one resident (R49) reviewed for discharge on the sample list of 26. Findings Include: The facility's Discharge Summary and Plan Policy Statement dated 2/17/24 documents when a resident's discharge is anticipated, a discharge summary and medication plan will be developed to assist the resident to adjust to his/her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's course of illness, treatment, or therapy since entering the facility, current laboratory, radiology, consultation, and diagnostic test results, physical and mental functional status, and the resident's ability to perform activities of daily living, among other things. R49's Medical Diagnoses dated September 2024 documents R49 is diagnosed with Acute Kidney Failure, Unsteadiness on feet, Reduced Mobility, Cognitive Communication Deficit, Depression, and Heart Failure. R49's undated Census Report documents R49 was admitted to the facility on [DATE] and discharged on 9/12/24. R49's electronic medical record does not include documentation of a recapitulation of stay, a final summary of R49's status, and a post discharge plan of care. On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed there was no discharge summary that includes a recapitulation of stay, a final summary of the resident's status, and a post discharge plan of care, including discharge instructions for R49. 145416 Page 5 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide complete antibiotic doses for a urinary tract infection for one resident (R42) of one resident reviewed for infections on the sample list of 26. Residents Affected - Few Findings Include: R42's Nursing Notes dated 11/9/24 at 2:13 PM, document per urology orders replaced indwelling catheter, also dip-tested urine to reveal abnormal urine sample, sending to lab for urine analysis (UA) and culture and sensitivity. R42's Nursing Notes dated 11/12/24 at 2:10 PM, document V22 Medical Director aware of UA results, new order received for Bactrim DS everyday for five days. R42's Medication Administration Record (MAR) dated November 2024, documents Bactrim DS tablet 800-160 milligrams (Sulfamethoxazole-Trimethoprim) one tablet by mouth twice a day for urinary tract infection for five days, with a start date of 11/12/24 at 8:00 AM. This same MAR has no indication that this antibiotic was given on 11/16/24 as the 8:00 AM dose and the 5:00 PM dose are not documented as given. R42's Nursing Notes dated 12/8/24 at 3:12 PM, document R42's family member reports that R42 is complaining of abdominal pain and pressure in bladder and would like to have a UA done, and that V22 was faxed. R42's Nursing Note dated 12/9/24 at 10:09 PM, documents new order received to obtain a UA and culture and sensitivity if indicated. R42's Urinalysis results dated collected 12/11/24 documents positive results for (infection) urine. R42's Nursing Notes dated 12/12/24 at 7:43 AM, document a new order for Augmentin oral tablet 500-125 milligrams give one tablet by mouth two times a day for infection related to extended spectrum beta lactamase (ESBL) resistance. On 12/12/24 at 10:10 AM, V2 Director of Nursing stated the orders were not written or transcribed correctly and the antibiotic was not completed on 11/16/24 and should have been. V2 also stated without finishing an antibiotic it could cause the infection not to be treated properly. V2 stated V2 is aware R42 has another urinary tract infection now and is being treated for it. The facility's Administering Medications Policy dated Reviewed 2/17/24, documents medications are administered in accordance with the prescribers orders. This policy also documents the individual administering the medication initials the resident's MAR after giving each medication. 145416 Page 6 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

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 accurately assess for smoking safety and failed to provide supervision for a potential smoking accident for one of one resident (R6) assessed for smoking safety on the sample list of 26. Findings Include: R6's Care Plan dated 1/31/2023 documents the following diagnoses: Presence of Right Artificial Shoulder Joint, Dependence on Renal Dialysis and Tobacco use. The same care plan for R6 documents a goal of (R6) will maintain safety while following smoking protocol. This was dated 7/9/24. An intervention for the goal was R6 is supervised while smoking. Date initiated 07/09/24. Another intervention for the goal was smoking materials are kept secured by staff. Date initiated 07/09/24. R6's Minimum Data Set (MDS) assessment dated [DATE] which was a re-admission assessment documents 15 for (R6's) BIMS ( Brief Mental Status) score. R6 is cognitively intact. The facility's assessment titled Smoking Assessment for (R6) on the following dates 8/2/24, 10/17/24 and 11/6/24 all document the following: Smoking Care Plan, The resident is a smoker, Goal: Resident will maintain safety while following smoking protocol. Intervention: Resident is supervised while smoking and Smoking materials are kept secured by staff. On 12/12/24 at 11:10 AM (R6) was in her room and stated I keep my smoking materials in here, the nurses don't have them which is my cigarettes and lighter. (R6) then took out her cigarettes and lighter. On 12/12/24 at 12:30 PM (R6) was sitting in the smoking area by herself smoking a cigarette. (R6) stated I thought I would grab a cigarette before I went to my doctor's appointment. I smoke outside here by myself. The staff does not come with me. If I am real nervous I will come outside at night and smoke a cigarette. I will let the nurse know I am going outside to smoke. I have never had staff sit with me while I smoke. On 12/12/24 at 3:00 PM V4 Minimum Data Set/Care Plan Coordinator stated Yes, (R6) is capable of smoking by herself we do not go with her to smoke and she keeps her smoking items with her. On 12/13/24 at 2:45 PM V2 Director of Nurses confirmed R6's smoking assessment and care plan need to be accurate and correlate with what R6 is actually doing. 145416 Page 7 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to notify the resident's physician of significant weight loss and failed to develop a plan of care to adequately address a resident's significant risk for weight loss. These failures affected one of one resident (R350) reviewed for nutrition on the sample list of 26. Residents Affected - Few Findings Include: The facility's Weight Assessment and Intervention policy dated September 2008 documents the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. Any change of 5% or more nursing will notify the Dietician and Primary Care Physician. Greater than 5% loss within one month will be considered severe weight loss. R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Dysphagia and Gastrostomy Status. R350's Physician Order Sheet (POS) dated December 2024 documents orders for R350 to be NPO (Nothing by Mouth) and for Enteral Feed, four times a day related to Severe Protein-Calorie Malnutrition. R350 is to be weighed weekly for four weeks. R350's Weight record documented an admission weight on 11/27/24 as 174 pounds. On 12/1/24 R350's weight was 170 pounds. On 12/10/24 R350's weight was 161.4 pounds. This is a documented severe weight loss of 7.24%. On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R350 has had significant weight loss in the two weeks since her admission. V2 confirmed the facility had not yet notified V22 Physician of R350's weight loss and had not implemented any new interventions. V2 confirmed R350 was administering her own enteral feeding. V2 confirmed R350 admitted to the facility at severe risk for weight loss due to her NPO status, Gastrostomy status, recent history of cancer, recent chemotherapy, recent radiation, severe protein malnutrition, recent hospitalization, recent infection, throat pain, dysphagia, and recent 30 pound weight loss prior to admission. 145416 Page 8 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on interview and record review the facility failed to monitor and obtain a physician order regarding Gastrostomy site monitoring, dressing changes and self administration of medication via Gastrostomy tube. These failures have the potential to affect one of one resident (R350) reviewed for Gastrostomy Tube on the sample list of 26. Findings Include: R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Dysphagia and Gastrostomy Status. R350's Physician Order Sheet (POS) dated December 2024 documents orders for R350 to be NPO (Nothing by Mouth) and for Enteral Feed, four times a day related to Severe Protein-Calorie Malnutrition. On 12/10/24 at 11:32 AM R350 stated she administers her own feedings and medications through her gastrostomy tube. On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R350 administers her own feedings and medications via her gastrostomy tube. V2 confirmed there were no orders for self administration of medication, gastrostomy site maintenance/dressings or monitoring by staff, and no documentation that nursing staff had been monitoring R350's gastrostomy site for abnormal signs or symptoms. 145416 Page 9 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

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 change, date and store oxygen tubing, humidifier bottles, nebulizer masks, and suctioning equipment in a sanitary manner for four of five residents (R4, R14, R34, R350) reviewed for oxygen in the sample list of 26. Residents Affected - Some Findings Include: The facility policy Departmental Respiratory Therapy Prevention of Infection dated reviewed 4/27/24 documents the oxygen administration supplies consist of oxygen tubing and humidifier bottle. This policy documents to change the oxygen tubing cannula every seven days, and to discard the entire administration set up every seven days. 1. R34's Medical Diagnoses list dated December 2024 documents R34 is diagnosed with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. R34's Physician Order Sheet (POS) dated December 2024 documents an order for oxygen per nasal cannula at three liters continuously. R34 also has an order for nebulizer treatments every four hours as needed. The oxygen tubing and humidifier bottle should be changed every Sunday night and stored in a plastic bag. On 12/10/24 11:54 AM R34's portable oxygen tubing was undated and hanging over the oxygen cylinder. R34's nebulizer tubing and mask were sitting on his bedside dresser. On 12/10/24 at 11:55 AM V8 (R34's Daughter) confirmed R34's oxygen tubing is never stored in a bag and neither is nebulizer tubing/mask. On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R34's oxygen tubing and nebulizer mask and tubing should be changed, dated, and stored in a bag when not in use. 2. R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Pneumonia and Sepsis. R350's Physician Order Sheet (POS) dated December 2024 documents an order that R350 may suction herself using an oral plastic suction catheter. Nursing to empty out machine after each use and clean catheter by putting catheter in a cup of water and suck it up until it is clear. On 12/10/24 at 11:34 AM R350 stated she has been doing her own suctioning. Oral suction catheter appears dirty and is not covered. On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R350's suction catheter should be cleaned after each use and stored in a bag. 3. On 12/10/24 at 10:10 AM, R4 was seated in an electric wheelchair in the North Hall wearing and utilizing oxygen from a portable tank mounted on the wheelchair through a nasal cannula tubing. R4's nasal cannula tubing did not have a date on it to indicate when it was last changed. On 12/10/24 at 10:12 AM in R4's room there was a room air concentrator with a humidifier bottle 145416 Page 10 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0695 Level of Harm - Minimal harm or potential for actual harm with a date written on the bottle of 12/1/24 to indicate the extension tubing was last changed on this date. There was a green plastic extension tubing connected to the humidifier bottle and the extension tubing had a piece of white tape with a date written on the tape of 11/17/24. There was a nasal cannula tubing connected to the green extension tubing with a piece of white tape on the cannula tubing of 11/17/24. There was a nasal cannula tubing on the seat of R4's recliner which was likewise dated 11/17/24. Residents Affected - Some On 12/10/24 at 10:12 AM, R4 stated he had requested the nasal cannula and extension tubing be changed once per month instead of the once per week routine the nurses had been conducting. R4's Physician Order Sheet dated 12/11/24 documents a physician order for R4's oxygen tubing, humidifier bottle, and plastic holding bag to be changed weekly on Sunday nights. R4's historical Physician Order Sheets dating back through August 2024 document R4 began continuous oxygen therapy on 8/5/24. R4's Nursing Data Collection assessment dated [DATE] documents R4 had no oxygen use. R4 Nursing Progress Notes dated back through 8/1/24 do not document that any of the nursing staff providing care for R4 had spoken to R4 to inform him of any risks of changing the oxygen tubing monthly instead of weekly, or alternative sanitation procedures to changing the oxygen tubing every week. On 12/12/24 at 10:31 AM V2, Director of Nursing, and V3, [NAME] President of Clinical Operations, both stated they had not heard about R4 requesting to have his oxygen tubing changed monthly instead of weekly, and to their knowledge no one had spoken to R4 to inform R4 about infection control risks, or to explore other possible methods to sanitize R4's oxygen tubing such as soaking the tubing in soap and water, nor had anyone documented any of this. 4. R14's undated Diagnoses list documents R14's diagnoses as Obstructive Sleep Apnea, Nasal Congestion, and Insomnia. R14's POS dated 12/13/24, documents oxygen at 3 liters per nasal cannula as needed for shortness of breath. On 12/10/24 at 10:20 AM, R14's oxygen tubing and water bottle were both dated 11/25/24. R14 stated he uses oxygen every night. 145416 Page 11 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 3. The Physician's Order Sheet dated December 2024 documents (R26) takes the following medication for the diagnosis of Schizoaffective Disorder: Quetiapine Sulfate (Seroquel) tablets 25 mg (milligram) 1 tablet orally every day. The start date for this medication was 7/1/24. On 10/27/24 V21, (Consultant Pharmacist) did a Medication Regimen Review (MRR) for (R26). V21 recommended a dose reduction of the psychotropic medications Trazodone 100 mg (milligram) two tablets at night, Fluoxetine 20 mg 4 tablets 80 mg daily , Seroquel 25 mg QD (every day) and Bupropion ER 100 mg BID (twice a day) due to self reported fall. This information was sent to V22, (Medical Director and R26's physician). V22 did not respond to the request until 11/19/24 on R26's Nursing home visit. V22 documented she did not want to do a drug reduction on any of the medications however no reason was documented. On 12/13/24 at 10:45 AM V2 Director of Nursing stated she does not receive the pharmacist recommendations from V21 because V21 emails them directly to V22. (R26) only had one MRR in her chart. V2 had to obtain the October visit from V22's office. 4. R12's Medical Diagnoses List dated December 2012 documents R12 is diagnosed with Dementia with Behavioral Disturbance, Major Depression, and Anxiety. R12's Physician Order Sheet dated December 2024 documents R12 is prescribed Risperidone (Antipsychotic) 0.25 milligram transdermal patch once daily related to psychosis with hallucinations, dementia with other behavioral disturbances, and anxiety disorder. R12 is also prescribed Sertraline (antidepressant) 50 milligrams daily related to major depressive disorder. R12's Registered Pharmacist Consultant recommendation recorded in R12's Nursing Progress Notes dated 7/27/24, 8/26/24, 10/27/24, and 11/23/24 documents a Pharmacist recommendation to conduct an Abnormal Involuntary Movement Scale (AIMS) assessment to monitor for side effects of long-term Antipsychotic use. There was no documented evidence of a physician response, and no documented evidence of follow-up by the facility to obtain a physician response, in R12's electronic medical record (EMR). As of 12/11/24 at 12:00 PM there was likewise no record of an AIMS assessment conducted for R12 historically. On 12/12/24 at 12:20 PM V3 [NAME] President of Clinical Operations confirmed R12 has not had any AIMS assessments completed prior to 12/11/24 and no psychotropic medication assessments completed at all. V2 also confirmed there was no documentation of any attempted Gradual Dose Reductions in the last year. The facility's Abnormal Involuntary Movement Scale policy dated 9/1/24 documents the AIMS assessment should be performed before starting Neuroleptic drug therapy and then repeated every six months. All information should be documented in the resident's medical record. The facility did not provide a policy regarding following pharmacy recommendations. Based on Interview and record review, the facility failed to follow through with contacting Physicians for unaddressed Pharmacist recommendations, and failed to maintain documented evidence of Physician responses to Pharmacist recommendations. This failure affects four residents (R12, R16, R22, 145416 Page 12 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0756 R26) out of six reviewed for unnecessary medications on the sample list of 26. Level of Harm - Minimal harm or potential for actual harm Findings Include: Residents Affected - Some 1. R16's Registered Pharmacist Consultant recommendation recorded in R16's Nursing Progress Notes dated 11/25/24 documents a Pharmacist recommendation to conduct an abnormal involuntary movement scale (AIMS) assessment to monitor for side effects of long-term Antipsychotic use. There was no documented evidence of a physician response, and no documented evidence of follow-up by the facility to obtain a physician response, in R16's electronic medical record (EMR). As of 12/11/24 at 11:20 AM, there was likewise no record of an AIMS assessment conducted for R16 historically. 2. R22's Registered Pharmacist Consultant Report dated 1/25/24 documents, This resident currently has an order for the Antipsychotic Seroquel 25 mg every night at bedtime. This resident does not have an approved diagnosis to support Antipsychotic use in the elderly with Dementia due to a black box warning of increased risk of mortality. CMS (Centers for Medicare and Medicaid Services) approves Antipsychotic use with the following diagnoses: Schizophrenia, Bipolar Disorder, Huntington's Disease, and Tourette's Syndrome. Please provide an approved diagnosis or justification for use below. The physician response section was blank. R22's EMR did not include any documented evidence of a physician progress note nor any physician response to this Pharmacist recommendation. R22's Medical Diagnoses List dated 12/13/24 nor Physician Order Sheet dated 12/12/24 documented an approved diagnosis for R22's Seroquel, listed as prescribed for Anxiety, Irritability and Anger. On 12/12/24 at 10:35 AM, V2, Director of Nursing, stated the consultant pharmacy review process is supposed to be that the Pharmacist does his reviews and makes a report, then he sends the report to the facility and to the doctor, then the doctor will address the recommendations when she is here. V2 and V3, [NAME] President of Clinical Operations, both stated R22's doctor is here every week. 145416 Page 13 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 4. The Physician's Order Sheet dated December 2024 documents (R26) takes the following medication for the diagnosis of Schizoaffective Disorder. Quetiapine Sulfate (Seroquel) tablets 25 mg (milligram) 1 tablet orally every day. Start date for this medication was 7/1/24. 12/11/24 (R26) chart did not have any AIMS (Abnormal Involuntary Movement Scale) assessment to review. When V2 was asked about (R26's) AIM's assessment at 11:20 AM, V2 stated I have to look and see if I can find it in the chart. V2 brought (R26's) AIM's assessment at 1:00 PM after it was completed. The assessment was dated 12/11/24 at 12:53 PM. V2 stated This is the only one I have. 5. R12's Medical Diagnoses List dated December 2012 documents R12 is diagnosed with Dementia with Behavioral Disturbance, Major Depression, and Anxiety. R12's Physician Order Sheet dated December 2024 documents R12 is prescribed Risperidone (Antipsychotic) 0.25 milligram transdermal patch once daily related to psychosis with hallucinations, dementia with other behavioral disturbances, and anxiety disorder. R12 is also prescribed Sertraline (antidepressant) 50 milligrams daily related to major depressive disorder. On 12/12/24 at 12:20 PM V3 [NAME] President of Clinical Operations confirmed R12 has not had any AIMS assessments completed prior to 12/11/24 and no psychotropic medication assessments completed at all. V2 also confirmed there was no documentation of any attempted Gradual Dose Reductions in the last year. The facility's Psychotropic Medication Use policy dated December 2016 documents Psychotropic Medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review. The need to continue PRN (as needed) orders for psychotropic medications beyond 14 days requires the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. The facility's Abnormal Involuntary Movement Scale policy dated 9/1/24 documents the AIMS assessment should be performed before starting Neuroleptic drug therapy and then repeated every six months. All information should be documented in the resident's medical record. Based on interview and record review, the facility failed to conduct psychotropic medication assessments, failed to maintain accurate documentation in psychotropic medication assessments, failed to conduct abnormal involuntary movement assessments for Antipsychotic medications, failed to obtain a time period duration for PRN (as needed) psychotropic medications, and failed to attempt gradual dose reductions for residents receiving anti-psychotic medications. These failures affect five residents (R12, R16, R22, R26, and R29) out of six reviewed for unnecessary medications on the sample list of 26. Findings Include: 1. R16's Medical Diagnoses list dated 12/13/24 documents R16 experiences medical conditions including Alzheimer's Disease and Dementia. R16's current Physician Order Sheet dated 12/13/24 documents 145416 Page 14 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0758 Level of Harm - Minimal harm or potential for actual harm R16 has physician orders for psychotropic medications including Sertraline (antidepressant) 25 milligrams (mg) daily, and Olanzapine (Antipsychotic) 2.5 mg daily. This same Physician Order Sheet documents R16 experiences additional medical conditions including Hallucinations and Paranoia, and Depression. R16's historical physician order sheets dating back to May of 2023 indicate R16 had been receiving these antidepressant and Antipsychotic medications routinely since that time. Residents Affected - Some On 12/10/24 at 11:05 AM, V17, Certified Nursing Assistant, stated R16 is a risk for elopement and experiences hallucinations and paranoia. R16's Social Service quarterly assessment dated [DATE] documents R16 as taking one psychoactive medication listed as Memantine (N-Methyl-D-aspartate (NMDA) receptor agonist, not psychoactive) for Dementia. The Olanzapine and Sertraline are not listed. R16's four most recent Minimum Data Sets (MDS's) dated 11/22/24, 8/23/24, 5/24/24, and 2/29/24 each document R16 had not had any attempted gradual dose reductions for the Antipsychotic medication Olanzapine, nor were there any documented physician notes to indicate R16 would be clinically contraindicated to attempt a decreased dosage. R16's Assessments area of the electronic medical record (EMR) did not include any required quarterly psychotropic medication assessments. As of 12/11/24 at 11:20 AM, R16's EMR did not include any required abnormal involuntary movement scale (AIMS) assessments. On 12/12/24 at 10:35 AM, V2, Director of Nursing, stated she would look into the facility's former EMR system to check if any of R16's quarterly psychotropic medication assessments or AIMS assessments were located there. At this same time, V3, [NAME] President of Clinical Operations, stated she would likewise look into the facility's former EMR system for any of R16's assessments. As of 12/13/24 at 2:55 PM, neither V2 nor V3 had provided any historical documentation that these assessments had been completed for R16. 2. R29's current Medical Diagnoses Lists dated 12/11/24 document R29 experiences medical conditions including Major Depression. R29's current Physician Order Sheet dated 12/11/24 documents R29 has physician orders for Bupropion (antidepressant) 300 mg extended release daily. R29's EMR, including the Assessments area, did not include any required quarterly psychotropic medication assessments. On 12/11/24 at 1:40 PM, V2, Director of Nursing, stated the facility practice is to place the psychotropic medication assessments and AIMS in the assessments portion of the EMR. V2 further stated the Psychotropic medications assessments are supposed to be completed quarterly, and the AIMS every 6 months. 3. R22's current Medical Diagnoses list dated 12/13/24 documents R22 experiences medical conditions including Dementia, and Irritability and Anger. R22's current Physician Order Sheet dated 12/12/24 documents R22 receives psychotropic medications including Quetiapine (Seroquel, Antipsychotic) 25 mg every 24 hours PRN (as needed) for Anxiety, and Lorazepam (Antianxiety) 0.5 mg every 8 hours PRN for Pain related to Irritability and Anger, give prior to showers and (urinary) catheter changes. R22's historical Physician Order Sheet documents R22 had been prescribed the Antipsychotic medication Quetiapine on a daily basis through December 4, 2024 when the Olanzapine was changed to PRN. The Quetiapine ordered on a PRN basis did not include any stop date nor duration of time for the order. 145416 Page 15 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Physician's Desk Reference 2024 documents Quetiapine is indicated for treatment of Major Depression (in conjunction with other antidepressant medications) and Bipolar Mania-Depressant Disorder. This same Physician's Desk Reference documents Lorazepam is indicated for the treatment of Generalized Anxiety Disorder. On 12/13/24 at 2:55 PM, V2, Director of Nursing, stated the facility nursing staff has had some discussions about making sure there are stop dates and durations for the PRN (as needed) psychotropic medications. V2 stated there are only two full time nurses at the facility so V2 spends a lot of her time working in the direct care aspect in the facility and that makes it difficult to keep up with paperwork. V2 acknowledged the requirement for PRN psychotropic medications to be limited to 14 days or there needs to be a physician evaluation and justification documented to continue use. 145416 Page 16 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to provide the services of a qualified director of food and nutrition services. This failure affects all 42 residents residing in the facility. Residents Affected - Many Findings Include: On 12/10/24 at 9:55 AM, V5, Dietary Manager, was actively supervising and directing the food preparation and wares sanitation processes in the facility kitchen. At 11:50 AM and 12:08 PM, V5 was actively supervising and directing the meal service for lunch. On 12/10/24 at 9:55 AM, V5 stated she was the Dietary Manager. V5 further stated she had a (national company) cooking sanitation certificate. V5 continued to state she did not have a Certified Dietary Manager certificate (CDM, 6 to 9 month clinical nutrition curriculum), nor a Certified Food Protection Professional certificate (CFPP, CDM equivalent). V5 stated the facility utilized the services of a Registered Dietician one day per month on a consultant basis. V5 concluded by stating she did not meet the state requirements for a Director of Food Services nor meet the definition of a Dietetic Service Supervisor by stating she was not a graduate of a national dietetic school program, had no experience in education or employment prior to 1990, and had no qualifying military experience. On 12/10/24 at 10:10 AM, V6, Regional Dietary Representative, stated she, like V5, did not have a Certified Dietary Manager nor a Certified Food Protection Professional certificate. V6 stated she was currently enrolled in the Certified Dietary Manager course and that the ownership company would enroll V5 in the same course after approximately 30 days of V5's employment. V5 confirmed she would be enrolled in the course. On 12/10/24 at 10:10 AM, V5's certificate was on the wall in V5's office and documented V5 held a valid Certified Food Protection Manager certificate (one day training certificate for cooking sanitation). There was palatability, sanitation, lack of alternative menu items, lack of bedtime snacks, and potential contamination issues identified in the facility kitchen and meal services (reference F565 and F812). On 12/10/24 at 10:40 AM, V1, Administrator, stated, the facility used to employ a Certified Dietary Manager, but she was off work on a family medical leave of absence and is not going to return to work, so the facility hired V5 and would work on getting V5 trained and qualified. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24 documents 42 residents reside in the facility. 145416 Page 17 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 failed to maintain kitchen utensils to prevent potential contamination of food, and failed to prevent food contamination by storing utensils in bulk food containers. These failures have the potential to affect all 42 residents residing in the facility. Findings Include: On 12/10/24 at 10:15 AM, there was a metal, long handle measuring scoop located inside the bulk sugar bin. The handle of the scoop was in direct contact with, and partially buried by, the sugar. On 12/10/24 at 10:15 AM, V5, Dietary Manager, and V6, Regional Dietary Representative, both stated the scoop should not be left in the sugar. On 12/10/24 at 10:20 AM, there was a silicone blade spatula in a kitchen utensil drawer with a broken corner approximately three-quarters of an inch diagonal, exposing the granulated and rough internal material of the spatula. This granulated surface potentially would crumble off and contaminate food during preparation, and was not easily cleanable. On 12/10/24 at 10:20 AM, V5 removed the spatula from the drawer to indicate she would throw it away. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24 documents 42 residents reside in the facility. 145416 Page 18 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to trend the facility's monthly infections. This failure has the potential to affect all 42 residents residing in the facility. Residents Affected - Many Findings Include: The facility did not provide an Infection Control Surveillance and Monitoring Policy and no documents were provided for how the facility trends monthly infections to prevent further infection throughout the facility. The facility has no documentation for the identified infections pattern/trend and interventions. On 12/10/24 at 02:10 PM, V2 Director of Nursing (DON) Infection Preventionist (IP) stated V2 has not kept up with a log for infections for residents, and only has October and November 2024, for infection logs and only for residents and not for employees. V2 stated V2 and does not complete any Quality Assurance (QA) on infections that reoccur. V2 also stated there has been no completed trending for the facility's infections. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24, documents there are 42 residents residing in the facility. 145416 Page 19 of 20 145416 12/13/2024 Heartland Nursing & Rehab 410 Northwest Third Casey, IL 62420

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop an infection prevention and control program that includes an antibiotic stewardship program and failed to review this policy annually. This failure has the potential to affect all 42 residents residing in the facility. Residents Affected - Many Findings Include: On 12/11/24 at 10:40 AM, V2 Director of Nursing (DON) stated V2 has not completed an Antibiotic Stewardship Program for the facility. V2 stated there are no antibiotic protocols or a system to monitor antibiotics in place. The facility's Antibiotic Stewardship Program stated the purpose of the policy is to monitor antibiotic use of the residents. This policy has a date of 2/7/23, which has not been updated annually. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24, documents there are 42 residents residing in the facility. 145416 Page 20 of 20