Inspection·August 27, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete again when R2 kicked R3. R4 then stated R2 kicked R3 again and he got up and said stop kicking her and that was when staff came and took R2 out of the dining room. R4 continued to state that there was not a lot of staff supervision in the dining room at the time because staff were bringing residents from their rooms to the dining room and then returned back to pick up other residents to bring to the dining room. R4 then stated R2 was back in the dining room the following day (8/8/25) and the staff supervision had not changed. R4 concluded by stating he had witnessed R2 walk up behind a resident (R6) about two and a half or three months ago and smack R6 in the back of the head when R6 wasn't doing anything, but there was no staff around at that time. R4's Minimum Data Set, dated [DATE] documents R4 received a score of 15 out of a possible 15 during a Brief Interview for Mental Status, indicating R4 is cognitively intact. On 8/20/25 at 2 PM, V2, Director of Nursing, stated she had not seen the actual event but did watch the video from the dining room and did see R2 standing by the window, then walk over to R3 who was several tables away and kick R3. V2 stated she had known R2 and her family for about 40 years and thought R3 had some resemblance to R2's mother who R2 used to act violently towards. V2 further stated R2 was on the Autism scale and often acted like whatever she wants, she wants right now, like a small child. V2 stated she had not heard any kind of report about R2 smacking R6 in the head. On 8/20/25 at 2:15 PM, V3, Minimum Data Set Coordinator, stated she had watched the kicking incident between R2 and R3 on the camera. V3 stated she had known R2 and her family for a long time. V3 stated R2 used to be violent with her mother and had talked with R2's sister (V10) who had questioned if R2 was having some regression to an earlier age. V3 stated R2's behavior had been getting worse not just with the Autism but also with her Dementia. V2 stated she had not heard anything about any event between R2 and R6. On 8/20/25 at 2:20 PM, V1, Administrator, stated he had reported the incident initially on 8/7/25 and finally on 8/13/25. V1 stated he had watched the kicking incident between R2 and R3 on video and saw R2 walk up to R3 and kick R3. V1 made a kicking motion with his leg as he made this statement. V1 confirmed R4 was alert and oriented and accurate in his statements. V1 stated he had not heard any reports about R2 smacking R6 on the back of the head. On 8/20/25 at 2:20 PM, there was a purple quart-sized drinking mug on the windowsill of the business office with a broken raised edge in the drinking rim. There was a note affixed to the drinking mug which documented R2 had thrown the cup at a staff member (V4, Certified Nursing Assistant) and broke the mug. Event ID: Facility ID: 145416 If continuation sheet Page 2 of 4 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 08/27/2025 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 implement fall and accident prevention interventions according to a resident's care plan and physician orders. This failure affects one resident (R3) out of three reviewed for falls on the sample list of eight. Findings include: R3's Face Sheet dated 8/20/25 documents R3 had a legally established power of attorney. R3's Medical Diagnoses list of the same date includes Dementia, Major Depression, Hypertension, and Osteoarthritis of the Right Knee. R3's Census Detail of the same date documents R3 was admitted to the facility 1/13/22. R3's Physician order Sheet dated 8/22/25 documents R3 has physician orders to include non-skid strips on the floor in front of her recliner initiated 7/1/24, and to wear (cloth protective leggings) initiated 5/31/25. R3's Minimum Data Set, dated [DATE] documents R3 requires staff supervision and assistance for all aspects of daily living including hygiene, dressing, bathing, transfers, and transitioning between sitting and lying positions, and transitioning from sitting to standing. R3's Care Plan for fall prevention dated from 7/14/24 documents R3 is a fall risk. R3's fall prevention interventions include the area around R3's recliner needs to be kept free of hazards, and (non-slip material) is to be kept in R3's wheelchair seat, both dated as initiated 7/14/24. This care plan includes additional fall prevention interventions including for staff to keep R3's nurse call device in reach, initiated 10/11/24. This same care plan documents R3 is unaware of her safety needs, has Dementia, and often bumps into furniture which results in impaired skin integrity. The staff intervention for this accident problem area was for staff to place (protective leggings) on both of R3's legs for added protection, dated as initiated 5/31/25. There was a second intervention for R3 to have these protective cloth leggings and sleeves on both legs and both arms, dated as initiated 6/2/25. R3's Nursing Progress Note dated 8/20/25 at 8:15 PM documents R3 experienced an unwitnessed fall from bed with multiple bruises, abrasions, and was complaining of right knee pain. A second note on this same date at 8:55 PM documents R3 had swelling of the right knee and above the right eyebrow and was sent to the emergency department for an evaluation. R3's Nursing Progress Notes dated 8/21/25 at 1:09 AM documents facility nursing staff received an update from the emergency department personnel of R3's evaluation results indicating R3 had no fractures, no internal head bleeding, and had surgical glue applied to her right forehead and right knee. A second note on this date at 4:04 AM documented R3's return to the facility and R3 was able to tell nursing staff she had been to the hospital and saw her son but he had to leave because it was getting late, was responding appropriately to questions, told the nurse she had fallen and what injuries she experienced, the nurse noted additional bruising on R3's right elbow in addition to documenting the surgical glue on R3's right eyebrow and right knee. This note further documents R3 stated she was ready to go to bed and might sleep in. On 8/22/25 at 10:20 AM, R3 was seated in her recliner in her own room approximately four feet away from her bed. R3's nurse call light device was hanging from the light fixture on the wall above the left side of R3's bed approximately seven feet away from R3 and on the opposite side of the bed from where R3 was seated. There were no non-skid strips on the floor in front of R3's recliner. R3 was not wearing the protective leggings, nor the cloth protective arm sleeves. On 8/22/25 at 10:35 AM, V3, Minimum Data Set Coordinator, stated she was the nurse on duty and was taking care of R3. V3 stated R3 should have the non-skid material in her wheelchair seat and she personally tries to go around and make sure every resident has the material in their wheelchair seat because the residents will slip out of the wheelchair. V3 observed R3's wheelchair and confirmed the non-slip material was not in the seat. Likewise, V3 affirmed R3's nurse call device was hanging on the light fixture on the opposite (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145416 If continuation sheet Page 3 of 4 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 08/27/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete side of the bed and was out of R3's reach. V3 stated R3 could hold the call light in her hand but would not realize what the device was to be used for, and R3 might accidentally push the button. V3 noted and confirmed there was not any non-skid strip on the floor in front of R3's recliner and stated that R3 had not attempted to stand up in months. On 8/22/25 at 11::25 AM, V2, Director of Nursing, stated the skin tear observed on R3's right lower leg was not from a resident-to-resident incident from 8/7/25 but rather was from when R3 fell out of bed on 8/20/25. V2 stated R3 often has wounds on both legs due to bumping into things when mobile in her wheelchair because she isn't aware of her own safety needs. V2 confirmed R3's fall on 8/20/25 was unwitnessed. V2 further stated she had personally gone around the facility to check for the non-skid strips for each resident who used them because there had been several residents who changed rooms and R3 was one of those residents. V2 nodded in confirmation that R3 was supposed to be wearing the protective leggings and protective sleeves. Event ID: Facility ID: 145416 If continuation sheet Page 4 of 4