Inspection·June 7, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to provide a clean, comfortable, homelike environment for 3 of 7 residents (R4, R5, R6) reviewed for physical environment in the sample of 7. Findings include: 1. On 6/6/24 at 9:40 AM, R4 was lying in bed in her room. She stated that she usually has to ask staff to change her sheets once a week. She stated that her main complaint about the Facility is clutter in the hallway and said, It's like an obstacle course out there. R4's Minimum Data Set (MDS), dated [DATE], documented that R4 was cognitively intact. On 6/6/24 at 10:35 AM, V3, Certified Nursing Assistant (CNA), stated some of the units could use more attention from Housekeeping. On 6/6/24 at 12:17 PM, the shower in the B Hall bathroom smelled strongly of urine. 2. On 6/6/24 at 12:30 PM, R5 was sitting in his wheelchair in his room. He stated, (Odors) are horrible about 90% of the time. It smells like a bathroom. They have put out deodorizers, but they are not very good. He stated CNA's change his bed sheets about once a month. R5's MDS, dated [DATE], documented that R5 was cognitively intact. On 6/6/24 at 1:05 PM, the E Hall bathroom smelled of bowel movement, and there was a smear of stool on the floor next to the shower drain. There was a yellow bin that was full of soiled linens and was not covered, leaving the contents open to air. On 6/6/24 at 3:35 PM, V19, R7's Family, stated that she visits every day, and the Facility does have odors. She also stated that her daughter would say it smells all the time, but she thinks it smells of urine or bowel movement about 60-70% of the time. On 6/7/24 at 8:50 AM, the F Hall Unit was lined with two mechanical lift machines, a specialty chair, a sit to stand device, a linen cart and a cart with a cooler. On 6/7/24 at 8:59 AM, the G Hall North Unit was lined with two sit to stand devices, a specialty chair, a linen cart, a blood pressure machine, a bedside table, and a Wet Floor sign. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145508 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 145508 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Health Care Center 1450 26th Street Highland, IL 62249 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)