Inspection·January 8, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 provide freedom from inappropriate physical restraint use for 1 of 1 residents (R5) reviewed for restraint in the sample of 8. Residents Affected - Few Findings include: R5's Face Sheet, undated, documents that R5 was admitted on [DATE] and has diagnoses of anxiety and Dementia. R5's Minimum Data Set, dated [DATE], documents that R5 is severely cognitively impaired and requires assist with ambulation and mobility. The facility supplied letter, dated 7/3/23, documents, On 6/29/23 at approximately 1:30 PM, (V2, Director of Nurses) reported to administrator that (R5) was restrained inappropriately in his wheelchair. It continues, It was noted that (R5) has been sitting his wheelchair at the nurse's station so that the staff could monitor him closely due to attempting to get up frequently without assist and was at risk for falling. It continues, (V5, Licensed Practical Nurse) then stated that she placed a gait belt around his upper abdomen loosely and his wheelchair to keep resident from standing up without assist. It continues, The facility was able to substantiated the alleged inappropriate restraint involving (R5). On 1/4/23 at 12:30 PM, V1, Administrator, stated that V5 did have a gait belt wrapped around R5 and it was looped around the wheelchair. V1 stated that V5 was educated and disciplined. V1 stated that restraining someone is not allowed. There were no other residents in the building with restraints. On 1/4/23 at 1:00 PM, V5, Licensed Practical Nurse, stated, (R5) was sitting in his wheelchair and he kept trying to get up. I had to get my evening medications passed so I was taking him down the hall with me and my cart. He had a gait belt around him already. I took the gait belt and looped it around the wheelchair handle. It was loose on him. It wasn't tight. I was just trying to keep him seated. He had it on for maybe 5 minutes. I know it was stupid. The Physical Restraint / Enabler Policy, undated, documents, To allow residents to be free of physical restraints which are not required to treat the resident's medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. 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: 145851 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 145851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastside Health and Rehabilitation Center 1400 East Washington Street Pittsfield, IL 62363 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)