Health inspection·August 25, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review, the facility failed to effectively supervise a cognitively and functionally impaired resident during a meal service. This failure resulted in R1 spilling hot coffee onto R1's leg and sustaining a second degree burn to the thigh requiring extended medical treatment. R1 is one of three residents reviewed for supervision in the sample of three. Findings include: R1's Medical Diagnosis sheet (8/25/2023) documents diagnoses including Cerebral Infarction (stroke), Speech and Language Deficit, Epilepsy (seizure disorder), Dysphagia (swallowing difficulty), Slurred Speech, Cognitive Communication Deficit, and Parkinson's Disease (neurodegenerative disorder). R1's Resident Assessment (8/8/2023) documents R1 has severely impaired cognition and is totally dependent on staff, including physical assistance, for eating and drinking. R1's Care Plan (8/2023) documents R1 has impaired cognitive function/dementia or impaired thought processes related to Cerebrovascular Accident (stroke) and Parkinson's Disease (neurodegenerative disorder). The same record documents R1 has a range of motion self-care performance deficit and wrist and elbow deficits. On 8/23/2023 at 10:25AM, R1 was seated in a reclining chair and had bilateral hand contractures. V3 (R1's family) was present and reported R1 is dependent on staff for drinking and has not been able to drink from a glass independently due to R1's hand contractures. R1 reported spilling coffee on R1's self on 8/14/2023. The facility Serious Incident Report (8/14/2023) documents R1 received a meal tray and beverage during supper on 8/14/2023, and when staff approached R1, R1's drink (coffee) was in a cup with a lid (sippy cup) and located upright on R1's lap. The report documents staff did not initially observe any injury from R1 spilling a drink onto R1's lap, but staff noted a reddened area with blister on R1's left upper thigh later in the evening on 8/14/2023. R1's nursing Progress Notes document on 8/14/2023 Resident (R1) noted to have a second degree burn to left upper thigh and on 8/16/2023 Large fluid filled blister noted to left upper thigh burn area. R1's medical Progress Note (8/18/2023) documents R1 has a left anterior second-degree thigh burn and blister. (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: 146030 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 146030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartland Senior Living 101 Trowbridge Road Neoga, IL 62447 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)