Health inspection·January 28, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse for one (R1) resident by another resident (R2) of three residents reviewed for abuse in a sample list of three residents. Findings include: The facility's Incident Report Form dated 1/19/25, documents R2 struck R1 on the cheek while in the sunroom. R1's Minimum Date Set (MDS) dated [DATE], documents R1 is cognitively intact. R1's Care Plan dated 1/19/25, documents R1 was an alleged recipient of an alleged abuse by another resident in the facility. This Care Plan also documents R1 is at risk for inappropriate altercations with other residents that are not able to respect boundaries and may encourage negative attention in the community. On 1/28/25 at 12:30 PM, R1 stated R2 backhanded R1 in R1's mouth. R1 stated R1 does not know why. R1 stated R1 might have bumped into R2 with his wheelchair but is not sure. R1 stated R1 does not try to hurt anybody. R1 stated R1 did not have any injuries. R2's undated diagnoses list documents unspecified Dementia, unspecified severity with Agitation and Cognitive Communication Deficit. R2's MDS dated [DATE], documents R2 is not cognitively intact. R2's Care Plan dated 1/16/25, documents R2 is verbally abusive to roommates and their families when R2 receives a new roommate and is verbally abusive to new residents that sit at R2's table in the dining room. On 1/28/25 at 9:54 AM, R2 stated R1 was trying to stop R2 from going anywhere and tried to get in front of R2. R2 stated R1 did not say anything to R2. R2 stated R2 attempted to slap R1 but doesn't know if he got the job done. On 1/28/25 at 11:07 AM, V4 Licenced Practical Nurse (LPN) stated R4 was standing at the medication cart and heard R1 yell he hit me so she moved R1 away from R2. V4 stated the other nurse (V3/LPN) went to R2 and R2 stated (V4 heard this) he has it coming. V4 stated R2 likes to be by himself, wants (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 01/28/2025 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)