Health inspection·September 15, 2023

F 0600 anyone in the facility, staff or otherwise, but that lady is brutal. I just stay away from her. Level of Harm - Minimal harm or potential for actual harm On 9/15/23 at 10:27 am, V12, LPN assessed R3's left arm, confirmed the bruise as noted above, on the top of R3's lower arm. V12, stated to R3 I only assessed your face. I did not realize (R4) pinched your arm. I will have to chart that. R3 stated to V12, LPN, You wouldn't listen to me. You (V12, LPN) told me (R3), (R4) did not do anything to me, when you checked my face. I know there wasn't a mark on it ( R3's face). I told you she (R4) pinched my arm and you (V12, LPN) didn't even look at this bruise on my arm. Residents Affected - Some On 9/15/23 at 11:25 R9, stated R9 witnessed R4, hit R3 in the face and the arm. R9 stated (R4) went berserk on (R3). The Final Report with facsimile date 9/12/23, signed by V1, documents the following: Summary: At 10:15 am on 9/08/23 an allegation that resident (R4) slapped (R3) in the lobby. It was reported to (V1, Administrator/Abuse Prevention Coordinator). Residents (R3 and R4) were separated and assessed. POA (Power of Attorney), MD (Medical Doctor), and Administrator notified. After receiving allegation the following was initiated /completed: Residents were immediately separated and assessed Initial report to IDPH ( Illinois Department of Public Health) MD notified Investigation initiated. The same Final Report documents staff and residents interviews. The interviews include: V3, Social Service Director who stated I was standing in east hall outside room [ROOM NUMBER] when I saw (R4) wheel up to (R3) and (R4) starting to hit (R3). (R4) hit her (R3) in the face and the arm. (R3) started yelling for her (R4) to stop. (V12, Licensed Practical Nurse) separated them (R3 and R4) immediately. The same Final Report documents, Conclusion: After a thorough investigation, the facility determined that the incident did occur, and the residents were immediately separated and assessed. It was most likely due to each resident's diagnosis. We will continue 15 minute visuals on (R4). IDT (Interdisciplinary Team) reviewed the investigation and determined that we will keep them from close proximity to each other and feel this an isolated incident. 2. R1's (POS) dated 9/15/23 documents the following diagnoses: Unspecified Dementia , Unspecified Severity, With Agitation, Major Depressive Disorder, Recurrent, Severe Psychotic Symptoms, Anxiety Disorder, Unspecified, Dementia In Other Diseases Classified Elsewhere, Unspecified Severity, With Other Behavioral Disturbance, and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. R1's MDS dated [DATE] documents the following: R1's BIMS score of six out of a possible 15, indicating severe cognitive impairment, totally dependent of two staff assistance for transfers and totally dependent on staff for mobility on and off unit. R2's POS dated 6/6/23 documents the following diagnoses: Nonpsychotic Mental Disorder, Unspecified, Other Disorders of Psychological Development, and Unspecified Lack of Expected Normal Physiological Development In Childhood. The MDS dated [DATE] documents R2's BIMS score of eight out of a possible 15 indicating severe cognitive impairment. The same MDS documents R2 requires supervision and set-up for locomotion on the unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 2 of 5 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R2's Care Plan documents a Focus area of concern initiated 8/7/23 as follows: Behavior: Physical Aggression. The resident is/has potential to be physically aggressive r/t (related to) poor impulse control. R1's Health Status Note dated 9/3/23 at 8:35 am signed by V14, LPN/ Agency documents the following: Note Text: (R1) was yelling out when a male (R2) resident came up beside her and (told) (R1) to shut up. Male resident (R2) then grabbed (R1) by the hair. Small abrasion noted to (R1's) left shoulder. Area cleaned and left OTA (open to air). Resident's (R1 and R2) immediately separated. Administrator (V1, Administrator/Abuse Prevention Coordinator) notified and investigation is underway. MD (unidentified physician) and POA (Power of Attorney) notified. On 9/14/23 at 11:55 am R1 was seated in a reclined geriatric chair in the serenity room waiting for lunch. R1 stated There is a guy (R2) that lives here. He (R2) scratched my neck and pulled my hair. I am not afraid of him either, unless he gets his wheel chair up close to mine. I start screaming for staff. I don't want him near me. Staff get his wheel chair as far as they can away from me. I haven't seen him mistreat anybody else. I hope I never do. I would be screaming for staff then too. I can' t walk, so I can't help myself or anybody else. On 9/15/23 at 12:00 pm V2, Director of Nursing stated the facility does not complete an abuse risk assessment. All residents in the facility are considered vulnerable. At risk for abuse. On 9/15/23 at 1:20 pm V14, Agency LPN stated I was in the hall just outside the dining room, with my med cart. (R1) was seated in her reclined (geriatric) chair up against the adjacent wall. (R2) was propelling his wheel chair down the middle of the same hall. (R1) was yelling she was ready to eat. (R1) yells, has dementia, and does not mean anything by it. It is how she (R1) communicates. (R2) rolled up next to (R1), told her to shut up and grabbed her hair. (R1) got pretty upset and started yelling he (R2) has her hair. I (V14) witness the whole thing. A Dietary Aide (unidentified) heard the commotion and came to help separate them (R1 and R2). I was trying to move (R2's) wheelchair. (R2) put his hands down and wouldn't let me or staff (unidentified) move his wheelchair. (R1) was taken to her room. I stayed with (R2). He acknowledged he pulled her hair. (R2) said he was going to report (R1) for yelling. I explained to (R2), even when others get loud, he (R2) cannot put his hands on them. (R2) can get easily agitated at times. At other times he is laughing and joking around. He is moody. When I went to check on (R1), she had an abrasion on her neck. It was close to wear (R2) grabbed her hair. It was not open, but red. I cleaned the area. It was not bleeding, so I did not put anything on it. The Final Report facsimile dated 9/06/23, investigation to the State Agency, is signed by V1 and documents the following: Summary: At 8:35 am on 9/03/23 an allegation that resident, (R2) pulled another residents hair, (R1) (sic) was reported to (V1). Residents (R1 and R2) were immediately separated and assessed. POA, MD and Administrator notified. After receiving allegation the following was initiated /completed: Residents were immediately separated and assessed. Initial report to IDPH ( Illinois Department of Public Health) MD notified. Investigation initiated. The same Final Report documents, Conclusion: After a thorough investigation, the facility determined that the incident did occur, and the residents were immediately separated and assessed. It was most likely due to each resident's diagnosis. (R2) will continue on 15 minute visuals (R1) is eating in the alternate meal room called the serenity room due to calmer atmosphere. This incident occurred secondary to both residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 3 of 5 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0600 diagnosis. Families were notified of the incident. IDT (Interdisciplinary Team) reviewed the investigation and determined that we will keep them from close proximity to each other and feel this an isolated incident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 4 of 5 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 146039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastview Healthcare & Senior Living 100 Eastview Place Sullivan, IL 61951 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview the facility failed to maintain complete medical records by failing to document resident physically abusive behaviors toward another resident for one of four residents (R2) reviewed for behavioral tracking on the sample list of nine. Findings include: R2's Care Plan documents a Focus area of concern initiated 8/7/23 as follows: Behavior: Physical Aggression. The resident is/has potential to be physically aggressive r/t (related to) poor impulse control. R2's Behavior Monitoring and Intervention Report documents R2's behaviors and interventions are tracked 9/1/23-9/15/23. There are no behaviors documented 9/1/23 - 9/13/23 on any shift. This includes the following witnessed physical abuse documented below. On 9/15/23 at 1:20 pm V14, Agency LPN stated regarding 9/3/23 allegation I was in the hall just outside the dining room, with my med cart. (R1) was seated in her reclined (geriatric) chair up against the adjacent wall. (R2) was propelling his wheel chair down the middle of the same hall. (R1) was yelling she was ready to eat. (R1) yells, has dementia, and does not mean anything by it. It is how she (R1)communicates. (R2) rolled up next to (R1), told her to shut up and grabbed her hair. (R1) got pretty upset and started yelling he (R2) has her hair. I (V14) witness the whole thing. A Dietary Aide (unidentified) heard the commotion and came to help separate them (R1 and R2). I was trying to move (R2's) wheelchair. (R2) put his hands down and wouldn't let me or staff (unidentified) move his wheelchair. (R1) was taken to her room. I stayed with (R2). He acknowledged he pulled her hair. (R2) said he was going to report (R1) for yelling. I explained to (R2), even when others get loud, he (R2) cannot put his hands on them. (R2) can get easily agitated at times. At other times he is laughing and joking around. He is moody. When I went to check on (R1), she had an abrasion on her neck. It was close to wear (R2) grabbed her hair. It was not open, but red. I cleaned the area. It was not bleeding, so I did not put anything on it. A facility document titled (the facility name) and Final Report dated 9/06/23 documents the following: At 8:35 am on 9/03/23 an allegation that resident, (R2) pulled another residents hair, (R1) was reported to (V1, Administrator/Abuse Prevention Coordinator). The same Final Report documents, Conclusion: After a thorough investigation, the facility determined that the incident did occur. On 9/15/23 at 12:55 pm V2, Director of Nursing confirmed R2's September 2023, behavioral tracking record is incomplete. V2 stated The behavior tracking is incomplete. Staff have not been documenting in the resident record like they should. They should be documenting every shift. If the resident had no behaviors, they are to check that column to indicate the resident did not have any. Either way they are to document. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146039 If continuation sheet Page 5 of 5