Health inspection·May 12, 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 ensure the right to be free from physical abuse for two (R1, R2) of three residents reviewed for physical abuse from a total sample list of three residents reviewed for abuse. Findings include: The facility provided, Abuse Policy dated 2001 documents that abuse of any kind against residents is strictly prohibited. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. 1.) R1's undated diagnosis sheet documents the following diagnosis sheet includes: Unspecified Dementia with Agitation and Behavioral Disturbance, Anxiety, Alzheimer's Disease, Alcohol Abuse, Psychotic Disturbance, and Mood Disturbance. R1's Minimum Data Set, dated [DATE] documents that R1 is severely cognitively impaired. R1's care plan dated 11/8/24 documents impaired cognitive function and thought processes due to Dementia. R1's 4/22/25 progress note documents an altercation between R1 and another resident (R2) documents that R1 had hold of R2's collar and was punching him in th eback of the head while yelling, He was *expletive* with me. On 5/12/25 at 9:20AM, V3 Licensed Practical Nurse stated that she had gone to the kitchen to obtain juice for another resident and As I walked into the kitchen I saw (R1) holding the back of (R2's) shirt while hitting him on the back of his head and yelling at him. 2.) R2's undated diagnosis sheet documents the following diagnosis sheet includes: Metabolic Encephalopathy, Paranoid Schizophrenia and Cerebral Infarction. R2's Minimum Data Set, dated [DATE] documents R2 as cognitively intact. R2's care plan dated 5/2/23 documents that R2 has the potential to be physically and verbally aggressive. (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 4 Event ID: 146039 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 05/12/2025 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)