Heartland Nursing & Rehab

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

again when Resident R2 kicked Resident R3. Resident R4 then stated Resident R2 kicked Resident R3 again and he got up and said stop kicking her and that was when staff came and took Resident R2 out of the dining room. Resident R4 continued to state that there was not a lot of staff supervision in the dining room at the time because staff were bringing residents from their rooms to

the dining room and then returned back to pick up other residents to bring to the dining room. Resident R4 then stated Resident R2 was back in the dining room the following day (8/8/25) and the staff supervision had not changed. Resident R4 concluded by stating he had witnessed Resident R2 walk up behind a resident (Resident R6) about two and a half or three months ago and smack Resident R6 in the back of the head when Resident R6 wasn't doing anything, but there was no staff around at that time. Resident R4's Minimum Data Set, dated [DATE REDACTED] documents Resident R4 received a score of 15 out of a possible 15 during a Brief Interview for Mental Status, indicating Resident R4 is cognitively intact. On 8/20/25 at 2 PM, V2, Director of Nursing, stated she had not seen the actual event but did watch the video from the dining room and did see Resident R2 standing by the window, then walk over to Resident R3 who was several tables away and kick Resident R3. V2 stated she had known Resident R2 and her family for about 40 years and thought Resident R3 had some resemblance to Resident R2's mother who Resident R2 used to act violently towards. V2 further stated Resident R2 was on the Autism scale and often acted like whatever she wants, she wants right now, like a small child. V2 stated she had not heard any kind of report about Resident R2 smacking Resident R6 in the head. On 8/20/25 at 2:15 PM, V3, Minimum Data Set Coordinator, stated she had watched the kicking incident between Resident R2 and Resident R3 on the camera. V3 stated

she had known Resident R2 and her family for a long time. V3 stated Resident R2 used to be violent with her mother and had talked with Resident R2's sister (V10) who had questioned if Resident R2 was having some regression to an earlier age. V3 stated Resident R2's behavior had been getting worse not just with the Autism but also with her Dementia. V2 stated

she had not heard anything about any event between Resident R2 and Resident R6. On 8/20/25 at 2:20 PM, V1, Administrator, stated he had reported the incident initially on 8/7/25 and finally on 8/13/25. V1 stated he had watched the kicking incident between Resident R2 and Resident R3 on video and saw Resident R2 walk up to Resident R3 and kick Resident R3. V1 made a kicking motion with his leg as he made this statement. V1 confirmed Resident R4 was alert and oriented and accurate in his statements. V1 stated he had not heard any reports about Resident R2 smacking Resident R6 on the back of the head. On 8/20/25 at 2:20 PM, there was a purple quart-sized drinking mug on the windowsill of the business office with a broken raised edge in the drinking rim. There was a note affixed to the drinking mug which documented Resident R2 had thrown the cup at a staff member (V4, Certified Nursing Assistant) and broke the mug.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Heartland Nursing & Rehab

410 Northwest Third Casey, IL 62420

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

side of the bed and was out of Resident R3's reach. V3 stated Resident R3 could hold the call light in her hand but would not realize what the device was to be used for, and Resident R3 might accidentally push the button. V3 noted and confirmed there was not any non-skid strip on the floor in front of Resident R3's recliner and stated that Resident R3 had not attempted to stand up in months. On 8/22/25 at 11::25 AM, V2, Director of Nursing, stated the skin tear observed on Resident R3's right lower leg was not from a resident-to-resident incident from 8/7/25 but rather was from when Resident R3 fell out of bed on 8/20/25. V2 stated Resident R3 often has wounds on both legs due to bumping into things when mobile in her wheelchair because she isn't aware of her own safety needs. V2 confirmed Resident R3's fall on 8/20/25 was unwitnessed. V2 further stated she had personally gone around the facility to check for

the non-skid strips for each resident who used them because there had been several residents who changed rooms and Resident R3 was one of those residents. V2 nodded in confirmation that Resident R3 was supposed to be wearing the protective leggings and protective sleeves.

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