Eastview Healthcare & Senior Living

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

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on interview and record review the facility failed to protect residents rights to be free from resident to resident physical abuse. This failure affects four of four residents (Resident R3, Resident R4, Resident R5, Resident R6) reviewed for abuse in the sample list of 13. Findings Include:Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 documents: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.The facility reported incident final investigation dated July 25th, 2025, documents on July 18th, 2025, at 4:50pm was reported by Resident R4 that Resident R3 made contact with Resident R4's right forearm. The same document documents: After a thorough investigation the facility has determined that the incident did occur.The facility reported incident final investigation dated August 13th, 2025, documents on August 7th, 2025, at 11:30pm it was reported to Nurse that Resident R3 went into Resident R4's room on the evening of the 6th. Resident R3 entered Resident R4's room through their adjoining bathrooms. Resident R3 was going through Resident R4's' things and Resident R4 yelled to make Resident R3 stop. Resident R4 then reported on the morning of the 7th that Resident R3 made contact with Resident R4's hand.The facility reported incident final investigation dated July 29th, 2025, documents on July 26th, 2025, at 3:00pm it was reported to the Nurse that Resident R3 made contact with Resident R6's right wrist. The CNA reported to Nurse that Resident R3 walked up to other residents playing cards. The other residents playing cards started yelling at Resident R3 to get away. Resident R3 then made contact with Resident R6's right wrist.The facility reported incident final investigation dated August 12th, 2025, documents on August 6th, 2025, at 10:00am staff witnessed a resident-to-resident incident. As V12 License Practical Nurse (LPN), was doing a one-to-one with Resident R3 when Resident R3 made contact with the top of Resident R6's hand. After a thorough investigation it was determined that Resident R3 wanted

the book that Resident R6 had and Resident R6 stopped her from taking it causing Resident R3 to react.The facility reported incident final investigation dated July 29th, 2025, documents on July 26th, 2025, at 07:30am it was reported that Resident R3 made contact with Resident R5. The facility has determined that the incident did occur.On 8/25/25 at 1:20pm, V12 LPN, stated that Resident R3 did make contact with Resident R6 on 8/6/25 while V12 was providing one-to-one cares to Resident R3.On 8/26/25 at 12:20pm, V1 Administrator confirmed that Resident R3 has been investigated and had been involved in multiple incidents involving Resident R4, Resident R5, and Resident R6 on various dates in which Resident R3 has abused the other residents.On 8/26/25 at 1:04pm, V3 LPN confirmed that Resident R3 has been investigated and known to make contact with Resident R4, Resident R5, and Resident R6 on various dates.

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

Event ID:

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

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 0689 Level of Harm - Actual harm Residents Affected - Few

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

Investigation dated July 9th, 2025, documents on July 5th, 2025, Resident R2 was pushing on bed during care and rolled onto her right hand. Staff stated that as he (CNA) rolled Resident R2 over to change her, Resident R2 put her right hand down on the mattress and Resident R2 rolled on top of Resident R2's right hand. Resident R2 was transferred to the ER for evaluation and the x-ray revealed a minimally displaced fracture involving the fifth proximal phalanx. Resident R2 returned to the facility with a soft cast in place.Review of Resident R2's hospital records dated 7/5/25 at 11:22 PM documents This is

an [AGE] year-old female NHR (Nursing Home Resident) with a history of dementia who is nonverbal at baseline brought to the ED (Emergency Department) by EMS after her right hand became caught underneath her in bed with audible pop and subsequent swelling and bruising noted to the right little finger and hand. IMPRESSION: Obliquely oriented minimally displaced fracture involving the fifth proximal phalanx.Resident R2's undated care plan documents diagnosis of: Unspecified Dementia; Type 2 Diabetes; Hypertensive Heart Disease; Generalized Anxiety Disorder; Major Depressive Disorder; and Cognitive Communication Deficit. The same document has an admission date 09/09/2019.Resident R2's MDS (Minimum Data Set) dated 8/8/25 documents Resident R2 as severely cognitively impaired. The same MDS documents Resident R2 as dependent on staff for all cares.On 8/25/25 at 11:49am, call placed to V13, Resident R2's Family, unanswered, Voicemail left.On 8/25/25 at 11:56am, V8 LPN stated V9 CNA was providing cares for Resident R2 by pushing Resident R2 over onto Resident R2's side and Resident R2 was pushing back. When Resident R2 relaxed Resident R2's body moved forward on to Resident R2's right hand and V9 heard an audible pop. V9 noted the right 5th digit was pointed in the wrong direction so V9 came and got the nurse.On 8/25/25 at 12:50pm, V9 CNA stated Resident R2 was being combative with cares after having a bowel movement. V9 stated V9 left the room to allow Resident R2 to calm down and returned a few minutes later. V9 stated that Resident R2 grabbed the side of the bed and was pushing against being turned but needed cleaned up. V9 was trying to clean Resident R2 up when Resident R2 relaxed Resident R2's body moved forward onto Resident R2 right hand. V9 stated he heard a pop and looked at Resident R2 noting Resident R2's pinky appeared dislocated and V9 got the nurse. V9 stated there was another agency CNA in the building and V9 could have asked her for help but did not want to scare her off on her first time working in the facility by asking her to help with a difficult resident so he chose to proceed on his own.

Event ID:

Facility ID:

If continuation sheet

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

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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on interview and record review, the facility failed to designate and maintain a full-time Director of Nursing (DON). This deficiency has the potential to affect all 50 residents in the facility by compromising the oversight and coordination of nursing services. Findings Include:Review of staffing schedules from 7/25/25 thru 8/25/25 confirmed that no licensed nurse was designated as Director of Nursing (DON) and no interim appointment was made.On 8/25/25 at 1:20pm, V12 Licensed Practical Nurse (LPN), confirmed there is no DON at this time and stated we haven't had a DON for a few weeks now.On 8/26/25 at 12:20pm, V1 Administrator stated, We've been trying to hire a Director of Nursing (DON), but we haven't been able to find anyone. We do have an interim DON starting soon.On 8/27/25 at 1:35pm, V2 Corporate Nurse stated

the facility does not have a DON at this time, but we do have an interim DON starting soon.The Facility Census dated 8/21/25 documents there are 50 residents currently in the facility.

Event ID:

Facility ID:

If continuation sheet

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

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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Based upon interview and record review, the facility failed to employee a certified dietary manager for food services. This failure has the potential to affect all 50 residents currently residing in facility.Findings include:Facility Census dated 8/21/25 documents there are 50 residents currently residing in the facility.Dietary Services food certifications reviewed on 8/21/25. Certifications include food safety for all dietary staff. Certifications do not include Dietary Manager Certification.On 8/21/25 at 1:00pm, V4 Dietary Manager (DM) stated she is not certified for dietary management.On 8/27/25 at 11:57am, V5 Registered Dietician (RD), stated she consults for facility and primarily approves menus and completes dietary recommendations for residents. V5 stated V5 is at facility on average approximately 16 hours a month. V5 confirms the facility has a newer dietary manager that is not certified at this time. On 8/27/25 at 12:50pm, V1 Administrator and V2 Regional Nurse confirmed that V4 DM is not a certified dietary manager and that V4 is not currently enrolled in any certification courses.

Event ID:

Facility ID:

If continuation sheet

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

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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

available included turkey burger and mashed potatoes. At 12:20pm, V4 was asked to perform temperature checks on hot food. No thermometer was available. This surveyor provided thermometer. Turkey burgers that were being held in steam table had internal temp of 117 degrees F, and mashed potatoes temped at 177 degrees F. 8/25/25 at 12:30pm, Resident R11 stated the chips are stale, there never seems to be enough to eat, and they don't offer seconds anymore.8/25/25 at 12:35pm, V6 Resident R1's spouse stated the chips are stale and you can't see the meat inside the bun. 8/26/25 at 1:35pm, Resident R12 stated that often the meals provided contain meat that seems overcooked. Resident R12 stated meat is rubbery and tough. Resident R12 also stated that potato items such as tater tots and French fries are very undercooked.On 8/27/25 at 1:30pm, V4 Dietary Manager (DM) stated she has not been provided any education since the first day of employment and neither has the dietary aides. V4 stated that currently the left side of the oven doesn't get to temp, the flat top griddle is slow to warm and the steam table that is utilized to hold food during meal service does not regulate temperatures. V4 confirmed staff does not always check food temperatures and is unclear if they know what unsafe food temps are.Facility policy titled Food Preparation and Service dated November 2022 documents proper hot and cold temperatures are maintained during food distribution and service and any food held in

the danger zone of 41 degrees F to 135 degrees F must be discarded after 4 hours. Any food held in steam table for service must be temped often.Facility policy titled Monitoring Food Temperatures dated 2020 documents all hot foods should temp no lower than 120 degrees F at point of service for palatability.

Event ID:

Facility ID:

If continuation sheet