Health inspection·January 30, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's personal funds were refunded upon discharge. This applies to 1 of 4 residents (R1) reviewed for personal funds in the sample of 4. Residents Affected - Few The findings include: R1's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE] and discharged on 12/12/23. Medicaid is listed as the payor source. Her diagnoses include Wernicke's Encephalopathy, depression, alcohol dependence, and COPD. On 1/30/24 at 10:33 AM, V7 (R1's family) said R1 was discharged from the facility on 12/12/23. She called the facility to follow up on R1's social security check, it was being directly deposited to the facility when she was there. V3 (Business Office) told her they received R1's Social Security check for January 2024, R1 has not received a refund for her January personal funds. V7 said the facility did not report to Social Security she was discharged and that's why her personal funds were deposited with the facility's management account. On 1/30/24 at 11:00 AM, V3 (Business Office) said she got a call from V7 regarding R1's Social Security check. V7 said, This was my first time experiencing a resident being discharged to the community with her personal funds being deposited with the facility. I did not notify Social Security of (R1's) discharge from the facility. (R1's) January check was deposited to the facility, we switched management systems and the previous company would report to Social Security when a resident was discharged . Someone must report to Social Security when a resident is discharged so the resident can receive their funds. (V7) was a little upset and I told her we were working on it. V3 said she requested a refund from the management company yesterday. R1's Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form dated 8/9/23 shows a signed signature by R1 and elected direct deposit of her social security funds with the facility's management service. R1's Resident Statement Fund provided on 1/29/24 shows a deposit on 1/10/24 (29 days after discharge) from Social Security for $1215.00. On 1/10/24 an auto withdrawal for care cost of $1185.00 (R1 was discharged on 12/12/23). A Check Request form dated 1/29/24 (48 days after R1's discharge) shows a refund was requested due to her discharge. The form shows an area For Office Use Only including account number, check amount approved by and date approved are all blank. 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: 145200 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 145200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franklin Grove Living and Rehab 502 North State Street Franklin Grove, IL 61031 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)