Inspection·April 5, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record review and interview the facility failed to notify, in writing, and maintain a copy in the Medical Record for notification of Resident/Resident Representatives upon Transfer/Discharge that were reviewed for Bed Hold Transfers. This failure has the potential to affect all 75 Residents residing in the Facility. Findings include: Facility Census and Condition Report, dated 4/2/24, documents 75 Residents residing in the Facility. Facility Bed Hold readmission Policy, dated 11/2016, documents: it is the policy of this Facility to readmit Residents after hospitalization or temporary therapeutic leave when the Resident requires services which can be provided by the Facility; this may be accomplished by holding a specific bed or by making available the next semi-private accommodations in the event a Resident does not desire to hold the specific bed; Residents, or their Designated Representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours; the Facility provides written notification at the time of transfer as included in the designated state form; the notice to the Resident or their representative will specify the Facility's Policy, the duration of the state bed hold policy and the reserve bed payment policy; in the event of an emergency hospitalization the Resident or their Representative shall be notified by telephone or in person of this policy, within 24 hours, and asked to provide the Facility with their decision; the staff member making the call or explaining the policy may accept verbal determination as to whether the Resident desires bed hold or having their name placed on the reservations/waiting list, and shall document same in the medical record and in the progress notes; and follow up written confirmation may be required; in the event a private pay Resident, or Representative, do not advise Facility upon receipt of bed hold notice as to whether or not the bed is to be held, authorization must be given within 24 hours or the bed will be released. On 4/3/24 at 10:49 am, V2 (Director of Nursing/DON) stated, I cannot find any copies of any notification to the Resident Representatives for any Bed Hold's for any of our Residents that discharged to the hospital. On 4/3/24 at 12:00 pm, V3 (Social Service Director) stated, I have not completed or sent any Bed Hold forms to any Family or Family Representative, for any Resident that has discharged or been sent to the hospital. On 4/4/24 at 11:53 am, V2 (DON) stated, We have not been sending any Bed Hold forms to the (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 8 Event ID: 145404 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 145404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farmington Village Nrsg 701 South Main Street Farmington, IL 61531 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)