Inspection·April 3, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to re-assess and allow a resident to return to the facility during an involuntary discharge appeal for 1 of 1 resident (R1) reviewed for discharges/transfers in the sample of 6. The findings include: R1's face sheet shows he was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol-induced persisting dementia. Unspecified mood disorder and Unspecified dementia with behavioral disturbances. R1's admission papers from a local community hospital show R1 had been brought to the emergency department on 5/30/2022 for threats to kill his spouse. He was then transferred and admitted at the facility on 6/6/22. R1's nursing progress notes dated 11/3/2022 at 7:35 AM, shows at 4:30 AM, R1 put his face into a new CNA's (Certified Nursing Assistant) face as he started hitting his palm with a closed fist stating this was going to be her face. At 4:35 AM, 911 was called and police and paramedics arrived at the facility and R1 was transported to a local community hospital emergency room for evaluation. On 4/3/23 at 10:00 AM, V6 (R1's representative) said she was contacted by phone on the morning of 11/3/22 from the facility that they sent R1 to the hospital and they were not going to allow him to return. She said she filed an appeal and R1 was still not allowed back to the facility. He had to remain at the hospital until they could find a new facility for him to go to which took until 11/21/22. V6 said the facility was not assisting the hospital to attempt to secure a new placement for R1 from 11/3/22 until the first appeal hearing happened on 11/18/22. At that hearing the judge told the facility they should be assisting with placement for R1. On 4/3/23 at 10:50 AM, V4 (Social Services) said she was made aware on 11/3/22 that R1 was issued an involuntary discharge from the facility. She said she was told R1 would not be allowed to return so she did not make further contact with the hospital about R1 until the hearing on 11/18/22, when she was asked to help send referrals to other facilities. On 4/3/23 at 12:05 PM, V5 (Ombudsman) said she was contacted on 11/14/22 about R1's involuntary discharge and appeal by the Social Worker (V14) at a local hospital. V5 said R1 was not allowed to return to the facility during the appeal of his involuntary discharge. (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: 145440 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 145440 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neighbors Health Center 811 West 2nd Byron, IL 61010 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)