Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0622
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.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to serve an appropriate non-emergent involuntary discharge
and allow the resident and resident's family time to appeal the notice, for one of three residents (R1)
reviewed for discharge in the sample of four. This failure resulted in R1 being removed from his environment
and suffering psychosocial harm that any reasonable person would after being placed over four and half
hours away from his family and friends without notice.
Findings include:
The facility's Transfer/ Discharge policy, dated 11/5/19, documents The interdisciplinary team and or
physician, in consult with the resident or his/her power of attorney (POA) for healthcare, may recommend
transfers or discharges. All resident transfers and discharges from this facility require notification and/or
authorization of the resident or his/her POA for healthcare, and his/her primary physician. In cases of
emergencies the nurse on duty may initiate transfer to a hospital or medical center as resident's status and
condition warrants it.
The National Institute on Aging online article titled Changes in Intimacy and Sexuality in Alzheimer's
Disease, dated 5/17/17 and located at www.nia.nih.gov, documents Hypersexuality: Sometimes, people
with Alzheimer's disease are overly interested in sex. This is called hypersexuality. The person may
masturbate a lot and try to seduce others. These behaviors are symptoms of the disease and don't always
mean that the person wants to have sex.
R1's admission record documents R1 was admitted to the facility on [DATE] with a principal diagnosis of
Alzheimer's Disease.
R1's recent Minimum Data Set assessment, dated 4/7/23, documents R1 suffers severe cognitive
impairment and requires extensive assistance of one person to transfer, walk and move around the facility
in a wheelchair.
R1's Care Plan, dated 2/6/23, documents (R1) does both independent and group activities. Staff will
observe and not leave (R1) unattended during activities. R1's Care Plan, dated 12/26/22, documents (R1)
has expressed sexual desires. R1's Plan of Care, dated 4/21/23 documents (R1) is at risk for
wandering/elopement and (R1's) safety will be monitored every shift by all staff. Interventions: One on one
monitoring as necessary, initiated 4/21/23. Targeted one on one supervision, initiated 4/28/23. R1's Care
Plan, dated 12/26/23, documents I currently have an alteration in my behavior status related to Alzheimer's,
impaired memory/thinking, and increased sexual drive and may exhibit behaviors such as increased
confusion, making inappropriate comments or physically attempting to touch staff
(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 3
Event ID:
145604
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
145604
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Henry Rehab and Nursing
1650 Indian Town Road
Henry, IL 61537
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 0622
and residents; will masturbate and is unable to comprehend or remember appropriate behaviors due to his
diagnoses. (R1) does get agitated at times with staff and other residents.
Level of Harm - Actual harm
Residents Affected - Few
R1's Progress Note, dated 5/25/23, document at 11:00 AM IDT (Interdisciplinary Team) met to discuss the
physical assault (R1) attempted with a CNA (Certified Nursing Assistant, V11) during transfer and
recommends the resident be discharged to accepting facility for the safety of other residents.
R1's Progress Note, dated 5/25/23, documents Administrator (V1) met with resident to discuss the events
happening this morning with Activity Director (V15) present. Involuntary discharge was explained and
issued to the resident. Resident did not have any questions or concerns.
R1's Notice of Involuntary Transfer or Discharge and opportunity for Hearing for Nursing Home Residents,
dated 5/25/23, documents R1 is to be an Emergency transfer or Discharge due to the safety of individuals
in this facility is endangered.
On 6/7/23 at 2:09 PM, V11 (Certified Nursing Assistant, CNA) stated The day of the incident, I went in to
get (R1) up and when I went to stand him, his hand was out and (R1) tried to kiss me but did not make
contact. I got him to the dining room, and I let activities know his behavior and I told the nurse (V7,
Licensed Practical Nurse).
On 6/7/23 at 11:34 AM, V8 (CNA) stated I was on the hall with (V11) when she came out of (R1's) room
and said (R1) tried to kiss me. That sometimes was a behavior for him. I hadn't seen him try to do that in
the last month or so and I did work with (R1) a lot. For his last couple days (in the facility) he was basically
one on one monitoring.
On 6/7/23 at 11:20 AM, V7 (Licensed Practical Nurse) confirmed being the nurse for R1 on the day he was
discharged . V7 stated (R1) was back in his room after breakfast. The CNA (V11) saw (R1) up in his room
and asked if she could help him back to his chair. (R1) held his hand out to (V11) and pulled her in and tried
to kiss her, no contact was made. (V11) came out and told me while I was doing medications and I told her
make sure to chart it and don't go back in the room without a buddy. I got done with medication pass and
was called into (V1's) office and was asked why I didn't report him being sexual inappropriate to them
immediately. I said (R1) was not inappropriate to another resident. We as staff are on our own if we get hit
or abused. We worry about the residents. I had no idea (R1) was being taken out of here (the facility). I
came back the next day and (R1) was gone. I didn't consider the situation an emergency. His wife (R4) is
also a resident here.
On 6/7/23 at 12:15 AM, V6 (R1's Family Friend) stated I have called and talked to (R1) since he's been
discharged . (R1's) first day he was so confused and didn't know how he got there and why he was there.
He said they had a room that (R4, R1's spouse) could come to. (R4) doesn't want to move that far away. We
(Friends and Family) don't want that either. It's sinful to take someone who has dementia that far away, over
four and a half hours. (R1) is originally from the Peoria area.
On 6/7/23 at 1:20 PM, V12 (R1's family member/ Power of Attorney) stated I am an international airline
pilot. I see a statement from (the facility) and of course don't always open the bills right away. Enclosed in
one of those was the notice of Involuntary Discharge. I had no idea that was coming. The fact that we didn't
talk is the problem. I live in Atlanta. It read that the date he was transferred was the date the letter was
signed. I was a part of the admission process. They told me they would provide extra care and as things
progressed, they would just up the care with (R1). I was under no direction that they were going to not care
for (R1). They have people in the facility in much
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145604
If continuation sheet
Page 2 of 3
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
145604
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Henry Rehab and Nursing
1650 Indian Town Road
Henry, IL 61537
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 0622
Level of Harm - Actual harm
Residents Affected - Few
worse condition than (R1) and so I knew if they are caring for them, they can care for an [AGE] year-old
man with severe Alzheimer's. The receiving facility (he transferred to) was just as shocked as me, they
didn't know why he was there. I want him back in the facility with his wife (R4). (R4) and (R1) were
inseparable. They had vacation houses together. (R4) and (R1) were always together. I just got the sense
that they (the facility) were not going to be bothered with (R1's) behaviors. You can't handle this
(Hypersexual) old man who's frail and can't get up without help? (R1's) not strong and they are trained to
handle him. He is not mean. Inappropriate, maybe, but not uncontrollable. I just want (R1) back there in (the
facility). They (R4 and R1) are wondering where each other are.
On 6/8/23 at 10:10 AM, V13 (R1's Physician) stated I was aware of the discharge. I did not hear the details
(of the incident) but just that (R1) assaulted a staff member. I did not know (R1) was issued with emergency
status discharge. I had no idea they were moving that quickly or trying to get (R1) out that same day. I do
not know why it was escalated that quickly, given the situation was not emergent. I was not aware it was an
emergency discharge.
On 6/8/23 at 12:10 PM, R4 was sitting in her room reading. R4 stated she knows her spouse (R1) has been
transferred far away and she knows the situation but of course she'd rather be in the building together. R4
stated We've have been married a long time and it's a sad situation. (R1) would rather be in the same
residence as me too.
On 6/8/23 at 1:00 PM, V1 (Administrator) stated Our basis on reasoning for discharging (R1) was because
he made the action of a physical altercation. He didn't make contact but made a physical attempt at a CNA
(V11). At that point he no longer was just a verbal threat, he took a step-in action to be physical. He is in an
all-male hallway in a smaller facility. He was transferred to the facility that would accept him. I think it's like
four hours from here. He was taken that day because it was urgent to get him right out of here with those
behaviors. He did not require emergency services or hospitalization.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145604
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F622 - Transfer and discharge-
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.
FAQ · About this visit
Common questions about this visit
What happened during the June 8, 2023 survey of HENRY REHAB AND NURSING?
This was a inspection survey of HENRY REHAB AND NURSING on June 8, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HENRY REHAB AND NURSING on June 8, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific info..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.