Health inspection·June 8, 2023

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 Page 1 of 3 145604 145604 06/08/2023 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

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 145604 Page 2 of 3 145604 06/08/2023 Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537

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. 145604 Page 3 of 3