Health inspection·March 18, 2024

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to allow a hospitalized resident to return to the facility. This failure affects one resident (R1) out of 5 reviewed for transfers and discharges in the sample of 5. Findings include: On 3/16/24 and 3/18/24, R1 was not residing in the facility and R1's designated room was not occupied by R1 nor any other resident. R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Diffuse Traumatic Brain Injury with Loss of Consciousness of Unspecified Duration, Functional Quadriplegia, Acute and Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes with Hyperglycemia, Morbid (Severe) Obesity Due to Excess Calories, Epilepsy, Body mass Index [BMI] 45.0 - 49.0 Adult, Cerebral Infarction due to Thrombosis of Cerebral Artery, Depression, Nonpsychotic Mental Disorder, Pseudobulbar Affect, Dysphagia Oropharyngeal Phase, Hyperlipidemia, GERD, Hemiplegia and Hemiparesis, HTN, Dependence on Supplemental Oxygen, Dependence on Other Enabling Machines and Devices, Wheezing, Sleep Apnea, Muscle Weakness and Need For Assistance with Personal Care. R1's Plan of Care Note dated 2/21/24 at 2:45pm documents Quality Assurance team met to discuss R1's behaviors. Staff reports R1 was screaming. This behavior occurs daily throughout the day and night. R1's call light is in reach and R1 knows how to use the call light. R1 chooses to scream for R1's needs at times. Staff respond to remind R1 to use the call light. R1's Behavior Note dated 2/21/24 at 4:02pm documents: Certified Nursing Assistants have reported to V6 Social Service Director twice today that while providing perineal care R1 was grabbing R1's penis. R1 reminded that this behavior is inappropriate. R1 just laughed. R1's Health Status Note dated 2/22/24 at 8:48pm documents: at 8:30pm R1 screaming that R1 didn't have snack. Gave R1 one of R1's snacks and told R1 he had 7 snacks already. R1's Behavior Note dated 2/23/24 at 10:05am documents: Certified Nursing Assistant reported to V6 Social Service Director that while providing care R1 had grabbed CNA's breast. CNA remined R1 that this behavior is inappropriate. R1 just laughed but did let go. R1's Health Status Note dated 2/23/24 at 12:02pm documents: R1 is refusing to go to R1's appointment this afternoon. V3 Power of Attorney was called to inform V3 of R1's refusal. V3 stated V3 would Page 1 of 3 145842 145842 03/18/2024 Flanagan Rehabilitation & Hcc 201 East Falcon Highway Flanagan, IL 61740

F 0626 call R1 and then call us back. Level of Harm - Minimal harm or potential for actual harm R1's Behavior Note dated 2/23/24 at 12:39pm documents: at 10:05 am while giving R1 care R1 was inappropriate and grabbed aide's chest. Residents Affected - Few R1's Behavior Note dated 2/24/23 at 6:00pm documents: R1 was on the call light 27 times within 42 minutes this morning requesting R1's breakfast. Explained to R1 each time that breakfast was being prepared and that we would bring it to R1 when its available. R1's Health Status Note dated 2/25/24 at 9:30pm documents: R1 yelling/screaming shortly after putting on call light. Care provided. R1's Health Behavior Note dated 2/26/24 at 9:42am documents Certified Nursing Assistant's reported the following behaviors from this past weekend (2/23/24, 2/24/24 and 2/25/24), ringing call light and when CNA's responded R1 would say nothing or just laugh, not cooperating when CNA's were providing care (holding side rail and not rolling so care could be given), grabbing at CNAs breast, putting R1's light on then screaming instead of waiting for light to be answered, upsetting other residents, refusing care, and asked to be changed when R1 did not need to be changed. Staff reminded R1 of appropriate behavior and R1 would just laugh. R1's Behavior Note dated 3/10/24 at 12:29pm documents R1 continues to require cares in pairs during the shift due to noncompliance, requiring 3 or more staff for cares, R1 continues to have attention seeking behaviors, sexually inappropriate comments, R1 also has continued to have yelling/screaming and disruptive behaviors when R1's call light is not on and when it is on and not answered immediately. V3, R1's Power of Attorney has been called and several times during shift to attempt to keep V3 updated, and messages left. The note documents R1 has been awake most of shift and for the short time R1 did appear to be asleep BI-PAP was placed but removed shortly after by R1 and oxygen per nasal cannula (NC) placed at 6 liters put back on after BI-PAP removal. Attempts to redirect and educate R1 have been unsuccessful and R1's behaviors continue. R1's Health Status Note dated 3/10/24 at 4:00pm documents R1 remained on frequent checks and last checked on at 3:45pm. V3, (R1's Mother and Power of Attorney (POA)) here at the bedside and concerned that R1 appeared to have an increase in twitching to R1's left shoulder and seemed tired. Offered R1, R1's BI-PAP and R1 stated NO! NO! NO! Attempted to explain to R1 the importance of using BI-PAP and R1 continued to refuse. R1 refused after numerous attempts to allow staff to assess R1. R1 refused to allow V2 Director of Nursing (DON) to take R1's oxygen saturation and refused to allow us to obtain any vital signs. V3 requested R1 be sent out to emergency room for evaluation and treatment. V7 Physician updated and ok with sending R1 out and updated on R1's noncompliance with allowing an assessment to be performed. R1's Health Status Note dated 3/10/24 at 4:10pm documents call placed to emergency medical service (EMS) for transport. R1's Health Status Note dated 3/10/24 at 4:30pm documents EMS here for transport to emergency room. R1's Health Status Note dated 3/10/24 at 5:40pm documents V1 Administrator in Training and V2 Director of Nursing (DON) at Hospital emergency room (ER) and spoke with charge nurse and given copy of Involuntary Discharge (IVD) paperwork as well as list of facilities that we have attempted referrals and attempted to place R1, and most had denied. Explained to ER Nurse that we would not be accepting 145842 Page 2 of 3 145842 03/18/2024 Flanagan Rehabilitation & Hcc 201 East Falcon Highway Flanagan, IL 61740

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1 back to the facility after discharge from hospital due to unable to meet R1's needs. ER Nurse verbalized understanding. Explained that V3, R1's Mom and Power of Attorney (POA), was also aware that facility was intending to Involuntarily Discharge resident. R1's Health Status Note dated 3/10/24 at 6:34pm documents call placed to V7 Physician and updated that facility was not intending to take R1 back upon discharge from hospital and V7 agreed with decision based on R1's care needs and agreed facility is no longer able to meet R1's needs. On 3/18/24 at 10:45am V2 Director of Nursing (DON) said, on 3/10/24 V3 R1's Mother and Power of Attorney (POA) was in the facility and requested that R1 be sent to the emergency room due to R1's shoulder twitching. V2 said, R1 was sent out per V3's request. V2 said, V3 was given a copy of the facilities bed hold policy and a copy put in R1's transfer packet. V2 said, V2 and V1 Administrator in Training (AIT) went to the emergency room and gave the emergency room charge nurse a copy of the involuntary discharge packet, and informed the nurse that the facility would not be taking R1 back. V2 said, V2 also call V7 Physician and informed V7 that V3 requested R1 be sent to the ER and that V3 and R1 were informed that they would not be re-admitting R1 to the facility. 145842 Page 3 of 3