Health inspection·October 10, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to notify resident/resident representative in writing of hospital transfers for two (R14 and R36) of two residents reviewed for hospitalization in a sample of 24. Residents Affected - Few Findings include: The facility's undated Transfer to Hospital Checklist documents, A resident must have the below listed items prior to transferring to the hospital. Please check off and sign at the bottom indicating these were given. Place this form in Medical Records to be scanned into resident chart. This checklist includes Bed Hold & Return to Facility Policy and Transfer Referral Form (nurse to keep a copy). The facility's undated Transfer Referral Form includes but is not limited to Date of Transfer and Reason for Transfer with a place for nurse's signature at the bottom. 1. R14's Nurse Progress note, dated 10/24/23, documents R14 was transferred out to a local hospital per ambulance. R14's clinical record does not document written notification was given to the resident/resident's representative. On 10/10/24, at 10:50am, V7, Social Service Director, could not locate a written notification to representative for R14's 10/24/23 hospital transfer. 2. R36's medical record documents R36 went to the hospital on 9/19/24. R36's medical record has no documentation R36 and R36's representative was notified of the transfer or discharge, and the reasons for the move in writing. On 10/10/24, at 10:55 AM, V7, Social Service Director, could not produce written notification to R36 and R36's representative for R36's 9/19/24 hospital transfer. 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 5 Event ID: 145933 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 145933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Skylines 7023 North East Skyline Drive Peoria, IL 61614 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)