Health inspection·May 15, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow their policy and procedures for discharge planning for three residents (R1, R2, and R3) and unplanned discharge for three residents (R1, R4, and R5) of four residents reviewed for discharge in the sample of six. Findings include: The facility's undated, Unplanned Discharge policy and procedure, documents: Policy: For purposes of providing the safest discharge possible, the facility will advise residents of the risks of early, unplanned discharge, and provide appropriate referrals and discharge instructions whenever possible. Discharge Against Medical Advice (AMA) procedure documents to obtain and witness residents' signature on AMA form. If resident refuses to sign, consider AWOL (Absent Without Official Leave) procedure documents: Resident not returning from pass, LOA (leave of absence), or outside appointments as scheduled will be considered AWOL. Resident who leaves the facility with staff knowledge, without following proper procedure and/or without signing AMA will be considered AWOL. This policy documents the Social Worker or Nurse will: Notify Adult Protective Services (APS), if applicable and Make necessary attempts to locate the resident's whereabouts. The Social Service Director (SSD) Job Description, dated 1/29/24, documents the SSD Must assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis; safeguard the health, safety, and welfare of all residents of the facility. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. The essential job functions include: Communicates with the elderly with communication problems and relay their needs/concerns to family, facility, and community agencies. 1. The Progress Note for R1, dated 5/9/25 at 12:00 PM, documents R1 is alert and oriented to person, place, time and event and able to make her needs known. R1 reported to Nursing she was leaving via local community transport and did not say where she was going. The Progress Note for R1, dated 5/9/25 at 9:15 PM, documents the day shift reported R1 left the facility via local community transport and at 9:00 PM, R1 had not returned. At 9:15 PM R1's closet was checked revealing all R1's belongings were gone. There are no Progress Notes documenting Adult Protective Services were notified or that anyone tried to locate R1. Page 1 of 5 145989 145989 05/15/2025 Parker Nursing & Rehab Center 516 West Frech Street Streator, IL 61364

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Progress Note for R1, dated 5/10/25 at 6:34 AM, documents a night shift CNA/Certified Nursing Assistant called reporting seeing R1 at a local fast-food restaurant with her belongings in a shopping cart that was parked outside the entrance of the establishment. On 5/13/25 at 9:30 AM, R1 was not residing in the facility. On 5/13/25 at 12:00 PM through 12:45 PM, Upon arrival to the local fast-food restaurant this writer noted a shopping cart at the corner of the building, on the entrance side of the establishment, filled with plastic bags with a blue beach chair on top of the cart. Upon entering establishment this writer noted R1 sitting in dining booth, wearing a black hooded sweatshirt with hood pulled up on her head, unkempt, messy, and disheveled, with her legs elevated resting on the booth's seat and with foul odor present. R1 was talking to herself, raising her arms and pointing into the air. Approached R1 in attempt to interview and R1 made no eye contact and did not respond to this writer. On 5/13/25 at 1:30 PM, V5 LPN/Licensed Practical Nurse stated on 5/9/25, at supper time, she asked if R1 had returned to the facility and was told no. On 5/13/25 at 2:00 PM, V8 Receptionist stated R1 was signed out of the facility on 5/9/25 and did not return. On 5/14/25 at 1:36 PM, V10 (R1) Friend stated she just found out she was listed as an emergency contact for R1, her telephone has not been disconnected, and she was not notified on 5/9/25 by the facility that R1 had left the facility and not returned. V11 (R1's) Friend is listed as R1's first emergency contact and was not notified of R1 leaving the facility either. V10 stated she received two missed calls from R1 the night of 5/9/25 and on 5/12/25 was notified by a friend that R1's shopping cart was located outside a local fast-food restaurant. V10 and V11 visited R1 at the local fast-food restaurant on 5/13/25 and R1 said no one has spoken to her from the facility. On 5/13/25 at 11:30 AM, V2 DON (Director of Nurses) stated on Friday night (5/9/25) V2 received a telephone call from the facility that R1 had not returned from her outing on 5/9/25. V2 DON stated the police were not called, no one went to look for R1, R1 never came back to the facility, and was discharged . On 5/14/25 at 9:30 AM, V1 Administrator stated she received a telephone call the night of 5/9/25 that R1 had gone out and didn't return to the facility. V1 Administrator stated nothing else was done after R1 left the facility, there is no investigation, police were not called, and no one looked for R1. 2. The Progress Note for R4, dated 10/21/24 at 10:45 AM documents R4 left with friend to go to doctors' appointment. The Progress Note for R4, dated 10/22/24 at 9:41 AM documents R4 was absent from the facility. The Progress Note for R4, dated 10/22/24 at 11:49 AM documents R4 was contacted and R4 stated she would go to the local emergency room for evaluation before returning to the facility. The Progress Note for R4, dated 10/22/24 at 6:00 PM documents R4 has not returned to the facility and if not back by 8:30 PM would be discharged . There are no Progress Notes indicating Adult Protective Services were notified or that anyone tried 145989 Page 2 of 5 145989 05/15/2025 Parker Nursing & Rehab Center 516 West Frech Street Streator, IL 61364

F 0627 to locate R4. Level of Harm - Minimal harm or potential for actual harm On 5/15/25 at 12:45 PM V4 SSD confirmed R4 signed out of the facility on 10/21/24, did not return, and nothing else was done. V4 SSD stated R4 was alert and oriented and it was her right not to return to the facility. Residents Affected - Few On 5/14/25 at 9:33 AM, V1 Administrator confirmed R4 left the faciity on [DATE], did not return to the facility, there is no investigation, police were not called, and no one looked for R4. 3. The Progress Note for R5, dated 10/1/24 at 8:15 AM documents R5 wanting to leave facility AMA, understands risks of leaving, refuses to sign AMA paperwork. The Progress Note for R5, dated 10/1/24 at 12:03 PM documents exit alarm sounded and R5 was noted outside with his belongings. Attempts were made to redirect back inside but R5 refused, stating he would become physically aggressive with staff. On 5/15/25 at 12:48 PM, V4 SSD confirmed R5 left the facility AMA with his personal belongings on 10/1/24 without signing AMA paperwork and nothing else was done. On 5/15/25 at 9:35 AM, V1 Administrator confirmed R5 left the faciity on [DATE] AMA and refused to sign AMA paperwork, did not return to the facility and nothing else was done. On 5/15/25 at 2:00 PM, V1 Administrator confirmed Adult Protective Services should have been notified of R1, R4, and R5's AWOL status and staff should have looked for R1 and R4. The facility's undated Discharge Planning Policy, Protocol, and Procedure documents its purpose: To identify appropriate candidates for inclusion in active discharge planning facilitating the transition to a less structured environment and to coordinate adequate supportive community care services. This nursing facility strongly emphasizes preparation and preparedness. The goals and objectives include: To anticipate and minimize potential problems related to discharge; To assist families and significant others in preparing for discharge; To assure the involvement of the Social Work staff in assessing discharge potential, documenting significant information related to discharge and coordinating community health care services. The Social Service Director Job Description, dated 1/29/24, documents the SSD assists in planning, developing, organizing, implementing, evaluating, and directing social service programs. Must assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. The essential job functions include: Coordinates discharge planning and maintain ongoing notes regarding discharge planning for appropriate residents. 4. The current Care Plan for R1, documents R1 would like to return to the community and live independently. The Quarterly Care Plan for R1, dated 4/19/25, documents there is no active discharge planning occurring for R1. 145989 Page 3 of 5 145989 05/15/2025 Parker Nursing & Rehab Center 516 West Frech Street Streator, IL 61364

F 0627 Level of Harm - Minimal harm or potential for actual harm The Progress Notes for R1 do not include any Social Service notes or further discussion regarding active discharge planning being done for R1 after 2/27/24. On 5/13/25 at 12:40 PM, V4 SSD stated R1 stated she did try to help R1 on 2/27/24 with filling out paperwork with the housing authority but R1 backed out and there has been nothing else since then. Residents Affected - Few 5. The current Care Plan for R2 documents R2 expressed the desire to move to a less structured environment, discharge potential and planning needs have been assessed, and R2 demonstrates self-sufficiency skills. The admission MDS (minimum data set) Assessment for R2, dated 2/12/25, documents R2 is cognitively intact and R2's overall goal is to discharge to the community and no active discharge planning occurring. The Discharge Planning Review for R2, dated 5/12/25, documents: R2's discharge potential as Fair; Discharge Status as Personal residence with support services.; and Discharge Plan as Do not initiate. The Progress Notes for R2 do not include any Social Service notes or active discharge planning being done for R2. On 5/13/25 at 1:42 PM, R2 was walking up the hallway independently, was clean, well kept, and without odors. R2 stated she is staying in the facility until she can find a three-bedroom house. R2 stated she has been asked about her discharge plan, but no one is helping her to get out of the facility. 6. The current Care Plan for R3 documents R3 expressed the desire to move to a less structured environment, R3's discharge potential and discharge planning needs have been assessed and R3 demonstrates self-sufficiency skills. The Quarterly MDS Assessment for R3, dated 4/16/25, documents R3 is cognitively intact with no discharge planning occurring. The Discharge Planning Review for R3, dated 4/6/25, documents: R3's Discharge Potential as Fair; Discharge Status as Personal residence with support services; and Discharge Plan as Do not initiate. On 5/13/25 at 1:48 PM, R3 was walking up the hallway independently, was clean, well kempt, and without odors. R3 stated she wants to find a place to live, the facility is aware, and she has asked for help but not getting it. On 5/15/25 at 12:40 PM V4 SSD stated discharge planning is different for every resident and is based on the resident's cognition and done case by case. If a resident is alert and oriented and choses to leave, they have the right to leave if they want to. If a resident or family member is helping a resident with discharging from the facility V4 SSD does not interfere but if asked to assist she will. Once a resident says they are ready or want to leave, V4 will then start the discharge plan, and the documentation would be found in the resident progress notes. V4 SSD stated R2 and R3 are related and are wanting to discharge together and is not sure what their plan is. V4 stated if R2 and R3 want her help she would help them but R2 and R3 have not asked her. V4 SSD confirmed there is currently no discharge plan in place for R2 and R3 and there was no active discharge plan in place for R1 145989 Page 4 of 5 145989 05/15/2025 Parker Nursing & Rehab Center 516 West Frech Street Streator, IL 61364

F 0627 prior to R1 leaving the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145989 Page 5 of 5