Inspection·August 29, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/24/23 at 10:11 AM, V1 (Administrator) said R1 had been transferred to an acute psychiatric hospital for behaviors. V1 said the hospital had notified the facility they were R1's base line behaviors and R1 would be discharged back to the facility. V1 said the facility had completed an emergency involuntary discharge after being notified there was no improvement to R1's behaviors. R1's Electronic Medical Record (EMR) documented several progress notes documenting the facility's attempts to find placement in group homes like the group home R1 had previously resided in. R1's EMR documented a 6/26/23 at 3:00 PM progress note .(Acute psychiatric hospital) called. They can accept (R1). They would like for him to be sent with 3 outfits and night clothes if he wears them . sent current medications . Transportation notified that (R1) has been accepted . R1's EMR documented a 7/3/23 at 12:17 PM progress note .(Acute psychiatric hospital) called and requested (R1) to be picked up from their facility this Friday at 1100. Transportation Supervisor is aware and will make arrangements for transportation. (Acute psychiatric hospital) reported that (R1) is still pinching and exit seeking but can be easily redirected . R1's EMR documented a 7/6/23 at 11:13 AM progress note .called with an update on (R1) today from (Acute psychiatric hospital). (R1) is eating and sleeping well, he is exit seeking, pinching, getting physical today when being redirected. Doctor has said this is his baseline behavior and they don't feel they can do anymore with him. They do feel like he has more behaviors with male staff and advise if we can avoid this it may be helpful, he prefers female staff. I did ask if they can keep him a bit longer to try and help with the behaviors as we feel it will put our other guests at risk. She said she understands and does feel like he would be in a better setting like his previous home but they're unable to do anything further as doctor said it's his baseline behavior . R1's EMR documented a 7/6/23 at 4:59 PM progress note . Phone call made this afternoon to (R1's) guardian, (V2), letting him know that the facility would be doing an involuntary/ emergency discharge at this time . R1's 7/6/23 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents documented an emergency transfer or discharge from the facility citing . your welfare and needs cannot be met in the facility, as documented in your clinical records by your physician . and .the safety of individuals in this facility is endangered The facility was not able to produce any documentation R1 was a danger to other residents or documentation from R1's physician why R1's needs could not be met in the facility. R1's 7/6/23 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents also documented . on the date of transfer or discharge, you will be relocated to: Facility/ Person: (V3/ R1's Legal Guardian) . R1 was discharged to an acute psychiatric hospital. On 8/24/23 at 12:29 PM, V2 (R1's Legal Guardian) said the facility had called him to inform him R1 would not be allowed to be readmitted to the facility after his stay in the acute psychiatric hospital because the facility could not handle R1's behaviors. V2 stated he was unsure why they were unable to find R1 placement in a group home after his return from the hospital. V3 said R1 was still at the acute psychiatric hospital at the time of this investigation. V3 said he was told there was an appeal process but V3 did not know what he was supposed to do or who to talk to about that. On 8/24/23 at 1:44 PM, V5 (Chief Nursing Officer at the Acute Psychiatric Hospital) said R1 had been in the Acute Psychiatric Hospital for almost 2 months and had only had approximately 5 days with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146019 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 146019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821 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 aggressive behaviors and was doing well. Level of Harm - Minimal harm or potential for actual harm On 8/29/23 at 9:45 AM, V1 (Administrator) was asked why an emergency involuntary discharge was performed when R1 had been at the acute psychiatric hospital for 10 days and responded R1 was initially sent to the acute psychiatric hospital for behaviors and when they called back and told us his behaviors were his base line that is when we initiated the emergency involuntary discharge. V1 said she felt like the acute psychiatric hospital was better equipped to care for R1's behavioral needs. V1 verified there was no documentation from R1's physician documenting why the facility could not meet R1's needs, what interventions had been put in place, and why the receiving facility was better equipped to care for R1. Residents Affected - Few The facility's 9/1/09 Transfer/ Discharge policy documented .1. When a resident is transferred or discharged , the resident's chart will be documented by a physician. 2. Each resident is allowed to request or agree to relocate within the community or transfer to another facility, and to participate in the transfer or discharge . 4. Notification of transfer or discharge will follow the regulations of the State in which (the facility) is licensed and will be made at least 30 days in advance unless the individual qualifies for a State- defined emergency relocation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146019 If continuation sheet Page 3 of 3