Health inspection·March 18, 2025

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interview and record review the facility failed to develop a discharge plan for administration of diabetic medications and wound care for one of three residents (R2) reviewed for discharge in the sample list of six. Findings include: The facility's undated Transfer and Discharge Policy documents the facility will assure resident transfers and discharges will be conducted in accordance with resident's rights, physician orders, and in such a manner as to maintain continuity of care for the resident. The Medication Administration Record dated 3/12/25 documents orders for R2 to have blood glucose checks before meals and at bedtime, Metformin (antidiabetic)1000 milligrams (mg) in the morning and at bedtime, Trulicity (antidiabetic) 3mg subcutaneously every Thursday, and Lantus insulin 10 units (subcutaneously) every morning. The Treatment Administration Record dated 3/12/25 documents and order for R2 to have a dressing change to R2's right great toe wound daily. The facility's Release of Responsibility for Discharge against Medical Advice (AMA) form dated 3/13/25, contains R2's signature on the resident signature line, and at the bottom of the document a handwritten statement documents the consent form was read out loud to R2 because resident is unable to read. R2's medical record does not contain a discharge plan or notification of the physician of R2's discharge. On 3/17/25 at 9:40 AM, V1 (Administrator) stated R2 was homeless prior to his admission from the hospital on 3/12/24. V1 stated the facility ran R2's background check prior to admission and nothing concerning came back so R2 was admitted on [DATE]. V1 further stated on 3/13/25 V1 was made aware that R2's CHIRP (Criminal History Information Response Process) came back that R2 was an identified offender. V1 stated she went to R2's room to discuss the CHIRP with him and R2 confirmed the report. V1 stated she told him that she needed to make room moves and put R2 in a private room. V1 stated V1 made R2 aware they would have to look for different placement because R2 would not be able to stay at the facility with his conviction. V1 stated R2 asked if there were any local facilities that would take R2 because he wanted to stay in the area. V1 stated she told R2 that individuals convicted as sex offenders usually go to Northern facilities, and they probably could not find a facility in the (continued on next page) 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 2 Event ID: 146104 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 146104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Farmer City 404 Brookview Drive Farmer City, IL 61842 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)