Health inspection·January 11, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with moderate cognitive deficits who was identified as a potential risk for elopement did not exit the building unattended for 1 of 3 (R2) residents reviewed for elopement in the sample of 5. This past non-compliance occurred between 12/30/2023 and 1/2/2024. Findings include: R2's Care Plan, dated 10/12/22, documents that R2 has Potential Risk of Elopement due to Cognitive deficit and History of wandering. It also documents Identify any Patterns or Exacerbating Factors, Identify Individual factors which seem to calm, alleviate, or reduce behavior, Keep familiar items in residents living space, Monitor whereabouts regularly; Recognize any unsafe conditions or escalating patterns, Provide re-direction and Diversion as needed, Respond to any alarm activation promptly. R2's Minimum Data Set, dated [DATE], documents that R2 is moderately cognitively impaired. R2's Face Sheet, not dated, documents unspecified Dementia, Unspecified severity, with other behavioral disturbance as diagnosis. R2's Elopement Assessment, dated 10/19/2023, documents that R2 is not at risk for elopement. R2's Elopement Report, dated 12/30/2023, documents Resident was reported to be outside in street, was noted by staff that an ambulance driver was attempting to assist resident. Staff intervened and assisted resident back to facility. Resident reported he was attempting to go home, no c/o (complaints), no injuries noted. Was reported to (V1-Administrator) (on call), order to have wander guard applied, (V8) from Transport applied, called Wife (V9), left message to call facility. It also documents that resident description was that he wanted to go home, he was going to church street. R2's Progress Notes, dated 12/30/2023 at 9:00 AM documents Resident was reported to be outside in street, was noted by staff that an ambulance driver was attempting to assist resident. Staff intervened and assisted resident back to facility. Resident reported he was attempting to go home, no c/o, no injuries noted. was reported to (V1) (on call), order to have wander guard applied, (V8) from Transport applied, called Wife (V9), left message to call facility. On 1/10/2024 at 10:00 AM V5, Certified Nurse's Assistant (CNA), stated that she has been at the facility for about a month. V5 stated that she has worked with R2 and R2 requires assistance with all his care. V5 stated that he tries to help but is pretty much dependent on staff for care. V5 stated Page 1 of 3 145273 145273 01/11/2024 Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that R2 is confused. V5 stated that R2 is alert to name but that is it. V5 stated that this has been this way since she has been here. On 1/10/2024 at 10:05 AM V6, CNA, stated that he was here when R2 left the building. V6 stated that he was pushing a resident down the hall and heard the door alarm go off. V6 stated that he walked towards the door and saw R2 outside. V6 stated that he went outside and helped R2 back in. V6 stated that when he went out to get R2 he was where the parking lot meets the road and 2 EMTs (Emergency Medical Technicians) was with R2. V6 stated that R2 did not have any injuries and did not appear in distress. V6 stated that R2 said he wanted to go across the street to his family house. V6 stated that R2 is normally confused and wanders the building in his wheelchair. V6 stated that he has not seen him attempt to leave the building but is aware of R2 wandering. On 1/10/2024 at 10:10 AM V3, Licensed Practical Nurse, stated that she was at dining room passing medications. V3 stated that the door alarm went off. V3 stated that she was notified by V6 that R2 had went out the door and made it to the street. V3 stated that she did not see R2 out there herself, but this is what she was told. V3 stated that she assessed R2, and no injuries were noted. V3 stated that R2 has always been confused and made statements that he wants to leave and go home. V3 stated that she is not aware of him making any attempts to do so. V3 stated that R2 has sat next to the doors and never went out. V3 stated that R2 wanders through the building in his wheelchair. V3 stated that R2's wife comes in the evening and spends time with him. V3 stated that R2 wants to be home with her but is not aware of any attempts to leave. On 1/10/2024 at 10:26 AM, R2 stated that he went outside to go across the street. R2 stated that he didn't make it because some guys stopped him. R2 stated that he made it to the middle of the street. R2 stated that the guys were nice, but he wanted to go across the street to his family house. R2 stated that he does not know who the men were. R2 stated that when returning to the building he felt like he was in trouble and felt like a prisoner. On 1/10/2024 at 11:31 AM V4, EMT, stated that he and his partner were leaving the hospital across the street. V4 stated that he saw R2 in the wheelchair out in the street. V4 stated that R2 was moving the wheelchair. V4 stated that they turned on the emergency lights to stop traffic. V4 stated that he got out to help R2 back to the facility. V4 stated that he asked where he (R2) was going. V4 stated that R2 told him (V4) that he was going to the church across the street. V4 stated that he told him that it was not a church and that it was a hospital. V4 stated that he helped push R2 back towards the facility and at that time the staff came out and took R2 back into the facility. On 1/10/2024 at 12:03 AM V7, EMT, stated that he and his partner were coming from the hospital and saw R2 trying to go cross the street. V7 stated that R2 was pushing his wheelchair. V7 stated that the only thing that kept R2 from making it all the way across was that he was stuck on a piece of ice. V7 stated that they turned on the emergency lights to keep R2 from being hurt. V7 stated that R2 was on the black asphalt. On 1/10/2024 at 1:14 PM V1, Administrator, stated that R2 did not elope. When asked how did she come to this conclusion? V1 stated because R2 did not get hurt. On 1/11/2024 at 11:08 AM, V1 stated that she was aware that R2 made it to the middle of the street. V1 stated that she checked the area where R2 went out and it's an incline. V1 stated that this (elopement) occurred in a matter of 5 minutes. V1 stated that she has spoken to her corporate about it to see if there is something that can be done. 145273 Page 2 of 3 145273 01/11/2024 Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650

F 0689 Level of Harm - Minimal harm or potential for actual harm The facility's Elopement and Missing Resident Policy, dated October 2009, located in the elopement binder's documents that it is standard policy to monitor and evaluate residents at risk for wandering and elopement. It also documents the Elopement Definition as elopement occurs when a resident leaves the premises or a safe area without authorization or staff notification and/or any necessary supervision to do so. Residents Affected - Few The facility's Wandering/Elopement Policy, dated 10/18/22, documents that the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 1/2/24. In attendance - V2, Director of Nursing (DON), V8, Transportation Aide, V10, LPN, V11, Social Service Director, V12, Maintenance Director, V13, Asst. Maintenance Director, V14, Asst DON, and V15, Wound Nurse. The following was discussed. The resident was brought back into facility, elopement risk was reassessed, applied wander guard. The Resident was added to the elopement book. The door alarm volume/level checked, and volume increased. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All resident's elopement assessments were reviewed for accuracy. 1/2/24. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: Staff have been re-educated on 1/2/24 on elopement policy and procedure. Staff were educated on the elopement book and location. 4. Plan to monitor performance to ensure solutions are sustained: Admin or designee will monitor 5 days per week door alarm functionality and residents with wondergaurds will be monitored BID (twice daily) for placement and weekly on Fridays for wondergaurds function. Audits will be reviewed by the QA committee monthly to ensure continued compliance and will revise as needed to maintain compliance. 145273 Page 3 of 3