Health inspection·July 10, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 severe cognitive impairment and a history of wandering was supervised to prevent elopement. This failure resulted in R1 eloping from a secured memory care unit, exiting the building without staff identifying and preventing R1 from eloping. R1 exited the building and ambulated without her walker crossing a six-lane busy intersection and was found approximately 0.8 miles away from the facility wandering outside of the local grocery store. This applies to 1 of 6 residents (R1) reviewed for safety in the sample of 6. The Immediate Jeopardy began on 7/1/25, when R1 got on the elevators with another resident's family on the secured memory unit. R1 exited the first-floor elevators and ambulated out the front entrance without staff identifying R1 was eloping the facility. R1 exited the building and ambulated without her walker crossing a six-lane busy intersection and was found approximately 0.8 miles away from the facility wandering outside of the local grocery store. V1 (Administrator) was notified of the Immediate Jeopardy on 7/10/25 at 8:22 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice was corrected, on 7/02/25, prior to the start of the survey on 7/08/25, and was therefore Past Noncompliance. This past non-compliance occurred from 7/1/25-7/2/25. The findings include: R1's face sheet shows she is an [AGE] year-old female, with diagnoses including vascular dementia, moderate without behavioral disturbance, hypertension, history of falling, ataxia, primary osteoarthritis, and hyperlipidemia. R1's Exit Seeking/Wandering/Elopement Risk Assessment, dated 6/9/25, shows she is at risk for elopement. R1's Fall Risk Assessment, dated 4/8/25, shows her mobility is unsteady and or/use of ambulatory aide, impaired memory and incontinent. R1's current care plan shows she has short term and memory impairment.she needs supervision and support throughout the day to maintain independence with activities of daily functioning (ADL). R1 has an ADL self-care deficit due to poor safety awareness, poor judgment, impaired balance, unsteadiness on feet and history of falling. R1 has a history of being at risk for elopement related to cognitive impairment. History of exit seeking behavior and physical ability to ambulate with walker. She continues to have compromised safety awareness. Interventions include frequent checks and supervision, monitor behaviors, staff/family escort when off secured unit. R1's facility EHR does not show documentation of R1 eloping from the facility in the medical record. R1's Final Incident Report, dated 7/7/25, shows on 7/1/25, R1 eloped from the facility, facility responded appropriately. R1 was taken to the local hospital for evaluation and returned. R1's Hospital Records, dated 7/1/25 at 8:31 PM, shows, (R1) arrives via EMS (Emergency Medical Services). EMS states someone called police, (R1) wandering around the streets to the grocery store with known baseline of dementia.brought in for evaluation for possible elopement. Family at bedside and they are upset that (R1) was not guarded appropriately and left the facility and found wandering.family and staff confirm (R1) has chronic cognitive impairment with occasional wandering behavior.On 7/8/25 at Page 1 of 4 145403 145403 07/10/2025 Alden Poplar Creek Rehab & Hcc 1545 Barrington Road Hoffman Estates, IL 60169

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 11:38 AM, V1 (Administrator) and V2 (Director of Nursing) confirmed R1 eloped from the secured memory unit on 7/1/25. After the dinner meal around 6:30 PM, staff could not locate R1. V9 (Receptionist) said he saw someone who looked like R1 walk out of the building with family. V9 did not recognize R1 was leaving the building without her family. Both said family members had the access code to get on the elevators leaving the secured unit, and there is no alarm that alerts the staff a resident is attempting to exit the secured unit. On 7/8/25 at 9:41 AM, R1 was on the secured memory care unit, sitting in the dining room with her walker next to her. R1 was alert to self only. R1 could not recall the date, time, or where she was. This surveyor asked about the incident on 7/1/25. R1 could not recall the incident and stated, I did that, Oh my God. Did I get hurt? Oh my God, I must be losing my mind. I did not know I did that. On 7/8/25 at 11:52 AM, V7 (Certified Nursing Assistant) said on 7/1/25, she was R1's CNA. R1 was in the dining room at 5:00 PM for the dinner meal. At 5:40 PM, she left the dining room to assist other residents back to their rooms. At 6:30 PM, she could not locate R1. She asked V11 (Activity Aide), who was in the dining room supervising the residents, about R1. V11 said she did not know where R1 was. V7 said she notified V3 (R1's nurse) R1 was missing. (R1) is alert to self; she had a history of wandering when she first came to the facility. (R1) likes to lay down after meals and requires staff assistance to get back to her room. She uses a walker, and she is definitely not safe to leave the facility on her own. (R1) probably got on the elevator with someone else's family. (R1) should have been supervised to prevent her from leaving the unit attended.On 7/8/25 at 1:09 PM, V11 (Activity Aide) said on 7/1/25, she was supervising the dining room. She saw R1 leave the dining room about 5:40 PM. About 6:40 -7:00 PM, staff asked me if (R1) was in the dining room; she told them (R1) left the dining room by herself when she was done eating. V11 said R1 was not on the wandering list, and she did not report to staff when R1 left the dining room. On 7/8/25 at 12:09 PM, V3 (Registered Nurse/RN) said on 7/1/25, she was R1's nurse. R1 was in the dining room during dinner at 5:00 PM, she gave R1 medications after dinner. At about 6:30 PM, she was finished passing her evening medications, and V11 (CNA) reported they could not locate R1. We called a code a green to search for (R1), but we could not locate her. She called V9 (Receptionist) and asked if he had seen R1. V9 said there was someone who fits the description of R1 who left the facility with family. V9 said he was not 100 percent sure if that was R1 because he was not familiar who R1 was. V3 said R1 got on the elevator, and she was busy passing medications. She was not paying attention who was getting on the elevator. R1 looks like a resident, and she is not safe leaving the building unsupervised. Increased supervision should have happened, those are the busiest times of the night, after the dinner meal. On 7/8/25 at 12:30 PM, V9 (Receptionist) said on 7/1/25, he was working at the front desk, he heard a code green overhead, and he received a call from V3 (RN) asking if he saw R1. V9 said he did recognize R1 by name, then looked her up in electronic health records and said he saw R1 leave the building with family. I assumed they were family because they were walking together. V9 said, (R1) looked normal to me. V9 said he could not recall about what time this occurred. He said there is an elopement binder at the front desk, with each resident's name and picture, but he had not seen R1 before and did not review the binder every shift. On 7/8/25 at 12:09 PM, V8 (CNA) said R1 was in the dining room during the dinner meal at 5:00 PM. About 5:45 PM, she left the dining room to assist other residents, R1 was still in the dining room sitting at her table. At 6:00 PM, she was in another resident room assisting with cares. About 6:30 PM, staff were looking for R1 and could not locate her. (R1) usually needs direction to get back to her room when leaving the dining room. There is usually someone supervising her to her to room. The activity aide should report to staff when a resident is leaving the dining room, so we are aware. I'm guessing she got on the elevator with 145403 Page 2 of 4 145403 07/10/2025 Alden Poplar Creek Rehab & Hcc 1545 Barrington Road Hoffman Estates, IL 60169

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few another resident's family because you need a code to get on the elevator and visitors are given the code.On 7/10/25 at 8:34 AM, V12 (RN) said on 7/2/25, he was R1's nurse after she returned back to the hospital. There was a concern she had fallen when she was found outside of the facility. They did x-rays and scans with no injury. (R1) is alert to self, she has a history of wandering into other resident rooms, and she needs to be directed and supervised. There is a reason why she is on a secured memory care unit, because she is ambulatory, she is at risk of eloping. You never know what's on her mind or what she is thinking.On 7/8/26 at 2:13 PM, V13 (R1's Power Of Attorney/POA) said she was out of the country when all this happened, but she received a call from the facility at 7:18 PM. They said they saw her last after dinner and thought she was with me. (R1) got on the elevator with another resident's family member. She called her other sisters to inform them of the incident. Her sister arrived in the facility about 7:45 PM, and the police had not been notified yet. Someone called the police and reported R1 was found wandering at the outside of the grocery store without her walker. They reported she fell because there was grass found in her hair. When R1 was living with her, she had an episode of eloping from her home, and that's when she was sent to the facility. She was no longer safe to be home because she needed more supervision. On 7/9/25 at 9:04 AM, V14 (R1's daughter) said, On 7/1/25 about 8:00 PM, I received a call from the facility asking me if my mom (R1) was with me. They said my mom (R1) had been missing since 7:30 PM. I was going to call my siblings to ask if they were with mom. My other sister arrived at the facility and asked if they had called the police yet. The facility had not notified law enforcement, which is a big problem, because my mom (R1) has dementia. My sister called the police and reported her missing, and they told her someone reported a wandering person at the local grocery store. My mom was sent to the local hospital for evaluation. When she arrived to the hospital, (R1) had grass clippings in her hair, and I was told (R1) was found on the floor by the paramedics. This was scary and nerve wracking. She got on the elevator and out the front door without anything alarming or anybody noticing she was a resident. They don't have a monitoring device to alert them someone is leaving their building; that should not be. I was concerned about her safety. She is not safe to be crossing that busy intersection. That's crazy she made it to the local grocery store in one piece she had to cross a busy intersection. The facility's Elopement and Management of Missing Resident Policy, dated 2023, states, Elopement is defined as a dependent (cognitively impaired, non-decisional) resident leaving a facility without staff awareness and under circumstances that place the resident's health, safety, or welfare at risk. Suspected Missing Resident. if a resident are unaccounted for, notify the Administrator and Director of Nursing. Direct all staff to make a thorough search of the building and external premises. In unable to locate the resident, call 911 to report the resident missing. Notify resident's legal representative/responsible party.complete incident report. Document accordingly in the medical record. The Immediate Jeopardy began on 7/1/25, and the deficient practice was corrected on 7/2/25, when the facility took the immediate actions to remove the immediacy. Abatement Plan was provided on 7/10/25. The facility implemented the following correction action/abatement plan after a meeting was conducted by the appropriate members of the Quality Assurance Performance Improvement (QAPI) committee. A head count was completed on all units to ensure no other Residents were affected. Everybody was accounted for. Completed 7/1/25.All facility door alarms were checked for proper functionality. All doors in working order. Completed 7/1/25 ongoing.All residents, including the resident in question, were assessed for exit-seeking behaviors. Completed 7/1/25.A body check and NP (Nurse Practitioner) evaluation completed upon return to facility. Completed 7/2/25.Resident care plan was updated pertaining to incident, and interventions added on 7/2/25.The Administrator, Nurse Consultant, and Medical Director reviewed 145403 Page 3 of 4 145403 07/10/2025 Alden Poplar Creek Rehab & Hcc 1545 Barrington Road Hoffman Estates, IL 60169

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the facility policies related to the occurrence: Door Alarms, Routine Resident Checks, Incidents/Accidents and Wandering. No changes were made. Completed 7/1/25.The DON (Director of Nursing, ADON (Assistant Director of Nursing), and Social Services/Designee reviewed and updated as needed related to patient safety care plans. Completed 7/2/25.The elopement binder was reviewed and updated on 7/1/25 and available at designated areas.All residents determined to have exit seeking behaviors have been evaluated for possible room change to the alarmed unit of the facility. Completed 7/2/25.All staff were in-service on the following topics: How to redirect residents that are wandering residents away from exits, how to promote safer outcomes for residents through supervision, answering door alarms promptly and reporting any changes in cognition or exit seeking behaviors to the nurse. Everyone that has worked has been in serviced. Inservice is ongoing until all employees have been educated.All staff and managers are being reeducated on routine resident checks, incident/accidents, wandering policy, and where to locate the at-risk elopement binders. Everyone that has worked has been in serviced. Inservice is ongoing until all employees have been educated.Pop quizzes are being completed by the staff to test competency on elopement, answering door alarms, change in cognition/exit seeking behaviors. Completion 7/2/25Elevator access code has been changed and only staff members have code. Staff will assist all visitors with elevator use. Visitors must sign in and receive a visitor badge to wear while in the building.A review of compliance using QA (Quality Assurance) tool for response to elopement and change in cognition and exit seeking behaviors completed on 7/2/25. Audits will be done daily for 1 month or until compliance is maintained.The QA meeting is held quarterly and as needed. An emergency QA meeting was held on 7/2/25 at 9am by the Administrator with the Interdisciplinary Care Team and Medical Director regarding the incident and to discuss the plan. QA Committee agrees with the plan above. 145403 Page 4 of 4