Inspection·December 5, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse policy by not ensuring R7 was free from verbal abuse by V18 (nurse). This failure resulted in V18 engaging in a loud verbal abusive argument resulting in R7 feeling threatened and belittled like a child. In addition, the facility neglected to ensure V18 provided care according to professional standard for R2 and R12 who had the diagnosis of Respiratory Failure with attention to Tracheostomy by not providing suctioning as needed. This neglect resulted in R2 having difficulty breathing. R12 having low oxygen saturation of eighty percent (88%). V18 also neglected to administer R6's nightly prescribed long-acting insulin as scheduled for 4 of 4 residents reviewed for abuse in a total sample size of 12. Findings include:On [DATE] at 11:44AM, R6 (R7's roommate) who was assessed to be alert and oriented to person, place and time said, V18 was yelling at R7. R6 said, V18 engaged in confrontational, loud, unprofessional argument with R6. On [DATE] at 1:27pm, R7 who was assessed to be alert and oriented to person place and time said, V18 (nurse) was verbally aggressive and combative when R7 wanted to go smoke prior to taking her evening medication. R7 said, she went outside to smoke and returned. R7 said, V18 came to her room at 10:00pm to administer medications. R7 said, V18 was argumentative, loud and verbally abusive without provocation. R7 said, V18 continued to call her another name despite being told R7's name. R7 said, V18 yelled at her about being impatient in the harshest threatening tone. R7 said, V18 snapped and she spoke to her like she was nobody, R7 said, V18 was yelling like she owned the facility, R7 was a child, and she felt threatened and belittled. On [DATE] at 2:53pm, V4 (nurse) said, when she arrived on the unit with her coat and bags, residents were asking for her to come to their rooms. V4 said, she told the resident to check with their current nurse because needs to get report first. V4 said, V18 started yelled at her without provocation. V4 said, V18 yelled at her and stated, she could not stand V4 and V4 got on her f****** nerves, and other abusive words included talking about V4's deceased parents at the nursing station. V4 said, R7 told her V18 was rude to her and called her out of her name. V4 said, R7 would not elaborate on the name calling. On [DATE] at 5:08pm, V2, Director or Nursing (DON) said, she was informed V18 demonstrated inappropriate nursing care. V2 said, V18 was terminated for conduct issues, being rude and discourteous behavior to staff and a family member. V2 said, if someone said, V18 did something, V18 did it. On [DATE] at 5:17pm, V1 (administrator) said, if a staff member was arguing loudly and being confrontational with a resident it is considered poor nursing and verbally abusive. Statement dated [DATE] document: R7 stated that V18 was rude to her and called her out of her name.R2 was diagnosed with acute and chronic respiratory failure with hypoxia and attention to tracheostomy. R2's care plan dated [DATE] documents: R2 is at risk for complication related to tracheostomy. Interventions: Daily trach care as needed. Monitor for secretions and suction as needed. R12 was diagnosed with respiratory failure with attention to tracheostomy. Requested for R12's care plan from facility. R12's care plan was not submitted during the survey.On [DATE] at 12:30PM, R2 was asked what happen with staff and his tracheostomy. R2 who was assessed to be alert and oriented to person, place and time wrote, he could not breathe, V18 did not suction his trach. R2 wrote, he started to panic. R2 wrote he tried to pull his call light, but it did not work. R2 wrote he may need suction once a day or less.On [DATE] at 2:53PM, V4 (nurse) said, R2 and R12 both reported V18 did not provide tracheostomy care. V4 said, she assessed both resident and tracheostomy care was not provided. V4 said, V18 was the assigned nurse. V4 said, R2 wrote, V18 did not suction his tracheostomy the entire shift. V4 said, R2 also wrote, that he pulled the call light, but it did not work. V4 said, R12 who could talk said, she could not breathe. V4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145424 If continuation sheet Page 2 of 7 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 145424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Richton Park Rehab & Nsg Ctr 22660 South Cicero Avenue Richton Park, IL 60471 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete said, R12 reported that V18 did not suction her tracheostomy. V4 said, R12 oxygen saturation was eighty eight percent (88%) which was low. The normal levels are between 94-100%. Levels below 90% requires medical attention. V4 said, R12 no longer resides at the facility. V2 said, she was notified by V4 via text about V18 on the night she found the residents without care and wrote a statement after the holiday. Nursing note dated [DATE] documents: R2 in bed with eye opened, Alert and oriented x 2-3 Head of the bed was flat, Writer elevated the head of the bed and observed that the Trach area is messy and nasty, and full of secretion. R2 pointed at the trach site, Writer asked him to write it down because she could not understand what that means by pointing at the Trach area. R2 wrote down on the white board that he needs to be suctioned and has not been suctioned. R12 in bed with eye opened, alert and oriented times three. Head of the bed elevated. R12 stated that she is not feeling the oxygen coming through and has not been suctioned through the shift. Oxygenation checked, R12 was sating at 88%. R6 had the diagnosis of Diabetes. Brief interview for mental status dated [DATE] documents a score of fourteen which indicates cognitively intact. R6's medication administration record dated [DATE] documents: Inulin Glargine-Inject 25 units subcutaneously at bedtime for diabetes. 2= drug refused, anl1- V18 initial). On [DATE] at 11:44AM, R6 who was assessed to be alert and oriented to person, place and time said, she was lying on her side after having a bowel movement. R6 said, V18 came into her room to take her glucose level. R6 said, she did not want to move to prevent from making a bigger mess, so she stuck out her hand towards V18 in order to get her blood glucose level taken. R6 said, V18 got an attitude, walked out and slam the door extremely hard without taking her blood glucose level or giving R6 her prescribed insulin. R6 said, she did not refuse her medication. R6 said, she knows the importance of taking her insulin. R6 said, she texted V25 (scheduler) to inform her that V18 did not give her insulin.R6 showed surveyor a text thread on her phone. R6's text dated [DATE] at 9:34pm documents: did not get my night meds. On [DATE] at 2:53PM, V4 (nurse) said, R6 reported, V18 (nurse) did not take her blood glucose or give her bedtime insulin.Nursing note dated [DATE] at 23:48 (11:48pm) documents: Resident (R6) in the room at the start, alert and oriented, sitting on her bed writer greeted the resident and she responded. The resident requested that the writer check her blood glucose. This writer asked the resident the reason she wanted her blood sugar checked at the time because she's not scheduled, and the writer cannot document it. The resident stated that her sugar was not checked and did not get her insulin. This writer checked the resident and her blood sugar was 251, 3 unit long-acting insulin given. Abuse Prevention Programs dated 1/2025 documents: The facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other resident, consultants, volunteers and other staff of other agencies, family members, legal guardian, friends or other individual. Verbal abuse: any use of oral, written, or gestured language that includes disparaging and derogatory term to residents or their families, or within their hearing distance to describe resident, regardless of their age, ability to comprehend or disability. Abuse Prevention Programs dated 1/2025 documents: The facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other resident, consultants, volunteers and other staff of other agencies, family members, legal guardian, friends or other individual. Neglect/mistreatment means the failure to provide, or willful withhold of adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident. Event ID: Facility ID: 145424 If continuation sheet Page 3 of 7 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 145424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Richton Park Rehab & Nsg Ctr 22660 South Cicero Avenue Richton Park, IL 60471 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their treatment/services to prevent/heal pressure and non-pressure wounds policy for one resident (R3) with multiple pressure sores by not following physician recommendations/orders for wound treatments, failing to document treatments administered and failing to document weekly measurements/assessments of wounds for one of three residents reviewed for wound care. Findings include:R3's was admitted to the facility on [DATE] with a diagnosis of type II diabetes, protein malnutrition, dependance on ventilator, muscle wasting and anxiety.R3's plan of care dated 9/17/24 documents: R3 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to: Impaired Cognition, Impaired Communication, Incontinence of bladder, Incontinence of bowel, Impaired Mobility Status, Impaired Nutritional Status, Diabetes, Comorbidities. Interventions include: Weekly measurements and documentation and Administer Wound Care (Treatments) per MD orders dated 9/17/24.R3 wound notes by V20 (wound MD) dated 7/31/25 documents wounds on sacral stage 4 pressure sore measuring 6.5 centimeters (CM) length x7.5 CM width x1.8 CM depth: treatment orders document: daily clean with saline, apply metronidazole 0.75%, calcium alginate and secure with foam dressing.R3's wound notes by V19, Nurse Practitioner (NP) dated 8/5/25, 8/12/25, and 8/19/25 documents: sacral stage 4 pressure sore wound measuring 7CMx 7.5x2. Treatment order documents: cleanse with wound cleaner, Dakin's gauze cover with abdominal pads secure with bordered gauze daily.R3's treatment administration record for August documents: sacrum leave allograft/contact layer on at least 3 days cleanse with normal saline, adaptic calcium alginate metrocream and cover with dry or foam dressing every day with start date of 6/5/25. Treatments not documented on 8/1, 8/3-8/8, 8/11-8/14, 8/18, 8/20-8/21.R3 wound notes by V20 (Wound MD) dated 7/31/25 documents head occipital stage 4 pressure sore measuring 12.5CMx 11.5 CMx0.8CM. Treatment orders document daily: clean with dakins, apply metronidazole cream 0.75% on calcium alginate secure with 4x4 gauze and abdominal pads.R3's wound notes by V19 dated 8/5/25, 8/12/25, and 8/19/25 documents: occipital wound stage 4 pressure sore measuring 12.5CM length x 11.5 CM width x0.8CM. treatment orders cleanse with wound cleaner, dressing applied hydro-feral blue foam and cover with abdominal pads and secure with gauze dressing daily.R3's treatment administration record for August documents: back of the head: cleanse with vashe. apply adaptic and vashe soaked gauze and cover with foam dressing. Wrap with kerlix daily with start date of 6/5/25. Treatments not documented on 8/1, 8/3-8/8, 8/11-8/14, 8/18, 8/20-8/21.R3 wound notes by V20 dated 7/31/25 documents left posterior knee stage 3 pressure sore measuring 1.7CMx 1.5x0.1 treatment orders document clean with normal saline, leave allograft/contact layer hydroferra blue and cover with dry dressing every other day.R3's wound notes by V19 dated 8/5/25, 8/12/25, and 8/19/25 documents: wound left knee stage 4 pressure sore measuring 1.7CMx1.5x0.2. No treatment/dressing orders documented.R3's treatment administration record for August documents: left posterior knee clean with normal saline, apply adaptic calcium alginate cover with foam dressing/or bordered gauze daily with start date of 6/5/25. Treatments not documented on 8/1, 8/3-8/8, 8/11-8/14, 8/18, 8/20-8/21.R3 wound notes by V20 dated 7/31/25 documents right ischium stage 3 pressure sore measuring 7CMx6x1.6 daily half strength dakins apply gentamycin calcium alginate and cover with foam island.R3's wound notes by V19 dated 8/5/25, 8/12/25, and 8/19/25 documents: right ischial stage 4 pressure sore ischial stage 7CMx6x1.6cm. Wound treatment: cleanse with wound cleaner, dakins gauze packing.R3's treatment administration record for August does not document any treatments for right ischial area.R3 wound notes by V20 dated 7/31/25 documents right posterior thigh proximal measuring 5CMx 1 x0.1 with treatment daily normal saline cover with xeroform; right posterior thigh distal measuring 0.6CMx0.8x0.1 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145424 If continuation sheet Page 4 of 7 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 145424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Richton Park Rehab & Nsg Ctr 22660 South Cicero Avenue Richton Park, IL 60471 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with treatment to clean with normal saline cover with xeroform.R3's wound notes by V19 dated 8/5/25, 8/12/25, and 8/19/25 documents: right thigh posterior stage 4 pressure sore measuring 5CMx1x0.2. Treatment documents: calcium alginate packing daily, clean with wound cleanser.R3's treatment administration record for August documents: right inner thigh monitor and off load daily. Treatments not documented on 8/1, 8/3-8/8, 8/11-8/14, 8/18, 8/20-8/21. There are no other treatments documented for right thigh area.R3's treatment administration record for August documents: left forehead, cleanse with normal saline and apply xeroform place dressing daily every Monday, Wednesday, and Friday. Start date 3/12/25. Treatments not documented on 8/1, 8/4,8/6, 8/8, 8/11,8/13, 8/18, 8/20.There are no assessments or measurements for left forehead wound in R3's medical record.R3's hospital record dated 8/23/25 documents: open area to left head measuring 1CM x 2 x 0.1.On 12/4/25 at 10:39AM, V2, Director of Nursing (DON) said wound care treatments are documented on the treatment administration record. Staff are expected to sign off after the treatment is completed. V2 was asked what if they record is blank what does that indicate. V2 said that the treatment was not done because if it is not documented than it was not completed.On 12/5/25 at 11:58AM, V2 and V6 (Wound Nurse) were asked to verify R3's treatment orders compared to the wound doctors' notes (8/5, 8/12 and 8/19). V2 and V6 were unable to find the orders the doctor recommended in his notes on R3's treatment record. V2 said she was unsure why the orders did not match but said the nurse is responsible for updating the treatment orders after the wound specialist visits. V2 was unable to find any documentation of treatments administered to R3's right ischium or thigh. V2 was unable to find any documents related to R3 left head wound beside the treatment record.On 12/5/25 at 2:41PM, V2 said she was unable to find any documents related to R3's left head wound, and treatment record order was old and should have been discontinued. V2 denied R3 having any open wound to her forehead.On 12/5/25 at 3:45PM, V22 (Medical Director) said he would expect the orders documented in R3's wound notes to be followed and documented.V19 (Nurse Practitioner, NP) interview was attempted but not available during the survey.Facility policy titled Treatment/Services to prevent/Heal pressure and non-pressure wounds with reviewed dated 11/2/23 documents: it is the policy of the facility to ensure it identifies and provides the needed care and services that are resident centered, in accordance with the residents preferences, goals for care and professional standards of practice that will meet each residents physical, mental and psychosocial needs. The pressure and non-pressure wounds will be valuated weekly by the wound care nurse and or wound care specialist. Documentation will be completed by the wound care specialist weekly with who they follow and uploaded into the electronic medical record under documents. If the wound care specialist does not evaluate the wound the wound care nurse will than fill out the weekly wound assessment in the electronic medical record. If the wound care specialist changes any treatments or indicates other interventions the wound care nurse will put these orders in the resident's electronic medical record.Facility policy titled Guidelines for nursing documentation dated 5/17/23 documents: Remember if you did not write it down, you did not do it. If you did not do it, you were negligent. Event ID: Facility ID: 145424 If continuation sheet Page 5 of 7 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 145424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Richton Park Rehab & Nsg Ctr 22660 South Cicero Avenue Richton Park, IL 60471 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 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 supervise R9 who was identified as high risk for elopement and moderate risk for wandering during a smoking break. This failure resulted in R9 climbing on top of a gazebo, jumping a fence, leaving the facility unauthorized without a pass, sleeping in an abandoned home with no utilities and on a train station platform for six days in cold inclement weather for one of one reviewed for supervision. Findings Include:R9 was admitted on [DATE] with the diagnosis of acute respiratory failure, pneumonia, asthma, hypertension, anemia and sleep apnea. R9 brief interview for mental status score documents 14/15 which indicates cognitively intact.R9's wander risk assessment dated [DATE] documents a score of ten (10) which indicate a moderate risk for wandering. R9's wander risk assessment dated [DATE] documents a score of fifteen (15). Score eleven and above indicate high risk to wander.R9's elopement risk review dated 10/10/25 documents high risk for elopement. Resident tried to escape through exit door 10 minutes after arriving at the facility.R9's care plan did not document any plan of care or interventions for elopement.On 12/4/25 at 3:25pm, R9 who was assessed to be alert and oriented to person, place and time said, during the 1:00pm smoke break, V12 (Activity Aide) gave him his cigarettes, and he went out on the patio to smoke. R9 said, V12 was in the building inside in the doorway and no staff was on the patio during his smoking break. R9 said, he got on top of the gazebo and hopped the fence on 11/27/25 Thanksgiving Day. R9 said, he fell and hurt his back when he jumped over the fence. R9 said, he lived near the facility in the past and his house was within walking distance of the facility. R9 said, he went to his house which was abandon with no working utilities and he slept inside his previous home until it became too dark and cold. R9 said, when he left his house, he slept outside at the train station because it had heated areas. R9 said, he wore three or four shirts, two pair of pants, two jackets and a vest. R9 said, he went back to the facility on Saturday 11/29/25 because he did not have anywhere else to go. R9 said, he was cold, dirty and smelled, but he was told by the facility receptionist (name unknown) that he could not come back until the head nurse returned to work. R9 said, he jumped the fence because he was told he could not have a pass unless someone signed him out of the building. R9 said, he did not have anyone to sign him out, it was an emergency, and he needed to see his family. R9 said, he was told he could not have a pass due to not being in the facility long enough.On 12/04/25 at 4:00pm, V12 (Activity Aide) said, she was the only activity aide monitoring R9'a smoking break. V12 said, she passed out cigarettes, open the patio door and light the cigarettes for the residents. V12 said, it was about ten to fifteen residents outside smoking. V12 said, if the weather is cold, she will stand in the doorway inside the facility. V12 said, she was not on the patio monitoring the residents smoking. V12 said, it was cold and she was inside the building in the doorway. V12 said, she was informed R9 jumped over the gate by R10. V12 said, she would have not known R9 was gone if R10 did not inform her. V12 said, nothing new had been implement since R9 jumped the fence. On 12/5/25 at 1:36pm, R10 who was assessed to be alert and oriented to person, place and time, said R9 stood on crate, jump on the gazebo railing and pulled himself up over the fence. R10 said, he finished his cigarette and then told V12, R9 jumped over the fence. R10 said, residents were standing inside of the gazebo smoking. R9 was at the back of the gazebo behind all the residents. R10 said, V12 was in the entrance way at the patio door. On 12/3/25 at 3:51PM, V13 (Nurse) said, R9 jumped over the fence. V13 said, a code was not called. V13 said, five residents coming off the elevator reported R9 left. V13 said, she could not recall the five resident's names. V13 said, she was the first nurse who was notified R9 left. R9 was chipper the day before he left. V13 said, R9 asked, if he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145424 If continuation sheet Page 6 of 7 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 145424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Richton Park Rehab & Nsg Ctr 22660 South Cicero Avenue Richton Park, IL 60471 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete could go out on pass the day he left. V13 said, R9 did not have an independent pass privilege. V13 said, R9 had not been admitted long enough to have an independent pass. V13 said, R9 reported he lived around the corner from the facility a few weeks before he left.On 12/4/25 at 5:18pm, V1 (Administrator) said, R9 jump the fence. V1 said, R9 did not elope. V1 said, R9 leaving was an unauthorized departure. V1 said, R9 was street savvy and responsible for himself. V1 said, the facility did not call R9's family. V1 said, the police were contacted. V1 said, R9's girlfriend was called. V1 said, R9's girlfriend number was not on R9's face sheet. V1 said, she guesses someone found R9's girlfriend's number but no one located a previous address for R9. V1 said, R9 summary episode has R9's previous address listed. V1 said, the police were familiar with R9 and was not concerned about his departure. V1 said, R9 came back because he didn't have anywhere else to go. V1 said, a resident can get a pass after being in the facility for twenty-one days.On 12/04/25 at 3:25pm, V15 (R9's family) said, she was not informed R9 left the building until she went to visit on Saturday (11/29/25). V15 said, at that time, she was informed R9 jumped over the fence on Thursday. V15 said, the receptionist, name unknown, informed V15 that R9 came back to the building before she arrived on Saturday and left. On 12/04/25 at 3:31pm, V21 (R2's family) said, she unaware that R9 left the building until being informed by V15 on Saturday. V21 said, we did not know where R9 was. V21 said, we started calling people to locate R9.On 12/4/25 at 5:25pm, V2, Director of Nursing (DON) said, when R9 came back, he looked bad. V2 said, R9 had on the same clothes that he left in and needed a shower.On 12/4/25 at 2:53 pm, V4 (Nurse) said, R9 was unkempt, dirty with mud all over his clothes. V4 said, R9 smelled and looked like he was homeless when he returned.On 12/4/25 at 5:32pm, V2 said, residents are not allowed to smoke unless staff is present. V2 said, staff should be present to pass out cigarettes and monitor the resident for safety while they smoke. V2 said, she expects staff to be outside on the patio monitoring residents for safety during smoking breaks. V2 said, one staff member is assigned to smoke breaks.On 12/5/25 at 1:40 pm, Surveyor observed Smoking patio that is surrounded by 6-foot wooden fence. Large area with patio and gazebo within the fenced area. The entrance/exit door is more than 10 feet away from the gazebo. There was a small black milk crate behind the gazebo on the facility's smoking patio.Hospital paperwork dated 12/3/25 document: R9 was seen for shortness of breath.R9's progress notes dated 11/27/25 documents: during the scheduled smoke break, resident was observed by several residents, jumping the fence and running down the alley, resident is alert and oriented x4, police called, director of nursing and administrator notified.V12's witness statement dated 11/27/25 documents: This was during smoke break, everyone but R9 and a few other residents were still outside for smoke break. I turned my back from the door to go back to the cigar box then R10 came to the door to tell me that R9 had just jumped the fence.Weather reports documents the following: November 27, high 34 degrees Fahrenheit low 18 degrees Fahrenheit, November 28, high 34 degrees Fahrenheit low 18 degrees Fahrenheit, November 29, snow high 28 degrees Fahrenheit low 22 degrees Fahrenheit, November 29,snow high 29 degrees Fahrenheit low 14 degrees Fahrenheit, December 1st, high 29degrees Fahrenheit low 19 degrees Fahrenheit, December 2nd , high 20 degrees Fahrenheit low 17 degrees Fahrenheit, December 3rd , high 28 degrees Fahrenheit low 7 degrees Fahrenheit.Facility policy undated titled: Policy and procedure regarding missing residents and elopement documents: it is the policy of the facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. All residents assessed to be at risk for elopement will have the issue addressed in their plan of care.Facility smoking policy dated 1/25 documents: all residents will be under supervision while smoking. Resident must remain with in eyesight of the smoking monitor no more than 8-10 feet away. Event ID: Facility ID: 145424 If continuation sheet Page 7 of 7