Health inspection·September 16, 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. Based on interview and record review the facility failed to immediately verify a resident (R1) had not eloped from the facility after an exit door alarm sounded. The facility alos failed to supervise a resident (R1) in a manner to prevent that resident from eloping from the facility. These failures apply to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3. The findings include: R1's progress notes dated 9/8/24 showed R1 was found outside of the facility around 1:30 AM. The notes showed R1 was last seen in bed by staff at 12:45 AM. The notes showed, At 1:12 AM, a (first-floor) door alarm was going off for the northwest courtyard door. Checked the door, no one seen outside, but is was dark. At 1:15 AM, resident not found in bed or bathroom . Search for resident commenced. Resident was seen though window . outside (of facility) by northwest courtyard . The notes showed staff immediately brought R1 back into the building. R1 appeared confused. R1 sustained no injuries or falls during the elopement. R1 was placed on every 15 minutes checks by staff, a wanderguard was placed on R1, and a bed alarm was reconnected on R1's bed. R1's physician and POA (power of attorney) were notified of the incident. R1 made no additional attempts to leave the facility on 9/8/24. On 9/8/24 at 7:10 AM, R1 was sent to a local hospital for a psychiatric exam. R1 did not return to the facility. R1's hospital records dated 9/4/24-9/6/24 were reviewed. The notes showed R1 was cognitively intact. R1 resided in his own home prior to his hospitalization for his elective hip surgery. The hospital records showed no documentation of R1 attempting to elope or exit the hospital during his stay. R1's admission note dated 9/6/24 showed R1 was admitted to the facility, from a local hospital, for short-term rehab and therapy. The note showed R1 was cognitively intact. R1's progress notes dated 9/6/24-9/7/24 showed no documentation of R1 exhibiting any exit-seeking behaviors. On 9/16/24 at 8:09 AM, V4 CNA stated she was R1's CNA from 2:30 PM on 9/7/24 until 7:00 AM on 9/8/24. V4 stated she repositioned R1 in bed around 12:45 AM on 9/8/24. V4 stated, He was alert, not confused for me. Around 12:55 AM, I let the other CNA know that I was going on break. She was on the other wing. I was getting on the elevator, a little after 1 AM, when I heard the door alarm go off but I couldn't stop the elevator door from closing so I went upstairs and did what I had to do. When I came back down (to the first floor), the door alarm was off. I started checking rooms on my floor. That's when I couldn't find (R1) in his room . That's when I let the other staff know he was missing. We started searching the building . (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: 145652 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 145652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley HI Nursing Home 2406 Hartland Road Woodstock, IL 60098 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)