Inspection·April 29, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for elopement risk and the use of a departure alert system. This failure affects two (R1 and R3) of three residents reviewed for supervision in the sample list of three. Findings include: The facility Exit Seeking list dated April 2025 documents R1 and R3 as exit seeking. 1. A Progress Note dated 4/3/25, documents R1 found wandering near door at approximately 10pm with door alarming. Further documents R1 assisted back to bed and departure alert system placed around right ankle. R1's Care Plan (current) does not document R1 as an elopement risk or R1's use of a departure alert system until 4/29/25. R1's Physician Orders (current) documents the following order dated 4/29/25: check placement and functionality of departure alert system daily in evening. R1's Exit Seeking/Wandering Assessments dated 10/15/24 and 4/7/25 documents R1 is at risk for exit seeking/wandering. R1's Behavioral Notes dated 8/29/24, 12/28/24, 3/1/25 and 4/13/25 documents R1's wandering behaviors. 2. R3's Care Plan (current) does not document R2 as an elopement risk or R2's use of a departure alert system until 4/29/24. R3's Physician Orders (current) documents the following order dated 4/22/24: check departure alert system placement on right wrist every shift. R3's Exit Seeking/Wandering Assessments dated 12/2/24 and 2/26/25 document R3 is at risk for exit seeking/wandering. On 4/29/25 at 12:48pm, V10 MDS/Care Plan Coordinator confirmed R1 and R3's care plan was updated today (4/29/25) to include elopement risk/wandering/exit seeking and the use of a departure alert system. (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: 145708 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 145708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Health 2304 C R 3000 N Gifford, IL 61847 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)