Health 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. Page 1 of 2 145708 145708 04/29/2025 Country Health 2304 C R 3000 N Gifford, IL 61847

F 0656 Level of Harm - Minimal harm or potential for actual harm On 4/29/25 at 12:57pm, V11 Social Services Director stated it is the responsibility of V10, V11 and nursing for the care plans. V11 stated V11 was not able to put R1's elopement risk/wandering/exit seeking on R1's care plan until the Physician's order for the departure alert system is in place. V11 stated the order is what triggers the care plan to be updated. V11 confirmed the order was just placed today for R1's departure alert system and that is why R1's care plan did not include that care area and interventions. Residents Affected - Few The facility Missing Resident/Elopement Policy dated July 2024 documents the following: Cognitive assessments and concerning activity log may be utilized to customize individual service/support plans. This information will be documented in the resident's medical record and used in the service/support planning process. 145708 Page 2 of 2