Inspection·February 9, 2024

F 0689 in the bushes in the courtyard. Level of Harm - Minimal harm or potential for actual harm Facility Daily Activity Report, dated November 17th, 2023, notes at 4:28 AM, notes skilled nursing 1J alarm was going off. V6 (Security Officer) responded and turned the alarm off. There was no sign of anyone outside of the door or inside. At 5:00 AM, skilled nursing department called the independent living desk stating R1 was missing. At 5:02 AM, a resident was missing from center. V6 reviewed the camera and found R1 in the garden area. Residents Affected - Few On 02/08/2024, at 12:26 PM, R1 stated, I remember leaving the building. I don't know why I wanted to leave. Something went wrong. I am awake a lot. It is hard to sleep. I cannot always remember names. I have a hard time hearing. On 02/08/2024, at 12:26 PM, V2 (R1's Resident Companion) stated, She has dementia and is hard of hearing. I just try to make the best life that she can while she is here. I usually stay with her for four hours. Sometimes its longer and sometimes its shorter. Some nights are hard for her. She is up a lot. On 02/08/2024, at 12:40 PM, V3 (Registered Nurse) stated, The [NAME] stairwell and elevator require staff badges to open them. All the floors have dementia residents. It is not just this floor. Before anyone gets outside the building there should be security at the front. I have taken care of R1. She is confused, but pleasant. She will say when she feels confused. She is in a wheelchair. But she can walk with a walker with supervision by one person staff. If I see the resident, I will try to redirect the resident if he/she got on the stairs or the elevator. A lot of the residents on this floor require redirection. There are alarms on the floor. There are bed and chair alarms. Certain residents have this. The elevator and door need badges and frequent rounds. If the resident tries to open the door to the stairwell or get on the elevator there is a loud alarm. Staff run to the alarm go to the stairs. Checks are supposed to be done up and down the stairwell. If I cannot find the resident, I ask the aides to check their residents. Staff are supposed to round on the residents every 15 minutes. On 02/08/2024, at 1:37 PM, V4 (Agency Certified Nursing Assistant) stated, I aware of R1. I was working as an aide that night on the second floor of the facility. I was working the night shift. I was doing rounds when I was alerted that a patient was missing from the floor. I became aware of this when other people were looking for her. I found out about it from another aide and a nurse. I do not recall if I was her aide that shift. When I was working agency, that was my first time working there when an elopement had occurred. I have only been to the facility a couple of times. I was not trained at the facility on how to handle an elopement. I recall seeing R1. She got up a few times. The aide put her back to bed. The very last time I saw her, the aide had put her back to bed. I do not remember the name of the aide. I was agency and I did not have a badge. I will ask staff to let me back in. I do not recall hearing any alarms going off while making rounds and providing care to the residents. Once staff and I found out she was missing we were very diligent looking for her. If I heard the alarm, I would just keep searching resident rooms and keep an eye out to see if she showed up again. On 02/08/2024, at 1:53 PM, V6 (Security Officer) stated, I have been the security officer for about a year. That night I was at the independent living desk. A nurse or aide called me on the phone and stated that a resident was missing; R1. There are cameras on the assisted living, independent living, and skilled doors. Usually, I keep the camera on the parking lot. I reviewed the camera and saw that R1 had exited through the independent living entrance leading towards the courtyard. There are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 2 of 5 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 alerts that go on the screens. I did not see any alerts because I was doing rounds. I did hear an alarm before going off in that section. I looked but I did not see anyone. I assumed it was a worker that left because I did not see anyone. It was going off by the independent living restaurant. There was another guard at the independent living desk. It was V7 (Security Officer). I went back to the desk a few minutes later. I reviewed the camera footage and saw that R1 had eloped. The alarm is set off all the time. I try to check it all the time. When they called me, I was at the independent living desk. Right away, I called the nurse, and we went after her through the independent living courtyard door. She was in the bushes or shrubs. It was dark outside. It was around 5:00 AM. It looked like she was kneeling or sitting. She was upward. She was agitated. She was saying things like you call yourself a police officer. The nurse got the wheelchair and brought her back in the facility and alerted the family. I work for an outside company. There are fifteen points (scanning points) that I have to monitor. The stairwells are part of the scanning points. The assisted living and skilled have nurses and aides are supposed to monitor the residents. On 02/08/2024, at 2:09 PM, V7 (Security Officer) stated, I can recall the incident. I can recall, it must have been early morning. One of the nurses asked me if I saw anyone leaving out the entrance door. I said no. Someone told me that there is a resident missing. The Nigerian nurse. We looked down in the basement, all the floors, and independent living. We did not see anyone. In the meantime, I called V6, the lead guard with the computer information. He was aware that we had a missing resident in the facility. I asked V6 if he could get the cameras back to the time the resident went missing. V6 called me back. The pharmacy guy was in the building in the same area. V6 went back further in the footage and thought he saw someone leave out the exit door. I went back to the front desk, and he went out where the pharmacy guy was. The door alarm went off. The pharmacy guy would not go out that way. We realized that it must have been whoever went out that door. I have been at that facility going on two and half years. When I do rounds, we monitor the stairwells as well. I did not hear the alarm. I was a rover. I check all the physical handicap button when they go off for independent living. The rover gets the information back to the lead guard. My little camera only covers the outside facility and the streets. The main camera covers everything. But you cannot watch everything at the same time. I believe where I am, there should be a bigger camera for monitoring. There should be more visibility. If the nurse hears the alarm, they should be answering them and alerting us. We are the only guys at night. There is more help during the day. On 02/08/2024, at 2:38 PM, V8 (Director of Nursing) stated, It is a collaborative effort between the administrator and me. We talked to staff, reviewed cameras, and talked with the security guards. The error found was there was no follow through by the staff member. The staff member acknowledged that the alarm was going off. The alarm was going off in the stairwell. R1 went down the stairs. Staff did not look in the stair well or look upstairs or downstairs. The staff did not tell me why. The alarm was addressed. Pharmacy had arrived to deliver medication. Staff was not aware that the resident was missing from the common room. They initiated a search on the unit. One of our nurse managers, initiated her search as well. They notified security. When we were reviewing the videos, R1 missed the security guard by a split second. The security guard noticed the alarm was going off. He went out to check and did not see anyone. The nurse manager found R1. The resident was in the bushes off the courtyard. She was laying on the ground. I believe she fell outside or into the bushes. That part we could not see in the camera so we could not tell. Staff attempted to do an assessment on her after she was found but she refused. She must have been agitated. She can be difficult to redirect at times. The alarm system has always been there on the second floor. Anyone can get on the unit but must be badged to leave. It is in place if the door is opened. If a resident is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 3 of 5 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 attempting to elope, it alerts staff. It is loud when it goes off. It is hard to ignore it. It is there to keep the resident safe. If they hear the alarm going off, they are supposed to investigate to see who triggered it. The assumption was the pharmacy guy set it off because he went that way. R1 went down the stair well. R2 was coming up corridor but the pharmacy guy was already on the unit. In my opinion, the staff could have investigated the alarm better. Residents Affected - Few On 02/08/2024, at 3:00 PM, V8 took surveyor the same way R1 took when R1 eloped from the facility. V8 pushed the door open on the second floor. This is where R1 resided. The alarm went off loudly and there was a blue flashing light. V8 took surveyor down the stairs to the door 1st floor stairwell door. V8 pushed the door open. The alarm sounded loudly, and a blue light flashed. Lastly, V8 took surveyor to the 1st floor door that led to the outside. V8 pushed the door. The alarm sounded loudly and there was a blue light flashing. R1 was able to get through three separate door alarms before R1 eloped from the facility. On 02/08/2024, at 3:07 PM, V1 (Administrator) stated, V8 told me that V5 (Registered Nurse) called him and told him what had occurred. V8 told me that R1 had eloped and that she was on the way to the hospital. A thorough investigation was completed. R1 was up and about. V9 (Former Certified Nursing Assistant) went to go change someone. R1 proceeded towards the door. At the same time the pharmacy came up and was trying to get V10's (Former Registered Nurse) attention. Then, R2 came out of her room. When staff went to investigate the alarm, it seemed as if R2 set the alarm off because she was standing in front of the door. The door was closed, and it was going off. V10 looked like he checked the pharmacy drugs. Shortly after staff noticed that R1 was not where she was supposed to be. They searched the unit first. Then, V10 went down to the first floor. He was searching for her. Security was doing his rounds and went out the door. He did not see anyone and shut the alarm off. He stated he presumed it was the pharmacy as well. Security should have come and reviewed if it was the pharmacy person. The security system was upgraded to the badge system because residents could learn the codes. The purpose for the alarm is to alert staff if someone is trying to leave the unit. I expect staff to go down the stairwell to see who went down the stairwell. V10 shut the alarm off and then was looking for R1 on the floor. The alarms are there to keep the residents safe. All my staff was in serviced on what to do about elopements before and after the incident occurred. On 02/09/2024, at 3:19 PM, V10 stated, I remember the facility was short staffed. There were high fall risks on the unit. I passed part of my medications. I returned to the nurse's station. The resident in question (R1) was being combative. There was no communication that she was trying to elope for the past two days. I found out from other staff about that. Nothing was done about it. I worked part time. This incident happened Tuesday. She was trying to get out bed and the bed alarm was going off. I asked the aide to bring her to the common room. She was sitting in the recliner. There was another high fall risk resident that pulled the call light. The aides were busy. I rushed down to the resident to make sure she did not fall. I helped that resident to the bathroom. I returned to the nurse's station to chart. The high fall risk resident pulled the call light again. I had to help the resident out of the bathroom and into bed. When I was coming back, I saw the medicine delivery guy. The door was beeping close to the elevator. His English was not very good. I assumed that he came through the door that was beeping. I used my badge to stop the beeping. I checked the stairs and there was no one there. R1 was not on the unit. I told the aide that we should look for the resident and stop what they were doing. We were checking on the floors and she was not there. I told security to check the stairs and they did not see anyone. Not long after that, the second security guy checked the camera again. He found out that R1 walked through the service door. Me and the security guy checked the ground floor. The wound nurse was at the facility at that time. She found R1 outside. When I got there, R1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 4 of 5 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 145904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smith Village 2320 West 113th Place Chicago, IL 60643 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 kneeling and was combative. R1 was saying, leave me alone I just want to leave. I put R1 in a wheelchair and took her to the floor. R1 was still being combative. I called 911 and she was transferred out. When the door is being opened, the alarm will go off. Without a badge, the door can be opened but it will be beeping. I was not sure if the medicine guy came through the stair's door or the elevator. I was in another resident's room providing care. I think R1 snuck down on the elevator. I do not know how she opened the door and left the floor. I worked with her before. This night it was one nurse and two aides for at least thirty residents. I did receive training on elopement, but it was long ago. On 2/09/2024, at 4:19 PM, V9 (Former Certified Nursing Assistant) stated, I came in on my shift from 10:30 PM to until 6:30 AM. Prior to me coming in, R1 was being noncompliant and giving the last shift a hard time. When I came in, she was sitting in a chair, by the television. She was sleeping. V10 stated he would watch her. She was fully clothed. She was handed off to me. The previous shift knew this patient was being non-compliant earlier. There was an aide sitting with her before I started my shift. There was one nurse and two aides. R1 should have been given a sitter. I had fifteen patients. I got an agency aide due to the staffing. Two months prior to this incident, I contacted my director of nurses and asked for more help. He hung up on me. They expect us to take care of all these patients with two aides and one nurse. The male nurse was supposed to be watching the resident. He told me to go do my rounds. Around 1:00 AM, R1 woke up. I took her back to her room and changed her. I brought her back up front. She would not sit down. I walked her up and down the halls. The nurse tried to give her some medication, but she refused. I was done with my rounds, and I started to chart. She fell asleep. I took my break, and the other aide watched her. When I was doing my rounds, somehow, she got out. When she did get out, I tried to call the nursing supervisor, but she was nowhere to be found. They started looking for her. R1 was found outside. It is hard for the nurses to watch these residents. I never heard an alarm going off because I was taking care of my patients. The facility let me go because she got out. They cannot expect us to do everything. I have heard that another resident got out. I do not know if it is true, but this is what I have heard. There are not enough cameras to protect these residents. I feel bad for R1, but I can only do so much. I alerted administration about staffing, but they hang up on me. If I had heard the alarm, I would have seen what was going on. If a sitter was put with this resident, this would not have happened. Facility final investigation dated 11/20/2023, notes the investigation notes that the alarms were fully functional. When the alarm was triggered, V10 responded and disarmed the alarm without investigating who set the alarm off. Facility procedure titled Code Purple: Resident Elopement, undated, notes to prevent elopement answer all alarms immediately. Do not assume someone else will answer it. This is an alert that something is wrong. When alarms go off check the entire stairwell. Facility procedure titled Elopement/Missing Resident, undated, notes should an employee hear the security alarm sounding, he/she should proceed to the security annunciator panel to locate the exit opened and immediately proceed through the same exit to determine who went through the exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145904 If continuation sheet Page 5 of 5