Health inspection·August 28, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some easily redirected. (electronic wandering device) in place. R1's current Care Plan contains no documentation of R1's elopement risk prior to 8/1/25.R1's elopement risk assessment dated [DATE], documents R1 is an elopement risk with a score of four (4).On 8/26/25 at 3:00pm, V1 (Administrator) stated, We do not have any documentation stating what the elopement risk assessment score means but anything greater than a one (1) means they are at risk so probably the higher the score the greater risk.R1's Risk Management Report, dated 7/31/25, documents, Exit behavior actively attempting to leave building staff successful in redirecting and (V14/Licensed Practical Nurse/LPN) statement: I (V14/LPN) received a phone call from dispatch around 8:33pm making us aware that a resident was trying to get on the bus. I was outside bringing him (R1) back in the facility when the police arrived. The resident was still on the facility property in the grass near the smoking patio/courtyard. He did not leave the property. He was easily redirected back inside. We moved him to the 4th floor for heightened supervision and increased security.On 8/22/25 at 1:30pm, V14 (Licensed Practical Nurse/LPN) stated on 7/31/25 around 8:30pm he (V14) was getting off the elevator onto the first floor when he noted the front lobby door alarm was going off and the reception phone ringing. V14 (LPN) answered the phone, and the local police dispatch was calling to inform the facility of a suspected resident attempting to get on the bus. V14 (LPN) went outside and found R1 in a grassy area, next to the curb in front of the facility attempting to get on a city bus.On 8/22/25 at 1:50pm V1 (Administrator) and V2 (Administrator in Training/AIT) stated that the front door alarm will alarm on the panel at the nurse's station on the second floor.On 8/22/25 at 1:55pm observation of alarm panel on second floor at the nurse's station shows no door alarm sounding when V1 (Administrator) set off the door alarm. V14 (Licensed Practical Nurse/LPN) was present at second floor nurse station and verified that the front door alarm was not sounding on the panel at the nurse's station.On 8/22/25 at 2:00pm, V16 (Maintenance Director) stated that he became aware approximately the middle of July 2025 of an issue with the facility's (electronic wandering device) door alarm system not always working as it should, meaning it should alarm at the nurse's station on the second floor if set off but it does not always do this. V16 verified V16 did not notify V1 (Administrator) or attempt to contact the electronic wandering device company regarding the faulty system. At this time, V16 showed the panel on the second floor at the nurse's station where the electronic wandering device system will sometimes alarm if set off. When asked about the door alarm going off not related to the (electronic wandering device), V16 stated, I don't know of any panel except for the front reception desk that will alarm if the front door is alarming. V16 verified that the front door alarm cannot be heard over the alarm panel at the second-floor nurse's station.8/22/25 at 2:10pm V13 (Human Resources) stated, No, if the front door alarm goes off and it is not because of a (electronic wandering device) then I am not aware that it is heard on any of the floors except the reception desk.On 8/22/25 at 2:30pm, V1 (Administrator) was noticeably frustrated and stated today is the first she has heard anything about there being issues with the door alarms. V1 verified V16 did not report the facility's (electronic wandering device) door alarm system not always working as it should to V1.On 8/26/25 at 11:55am, V17 (Registered Nurse/RN) stated, I was R1's nurse the evening he got out of the building. Approximately 8:30pm I received a phone call on my personal cell phone from V14 (Licensed Practical Nurse/LPN) stating he (V14) was outside with R1 because he (R1) was trying to get on the bus. I went down to assist getting R1 back into the building and then called V2 (Administrator in Training/AIT) and told her what had occurred and was advised to move R1 to the 4th floor to the secured unit for increased safety. R1 was fully dressed in only socks on his feet when he was found but did have his (electronic wandering device) in place to his ankle. The (electronic wandering device) was checked to make sure it was functioning, and it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145950 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 145950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Generations at Rock Island 2545 24th Street Rock Island, IL 61201 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 - Immediate jeopardy to resident health or safety Residents Affected - Some showed that it was but unsure why the door did not stop him from going out. I do not recall hearing any door alarms sounding from the panel at the second-floor nurse's station. I don't know how V14 (LPN) knew R1 was outside but if it wasn't for him, I'm not sure when we would have known R1 was gone since there is no one watching the front door after 8:00pm. I was informed a few days later that there is a glitch to the door system when it comes to the (electronic wandering device).On 8/26/25 at 11:44am, V18 (Certified Nursing Assistant/CNA) stated, I saw (R1) around 7:30pm-8:00pm when I was doing rounds on (R1's) roommate. (R1) had asked me if his shirt looked like it fit so I helped him button it up and then started telling him how nice he looked. He was wearing that button up shirt, a pair of boxers and socks sitting on the side of his bed. He then laid down in bed. I did not hear any door alarms go off on the panel at the nurse's station but was informed by V17 (Registered Nurse/RN) that (R1) was outside, so I ran down the stairs to assist getting him in the building and then realized he needed his wheelchair, so I went back up to get it. Once I got back downstairs, they had him in the building. I assisted him into the wheelchair, and he (R1) was yelling at me I told you I was going to the tavern to see the ladies. (R1) never said anything to me about going to the tavern prior to that statement.On 8/26/25 at 10:17am, V37 (City Bus Head of Security) stated, It is documented that our driver called 911 at 8:32pm stating there was a confused man in socks trying to get on the bus.On 8/26/25 at 10:39am, V38 (Front desk Clerk of Police department) stated, (City Bus) called around 8:21pm, police dispatched but no need to engage due to staff had resident and were taking him back to the building.On 8/26/25 at 12:25pm, V20 (Licensed Practical Nurse/LPN) stated, There is no way to hear the front door alarm up here on the third floor. Just the stairwell door alarms are heard here. I was not aware of an issue with the alarm system until (R1) got out. If a (electronic wander device) is near the doors, they lock down so you can't go out, so I don't know at what point it stopped working.On 8/27/25 at 9:15am, V1 (Administrator) stated, The alarms, front door alarm and (electronic wander device) are supposed to be sounding on the second-floor alarm panel.On 8/26/25 R4, R5, R6, R7, R8, R9 and R10's elopement risk assessments reviewed indicating they are all at risk for elopement and facility census report documents they all live on the second and third floors of the building which are not secured units. V1 (Administrator) and V2 (Administrator in Training/AIT) were notified of the Immediate Jeopardy on 8/27/25 at 11:32am.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 was immediately assessed by nursing and moved to the 4th floor secured unit on 7/31/2025.2. Staff were in-serviced/trained on elopement precautions and facility's policy and procedure for monitoring residents at risk for elopement on 8/1/2025 by facility management.3. Resident elopement assessments for all residents reviewed and updated accordingly on 8/1/2025 by the IDT/Interdisciplinary Team. Elopement care plans reviewed and updated by the IDT team.4. Staff educated by QAT (Quality Assurance Team) members on 8/1/2025 on identifying residents at risk for elopement and policy and procedure for reporting to leadership to ensure proper interventions/care plans are initiated timely. Residents at risk were placed/updated in missing resident binder at the reception desk.5. Social services assessed current residents for elopement precautions on 8/1/2025 and ensured all at risk residents have updated care plan and intervention in place.6. Code [NAME] (Elopement-missing person) drill was performed on 8/1/25 and ongoing by Administration.7. Maintenance Director (V16) completed an immediate audit of door security systems on 8/1/2025 and daily thereafter.8. On 8/1/2025 Local Vendor was in facility to check over the Access and Wander guard and noted it to be working with a low volume and inconsistently. Quote for upgrade was being drafted for wander guard system.9. 8/22/2025 Facility implemented 24/7 reception area observation until such time that all staff are educated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145950 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 145950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Generations at Rock Island 2545 24th Street Rock Island, IL 61201 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 - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete on the camera monitoring process and/or the repairs are completed.10. 8/22/2025 facility placed a designated camera alert system at the main entrance to alert 2nd floor staff when the (electronic wandering system) and or main entrance door alarm sounds. This system will remain in place until (electronic wandering system) is fully operational. (V1) will conduct random audits every shift to ensure that the camera alert system at the main entrance functions appropriately.11. 8/22/2025 Local Vendor and (electronic wandering system) Vendor in communication with Maintenance Director and Facility V1 (Administrator)/V2 (Administrator in Training) in relation to repairs vs replacement. On 8/25/25 after communications with vendors it was determined that repair was not feasible, and system replacement would be required. On 8/26/2025 Quote for replacement of system was approved and signed for installation. 12. 8/29/25 Vendor representatives are scheduled to be on-site to coordinate final installation details and requirements. Installation will be initiated promptly thereafter.13. On 8/22/2025 all staff in all departments were in-serviced on Elopement prevention, Missing residents and Door Alarm Policies and procedures by QAT members. No staff will be allowed to work after 8/22/2025 without the listed training.14. Code [NAME] (Elopement-missing person) drill will be performed randomly for one month and monthly thereafter for 6 months by QAT members.15. Maintenance Director/Designee will do daily door alarm audits for 30 days and then weekly and as needed going forward.16. V1/V2 will enforce the interventions of plan of removal of immediacy and assurance of continued compliance.17. V1/V2 and QAT will ensure that monitoring interventions are implemented immediately, and care planned appropriately. Event ID: Facility ID: 145950 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 145950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Generations at Rock Island 2545 24th Street Rock Island, IL 61201 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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to employ a full time qualified Social Worker in a facility licensed for 177 beds. This has the potential to affect all 70 residents who reside in the facility.Findings include: The facility Director of Social Services job description, not dated, documents but not limited to, Qualifications: 1. Either a B.A. (Bachelor of Arts) in Psychology or Sociology; a B.A. or M.A. (Master of Arts) in Social Work; or a Licensed Clinical Social Worker's certificate. 2. Two years experience in the field of social work in a long term care environment is preferred.Facility Midnight Census Report, dated 8/22/25, documents occupied facility beds at 70 with empty beds at 107 and Detailed Census Report, dated 2/1/25 through 8/28/25, documents a daily census ranging from 66-81.On 8/28/25 at 9:35am, V2 (Administrator in Training/AIT) stated, We are licensed for 177 beds. V2 also verified that V15 (Social Service Director/SSD) is not Licensed and stated that she was a CNA (Certified Nursing Assistant).On 8/28/25 at 10:26am, V15 (Social Service Director/SSD) stated, I was a CNA (Certified Nursing Assistant) prior to this Social Service position. I took this around the end of May. I do not have a license or certificate in Social Services or any type of degree and no previous Social work experience.Neither V2 (Administrator in Training/AIT) or V15 (Social Service Director/SSD) were able to produce a license or certificate for V15 (SSD) in Social Work. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145950 If continuation sheet Page 5 of 5