Health inspection·September 21, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement safety measures for residents at risk for wandering, to prevent a cognitively impaired resident from eloping from a locked unit and exiting the facility without supervision on two separate occasions. This failure resulted in R1 eloping from the facility without staff knowledge or supervision, walking past a pond and across a thoroughfare to a movie theater parking lot where R1 remained for an hour. R1 eloped from the facility a second time in the afternoon six days later when she walked past the receptionist and into the parking lot. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 09/04/2024 at 8:03 PM when R1 eloped from the facility unwitnessed by staff. This failure effects 1 of 5 residents (R1) reviewed for elopement risk in the sample of 8. V1 (Administrator) and V18 (Nursing Consultant) were notified of the Immediate Jeopardy on 09/18/24 at 9:29 AM and the IJ template was provided. V1 provided an Immediacy Removal Plan at 10:45 AM on 9/18/2024, which was rejected and returned to V1 at 11:55 AM. The facility's second Immediacy Removal Plan was provided by V1 at 1:30 PM and it was accepted at 1:55 PM. The Surveyor confirmed the immediacy was removed on 09/19/2024 at 2:38 PM, however the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of new procedures and Quality Assurance monitoring. Findings include: 1. On 9/13/2024 at 10:45 AM, R1 was in her bed on the locked dementia unit with the head of her bed elevated. R1 was asked a few questions to which she provided short answers or shook her head yes or no. R1 was asked if she remembered leaving the facility and being at the movie theater parking lot and she shook her head no; R1 shook her head no when asked if she knew the name of the facility; and R1 answered she had been at the facility for 15 days (R1's Face Sheet showed she was admitted [DATE], five months earlier) when she was asked. R1 answered no when asked if she knew where she lived before, and stated she was not sure what town her daughter lived in. R1 answered she doesn't know if she had ever left the facility unsupervised before. R1 answered yes to using the elevator before, but wasn't sure of how she got there, or where she was going. R1 responded slowly to questions and her Page 1 of 7 145963 145963 09/21/2024 Alden Estates of Orland Park 16450 South 97th Avenue Orland Park, IL 60467

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few voice was very quiet. R1's Face Sheet showed her diagnoses include moderate vascular dementia, unspecified psychosis, and major depressive disorder, single episode, severe with psychotic features. On 9/13/2024 at 12:15 PM, V1 (Administrator) showed and explained facility video covering R1 leaving the facility unattended on 9/4/2024. V1 stated video was timestamped as 8:03 PM when R1 was noted descending the concrete stairs in front of the building and then walking off to the right, out of the frame. V1 stated the facility received a call from the movie theater at 9:11 PM (over an hour later) that R1 was in their parking lot. V1 stated R1 was gone from the facility for over an hour and she did not know how R1 was able to get off the locked unit. On 9/13/2024 at 2:00 PM, V7 (Operations Manager at local movie theater) showed the theater's security video from the evening of 9/4/2024, explaining it as it was viewed. V7 stated R1 is first seen on camera at 8:17 PM (14 minutes after leaving the facility). V7 stated there was one car parked behind a tree in the north parking lot and R1 walked up to it and waited. At 9:03 PM (45 minutes after R1 coming into view), two movie patrons exited the theater and went to their car and found R1 waiting there. V7 explained that one [NAME] stayed near the car and the other went back into the theater to get the manager and security. V7 stated that at 9:06 PM, security and the manager came out to talk to R1, and R1 was only able to tell them her name and that she was thirsty. V7 explained that a Police car drove by and theater staff flagged him down. V7 stated that an item R1 was carrying had the facility name on it. V7 stated a call was placed to the facility at 9:11 PM, notifying them that R1 was at the theater. V7 stated at 9:17 PM, facility staff members arrived at the theater parking lot to escort R1 back to the facility. On 09/13/24 at 1:50 PM, Surveyor drove in a car from the facility to the movie theater. The GPS (GPS/Global Positioning System) showed if walking along the roads to the theater, the distance from the facility to the movie theater was 900 feet. There was a thoroughfare between the facility and the movie theater and a retention pond between the facility and the movie theater. On 9/13/2024 at 12:35 PM, V13 (Therapy Director) stated she had worked directly with R1 and R1 had confusion and diminished safety awareness. V13 stated R1 had problems with task segmentation and higher-level tasks where there is more complexity and difficulty. R1's 7/22/2024 Minimum Data Set showed R1 was moderately cognitively impaired. R1's 4/16/2024 Exit Seeking/Wandering/Elopement Risk Assessment showed R1 had the physical ability to leave unit/facility, cognitive impairment with a diagnosis of dementia, and history/current behavior of elopement attempts and exit-seeking. The Assessment category showed R1 was At Risk for elopement. R1's 4/22/2024 Behavior/Interventions progress note showed she was attempting to exit the stairwell doors. R1's 8/9/2024 Social Services progress note showed Noted to be standing by elevator frequently, attempting to board elevator . R1's 8/15/2024 Behavior progress note showed Noted to be standing by elevator she was attempting to board elevator and becoming aggressive with staff . R1's 8/20/2024 Behavior note showed R1 was standing by the elevator, attempting to push button to open the door . R1's 9/5/2024 Exit Seeking/Wandering/Elopement Risk Assessment (the day after R1's 9/4/2024 elopement) continued to show R1 was At Risk for elopement. On 09/13/2024 at 9:34 AM, V15 (Memory Care Director) stated we are not sure how R1 was able to get 145963 Page 2 of 7 145963 09/21/2024 Alden Estates of Orland Park 16450 South 97th Avenue Orland Park, IL 60467

F 0689 out of the building. V15 stated R1 was scored as high risk for elopement when she was admitted on [DATE]. Level of Harm - Immediate jeopardy to resident health or safety On 9/13/2024 at 1:15 PM, V10 (RN-Registered Nurse) stated If people mistakenly push 3rd floor on the elevator, the elevator goes up to 3rd floor. Residents Affected - Few On 9/18/2024 at 12:05 PM, V1 stated at 8:00 PM, the Receptionist is to deactivate the front door to be opened if someone tries to enter from outside, and it then alarms any time it opens at all. V1 stated the Receptionist punched out at 8:11 PM the night of 9/04/2024 and did not set the door alarm before leaving work. On 09/19/24 at 12:34 PM, V22 (Medical Doctor) stated he is the primary Physician for R1 while she resides in the facility. V22 stated he was aware of R1 eloping from the facility two times. V22 stated R1 has diagnoses of dementia and psychosis and R1 is not decisional due to her diagnoses. R1's 9/8/2024 Nursing progress note showed Resident was standing by elevator. [Certified Nursing Assistant-CNA] tried redirecting resident to room. Resident became aggressive and tried to punch CNA. R1's 9/9/2024 Social Service note showed Per [night shift] staff, [R1] was agitated, attempting to get onto elevator all shift, attempting .to enter the elevator by using force to move staff out of the way . On 9/13/2024 at 9:34 PM, V15 (Memory Care Director) stated that on 09/10/2024, R1 was found in the parking lot and was brought back to the unit by a staff member around 3:30 PM. V15 stated we do not know how R1 was able to get on the elevator a second time. V15 stated R1 walked past the receptionist and went outside on 9/10/2024. V15 stated our receptionist sits at the desk from 8:00 AM to 8 PM. V15 stated a resident with dementia that leaves a locked unit unsupervised could have a fall, leave the grounds where they can't be located, and put themselves in dangerous situations. V15 stated it is all staff members responsibility to make sure the residents are safe and in the building. On 9/13/2024 at 12:30 PM, V1 (Administrator) showed and explained facility video surveillance for R1's second elopement on 09/10/24. V1 stated R1 walked out of the main entrance of the facility at 2:53 PM, and then leaves the video frame. V3 (Receptionist) is then seen outside the front door at 3:17 PM (24 minutes later), looking toward the parking lot. V1 explained V3 got V4 (Human Resources/Business Office Manager-HR/BOM) and V5 (Activity Aide) for help and at 3:33 PM, R1 was brought back in the facility in a wheelchair. On 09/13/2024 at 3:50 PM, V3 (Receptionist) verified she was the receptionist on duty on 09/10/24 when R1 eloped from the facility the second time. V3 stated she was sitting at the reception desk and she did not see R1 go past her and leave. V3 stated a family member called the facility and said, a lady was trying to get into her car and I think she's one of your residents. V3 stated she went outside and saw R1 in the parking lot. V3 stated she informed V4 (HR/BOM) that R1 was outside in the parking lot. V3 stated she did not call a code green for resident elopement. On 09/13/24 at 12:55 PM, V14 (Speech Language Pathologist) stated R1 was not oriented to time and place and had moderate to severe dementia. V14 stated while R1 was receiving therapy, the sessions were cut short due to R1 always having somewhere to go. R1's Elopement care plan (initiated 4/16/2024) showed a focus of .at-risk for elopement related to 145963 Page 3 of 7 145963 09/21/2024 Alden Estates of Orland Park 16450 South 97th Avenue Orland Park, IL 60467

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few cognitive impairment, physical ability to leave unit/facility. She will also stand in front of the elevator, attempt to push the button. An intervention from 4/16/2024 showed Monitor behaviors. The facility's 3/28/2023 Elopement and Management of Missing Resident Policy defined elopement as .a dependent (cognitively impaired, non-decisional) resident leaving a facility without staff awareness and under circumstances that place the resident's health, safety, or welfare at risk. The policy further showed 2. i. The Administrator and Director of Nursing will evaluate the situation and develop a plan of action based on the individual resident . The Immediate Jeopardy that began on 9/4/2024 was removed on 9/19/2024 when the facility took the following actions: Allegations of non-compliance #1 * Lack of supervision of a cognitively impaired resident who wanders. Corrective Action Taken: * Resident was reassessed for elopement risk on 9/5/2024 after the elopement occurred and deemed an elopement risk. The resident elopement risk assessment was reviewed on 9/11/2024 by Memory Care Director with no changes warranted. * Resident was located and returned to the facility on 9/4/2024 and on 9/10/2024. A head-to-toe assessment was completed (by the assigned nurses), with no signs of injury on either occurrence. * The Resident care plan was updated pertaining to the elopement that occurred on 9/4/2024, (by the Memory Care Director - MCD) and further reviewed and updated on 9/10/2024 (by the MCD). * On 9/10/2024 the DON, Administrator, ADON, and Medical Director reviewed the facility policies related to the occurrence: Elopement, Routine Resident Checks, Exit Seeking, and Incidents/Accidents. No changes were made. * Starting on 9/5/2024, the Memory Care Director and Social Service Director updated the assessments and care plans for elopement risk residents. The assessments were completed on 9/11/2024. On 9/10/2024 the Administrator initiated further education that a resident exhibiting exit seeking behaviors should be placed on enhanced monitoring including 15 minute checks and 1:1 supervision until the behavior subsides or alternate measures are put into place. Staff were educated to alert the nurse of exit seeking behaviors who would then implement increased intervention. This was completed on 9/11/2024. 145963 Page 4 of 7 145963 09/21/2024 Alden Estates of Orland Park 16450 South 97th Avenue Orland Park, IL 60467

F 0689 Identifying other residents having the potential to be affected by the same deficient practice: Level of Harm - Immediate jeopardy to resident health or safety * Residents Affected - Few All residents were reassessed for elopement risk on 9/5/2024 and completed on 9/11/2024. A further review was conducted by Social Services Director and Memory Care Director on 9/11/2024 to determine if there were any changes and there were none. * All new admissions will have an elopement risk assessment that will be completed within 24 hours upon admission and interim care plan will be initiated based off the assessment, and will be reassessed every three months, and as needed (by MCD). * All residents that are identified as-risk for elopement during admission had a review of their care plan and updates were made where applicable, completed on 9/10/2024 and further reviewed on 9/11/2024. Pictures of at-risk residents were placed in a binder on all nursing stations (1st,2nd,3rd floors) and the receptionist desk which was completed on 9/10/2024 and reviewed on 9/11/2024 (by MCD). * All residents determined to be at-risk for elopement and with active exit-seeing behaviors will be evaluated for a possible room change to the secured unit on the third floor to limit access to the front entrance door on the first floor. * Beginning on 9/4/2024, interviews were conducted (by the Administrator) with staff to determine further potential risk and completed on 9/5/2024. Additional interviews were initiated on 9/10/2024 and completed on 9/11/2024 to further identify any potential risk factors. Measures taken to ensure that the problem is corrected and will not recur: * All staff and managers are being reeducated on routine resident checks, exit seeking, incidents/accidents, elopement policy and procedure and where to locate the at risk of elopement binders. The reeducation was provided on 9/5/2024 and was completed on 9/10/2024. * All staff and managers are being reeducated on elopement risk and reporting behaviors or changes in factors related to elopement risk to appropriate discipline. This was started on 9/5/2024 and completed by 9/10/2024. * 145963 Page 5 of 7 145963 09/21/2024 Alden Estates of Orland Park 16450 South 97th Avenue Orland Park, IL 60467

F 0689 All reception staff were reeducated on monitoring the front doors and resident safety and proper procedure for code green completed on 9/11/2024 Level of Harm - Immediate jeopardy to resident health or safety * Residents Affected - Few Exit doors will be monitored by staff when unalarmed. The receptionist will monitor the front entrance door 8am-8pm. From 8pm-8am door will be armed by receptionist and monitored by 1st floor nurses through the duration of that time. * Exterior door alarms will be checked daily by the maintenance director and EVS Supervisor to ensure they are in working order and secured. Completed 9/5/2024 and checked again on 9/11/2024. * After initial elopement on 9/4/2024 resident was placed on 15 minute checks for 24 hours. During that time the facility met with daughter and discussed new interventions. A plan was established and implemented. * 1:1 Visual monitoring was initiated (by staff) for the resident (9/11/2024). Intervention will remain in place until the facility's wandering management system is installed and determined to be effective to prevent further incident. * Elevator monitor was initiated for 3rd floor (9/11/2024). Elevator will remain monitored 24 hours a day until wandering management system is installed and determined to be effective to prevent further incident. Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur. * A review of compliance using Quality Assurance Audit tool for elopement started (by the Administrator) on 9/5/2024. The Audits will be done daily for two weeks then twice weekly for four weeks, then monthly x 3 months, and evaluated at the monthly QAPI meeting to determine compliance. Audits to be completed by members of the IDT team and turned into Administrator who will ensure audits are being completed. * A review of results of audit regarding elopement and door alarm working condition with the facility's interdisciplinary team started on 9/5/2024. Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee until goal is attained. Results of these audits will be reviewed at the monthly QAPI to determine compliance. 145963 Page 6 of 7 145963 09/21/2024 Alden Estates of Orland Park 16450 South 97th Avenue Orland Park, IL 60467

F 0689 * Level of Harm - Immediate jeopardy to resident health or safety Administrator to Audit daily that exterior front door alarm is being activated each day by receptionist at 8pm prior to leaving. * Residents Affected - Few A facility wandering management system install was initiated 9/10/2024. * During orientation of new hires, the facility (Business Office Manager) will educate newly hired staff on elopement and conduct competency quizzes. Quality Assurance Plans to monitor facility performance: * The facility Quality Assurance Team/ IDT (including Medical Director, Administrator, Social Services, DON, ADON and facility consultant) shall meet at least monthly to review elopement risk residents, trends, patterns and develop and implement action steps as necessary. * The QA meeting is held monthly for three months, then quarterly and as needed. An emergency QA meeting was held on 9/5/2024 and 9/10/2024 by the Administrator with the Interdisciplinary Care Team and Medical Director. The Elopement from the facility on 9/4/2024 and 9/10/24 were discussed along with the Removal Plan. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator, DON, ADON, and Social Services. 145963 Page 7 of 7