Health inspection·November 29, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An Elopement Details Report dated 11/9/23 documented, Time resident went missing: 11/9/23 at 5:15pm. Time resident found: 11/9/23 at 5:15pm, at Wing 7 entrance, found by (V3, Certified Nurses Assistant). Conclusion: Root Cause: Resident had an appointment outside the facility earlier in the day. Resident stated (to V3) that she 'needed a break from everything.' Resident also thought she saw her husband outside. Head to toe assessment: No injuries noted. (Personal perimeter alarm) in place and functioning. Window alarms assessed for function and batteries were checked. (Initiated) Frequent checks for 72 hours. A Smart Action Plan documented a problem,Resident eloped through a window on the Memory Care Unit, with a corresponding goal, No resident will leave the premises or a safe area without authorization or necessary supervision, and corresponding action items, Head to toe body assessment, frequent checks for 72 hours, replace batteries in window alarm, assess (personal perimeter bracelet alarm), husband to decrease frequency of visits as visits increase behaviors. Target completion date 11/10/23. Audit all Elopement Assessments to ensure any resident at risk is identified. Target completion date 11/10/23. Audit care plans of residents who are at risk of elopement. Target completion date 11/10/23. Test window alarms weekly. Target date 11/10/23 and ongoing. Re-inservice staff on Elopement Policy. Target date 11/13/23. On 11/28/23 at 11:10am, V5, Memory Care Unit Coordinator, stated R1's cognition varies widely according to the day, and her exit seeking behavior seems to be exacerbated by her husband visiting. V5 stated on 11/9/23 at about 5:15pm, after V5 had left for the day, R1 was observed by staff to be standing outside the Wing 7 entrance doors. V5 stated it was determined by investigation that R1 had exited the building via the window of her room. V5 stated the investigation determined the battery in the window alarm was dead, resulting in the alarm not sounding when the window was raised. V5 stated there was a trail of clothing and personal care items outside the building leading from underneath the window to the Wing 7 entrance door. V5 stated R1's personal perimeter alarm was in place and was working, but is only triggered if one of the doors to the outside is breached, therefore it did not sound when R1 crawled out the window. V5 stated V4, Maintenance Director, was supposed to be checking the window alarm batteries. V5 stated she is now responsible for checking them weekly. On 11/28/23 at 11:30am, R1 was alert and oriented to herself only. R1 stated she did not remember anything about having crawled out her window to exit the building. R1 stated her memory is bad and she often forgets things. On 11/28/23 at 11:40am, V4 stated after the elopement he checked all the window alarms in the building, all of which are located on the Memory Care Unit (Wing 6) which were all working with the exception of R1's room, due to the battery being dead. V4 stated he immediately replaced the battery, which he estimates, Should last about a year. V4 stated he checked the batteries in all the window alarms approximately 2 months prior to the incident, and stated this is not documented. V4 stated he doesn't think there is any policy about when to check the batteries. On 11/28/23 at 11:50am, V2, Assistant Administrator, stated there is no policy as to when the batteries in the window alarms should be checked, but the action plan that was developed after the elopement specifies that V5 will now be checking the batteries weekly and documenting. On 11/28/23 at 12:20pm, V3 stated she works the 2pm to 10pm shift, and on 11/9/23 she was working on Wing 7. At about 5:15pm, she saw somebody standing outside in front of the Wing 7 entrance door. V3 stated it was R1, wearing a T-shirt, jacket, sweatpants and shoes. V3 stated R1 seemed confused and anxious, which she usually does. V 3 stated when she opened the door for R1, her personal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146019 If continuation sheet Page 2 of 3 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 146019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wabash Senior Living & Rehab 216 College Boulevard Carmi, IL 62821 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 perimeter bracelet alarm set off the door alarm so it was obviously working. V3 stated she asked R1 what she was doing and how she got outside and R1 said 'she was taking a break from everything'. V3 stated there were no signs of injuries. V3 stated the temperature outside was in the 50s, it had been sunny that day, there was no rain, and it was around sunset but it wasn't completely dark out yet. V3 stated she took R1 back to Wing 6, where staff were not aware she had gotten out. Residents Affected - Few On 11/28/23 at 2:05pm, V2 stated on 11/9/23, R1 was last seen in the Wing 6 Dining Room at 4:45pm headed back to her room after eating supper. V2 stated R1 would have been outside for a maximum period of 15 to 30 minutes. V2 stated a full body assessment was immediately performed and R1 had no injuries. V2 stated frequent checks for a 72 hour period were immediately implemented. V2 stated R1's window alarm battery was found to be dead and was replaced. V2 stated all other window alarms were checked and found to be operational. V2 stated V5 is now doing weekly window alarm battery checks for all Wing 6 windows. V2 stated R1's husband has agreed to do fewer visits, and to not knock on windows or doors when he is leaving, as he sometimes does. V2 stated all Elopement Risk Assessments in the facility, including R1's, were updated to make sure any at risk residents had been identified. V2 stated all staff were re educated on the Elopement Policy, and R1's Care Plan was also updated. V2 stated all members of the Quality Assurance Committee, including the Medical Director, have discussed the incident and approved the resulting action plan. V2 stated R1 had an doctors appointment and a visit from her husband the day before the incident, and staff feel this led to an increase in exit seeking behavior. An Elopement Prevention and Response Policy dated 2/19/21 documented,The community provides a safe environment for all residents. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. On 11/10/23, members of the Quality Assurance Committee met to discuss the elopement and team members reviewed the Smart Action Plan and the Elopement Policy. 2. On 11/10/23, all staff members were re-inserviced on the facility's Elopement Policy. 3. On 11/9/23, the batteries in R1's window alarm were replaced, and the batteries in all the window alarms on the Memory Care Unit were tested and found to be working. 4. On 11/16/23, V5 initiated weekly testing of all the window alarms on the Memory Care Unit, with documentation on the 'Wing 6 Window Alarms flow sheet. 5. On 11/10/23, R1's husband agreed to reduce the frequency of his visits in order to minimize R1's exit seeking behavior following his visits. 6. On 11/10/23, R1's Elopement Risk Assessment and Care Plan were updated, and all Elopement Risk Assessments in the facility were audited. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146019 If continuation sheet Page 3 of 3