Health inspection·October 31, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few out. V1 stated someone checked the alarm but didn't see anyone at the doors. V6 CNA went out the door of the facility by the conference room and out the front door. V6 said she saw a resident running. V1 stated she didn't know how R1 could have been running when he walks with a walker and it didn't make sense R1 got that far away in the time frame the staff stated. V1 stated R1 was wearing a baseball hat, T-shirt, incontinence briefs and gym shoes. V1 stated V6 told her she could see someone outside but didn't know who it was until she got to R1. V6 then called for the nurse on her walkie talkie. V1 stated staff should have called her right away; she received an email stating R1 had a fall but it was more than that, it was an elopement. V1 stated all the staff should have immediately went and checked the doors for this reason alone. It needs to be done for residents safety. On 10/31/23 at 10:13 AM, V3 LPN stated she was in the kitchen getting coffee for a resident when the alarm went off. V6 CNA heard the alarm and left. V3 said she went over to look at the alarm light on the wall and it said it was the front door. V3 stated she then went down the hall and V6 had used a walkie talkie radio to tell her it was a different resident that got out. Then the CNA radioed back that it was R1 that got out. V3 stated by the time she got to the door of the facility V6 was holding R1 who had been running to the street and fell. V6 stated she went and assessed R1 and V6 went to get a wheelchair and brought it back. V3 stated they put R1 in a wheelchair and brought him back to the facility. V3 stated R1's blood pressure was a little elevated, he had a cut to his hand, by his eye and lip that she put a steristrip on and abrasions to his knees. V3 stated V5 CNA and V6 CNA were at the nurse's station when she went to the kitchen. V5 then went to do checks on residents and she didn't know where V6 had been. On 10/31/23 at 12:49 PM, R1 was laying on his back in bed. R1 was fully dressed and had his gym shoes on. R1 had a wheeled walker next to him. R1 stated he remembered leaving; he stated, I got up and left. I wanted to go home. My home is about 1 mile from here. I fell outside. R1 stated he didn't tell anyone he was leaving. R1 stated he heard an alarm go off when he left. R1 stated he fell and face-planted but he had gotten pretty far from the facility. R1 stated he did not know how long it took to get help. On 10/31/23 at 1:43 PM, V6 CNA stated she was the CNA on the hall that R1 left on; she was not his CNA for the night. V6 stated she had been doing rounds and the last resident she had checked was a lady whose catheter was leaking. V6 stated she went to tell V3 LPN about the catheter and an alarm went off. V6 stated that R4 was a resident that usually goes out at night and it was usual for the alarm to go off. V6 stated when she went to the panel she saw the light was on for her hall door. V6 stated she went out her hall door, had to check the old hospital hallway to the left and offices to the right. V6 said she looked out the door into the parking lot and didn't see anything. V6 stated she then looked again out into the parking lot and saw bare legs and an incontinence brief. V6 stated she saw R1 running. V6 stated she couldn't really tell if R1 was running because he meant to or if it was the momentum and he fell; he face-planted. V6 stated when alarms go off the staff is supposed to check them immediately to see what has happened. V6 walked down the hall to the door R1 used to exit, put in a code to open the door. V6 exited the door of the extended care facility in the building but was still in the building. There was a hall to the left that went to the old hospital. A short hall to the right that had offices. Then walked towards the foyer area where there is an office to the left and right as well as a sitting area. V6 went to the exterior door and opened the door. V6 stated the exterior door is not alarmed or locked. V6 pointed down the road to a large tree and stated R1 had went across the parking lot, the street and over to the ditch on the other side of the road in front of the large tree. She stated that is where she saw him. On 10/31/23 at 2:13 PM, V5 CNA stated R1 was a resident on the hall she had been working on that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 2 of 4 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 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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 night. V5 stated she was doing checks on residents, went into a different residents room and he was not in bed; he was on the toilet. She waited for that resident to finish on the toilet and helped him to bed. V5 stated she then checked on that resident's room mate. V5 stated she heard the alarm go off at some point but was in a room helping those residents. V5 stated that there was also R4 that goes out onto the patio nightly so she thought it was him that set the alarm off. V5 said she didn't check the alarm right away because she was busy. V5 stated she didn't remember when the alarm was shut off because she was still in that room. V5 said that since the alarm was shut off she figured everything was okay and went to check another resident in a different room. V5 said when she was in the second room V6's voice came over the radio saying she thought a person was outside and for the nurse to come outside. V5 said she then heard V6 yell into the radio that it was R1 and she told V5 to get out there. V5 said she didn't know which door they had went out. V6 said she ran to the door she saw propped open. V6 said she saw V3 and V6 pushing R1 in a wheelchair. On 10/31/23 at 2:50 PM, R4 stated he is a night owl and stays up at night. R4 stated that he goes outside anywhere from 10:00 PM - 2:00 AM for some fresh air. R4 stated he doesn't tell anyone that he is going outside, he puts the code in and leaves. R4 stated he goes out onto the patio and the front door by parking lot. R4 stated he has a hard time seeing the keypad to put the numbers in when he comes inside because of a glare so he opens the door, sets off the alarm and enters the code into the keypad once he is inside. R4 stated the staff don't respond because they know it is him. R4 stated if the alarm goes off for a long time then the staff should know it is not him. R4 stated the staff should then check because there are crazy wanderers here that wander day and night. The Face Sheet dated 10/31/23 for R1 showed medical diagnoses including parkinson's disease, osteoarthritis, actinic keratosis, neurocognitive disorder with lewy bodies, hypertension, tinea unguium, and other specified mental disorders due to known physiological condition. The Restorative Note dated 8/18/23 for R1 showed, R1 is a new admission to the nursing home. He has a diagnosis of Parkinson's disease. His gait is mildly unsteady and he walks with a shuffling gait. He participates in the restorative program daily. He rides the recumbent bike for 20 minutes, AROM (active range of motion) group exercises, and he is on a walk to dine program. He is ambulatory using a FWW (front wheeled walker) and limited assist of 1. He is limited assist for most ADLs (acitivities of daily living). He does require extensive assistance for lower body dressing, toileting, and bathing. He does not have any functional limitations in ROM (range of motion) to both upper and lower extremities. He is frequently incontinent of bladder and bowel mostly due to not being able to make it to the bathroom in a timely manner. He is able to recognize the urge to urinate. He is able to make his needs known. He scored a 10/15 (moderate cognitive impairment) on his BIMS (brief interview of mental status). The MDS (Minimum Data Set) dated 8/15/23 for R1 showed moderate cognitive impairment; limited assistance needed for bed mobility, transfers, walking, toilet use and personal hygiene; extensive assistance needed for dressing and bathing. The facility's Resident Elopement policy (no date) showed, Objective: 1) To protect resident health and safety; 2) To establish a system for immediate location and return of a resident to the facility. Any resident leaving the facility without staff acknowledgement is recognized as elopement. All exit doors to the facility have door alarms in place 24 hours per day and alarm when a person enters or exits the unit without entering the correct code in the keypad. When the alarm sounds, the charge nurse will determine which alarm has sounded. Any available nursing home staff shall immediately check the door that has alarmed for a resident or patient who may have gone out the door. All (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 3 of 4 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 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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 available staff from all departments shall respond to the closest nurses' station to assist with the search. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146140 If continuation sheet Page 4 of 4