**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain safe and comfortable temperatures in the facility, failed to monitor residents for heat exhaustion, failed to provide adequate hydration during hazardous temperature, and failed to assess and supervise one resident (R21) with a change in condition related to heat exhaustion. These failures affected R21 who was sent to the hospital exhibiting heat related signs and symptoms and has the potential to affect all 132 residents. This was identified as an Immediate Jeopardy which began on 8/23/23 at 9:35 am per (8/23/23) facility temperature log which documents a temperature of 81.2F (Fahrenheit) in resident room. On 8/30/23 at 2:22 pm, V9 (RDO/Regional Director of Operations), V17 (Corporate Administrator), V18 (Chief Financial Officer) and V19 (Attorney) were notified of the immediate jeopardy. The facility presented a final removal plan on 8/30/23 at 6:39 pm which was not approved. The facility presented a revised final removal plan on 9/1/23 at 12:46 pm which was not approved. The facility presented another revised final removal plan on 9/1/23 at 4:36 pm which was accepted/approved on 9/6/23 at 8:45 am. The surveyor conducted additional interviews and record reviews on 9/25/23 to 9/27/23 verify the plan was implemented. The immediate jeopardy was removed on (10/2/23) based on actions from the removal plan. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: The 8/23/23 census includes 132 residents. The (August 2023) Daily Air Temperature Logs affirm temperatures were documented 8/4, 8/7, 8/8 and 8/23 - not Daily as directed. On 8/23/23, the Chicago temperature was 98F (Fahrenheit) with heat index 116F per National Weather Service. On 8/23/23 at 6:24 pm, observed residents sitting outside of the facility in wheelchairs on the sidewalk with staff. No observation of water being offer or given to the residents outside. R21's admission Record documents, in part, that R21's diagnoses include Diabetes, depression, neuropathy, dementia, Alzheimer's, glaucoma, and hypertensive heart disease. R21's admission date to the facility is documented as 3/26/23. R21's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 10 which indicates that R21 is moderately impaired. R21's (6/30/23) functional assessment affirms (1 person) physical assist is required for bed mobility, transfers, locomotion, personal hygiene, and toilet use. On 8/23/23 at 7:30 pm, surveyor observed R21 sitting in a wheelchair leaning over throwing up (3 times) in the (1st floor) dining room. R21 stated I need to lay down. V11 (LPN/Licensed Practical Nurse) pushed R21 via wheelchair into V2's (Director of Nursing) office where there was a window unit air conditioner. R21 stated, I'm not feeling well, it's too hot. I need to lie down, I feel weak. V11 took R21's blood pressure which read 100/62. V11 attempted to obtain R21's pulse oximeter reading a total of three times, however, was unsuccessful. No other vital signs were taken for R21 before leaving the building with the CFD (Chicago Fire Department). On 8/23/23 at 7:40 pm, R21 was transferred from the wheelchair to bed. V12 (CNA/Certified Nursing Assistant) attempted to obtain R21's pulse oximetry and was unsuccessful. On 8/23/23 at 7:43 pm, V11 (LPN) affirmed the physician was contacted and orders were received to send R21 to the hospital. V11 instructed V13 (CNA) to stay in the room with R21. On 8/23/23 at 7:50 pm, R21 stated, I felt like I was going to pass out, I've been hot all day. V10 (LPN) obtained R21's temperature which was 96.2 (axillary) at this time then left the room. V13 (CNA) also left the room leaving R21 unattended. Surveyor observed R21 from 7:50 pm to 8:31 pm (41 minutes) however, staff did not reassess and/or check on the resident. R21 was left in room unattended to. On 8/23/23 from 7:30 to 8:31 surveyor observed R21 not offered or given any kind of hydration from staff. On 8/23/23 at 8:31 pm, the Fire Department arrived to transport R21 to the hospital who was appearing weak and slow to respond to questions. The (8/23/23) facility Air Temperature Log affirms the temperature was 86.2F with humidity 76.1F in resident's room, 86.0F with humidity 77.2F in another resident's room and 86.1F with humidity 78.2F at the (2nd floor) Nurse's station documented 10:00am-10:20am. The last temperature documented (8/23/23) was at 10:40am - not hourly as warranted due to temperature above 80F. On 8/23/23 at 7:07 pm, R79 stated it has been hot for about a month now, they (staff) provided fans. R79's (6/6/23) BIMS determined a score of 12 (moderate impairment). On 8/23/23 at 7:15 pm, staff on the first floor were noted to be sweating and their clothes visibly wet. On 8/23/23 at 7:22 pm, R92 reported feeling hot. R92 affirmed she was in her room and (approximately 1 hour ago) staff brought her to the 1st floor dining room. R92's (7/25/23) BIMS determined a score of 15 (cognitively intact). On 8/23/23 at 7:27pm, R75 stated, I feel terrible, I feel hot, I have not had anything to drink. Staff offered me something to drink but I refused to keep from having to use the bathroom. R75's (8/17/23) BIMS determined a score of 10 (moderate impairment). On 8/23/23 at 7:30 pm, R45 stated yesterday and today it got really hot. The AC in my room didn't work this morning, staff tried to turn it on, but it didn't work. R45's (7/21/23) BIMS determined a score of 12. On 8/23/23 at 7:45 pm surveyor observed R12 sitting in the hallway not given any food or water. V10 (LPN) stated R12 has a g-tube and receives bolus feedings. R12's lips were dry and cracked. R12's MAR (Medication Administration Record) reviewed excluding R12's 5:00 pm feedings signed out on 8/23/23. No observation of incontinence care given to R12. On 8/30/23 at 11:00 am V2 DON (Director of Nursing) stated that the building was warm, and I instructed my staff to keep checking on the residents and hydrating them. We (facility) did have a cooling bus for the residents till around 6:00 pm. The building inspector said the facility had to evacuate due to high temperatures in the building. The facility started to evacuate the building around 12:00 pm. V2 DON stated that a resident with change in condition should have vital signs taken every 15 to 30 minutes until they get out of the building. V2 stated a resident with a blood pressure of 100/62 should have their vital signs taken every 15-30 minutes. Surveyor inquired about the frequency of R21's vital signs and V2 stated the nurse should have taken more vital signs. V2 stated that every nurse and CNA in the building is equipped to take vital signs. V2 stated that staff should not leave a resident unattended if the resident is unstable. Surveyorasked the DON, if a resident says they're hot, feeling weak and feel like they're going to pass out are they considered unstable? V2 stated yes, they are unstable and should have staff at bedside. On 8/31/23 at 11:43 am V11 LPN (License Practical Nurse) stated on 8/23/23 V11's shift started at 7:00 am and that morning the temperature in the building was warm and became warmer throughout the day. V11 stated after lunch at approximately 11:30 am-12:00 pm, staff was told that the building was being evacuated and all residents need to be transferred to another facility. The first thing we (Staff) did was put residents on a CTA cooling bus. V11 stated, I don't know if all the residents got on the bus. I saw two cooling buses. The buses stayed from 2:00 pm-5:00 pm. Surveyor asked V11 about R21's change in condition and V11 stated one of the staff members yelled that R21 was throwing up. V11 stated, I (V11) went into the dining room where R21 was and asked the staff to get some ice to help cool R21 down because of the hot temperature in the building. V11 stated R21 said, I (R21) do not feel good and feel weak. V11 stated R21 had been sitting up for a while and it was hot in the facility. The only cool place on the 1st floor was the Director of Nursing's (DON's) office. I took R21 to the DON's office where I took his VS (Vital Sign). Surveyor asked V11 what vital signs were obtained at that time? V11 stated, I took the blood pressure, pulse oximetry, pulse, respirations, and Accucheck. I didn't document the vitals because I did not have access to a computer. I did call the doctor because the blood pressure was low. The blood pressure was 100 over something. Surveyor asked V11 what the other VS were. V11 stated I don't remember. Surveyor asked V11 if the pulse oximetry was working and V11 stated, Oh, I forgot that the pulse oximetry was not working so I did not get the pulse oximetry or a pulse. I think the respirations were 22. V11 stated, R21 said again that he (R21) did not feel well, felt weak and wanted to lie down. I asked staff to assist me to move R21 to a room where R21 could lie down. Surveyor asked V11 if another set of VS was taken and V11 stated V11 did not take another set of VS. V11 stated, with it being very hot in the facility and R21 vomiting, V11 wanted to call the Doctor. V11 stated there was a male CNA (V12) and a female CNA (V13) in the room, and I told the female CNA (V13) to watch and monitor R21 while I went to call the doctor. V11 stated the doctor said to send R21 to the nearest ER (Emergency Room). V11 stated, I did not return back to R21's room until the ambulance came to pick up R21 at 8:31 pm. V11 stated a complete set of Vital Signs were not taken on R21 due to not having the assessable tools to assess the resident correctly. V11 stated that a complete set of vital signs is the temperature, blood pressure, respirations, pulse oximetry and if a diabetic we take an Accucheck as well. V11 stated if a resident has a change in condition, then VS should be taken every 30 minutes to an hour and the resident should be reassessed. Surveyor asked V11 if R21 should have had repeated VS and V11 stated, Yes, R21 should have had VS repeated. V11 stated, I'm upset because the residents had to leave their homes and the facility could have done better with the air conditioner situation. V11 stated V11 has not had any training on the heat exhaustion or the emergency evacuation plan. R21's (8/23/23) hospital records documents in part, history & physical states - presents with general malaise. The Nursing Home lost the air conditioning tonight and in the process of moving the patient to another facility, the patient vomited few episodes. Differential Diagnosis: dehydration, electrolyte imbalance, weakness, influenza, urosepsis, viral syndrome, dizziness. R21's (8/24/23) Critical care notes, documents in part, critical interventions of IV Fluids. R21's (8/27/23) progress note states nursing home patient presented to the emergency room complaining of nausea and weakness due to no air conditioning during the heat wave. Nausea and vomiting/weakness secondary to heat exhaustion. On 8/31/23 at 12:28 pm, V13 CNA (Certified Nursing Assistant) stated the scheduler called V13 into work. V13 stated, I (V13) got to work around 5:30/6:00 pm on 8/23/23. I was instructed to take the residents out to smoke to keep them calm. I came into the room with R21 to check on R21and to put some ice on R21's head because the facility was hot. Surveyor asked V13 if V13 was instructed to stay with R21 when V11 (LPN) left out of the room and V13 stated she do not remember V11 telling her to stay with R21. V13 stated I went back into the room with R21 to check on him. V13 stated if a resident has a change in condition, then someone is supposed to stay with them. V13 stated that a resident who has a change in condition VS should be taken every 15-30 minutes. V13 stated, I did not get any report to say what I should be doing with R21. I went into R21's room on my own because I heard R21 was throwing up. It was hot in the building. I felt like I was going to pass out because of the temperature in the building, I just kept drinking water because of the heat. V13 stated I have never had any training on emergency evacuation or training on identifying heat exhaustion. On 8/31/23 at 12:45 pm, V12 (CNA) stated that he (V12) works 11pm-7am. I (V12) came in early to help put residents into the van to transfer out with the evacuation and when the residents wanted to smoke, we (staff) would take them out and try to make them (residents) comfortable. V12 stated that day it was extremely hot. V12 stated he saw they needed helped getting R21 in bed, so I went into the room to help. I tried to get a pulse oximetry on R21, but it was not working. The nurse did not tell me to stay with R21. There was another (CNA)V13 in the room when I (V12) left out of the room. V12 stated vital signs should be taken every hour with a change in condition resident. V12 stated that the last resident left the building around 1:00 am on 8/24/23. V12 stated V12 left the facility at 1:30 am after the last resident left. V12 stated, I have never had any training in emergency evacuation at the facility. On 8/31/23 at 2:00 pm V6 (LPN) stated I (V6) was working alone that day on the 1st floor. There were 33 residents on the first floor. V6 stated I work 7 am-3 pm and on 8/23/23 was asked to work a double. V6 stated that when I knew the facility had to evacuate the second shift had already come in, and the second shift starts at 3:00 pm. V6 stated it was warm in the building because it was warm outside. V6 stated on the second and third floor it was warmer, so the staff started bringing the residents from the second and third floor to the first floor around 4:00 pm, and that is when the evacuation began. The cooling buses came after lunch and the residents ate lunch around 11:30 am. I remember serving lunch and the buses came after that time. The surveyor inquired if V6 remembered R21. V6 stated R21 started vomiting in the dining room, R21 was leaning over, and I sat his (R21) head up then R21 started vomiting again. V11 (LPN) came to assist with R21. I went to get the blood pressure machine then R21 vomited a third time, so V11 pushed him (R21) in the DON's office where it was cool. V6 stated that she thinks R21 went to the hospital, but not sure. I do not remember V6 stated, V11 telling me to keep an eye on R21, as far as I know she was watching R21. R21 was moved from the DON's office into a room to lie down. I don't even know what room he went into. I was busy packing medications. I do not recall V11 telling me (V6) to watch R21. The Surveyor inquired about a change in condition, how often should vital sign and reassessment be done and what does a complete set of vital signs consist of? V6 stated, A change in condition the vital signs should be done every 2 hours. If a resident say that they feel weak, hot, and feel like they're going to pass out then you take vital signs every 1 hour. If a resident is going to the hospital check vital sign every 30 minutes to an hour. If a pulse oximetry device is not working, then you must find a pulse oximetry that works or put the resident on oxygen. V6 stated a complete set of vital signs consist of blood pressure, pulse, respirations, temperature, pulse ox, and Accucheck if a diabetic. V6 stated, the air conditioner in the building has been broken all year. Once it started to get warm that's when they (facility) started to get chillers to help cool the building down. The chillers came into the facility in July. V6 stated that she has not had been educated or in-serviced on extreme weather hot/cold or the emergency evacuation plan. On 8/31/23 at 3:30 pm V21(Primary doctor) stated he (V21) is very familiar with R21. V21 stated the nurse (V11) called and said that R21 was vomiting. V21 stated, I (V21) thought R21 could be septic because he has a wound, so I told the nurse to send R21 to the hospital. V21 stated the nurse (V11) did not tell him that the building was without AC (Air Conditioner). I was not aware of the extreme temperature in the building, that day (8/23/23) was very hot outside, so I can imagine how hot it was inside of the building where the residents were. V21 stated, If I had known the building did not have AC, I would have given an order to call 911 asap (as soon as possible) because in hazardous temperatures the residents can die. Some years ago, in Chicago there was an extreme heat advisory and there were 300 people who died in the city of Chicago because of extreme heat. I pronounced 20 of them, so I do not take lightly extreme heat situations. If I knew there was no AC, I would have told V11 to get him out of there now. Surveyor inquired if the signs and symptom R21 was exhibiting could have been due to the extreme temperature in the building. V21 stated, I could say yes, his condition was due to the extreme heat that could cause heat exhaustion. The signs that could have been related to the extreme heat is hypotension, mental status change then death. The facility cannot have an AC not working in a heat advisory situation. Residents who have comorbidities and even staff who is working there with normal conditions are at risk with extreme heat advisories. R21's condition was due to the physical environment that caused him to be like he was with the weakness and vomiting. I did not have the information about the AC. If I had that information, I would have given an order to call 911 and get him (R21) out of there (facility). This situation with R21 was preventable. I feel bad for the residents. This is the facility's responsibility to make sure the residents are taken care of 100%. The residents should have been kept safe and this was not a safe environment for the residents. On 9/6/23 at 12:10 pm V10 (LPN) stated that he came into work at 7:00 am on 8/23/23 and around 11:00 am the city came into the building because it was warm in the building. V10 stated, around 1:00 pm staff started moving mobile residents to the first floor. The non-mobile residents when down to the first floor after the mobile residents. Surveyor inquired about R21 and V10 stated the staff said R21 was sick so that's why I (V10) went into the room. I took a blood pressure and a temperature; I did not document my vital signs. I did give the vital signs to V6 (LPN). A resident with a change in condition VS should be taken every 15 minutes. I left out of the room and did not go back into the room where R21 was. A resident with a change in condition should not be left alone. 911 should have been called for R21. I've been hot since April. R21's progress notes reviewed for 8/23/23, excludes documentation regarding the change in condition and transfer to hospital on 8/23/23. R21's vital signs reviewed for 8/23/23, excludes documentation for blood pressure, temperature, pulse, and pulse oximetry regarding the change in condition. R21's name was on the list of vulnerable residents in the facility. Facility document titled List of Vulnerable Residents included R3, R12, and R13 on the list. Records reviewed for R3, R12 and R13 excluded documentation for vital signs on 8/23/23. Surveyor observations from 9:00 pm-10:00 pm residents in the first-floor dining room and by 1st floor nursing station. Eleven residents in the dining room and eight residents in the hallway by the nurse's station waiting to be transferred. Residents were frustrated and tired of waiting to be transferred. One resident stated, I'm sleepy and tired, I go to bed at 8:00 o'clock, why am I still waiting? No staff responded to resident. No observations of vital signs, fluids being offer to the residents or incontinent care to the residents who were still waiting to be transferred out. Facility Policy dated 4/2020 and titled Change in Condition, documents, in part, Guideline: To keep the physician or extender, who is in charge of medical care, responsible party, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. Standard: A need to alter treatment. Facility Policy dated (11/1/22) titled Hot Weather/Heat Emergencies, documents, in part, the Administrator will be aware of the weather forecast of extreme temperatures and comfort levels inside the facility. The Maintenance Director will monitor the facility's air conditioning to ensure that all are in good working order. The maintenance director will monitor temperatures to ensure that air temperatures in the facility maintain comfortable temperature range of 71-80 degrees F. If temperatures increase, readings will be taken every hour. Emergency Operations Plan: Remove residents from areas that are exposed to direct sunlight. Recommending residents to stay indoors during extreme heat conditions. Report any changes in the resident's condition. Be sure to have an up-to- date and accurate list of all residents who are high risk to be adversely affected by extreme temperatures. Facility job description undated and titled Registered Nurse, documents, in part, General Job Description: The primary purpose of the job is to provide licensed nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines and regulations. Duties and Responsibilities: Monitor the care delegated to the Certified Nursing Assistant. Document resident status, clinical care, and interactions in the medical record. Provide updates regarding resident's status to the health care providers. Facility job description undated and titled Licensed Practical Nurse, documents, in part, General Job Description: The primary purpose of the job is to provide licensed nursing care to residents on assigned unit in accordance with current federal, state, and local standards, guidelines and regulations. Duties and Responsibilities: Monitor the care delegated to the Certified Nursing Assistant. Document resident status, clinical care, and interactions in the medical record. Provide updates regarding resident's status to the health care providers. Facility job description undated and titled Certified Nursing Assistant/Guest Experience Coordinator, documents, in part, General Job Description: The purpose of the job is to provide ADL (Activity of Daily Living), Restorative and other care to residents of the facility within the scope of practice .Duties and Responsibilities: Report all changes in the resident's condition to the nurse as soon as practical. Report all accidents and incidents you observe on the shift that they occur. Perform Vital Signs, weights and other task as assigned. The surveyor confirmed on 10/2/23 through interview, record review, that the facility took the following actions to remove the Immediate Jeopardy: The facility implemented all measures on the removal plan. 1) The facility has taken the following action concerning the IJ component: a.) R21 was transferred to the hospital on 8/23/23. Per hospital, R21 has since been discharged on 8/28/23 to (alternate) facility to be closer to family. *On 9/6/2023, surveyor contacted alternate facility and affirmed R21 resides there. b.) All residents in the facility were safely relocated to other facilities in an orderly manner. *Resident evacuation from the facility was completed on 8/24/23 at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). c.) The facility reached safe and comfortable temperatures in the building on 8/23/23. *The (8/30/23) letter provided by contractor states company was engaged to supply necessary equipment to provide temporary air conditioning to the building due to broken compressor to the facility air conditioning equipment. The temporary equipment was brought in and set up by 6:00pm CST on 8/23/23. After the equipment was running for about 30-40 minutes it brought the temperature down considerably. By the time we (contractors) left the site it was already comfortable inside the building. 2) Statement regarding residents that have the potential of being affected. a.) All residents in the facility that have been identified to have potential to be affected were relocated on 8/23/23. *Resident evacuation from the facility was completed on 8/24/23 at approximately 1:00am per V20 (Chicago Building Department Deputy Commissioner). 3) Measures the facility will take or systems to ensure the problems will be corrected and will not recur. a.) The facility contracted a vendor to provide temporary cooling of the entire building. Temporary cooling was installed on 8/23/23. *The (8/23/23) service agreement affirms temporary air conditioning at the facility was provided by (2) 30-ton air conditioners. b.) The facility purchased replacement compressors to be installed in the facility. The compressors were delivered on 8/30/23. The installation is in process. *The (8/23/23) service agreement includes scope of work: non-functioning AC. Approximate start date 8/24/23. *The (8/29/23) consignee delivery receipt includes three (3) compressors sent to facility address. *On 9/25/23 at 2:25pm, V17 (Corporate Administrator) stated the AC is completely fixed. c.) The facility initiated in-servicing for all staff on the facility policy provision and maintenance of comfortable temperature in the facility. Staff in-servicing was completed on 9/1/23. *On 9/25/23 at 2:25pm V17 stated we completed the in-services by 9/1/23 except for the staff that were on vacation and affirmed the facility remains vacant. *The (Undated) facility staff roster (including phone numbers) affirms there are 150 employees. * The facility provided PowerPoints titled Maintaining Facility Temperatures which excludes a date and/or topic discussed. * On 10/3/2023, the facility provided the attachment to the staff/roster signature page including in-service date and topic of discussion. d)The facility will initiate in servicing for all staff. On the facility policy for monitoring and supervision of residents during inclement weather condition. In-services was initiated on 8/31/23 and completed by 9/1/23. The facility nurses were in-service on identification of residents showing signs and symptoms of heat exhaustion and providing hydration during hazardous temperatures. The (undated) facility staff roster (including phone numbers) affirms there are 150 employees. The facility provided Power Points entitled Maintaining Facility Temperatures & Evacuation Plan: What is my role and staff roster (endorsed by 91 staff) which excludes a date, citation number and /or topic of discussion. On 10/2/23 facility provided more in-services for facility nurses. Topic: Facility Policy on Change in Condition. Nursing signatures noted on in-service sheet were 5RN (Register Nurses) and 17 LPN (License Practical Nurses). e) All employees on vacation and any contract staff will be in serviced before their first day of work. New signatures received on 10/2/23 after the initial signature page. f) Post education will include the facility staff will demonstrating their knowledge of the facility policy related to identifying signs and symptoms of heat exhaustion. On 9/26/23 Staff interviewed about the in-services received and could not recall the content of the in-services. 4)The Director of Nursing will monitor continued compliance via the following Quality Improvement Programs once re-entry to the building is permitted by the City of Chicago: a) A QA tool will be developed to ensure safe and comfortable temperatures are maintained throughout the building by auditing the temperature logs in the building daily. The monitoring will continue for 4 weeks and twice weekly for 8 weeks. On 9/27/23 at 10:52 am, V17 affirmed the F684 QA tool was not implemented yet due to building closure ongoing. The temperature QA tool content includes Direction: The maintenance director/designee will daily check temperature on all floors and audit the temperature log to determine if the temperature is at a comfortable level. Date, Floor, was temp log audited? If yes, is temp at comfortable level? If no, what corrective action taken? Comment. b) A QA tool will be developed and completed daily to monitor residents showing a change of condition and determine the cause. On 9/27/23 at 10:52 am, V17 affirmed the F684 QA tool was not implemented yet due to building closure ongoing. F684 QA tool content includes Direction: Daily, The DON/Designee will conduct rounds on the floor to monitor if there is any resident showing signs and symptoms of change in condition (heat Exhaustion) and determine root cause. Date, Floor, was all residents monitored? If yes is there any resident showing signs of change in condition? If yes, was action taken including finding root cause? c)The results of the monitoring will be submitted to the QA/QI Committee Quarterly for review and follow-up. On 9/27/23 at 10:52 am, V17 affirmed the F684 QA tool was not implemented yet due to building closure ongoing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to monitor and supervise a resident (R2), who was placed on facility's 24-hour safety monitoring, who has a history of illegal substance abuse and suicidal ideation. This failure resulted in R2 eloping from the facility and presenting at a county hospital reporting hallucinations and suicidal ideation with a plan to jump into the lake. This was identified as an immediate jeopardy which began on 1/10/2023 when R2 eloped from the facility. V1(Administrator) was notified of the Immediate Jeopardy on 2/07/23 at 10:17am. The facility presented a removal plan on 2/07/23 at 12:45pm. On 2/07/23 at 2:08pm, regional office acknowledged receipt of removal plan and began review at 2:40pm on 2/07/23. At this time the removal plan was not accepted. On 2/08/23 the facility re-submitted removal plan on 2/08/23 at 11:16am. The second removal plan was reviewed and conditionally accepted by the state agency, on 2/08/23 at 2:22pm. On 2/09/23 at 1:42pm, the surveyor verified by observation, record view, and interview, the immediacy was removed. The deficiency remains out of compliance at a level 2 harm until the facility can evaluate the effectiveness of the implementation of their removal plan and maintain substantial compliance with this regulation. Finding include: According to a face sheet, R2 is a [AGE] year-old resident admitted to the facility on [DATE]. According to psychiatric rehabilitative service coordinator note dated 12/09/2022, R2 has a history has a psychiatric diagnosis of suicidal ideation, depression and the history of bipolar disorder and schizophrenia. R2's Minimum Date Set assignment dated 12/20/2022 indicated R2 has a Brief Interview for Mental Status (BIMS) score of 15, which indicates resident has intact cognitive response. R2's care plan dated 01/09/2023, indicated R2 has a history of substance abuse and self-harm or suicidal ideation. Nursing Progress Note dated 01/10/2023 authored by V16 document: Resident noted with unauthorized departure from the facility today, staff has presented statements due this action, MD, social services, DON, and administrator are aware, no guardian/family listed, resident is responsible for self. Safety Checklist (dated 01/10/2023) documents R2 as being in another resident's room at 4pm. The checklist does not list R2's whereabouts starting from 5pm as R2 eloped. On 01/31/2023 at 9:40am V1 (administrator) stated, R2 is no longer at the facility. R2 just left and later that day we found out that R2 was at the hospital. R2 did not even sign out against medical advice (AMA), R2 just left. R2 was no trouble as a resident, maybe on occasion R2 would use vulgar language. R2 came from the sister facility to be closer to the city. R2 would go outside and smoke and would return. On 01/10/2023, we were passing trays for diner, and we realized that R2 was not here at the facility. R2 left the building and never came back. We believe that R2 left when they went out to smoke and R2 never returned. The smoke break was at 2:30pm and we believe that R2 left the facility premises during the smoke break. R2 was never a resident who we were concerned about because R2 never attempted to leave or elope. On 01/11/2023, we received a call from the community behavioral hospital, informing us that R2 was there and wanted to know if he could return. The facility's admissions department contacted the hospital and informed the hospital that we would take R2 back to the facility. They never brought the resident back and the admissions director called the hospital several times to follow up if R2 was returning. R2 did not have a pass to go out into the community alone because R2 was still being evaluated. When R2 was admitted here on 12/09/2022, R2 was still in the process of being evaluated for an independent community pass. At the time R2 left, he was able to go into the community only with supervision and was in the process of being evaluated for an independent community pass but did not possess an independent community pass at the time R2 eloped from the facility. When the residents go out to smoke, they go out to the patio. The exit door to the patio is locked. The patio is monitored by 4 to 5 staff members when the residents are outside smoking. I did not conduct an investigation on how R2 eloped, we did a whole house search and since R2 is alert and oriented, we did not report it to the police. R2 had his jacket on him at the time R2 left because he was outside smoking so he must have planned to elope. Residents at times do attempt to climb the fence to elope from the smoking patio, that's why we have staff there to monitor the residents and prevent them from eloping. I really don't know if R2 escaped from the smoking patio. There were no door alarms going off, so the process of elimination indicates that R2 eloped from the smoking patio. It is possible for residents to elope from the smoking patio. If the resident is alert and oriented, we don't investigate on how they eloped. If they are alert and oriented it's their decision if they want to leave. R2 had the capacity to make his own decision and R2 had the capacity to leave the facility. R2 never expressed the desire to leave the facility. As of right now, I do not know how R2 left, this is only our suspicion that R2 eloped from the smoking patio. R2 somehow ended up in the community psych hospital and did not get his medication and was cold and hungry and probably ended up at the psychiatric hospital. There is a loophole of how R2 eloped, so there are other residents who are potentially able to elope from the facility. We are aware of the fact that there is a loophole on how R2 escaped, and we are monitoring other residents closely. I honestly don't know how R2 escaped it is only our suspicion that R2 escaped from the smoking patio. We did not put in any new interventions, since R2 eloped, we are just closely monitoring the residents and the doors are locked. R2 has a diagnosis of schizophrenia so R2 does have a history of psychiatric disorder. As of right now, the last we know R2 was at the hospital, and I believe R2 was discharged . R2 was not suicidal at the time. In R2's diagnosis R2 does have suicidal ideation but R2 wasn't suicidal at the time. I did not report this incident to the IDPH because R2 was alert and oriented and R2 wasn't a problem. On 01/31/2023 at 10:50am, V1(administrator) identified 8 residents at risk for elopement at the time of investigation. The following residents were identified as being at risk for elopement: R6, R7, R8, R9, R10, R11, R12 and R13. On 01/31/2023 at 11:32am V3 (social service director) stated, When a resident elopes and once we are made aware of the elopement, we call a code pink. Code pink means that there is a missing resident or elopement. We search for the resident that's missing in the facility and outside. If need be, we will call the Chicago Police Department. If the residents have family listed on the contact list, we will call them and make them aware. If we cannot find the resident, we will call the police and make a missing police report right away. That is protocol, that when a resident is missing and cannot be found, we have to call the police and make a missing police report. The protocol to call and make a police report when the resident is missing is for every resident, regardless of their cognitive status, a police report must be filed when a resident is missing. It does not matter how alert the missing resident is, when we cannot locate that resident when a search is unsuccessful, we are supposed to call the police immediately. On 01/31/2023 at 11:52am V4 (psychiatric rehabilitation service director) stated, R2 was living at our sister facility and was admitted to this facility on 12/09/2022. When we have a new resident admitted to this facility, we have to do a 72-hour behavior safety check list where we monitor them. After reviewing R2's admission packet from the hospital, we discovered that R2 has a past history of aggression, history of substance abuse and suicidal ideation. The social service department enrolls the resident into the substance abuse program. After reviewing R2's referral packet, R2 was placed on a facility safety monitoring rounding checklist because R2 has a history of suicidal ideation and substance abuse. R2 was residing on the 3rd floor which is a psychiatric floor. The rounding check list requires the staff to monitor R2 every hour and record R2's whereabouts on the checklist. According to the checklist filled out by V15 (psychiatric rehabilitative service aide) on 01/10/2023, R2 was last seen at 4pm, at that time R2 was in another resident's room. After 4pm, R2 was no longer seen. I received a call from V5 (PRSC) stating that they could not find R2 inside facility. Immediately after receiving that call, I notified the V1 (administrator) and explained to V1 that R2 is missing. I asked my staff to document on the computer about the elopement and we updated the care plan and the elopement form. The facility was searched prior to calling me and when they could not find the resident, they called me, and they called the administrator. The administrator did not call the police because R2 is alert and oriented. According to the administrator, if the resident is alert and oriented, we do not notify the police and we do not make a missing police report. R2 did not discharge from the facility, R2 eloped. R2 has a major depressive disorder and schizoaffective disorder bipolar type and schizophrenia and suicidal ideation and cocaine abuse usage and cannabis dependence which is why R2 was admitted to the facility in the first place. Medically, R2 is not fit to leave the facility. R2 needs help to be stabilized. R2 has a lot of mental health issues and should on be out of this facility according to his medical history. We do not know R2's mental state at the time R2 eloped. The facility's administrator would be the one who calls and makes a police report. On 01/31/2023 at 3:26pm V6 (certified nursing assistant) stated, I was the C.N.A working with R2 on 01/10/2023, when R2 eloped. The last time I saw R2 was at 1:30pm, when R2 was going down to smoke a cigarette on the smoking patio. I saw R2 leaving the 3rd floor to go to the 1:30pm smoke break. I do not recall seeing R2 return from the smoke break. R2 never mentioned that he wanted to leave the facility. I finished my shift at 3pm and when I returned to work on 01/11/2023, I was informed that R2 eloped. On 02/01/2023 at 9:56am V7 (certified nursing assistant stated, I was working on the 3rd floor on 01/10/2023. I saw R2 on 01/10/2023. The last time I can recall seeing R2 was during lunch time. I don't recall seeing R2 after lunch. The last time I saw R2 was during lunch time when I was passing trays. Typically, R2 was usually in his room. I don't recall ever seeing R2 visiting other resident room. R2 kept mostly to himself and stayed in his room. On 02/01/2023 at 12:32pm V10 (primary physician) stated, They called me from the facility and told me that R2 eloped. They told me that R2 just walked out from the facility. There was no AMA, there was no discharge for R2, he simply just left and walked out from the facility. The facility told me that R2 just left. R2 just ran away. R2 was being monitored for safety at the facility. I think that R2 could have jumped the fence, but I don't know. R2 was being monitored for safety and R2 was a psych patient. Often, the psych residents want to leave the facility and that's what R2 did, he just walked out of the facility. The nursing home was monitoring him for 24 hours a day. Based on the diagnosis that R2 has, R2 needs to be monitored and I hope that R2 does not kill himself or someone else. I thought that the facility called the police and made a police report and reported R2 missing. I thought it is protocol to call the police when a resident elopes. I thought that the facility called the police to report that he ran away. On 02/02/2023 at 10:32am V13 (Psychiatric Rehabilitative Service Coordinator) stated, I was the one that was supervising the smoking session on the day that R2 eloped. There was 4 of us supervising the smoking break. Typically, there should be an activity aide, a CNA, a PRSC and a PRSA. On 01/10/2023, there was only 4 of us supervising the smoke break. I don't remember if an activity aide was there and I don't remember if there was a CNA present. I don't remember seeing R2 on the patio during the smoke break. We monitor the residents during the smoke breaks. We have staff members on each side of the gate and a staff member in the middle to provide supervision during a smoke break. On the day that R2 eloped, I don't remember seeing a staff member on each side of the gate to supervise during the smoke break. There is usually a staff member supervising the front gate, but I don't remember seeing a staff member supervising the other end gate, the gate that is away from the front entrance. We wait until all of the residents come inside from the smoking patio. Once all the residents come in, we lock the door. On 02/02/2023 at 10:52am V14 (front door receptionist/Psychiatric Rehabilitative Service Assistant) stated, On 01/10/2023, R2 came down from the 3rd floor to the front lobby close to 2pm. R2 approached me and requested to speak to V1 (administrator). R2 remained in the front lobby, and I went to inform the administrator, that R2 was requesting to speak to V1, however, V1's door was closed. I came back out to the front lobby to let R2 know that V1 was in the meeting, and I told R2 to come back in 30 to 40 minutes. R2 said R2 would come back to speak to the administrator and got on the elevator. That same day, I saw R2 on the second floor around 3pm, visiting R5's room. That was the last time I saw R2. R2 did not escape during the 1:30pm smoke break because I saw R2 around 3pm on the second floor in R5's room. That was the last time I saw R2. I was informed around 5:30pm that R2 was missing and R5's room was the first place I went to search. I called a code Pink, which is a code called when a resident is missing. On 02/02/2023 at 11:23am, V15 (Psychiatric Rehabilitative Service Assistant) stated, On 01/10/2023, I was the one who signed the round sheet for R2 at 3pm and 4pm. The round sheet is used to monitor residents for safety. I witnessed R2 at 3 and 4 pm on the second floor, in R5's room. I did not see R2 in the facility after 4pm. On 02/02/2023 at 12:28pm V17 (maintenance director) stated, I checked all the exit doors with alarms in the entire building. All the door alarms are working properly. All the exit doors are secured and locked. After R2 eloped, I checked all the doors and alarms in the building, and everything was working properly. It is a possibility that R2 escaped through the service door in the basement, by the kitchen. We have food delivery and supply delivery, and everything is delivered through the back service door, so it is possible that R2 escaped through the service door in the basement. We had other residents attempt to elope through the basement service doors. We have cameras all over the facility. Surveyor, accompanied by V17 (maintenance director), checked all the door alarms in the facility. Surveyor observed the door alarms to be working. County Hospital Records (dated 01/11/2023) document: Voluntarily brought self in states that he has suicidal thoughts with a plan to jump off a bridge; denies HI and hallucination. Hospital Records dated 01/11/2023 document: Pt is a [AGE] year-old male who presented to behavioral hospital as a direct transfer from county hospital Emergency Department. Per hospital fax, pt presented with suicidal ideation with a plan to jump in the lake. Pt also reported visual hallucinations stating that people are following him. Pt has a history of schizophrenia and bipolar. Pt reported that he is compliant with his medications. Pt reported that he lived in a nursing home that provided him with the medication. Pt endorses cocaine. Pt was unable to contract for safety. Pt is a danger to self and is in need of inpatient psychiatric treatment for safety and stabilization of suicidal ideation and psychosis. Emergency Operations Plan: Elopement vs. Unauthorized/Unplanned Discharge Policy and Procedure (dated 11/17/2022) states: In the event of a possible elopement, the following procedures shall be utilized: a.) Proper code will be called overhead. b.) An investigation shall be coordinated by the facility administrator, director of nursing or manager/supervisor on duty. A search will be conducted to assist in locating the resident. d.) The local law enforcement will be notified. e) If the incident/falls into IDPH Reporting Guidelines, designated facility staff will report incident to IDPH within 24 hours. Progress note dated 01/10/2023 documents, The writer was notified by the facility staffs that the resident made an unauthorized departure on 01/10/2023. The writer informed the writer, the staffs carried out room search, the resident was located. Psych social will continue to monitor and document as needed. Progress note dated 01/11/2023 documents, The nurse M. called from the community behavioral hospital; stating that they have the above resident there and they will be admitting him and wanted to know if he can return. I advised the nurse to call the facility back later in the morning to speak with social services. She stated, OK! The writer also informed the nurse the resident eloped from our facility. Nurse Practitioner Progress Note dated 01/14/2023 document, Psychiatry Note Attempted to see patient for evaluation this date but was informed by RN that he was not available because he eloped a few days ago. The surveyor confirmed through observation on 02/09/2023, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The facility has taken the following actions concerning the IJ component a. The facility will review all residents who are at risk for an elopement and will update their care plans for resident specific interventions. Review and update by PRSD initiated on 2-7-23. b. Facility will immediately conduct a (RCA) root cause analysis, to be conducted by administrator, on how the resident was able to elope from the facility and what additional care plan measures could be put into place should the resident return. Plan started on 2-7-23 by the administrator. c. The resident that has been identified to be at risk of elopement has been placed on Q1-hour safety monitoring. Monitoring initiated on 2-7-23 d. Facility will ensure that residents who are at risk for self-harm, who leave the facility without authorization, will be reported to the Chicago Police Department by PRSD or designee. 2. Statement regarding how the facility identify other residents having potential to be affected by the same IJ component? a. All those at high risk for elopement have been identified to have potential to be affected. 3. Measures the facility will take or systems to ensure the problems will be corrected and will not recur. a. All residents have been reassessed for elopement risk by PRSD. The facility has used the Elopement Risk Assessment to complete the reassessments. b. Care plan for residents identified as an elopement risk have been reviewed with individualized interventions for safety. Review initiated on 02/07/23. These include hourly safety checks and behavior monitoring as needed. c. The facility has initiated an educational in-service for all staff, including Social Services, Nursing, Activities, Front Office, Housekeeping and Managers, on the facility elopement policy and the code procedures in any incident of elopement. on monitoring resident's at risk for elopement, interventions for prevention of the elopement, and the system for monitoring residents at risk for elopement; as well as steps the staff should follow should an elopement occur. Any staff on vacation or leave will be in serviced before their next scheduled shift. In-service initiated on 02/07/23. 4. The Director of Nursing or designees will monitor continued compliance via the following Quality Improvement Programs: a. Daily, the PRSD or designee, will ensure that all resident that have been identified to be at risk of elopement are monitored hourly all through the shift. b. Quarterly the care plan for residents identified as an elopement risk have been reviewed with individualized interventions for safety. c. The results of the monitoring completed under this POC are submitted to the QA/QI Committee for review and follow-up. The QA/QI committee is made up of IDT members which include Nursing, Social Services, Psycho-social Rehab, Activities, Therapy, Administration, and Medical Director.