**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interviews and record review the facility failed to: conduct head counts (every two hours); failed to provide supervision for one resident (R7) in the sample; failed to follow Doctor's pass order for one resident (R5); and failed to implement the elopement and pass policies for three residents in a sample of 15 (R5, R6 and R7). These failures resulted in an immediate jeopardy and has the potential to affect 123 residents that reside in the facility.An immediate jeopardy began on 8/9/25 at 9:00 am, when R6 left the facility unauthorized and continued with subsequent failures that led to R5 and R7 also being away unauthorized.On 8/14/25 at 3: 47.pm, V1 (Administrator) and V20 (Regional Consultant) were notified of the Immediate Jeopardy and the IJ template was presented.On 8/19/25 an acceptable removal plan was accepted after revisions to other removal plans that were submitted on 8/18/2025.The immediacy was removed on 8/19/25, however deficiency remains at a level two because more time is needed to evaluate the implementation and effectiveness of staff training. Findings include:R7 is a [AGE] year-old with diagnoses including but not limited to: Suicidal Ideations, Major Depressive disorder, Bipolar disorder and Generalized Anxiety disorder.R7's admission Record documents an admission date of 8/11/25.On 8/12/2025 at 11:15 am, V1 (Administrator) stated the following, R5 left the facility alone on yesterday (8/11/2025) at 1:30 pm and has not returned to the facility. R7 eloped during a smoke break on yesterday (8/11/2025). R6 left out on pass on 8/9/2025 and has not returned yet. I have been in contact with the police department and there is no new information regarding their whereabouts.On 8/13/25 at 3:37 pm, V6 (Smoking Monitor) stated the following, On Tuesday (8/11/25) during the 2:00 pm smoke break, a new resident (R7) was outside smoking and began walking off. Another smoking monitor was following him (R7) and he crossed the street. I came in the building and announced a code 99 (elopement code) because he (R7) was away from the smoking area. At that time, staff members ran out to try and get him but couldn't find him. I have not seen him since.On 8/13/25 at 4:30 pm, V12 (Social Service Director) stated the following, R7 had just been admitted to the facility. Usually, a smoking and elopement assessment is done within 24 hours of admission. In certain cases, I will allow the resident to smoke with supervision prior to the assessments (smoking and elopement). Residents who are elopement risks and new admits are scheduled a specific time to smoke (apart from the other smokers) to have special supervision. I had allowed R7 to smoke with the regular smokers and smoking monitor because he was agitated and stated that he had not smoked in days.On 8/18/25 at 4:55 pm, V26 (Medical Doctor) stated the following, When a patient is admitted to the facility, the patient should have an evaluation prior to being allowed to go out and smoke or to go out on pass. If no evaluation is done, there is a great risk taken when a resident is allowed out of the facility because we don't know that patient. If a patient elopes, especially a psych patient, we don't know what can happen because they are mentally unstable.Employee statement written by V6 (Smoking Monitor) on 8/11/25 documents, V27 (Smoking monitor) had lit R7's cigarette and sat down. I (V6) was bringing the wheelchair (residents) up (the ramp back into the facility) and as I was focusing on that, R7 started to get up and walking away from the smoking area. V27was following him and asking where he (R7) was going. The moment R7 passed the curb of the sidewalk. I had went up the ramp and yelled out to the receptionist to announce a code 99 over the intercom. A code 99 stands for a resident who is fleeing or running away. On 8/20/25 at 11:30 am, V1 (Administrator) stated that R7 had not returned to the facility.R7's Medical Chart excludes an elopement assessment, elopement care plan, smoking assessment/ agreement or smoking care plan.Facility Census report dated 8/11/25 excludes R7 as an active resident.R6 is [AGE] year-old with diagnoses including but not limited to: Suicidal Ideations, major depressive disorder, bipolar disorder and schizoaffective disorder.During investigation on 8/12/25 at 2:00 pm, V4 (LPN/ Licensed Practice Nurse) stated the following, when R6 went out on pass on 8/9/25 I gave him a pass. R6 came to the nursing station and said that he was leaving the facility and coming back at 4:00 pm. Once he takes the pass to the front desk, he is supposed to sign out and back in by 4:00 pm. My shift ended at 3:30 PM. When I was leaving that day (on 8/9/25), I (V4) informed V5 (LPN) that R6 had not returned yet since V5 was R6's night nurse. When I came in the next day (on 8/10/25), I also notified management once I realized that R6 still had not returned to the facility. I am not sure if management was notified prior to my notification.On 8/12/25 at 12:48 pm, V2 (Director of Nursing/ DON) stated the following, We (facility staff) are responsible for the residents, and it is important to recognize early if a resident is missing so that the resident can be searched for and reported to the police. Most residents take medication and have medical conditions and psychiatric issues. We want to make sure that they are safe. I am mainly concerned with their safety and them committing suicide. The receptionist is contacted between 4:30pm and 5:00 pm by the assigned nurse if a patient has not returned on a unit. At that point, the receptionist can verify whether or not the resident has signed back into the facility. If the patient has not signed back in, I (V2) or V1 (Administrator) are notified and a head count is done. V5 texted me at 8:18 pm (on 8/9/25) and notified me that R6 was missing. Everyone (staff) on each floor check for the missing resident. We notify the family in case the family may know where the resident may be, we call nearby hospitals and the physician is also notified at that time. It is imperative that we are notified of a missing resident as soon as possible. If a resident does not sign back in by curfew at 4:00 pm, management should be notified.On 8/13/25 at 3:00 pm, V7 (Receptionist) stated the following, I work 7:30 am- 3 pm. V10 (Receptionist) works from 3:00 pm - 11 pm. Any residents that come in and out has to sign in and out. The residents' curfew is 4:00 pm and the times that they stay out of the facility overnight is prearranged by family or friends. The family or a friend will have to sign the resident out and it will be documented in the system that the resident is out overnight and for a certain period. If a resident is not in the facility by 4:30 PM, the receptionist informs the nurse and also the social worker.On 8/13/25 at 3:45 pm, V10 (Receptionist) stated that if a resident is not back by 4:00 pm, that she notifies the nurse on duty at 4:00 pm so that the nurse can initiate the notification process. On 8/20/2025 at 2:35 pm, V5 (LPN) stated the following, Normally the curfew is 4:00 pm. If I don't see a resident after dinner at 4:30 pm, I am alarmed to look for the resident. During dinner, we are supposed to do head counts and the CNAs (Certified Nurse Assistants) do head counts every two hours. The CNAs have a piece of paper (roster) with resident's names (per floor) and they (CNAs) check off the residents' names. I realized that R6 was missing at 6:30 or 7 pm (on 8/9/25). I thought that his pass was extended or something, so I didn't worry too much about R6. I notified management around 8:30 pm but I don't know if I documented it or not. It is important to notify management immediately so that they can start the investigation process early to see if they (the residents) are hurt or in the hospital. Management should be notified immediately.On 8/18/25 at 4:55 pm, V26 (Medical Doctor) stated the following, mentally unstable residents are at risk for danger and their safety should be a priority. Routine head counts are important to recognize if a patient is not present in the facility.On 8/20/25 at 3:30 pm, V1 stated that he could not locate the resident rounding checklist (roster) for the third floor (R6's floor) for 8/9/25.R6s' Nurse's Note dated 8/10/2025 at 12:27 pm and authored by V4 (LPN) documents, writer called 911 of missing person since yesterday. R6 did not return to the facility by 4:00 pm. R6s' Nurse's Note dated 8/10/2025 at 10:34 pm documents, R6 has not returned back to the facility. Facility's Resident Sign-out Sheet dated 8/9/2025 documents exclude R6's signature.R6's Nursing Progress notes excludes any documentation on 8/9/25 of R6 signing out of the facility. Missing Persons Police Report dated 8/9/2025 documents R6 missing as of 8/9/2025 at 9:00 am.On 8/20/2025 at 3:30 pm, V1 stated that R6 returned to the facility on 8/17/25 (eight days later).R5 is a [AGE] year-old with diagnosis including but not limited to: Schizoaffective disorder, schizophrenia, essential hypertension and chronic obstructive pulmonary disorder.During investigation on 8/12/25 at 11:15 am, V1 (Administrator) stated the following, R5 left the facility alone on 8/11/25 at 9:00 am and has not returned to the facility. I have been in contact with the police department and there is no new information regarding R5's whereabouts. I was notified at 9:15 pm (on 8/11/25) that R5 was missing. On 8/12/2025 at 12:48 pm, V2 (DON) stated that all residents required a doctor's order to leave the facility independently and that she (V2) was not aware that R5 did not have a doctor's order for independent pass privileges. At that time, V2 also stated that she was new in her role and was not totally sure of whose responsibility it was to update pass orders. On 8/13/2025 at 3:00 pm, V7 (Receptionist) stated the following, R5's pass privileges are posted on the pass list at the front desk. His pass privileges are with supervision meaning that he may not leave the facility without supervision. He signed out on 8/11/25 without supervision.On 8/13/2025 at 4:30 pm, V12 (Social Service Director) stated the following, I update the pass list for the front desk according each residents current doctor's orders. I was not aware that R5 did not have a doctor's order to go out on pass. Any nurse in the facility has the authorization to update a resident's orders per Doctor. On 8/18/2025 at 4:55 pm, V26 (Medical Doctor) stated the following, All patients need a doctor's order to go out on pass and In order to go out overnight, the patient's family would have to sign the patient out of the facility. If a patient does not sign back into the facility after being out, the Doctor, family and facility administrator should be notified immediately. Anything could happen to the resident in a short period. I personally know of an incident involving a resident getting hit by a train after leaving a facility unauthorized.On 8/20/2025 at 2:50 pm V11 (Registered Nurse/ RN) stated the following, We (nurses) usually give the resident the pass to leave. I gave R5 a pass on the day that he left (8/9/25). I was not aware that R6 did not have a physician's order to leave the facility. Before we (nurses) were not checking the pass privileges before resident leaves but now we do. When a resident goes out on pass, they have be back at the facility by 4:00 pm. There is a two-hour rounding documented by the CNAs. If a resident is not here by 4:00 pm, we must notify the DON (Director of Nursing) immediately and investigate.On 8/20/25 at 3:30 pm, V1 stated that he could not locate the resident rounding checklist (roster) for the third floor (R5's floor) for 8/11/25.R5's Nurse's Note dated 8/11/25 at 10:19 pm documents, R5 left on pass and failed to return.R5 Physician Order sheet documents the following active order as of 7/22/25, may not go out on pass. Facility Front Door List dated 8/12/25 documents R5's pass privileges as ‘with supervision'.Facility's Resident Sign-out Sheet dated 811/25 documents, R5 signed out of the facility at 1:30 pm.Missing Persons Police Report dated 8/12/25 documents R6 missing as of 8/11/2025 at 1:30 pm.An IJ occurred when: R6 signed out at the receptionist and left the faciity on [DATE] at 9:00 am with temperatures over the weekend ranging in the 90s and did not return until eight days later; the facility failed to conduct resident checks (every two hours), therefore did not notice that R6 was not in the facility on 8/9/25 until around 8:00 pm; R6's assigned nurse (V5) did not notify management (Administrator or Director of Nursing) that R6 did not return to the facility until hours after 4 pm curfew (at 8:18 pm).R5 left the facility unsupervised and without a doctor's order on 08/11/25 at 1:30pm. R5's assigned nurse (V11) did not follow Doctor's order regarding R5's pass privileges; The facility failed to ensure R5's safety as he was allowed out of the facility (unauthorized); staff did not notice that R6 was not in the facility on 811/25 until around 9:00 pm; V5 (LPN) did not notify management that R5 did not return to the facility until hours after 4 pm curfew (at 9:15 pm); as of 8/21/25, R5's whereabouts still could not be confirmed.And when R7 eloped from the facility shortly after his admission on [DATE] during a smoke break around 2:00 pm; R7 was never assessed for smoking or elopement risk prior to being permitted outside to smoke; As of 8/21/25, R7's whereabouts still could not be confirmed.On 8/21/25, IDPH (Illinois Department of Public Health) was notified of R7's 8/11/25 elopement and R5's unauthorized leave on 8/11/25 (10 days after incidents occurred).On 8/21/25, IDPH (Illinois Department of Public Health) was notified of R6's unauthorized leave on 8/9/25 (12 days after occurrence). Facility Policy titled Wandering and Elopements documents, the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.Facility Smoking policy documents, the resident will be evaluated on admission to determine his/ her ability to smoke safely with or without supervision (per a completed smoking evaluation); The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the smoking evaluation. Facility Outside Pass Policy documents, residents may not be considered for community outside pass privileges without physician order. Facility policy titled Missing Resident documents, at the beginning of each shift, during med pass, and each meal the staff shall account for all at-risk residents under their perspective care. Facility Census dated 8/12/2025 documents a total of 123 active residents. On 8/19/25 and 8/20/25, surveyor confirmed through record review and interviews that the facility took the following actions to remove the Immediate Jeopardy: (However deficiency remains at a level two because more time is needed to evaluate the implementation and effectiveness of staff training). 1. The reception desk and each nurse station were provided with updated list of residents who can and cannot go out on pass. This was initiated on 8/15/25 and ongoing. 2. Pass Orders were initiated for all residents by the DON (director of nursing)/designee. Out on Pass Orders will be reviewed for all admissions, readmissions, or change in status by the DON (director of nursing), Administrator, Social Services/ Designee. This was initiated on 8/15/25 and ongoing. 3. The Front desk staff were up-dated on the following pass procedures: Front desk staff will monitor return times for those out on pass; Each resident is expected to sign back into facility by 4:00 pm (unless previous overnight arrangements were made and approved); Immediate investigation and notification of missing person is initiated if a resident does not return from being out on pass: Investigation begins with a facility-wide search of resident; Notification of missing person to Administrator, DON/ designee and family of suspected absence as soon as practical; local area hospitals are contacted. This training was conducted on 8/15/25 and ongoing. 4. On 8/14/2025, Resident head count of the facility was initiated and documented by the DON; headcounts are conducted during shift change as part of the nurse-to-nurse shift reporting and when the staff identifies that a resident is missing; On 8/18/2025, Resident 2-hour rounding was initiated by Nurses and CNAs (Certified Nurse Assistants) on duty to ensure residents are accounted for; On 8/18/2025, head counts during smoking breaks initiated by Smoking Monitors/PRSC's/Maintenance staff/Designated staff monitoring smoke breaks; Residents are signed in and out of facility during smoke breaks. 5. Social Services Director/ Designee updated the facility elopement binders with pictures of residents and care plans with interventions for those who are restricted from leaving by physician's orders; elopement binders were placed in all nursing stations, kitchen, front desk, and department head offices; the elopement binder is updated when a new resident is added to the binder; A resident is added to the binder when the resident is identified with exit- seeking behavior/risk for elopement. Initiated on 8/15/25. 6. The Social Services Director/ Designee developed care plans for all residents identified with wandering behavior/ elopement risk on 8/15/25. 7. On 8/21/2025, IDPH was notified of R7's 8/11/25 elopement, R5's unauthorized leave on 8/11/25 and R6's unauthorized leave on 8/9/25.