**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record the facility failed to avoid an accident by not ensuring that the window safety latch was engaged to prevent a window from opening no greater than the 1 1/4 inch in height. This failure affects one of three residents (R9) reviewed for accidents. R9 room window observed open at its highest and R9 observed outside on the ground, and unresponsive, R9 subsequently noted cold to touch, with rigor in the jaw and with obvious signs of death, R9 pronounced deceased at 5:49am on [DATE]. This was identified as an immediate jeopardy which began on [DATE] when R9 was found outside the facility on the ground below his room window. The immediacy was removed on [DATE]. V7 (Administrator) was informed of the immediate jeopardy and the immediate jeopardy template was presented on [DATE] at 10:32 am. The facility provided an acceptable removal plan on [DATE]. On [DATE] the surveyor was onsite to confirm the removal plan was implemented. Although the immediacy was removed, the deficiency remains at the second level of harm until the facility can determine the effectiveness of the implementation of removal plan. Findings include: R9 face sheet shows R9 was admitted to the facility on [DATE]. R9's care plan shows R9 had diagnosis of major depressive disorder, metabolic encephalopathy, asthma, chronic kidney disease, long term use of aspirin, personal history of other venous thrombus and embolism, history of falling, psychotic disorder with delusions due to known physiological condition, hypertension, heart disease, unspecified atrial fibrillation, sarcoidosis, other obesity, type 2 diabetes, vascular dementia, other seizures, benign paroxysmal vertigo unspecified ear, cerebral ischemia, other speech and language deficits following cerebral infraction, osteophyte right hip, facial weakness, acquired absence of eye, and presence of artificial eye. R9's MDS dated [DATE] denotes in part section C for BIMS (brief mental status) denotes a score of 9 (cognitive impairments), R1 has disorganized thinking- 1. Behavior continuously present, does not fluctuate. Section D for mood shows for 7-11 days R9 has trouble falling or staying asleep or sleeping too much , section E for behavior denotes behavioral symptoms presence or frequency, other behavioral symptoms not directed toward others; number 1 is denoted for behavior of this type occurred 1 to 3 days, E0500 denotes did any of the identified symptoms put the resident at significant risk for physical illness or injury; number 1 is denoted for yes, significantly interferes with resident care; number 1 is denoted for yes, E1100 for changes in behavior or other symptoms; how does resident current behavior status, care rejection, or wandering compare to prior assessments (OBRA or scheduled PPS) - 0 denoted for same. Section G for functional status denotes for bed mobility- R9 requires extensive assistance with two-person physical assist, transfer- R9 requires extensive assistance with two-person physical assist, walk in room / corridor - activity did not occur. Facility initial incident report to the department dated [DATE] denotes in-part, resident name (R9), date of incident: [DATE], time of incident: 4:45am, location of incident: facility. Description of incident: resident (R9) accessed the window to his room and was found by staff on the ground. The facility is ground level and all one floor. The staff immediately brought the resident back in the building via wheelchair. The resident was alert at that time and the nurse was speaking to him trying to get information on what occurred. The CNAs put the resident to bed while the nurse initiated a call to 911, the nurse went to the room to assess the resident he became unresponsive and immediately CPR was initiated. Shortly after CPR was initiated, the paramedics arrived and continued resuscitation efforts. The resident was pronounced deceased by paramedics at 5:49am. Investigation initiated. Final will be sent per protocol. Type of incident; other box is checked. Type of injury; nothing is checked, environmental; nothing is checked. Notification denotes, physician on [DATE] at 6:30am, family on [DATE] at 630am and police on [DATE] at 4:45am. Hospitalization; no box is checked, 24-hour preliminary report box is checked. Signature box denotes V25 (DON- Director of Nursing). Facility incident report titled other dated [DATE] completed by V24 (Nurse) at 10:30am completed by V24 (Nurse) denotes in-part incident location- outside, resident found on ground outside below window, resident unable to give description, 911 called, no injuries observed at time of incident, no injuries observed post incident, predisposing environment factors- other is checked, predisposing physiological factors; confused, predisposing situation factors; other is checked, agencies, people notified; DON on [DATE] at 10:36am. R9 Fire Department report dated [DATE] denotes in-part Medics 612 and 602 were dispatched to the above location for the heat/cold emergency. Upon our arrival crew found a [AGE] year-old male laying supine in bed, apneic and pulseless. Patient nurse stated, we found him hanging out the window next to his bed. At this time, an assessment was performed from head to toe. Crew found the patient to be cold to touch, fixed pupils, and rigor to the jaw. Patient was placed on the cardiac monitor and showed asystole. Patient nurse was asked by crew the last known normal of the patient and she stated we saw him at 4:00am LUMC (hospital initials) was contacted for medical control and time of death was given of 0549 by nurse 8067 and Doctor (physician name noted). Patient was left in the hands of police, and they were given TOD (time of death) and Doc (Doctor) name. Patient was laying supine in bed apneic and pulseless. Patient was cold to the touch and rigor to the jaw. Chief complaint hot/cold exposure, patient nurse stated, we found him hanging out the window. Arrest present; yes prior to any EMS arrival, who witness; not witness, etiology; presumed cardiac, initial rhythm; asystole, CPR (Cardiopulmonary resuscitation) provided prior to EMS arrival: no, CPR started; 00:00, CPR by first responder, resuscitation; not attempted- considered futile, AED uses: no, Defib type: N/A. Impression/diagnosis; system cardiovascular, symptoms death, impression: obvious death, initial patient acuity: dead without resuscitation efforts (black). Cardiac monitor performed: role performing paramedic. Patient was placed on the pads to conform asystole, size pads, successful. Complication: none. Authorization: Via protocol. Patient response: unchanged. Paramedic consulted with (physician name noted) via radio, attempts 1; successful. Response factors affecting care; none. Scene factors affecting care: none. Transportation factors affecting care: not applicable. Dispatch factors: none. Turn around factors: none. Electronically signed by V26 (Fire department medic) at 6:43am. On [DATE] at 12:50p.m during observation of R9's room identified via facility census with V6 (Maintenance Supervisor), V6 identified the bed by the window as the bed that R9 was assigned to, the bed was observed pushed up against the window, bed frame touching the wall where window is located. The window locks were pointing outward (V6 said the window was unlocked), the window screen was observed missing, V6 identified the window screen that was observed outside the window on the ground to belong to R9's room window. The window screen was observed outside the window next to the bushes, portion of the metal frame was observed bent. The window blinds were observed to be missing, there was an additional mattress noted leaning on the wall. V6 said the blinds are missing because R9 pulled the blinds down, V6 did not have time frame of when R9 pulled the blinds down. Window measurements conducted with V6, when the bottom window was open to its highest the window opening was observed to measure at 27 inches in high, V6 said a resident can fall out the window when it's open to its highest. The measurement from the floor to the window seal was 13.75 inches (measured by V6). The measurement from the floor to the top of R9's mattress was observed to be 19.25 inches (measured by V6). At 5:10pm during observation of the facility widows to determine if they have locks, several room windows were observed with screws in them. V6 said the screws are there so that the window does not open too far. On [DATE] at 10:43am during follow up observation of the window in R9's room, there were 2 white apparatus on the top window (left and right side), V6 identified the apparatus to be a safety latch, V6 said the latch is to prevent the bottom window from opening too far. V6 moved the latch to the out position, V6 opened the window with the latch engaged, the window opening was observed to open no greater than 1.25 inches (measured by V6). V6 said the safety latch should always be in the out position, V6 said the last time he checked the window safety latch was 2 weeks ago, V6 said he checks the safety latch whenever, V6 said there is no frequency as to how often the windows should be checked to ensure that the latches are in the out position. V6 said when the latches are in the out position, it prevents the window from opening too high. V6 said when the safety latch is in the out position the window will not open wide enough for the resident to fall out. V6 said it is his responsibility to check the window safety latches to ensure they are in the out position. During the tour of the other residents' rooms to observe if there were safety latches in place and in the out position, there were 11 windows noted with the safety latch not in the out position thus allowing the window to open greater than 1.25 inches and or at its highest. During the tour V6 did not position the safety latches in the out position to prevent the windows opening greater than 1.25 inches. On [DATE] at 1:45 pm V24 (Nurse) said she was passing medication when V17 (CNA- Certified Nursing Aide) reported to her that R9 was outside on the ground. V24 said she looked out R9's room window and saw R9 on the ground, no one else was out there. V24 said they went outside, R9 was groaning, R9 had on a gown, no socks, no shoes, and she was not sure if R9 had on a brief. V24 said she asked R9 what he trying to do and R9 just looked at her and did not respond. V24 said they picked R9 up off the ground, R9 was not able to stand. V24 said they went and got a wheelchair and brought R9 back inside the facility. V24 said they put R9 in the bed, R9 was moaning, and she went to call 911 and get the blood pressure cuff. V24 said when she came back to R9's room that's when R9 stopped breathing. V24 said she initiated CPR- chest compressions. V24 said she stopped CPR and came out the room to allow for the medics to go in R9's room. V24 said the aide last saw R9 at 4:00am. V24 said R9 bed was in the low position. V24 said R9 bed is by the window. V24 said sometimes R9 sleeps at night and sometimes R9 is busy tossing and turning. V24 said she's sure R9 opened the window. V24 said R9 has confusion and is a fall risk. V24 said R9 never had any exit seeking behavior, and R9 did not have any bed alarms. V24 said when she called 911, she informed them that R9 was outside the window on the ground. V24 said she does not know how R9 got outside the window, she does not know how long R9 was outside on the ground. V24 said R9 room window was open pretty high. V24 said R9 was a full code. V24, said she did an assessment and R9 was not breathing, and she initiated CPR. V24 said the medics came and took over. V24 said the medics worked on R9 for 45minutes to an hour. V24 said R9 not revived. V24 said she notified the family and the physician. During a follow up interview with V24 on [DATE] at 3:12pm, V24 denied telling the police that R9 was hanging out the window. V24, she doesn't remember what she told the 911 dispatcher when she called for emergency services. On [DATE] at 7:47a.m during a follow up interview, V24 said she was in the hallway getting her things together to start medication administration. V24 said that's when V17 informed her that R9 was outside on the ground below the window, V24 said she went to the room and looked first then her and V17 went outside immediately, V24 said she saw R9 on the ground. V24 said R9 was moaning, V24 said she checked R9 to make sure he was not bleeding, and she looked at his limbs and head. V24 said she told V17 to go and get V18 to help pick R9 up. V24 said V17 walked toward the front of the building to get V18. V24 said V18 arrived with the wheelchair, they picked R9 up, V24 said they picked R9 up on the first attempt. V24 said her and V17 had R9 legs and V18 had R9 upper body. V24 said they was outside with R9 for about 10 minutes. V24 said V18 pushed the wheelchair with R9 in and her and V17 held R9 legs. V24 said they put R9 in the bed, R9 continued to moan. V24 said after they put R9 in the bed, she left the room to call 911 because there was not a phone in the R9 room. V24 said she got the blood pressure cuff from the medicine cart also. V24 said her cell phone was at the nurse station and she used her cell phone to call 911. V24 said she reported to the 911 dispatcher that R9 was on the ground by his window, V24 said she believes that's what she said. V24 said she reported to the 911 dispatcher that R9 was breathing, and she reported that the CNA was with R9, and she believes that's all she reported. V24 said when she got back to the room, she told the CNA to get blankets for R9. V24 said when she got back to the room R9 had stopped breathing, R9 chest was not rising and falling, R9 did not have a pulse, she checked his carotid artery. V24 said she yelled out for someone to bring the backboard that was hanging on the crash cart, so that she could do CPR on R9. V24 said she don't know who she yelled out to. V24 said V17 was in the room with her but it was not V17 that went and got the backboard. V24 said she don't know who it was that brought her the back board. V24 said by the time she started CPR (chest compressions) the medics came. V24 said she saw the medics lights when they pulled up to the facility, V24 said she could see outside of R9's room window. V24 said she saw the medics get out the vehicle and approach the ramp to come inside the facility. V24 said that's when she stopped doing chest compressions on R9. V24 said she may have done 30 compressions. V24 said she should have not stopped doing chest compressions on R9 before the Emergency Medics took over CPR efforts for R9. V24 said she did not used the Ambu-bag on R9. V24 said when she saw medics pull up to the facility, she also told V17 to go and let them inside the facility. When asked V24 if she called 911 immediately, V24 replied I believe I called 911 immediately. V24 said she did not tell the 911 dispatcher that R9 got naked and was hanging out the window. V24 reviewed her phone log and said she called 911 at 5:30am. V24 said she don't know why 911 was not called until 5:30am. V24 said she don't remember what R9 pulse rate was, she did not write it down, V24 said she know that R9 was breathing because R9 was moaning, V24 said R9 respiratory rate was 16. V24 said she don't know when R9 respiratory rate was 16. V24 said she did not call code blue because she was the only nurse there (in the facility) and when you call a code blue, that's to get assistance from another Nurse. When asked can the CNA assist you during a code blue, V24 said everyone, the Nurse and CNA should respond to a code blue. V24 said she don't know why she didn't call a code blue, V24 said it was a very frustrating night. V24 said she last saw R9 around 3:00am or 4:00am and R9 was laying in his bed awake. V24 said she don't recall the window being open. V24 said she was not aware that R9 could open the window in his room. On [DATE] at 4:25p.m V17 (CNA) said she was the aide responsible for R9 care on [DATE] for the 11:00pm-7:00am shift. V17 said she checked on R9 at 3:30am, and at 440am when she went to check on R9, she went in the room, she did not see R9 in the bed, and she went further and saw R9 outside the window on the ground. V17 said she went and got the nurse V24, and she went and told V18 (CNA) to get a wheelchair for R9. V17 said R9 was outside laying in a fetal position, naked with his gown on his arm. V17 said her and V24 had R9 by the arms and V18 had R9's legs and they picked R9 up and put him in the wheelchair and brought him back inside the facility, V17 said they put R9 in the bed. V17 said R9 was cold so she got blankets to try and warm R9 up, V17 said she stayed with R9 until V24 came back. V17 said she left R9 room to wait for the paramedic at the entrance door with the ramp. V17 said she did not see V24 do CPR on R9. V17 said she saw R9 snoring, V17 said R9 was not talking. V17 said she did not do CPR on R9. V17 said she does not know how long R9 had been outside on the ground. During a follow up call with V17 on [DATE] at 3:41pm, V17 denied telling the police that she saw R9 hanging out the window. On [DATE] at 7:00am during a follow up call V17 said the police misquoted her statement in the police report, V17 said she read and reviewed the report. V17 said she told the police that she was hanging out the window and saw R9 on the ground, V24 said she did not say R9 kicked out the screen, she did not say she pulled R9 back inside the window. V17 said on [DATE] at 4:50am, V17 said she knew it was 4:50am because she always looks at her clock, V17 said she was going into R9's room to get him up, V17 said she was not preparing her cart at 4:50am, she was at R9's room at 4:50am. V17 said R9's room door was open a little. V17 said when she went inside the room she felt a burst of air, V17 said she didn't see R9 in the bed, V17 said she looked out the window, and when she looked down, R9 was on the ground. V17 said she ran and told the nurse (V24), that's when her and V24 went outside where R9 was. V17 said they went out the exit the building at the east door (where the ramp is). V17 said the nurse was looking R9 over calling R9's name, trying to get him to respond. V17 said the nurse lift R9 left arm, trying to bring R9 to a position so that he was on his back. V17 said the nurse asked her to go and get V18. V17 said at that time V18 was on his break and was sitting in his car, the car was parked down the street a little pass the main entrance door. V17 said she went and got V18, and they came back to where R9 and V24 was, V24 informed V18 to go and get a wheelchair for R9. V17 said V18 came back with the wheelchair, they picked R9 up and put him in the wheelchair, V17 said it took at two attempts to get R9 up. V17 said her and V24 had R9 legs while V18 had R9 by the arms. V17 said they was outside with R9 for about 10 minutes. V17 said V18 pushed R9 inside the facility, V17 said all three of them put R9 back in the bed. V17 said once R9 was in the bed, R9 was still making snoring sounds. V17 said after R9 was in the bed, V24 (Nurse) left the room, V17 said she assume V24 was going to call 911, but V24 did not say she was calling 911. V17 said when V24 came back to the room she had the blood pressure cuff and she heard V24 on the phone with 911. V17 once V24 came back to the room she went to her cart and got blankets for R9 (cart at room door). V17 said she saw the nurse put the blood pressure cuff on R9's left arm. V17 said she saw V24 put two fingers on R9 wrist and neck to check R9 pulse, and V24 was calling R9's name. V17 said she stayed in the room with V24 and R9 until she had to leave the room to let Medics in. V17 said she could see from R9 room window when the medics/911 pulled up, V17 said when she saw the lights flash, she went to let them inside the facility at the east exit door (door with the ramp). V17 said when she was in the room with V24 she did not see V24 do CPR on R9, V27 said she did not see V24 do chest compressions on R9. V17 said code blue was not called. V17 said she did not call 911. V17 said V28 (CNA) did not help them with R9. V17 said her CPR certification was expired that's why she renewed it on [DATE]. V17 said she do remember having her CPR certification within the last two years. On [DATE] at 11:05am V28 (CNA) said she was working on [DATE] on the 11:00pm to 7:00am shift, V28 said she was not assigned to R9's care, V28 said she held the door open for the staff to bring R9 into the facility. V28 said R9 did not have a gown on, R9's gown was wrapped around his arm. V28 said V24 and V17 took R9 back to his room. V28 said she is not aware of whatever else happened after that because she went to finish getting up her assigned residents. V28 said she did not hear an announcement for code blue. V28 said she did not open any windows for R9 that night or early morning. On [DATE] at 3:41p.m V18 (CNA) said he was working on [DATE] on the 11:00pm to 7:00am shift, V28 said he was not assigned to R9's care. V18 said he was providing patient care when V17 came and got him to assist with R9, V18 this was around 5:00am or 5:30am. V18 said he dropped everything and ran outside to see. V18 said he saw V24 and V17 holding R9 up, the window was wide open, the screen was on the ground. V18 said R9 was awake, his eyes were open and R9 was not saying anything. V18 said he called R9's name but he did not respond and R9 would usually respond. V18 said R9 only had on a diaper, and it was not really on him. V18 said he ran and got a wheelchair, and they placed R9 in the wheelchair. V18 said he thinks V17 came and got him because they could not lift R9. V18 said they was waiting for him to come and help them lift R9. V18 said he does not know how long R9 was outside. V18 said he rolled R9 inside and all of them put R9 in the bed. V18 said R9 did not assist them with getting him in the bed. V18 said R9 was breathing, blinking his eyes, and making a sound like a smokers cough, growling and R9 was not responding. V18 said R9 skin was cool. V18 said when he felt R9 skin, it wasn't enough to say R9 was freezing, it seemed like he could have been out there for 20 minutes. V18 said he did not see R9 20 minutes prior to R9 being found either. V18 said after he assisted with getting R9 in the bed he left and went back to his assignment. V18 said he does not know how R9's room window got open. V18 said the last time he saw R9 was at 11:15pm in the bed, R9 was sleeping, and the room window was closed. V18 said if the window was open at that time, he would have felt the cold air. V18 said he don't know if V24 or V17 did CPR. V18 said code Blue was not called. V18 said if a code blue is called, they announce it over the PA system and all staff come, and you grab the crash cart. On [DATE] at 11:19am V26 (Fire Department Medic) said he was the responding medic for the emergency call for R9. V26 said when he arrived to R9 bedside, there were no staff observed implementing CPR to R9, V26 said he did not take over CPR efforts from any staff member at the facility, V26 said he initiated CPR for R9. V26 said R9 was laying in the bed in supine position. V26 said on his assessment R9 body was cold to touch, R9 upper body temperature felt the same as his lower body temperature, R9 was pulseless and there were no respirations observed. V26 said R9 had obvious signs of death when he got to him. V26 said rigor mortis was noted in R9 jaw, V26 said rigor mortis is stiffing of the body when some has died, V26 said rigor starts to set in with 30 minutes to 2 hours of death. V26 said R9 was placed on a cardiac monitor, and it shows asystole: meaning no electrical activity in the heart. V26 said he does not recall seeing a back board under R9. V26 said V24 (Nurse) reported to him that R9 was hanging out of his window, V26 said it was cold that night/ early morning hours. V26 said he saw a heat vent near R9 bed. (V26 said he thought it was strange that R9 was hanging out the window next to the heat vent and the lower part of his body was the same temperature as the upper part). V26 said V24 said R9 was last seen by staff at 4:00am and everything was okay with R9. V26 said V24 reported that R9 had dementia but he didn't see the diagnosis listed in the records that was presented to him, V26 said the documents did show that R9 had a stroke with right-side paralysis. V26 said he did not observe any alarms or sensors on R9 room window. V26 said when he arrived, he observed several windows that appeared to be open. V26 said R9 case was turned over to the police department, and he did not have any details from the police department. V26 said the fire department medics report to (LMC-hospital name given) and the medical Doctor gave the time of death, of 5:49am. V26 said the cardiac monitor did not suggest shocking R9, V26 said the resuscitation was minimal because R9 had obvious signs of death. V26 said he was concerned about the supervision of R9. V26 said in his experience as a fire department medic, if a resident or a person is found on the ground, that person should not be moved, V26 said there could be an injury to the neck or any trauma and or moving them without knowing if theres a serious injury would not be appriopriate. V26 said this is not routine for the nurse and CNA to move a resident and bring them back inside the facility after finding the residnet on the ground. V26 said R9 should have remained there for the emergency team to assess R9 where he was. On [DATE] at 11:34p.m V27 (Responding Officer) said he was the responding officer to the emergency call for R9, V27 said he interviewed V17 and V17 statement is in his report, V27 said the statement is not verbatim but that's what was reported to him. V27 said he spoke to V24 briefly and V24 statement was the same as V17, and so he didn't put V24 statement in his report. V27 said he contact the medical examiner's office and he was informed that it was not a medical examiners case, V27 said he notified the facility and he contacted R9's family for notification. Review of the 911 call on [DATE] at 0530 hours, V24 is heard telling the 911 dispatcher that the location of the emergency was 5909 west North avenue, on the oak park side, V24 is heard saying to the dispatcher that I have a patient here that got naked and hanging out the window and now he's hyperthermia when asked what number she was calling from V24 said this is my personal number and gave the dispatcher the phone number, after 1 minute and 51 seconds V24 told the 911 dispatcher that she was not with R9 and she was walking back there now V24 is heard saying she was getting the paper work together for the ambulance. At 2 minutes and 13 seconds 911 dispatcher asked V24 if the resident was awake, V24 said he was but it don't look like it now, V24 said she don't know if R9 was sleeping or not. At 2 minutes and 34 seconds V24 said it looks like he is snoring. V24 is heard saying where's that thing for the blood pressure, when the dispatcher asked was the resident snoring like he was sleep or like he was having trouble breathing, V24 responded like he went back to sleep, V24 said R9 was breathing, no concern for covid 19, at 3minutes and 28 seconds V24 is heard saying R9 breathing was completely normal, At 3 minutes and 48 seconds when the dispatcher asked V24 if R9 was conscious and alert , V24 is heard saying he was snoring but, V24 denied that R9 was responding normally when he was awake, V24 denied that R9 had any issues with heart problems, at 4 minutes and 23 seconds V24 denied having a defibrillator. 911 called ended after 4 minutes and 57 seconds. Review of the ambulance run report it denotes that 911 call received at 531, dispatch at 532, enroute at 534, at reference at 538, at patient at 539, leave reference at 605, available at 610. On [DATE] at 12:46p.m V29 (Physician) said he was notified of the incident/accident with R9 on [DATE] around 6:30am by the facility. Survey findings was reviewed with V29, V29 said the incident is an unfortunate situation, V29 was made aware that the nurse and aides said R9 was snoring, V29 said in his opinion because he was not there, but there's no was that R9 was snoring. V29 said maybe the Nurse was not able to recognize when someone is having difficulty breathing. V29 said he does not know the cause of R9 death but if R9 was outside for an unknow period, no clothes on and the staff said R9 body was cold it is likely that R9 was dealing with hypothermia. V29 said any person will be cold with clothes on within 10 minutes of being outside in 26-degree Fahrenheit weather. V29 said situation of R9 accessing the window would not have occurred if the safety latches were engaged to prevent the window from opening to high and R9 climbing out. V29 said safety is important. V29 said the facility needs to take measures to prevent this from happening again. V29 said if the staff observed R9 outside on the ground at 4:50am the nurse should have called 911 right away. V29 said the nurse should have initiated basic CPR, i.e., check the airway, do chest compressions as appropriate. V29 said calling 911 after 40minutes of finding R9 was a lot of time. V29 said he wish the nurse would have called sooner. V29 said in his career he has seen rigor mortis start to set in within 1 to hours of death, depending on the environmental factors. Review of the national weather report it shows that the temperature in Oak Park, Il on [DATE] between the hours of 3:30am to 4:50am, the temperature ranged 25 to 26 degrees Fahrenheit and the wind chill ranged between 16 to 21 (MPH), making the outside temperature feel like 11 to 13 degrees Fahrenheit. The windchill chart denotes that at a temperature of 25 to 26 degrees and a wind chill of 16 to 21 mph, will produce frostbite in humans in 30 minutes. Request was made to review facility video recording for [DATE] for the hours of 1:30am to 6:00am. On [DATE] at 445pm V7 (Administrator) said the video was not available due to the internet connection being out at that time. The surveyor on [DATE] via observation, interview and record review confirmed the following removal plan was implemented by the facility: [NAME] Nursing and Rehab Removal/Abatement Plan 1. The facility has taken the following actions concerning the IJ component a. The facility maintenance director has started working on all the windows in the facility to ensure that all safety latches on all window are engaged and will not permit anyone to go through the window. These checks and any adjustments will be completed on or before the end of day [DATE]. An additional screw was added to all windows to enhance safety, that cannot be removed without a tool. b. The facility has reviewed the floor plan to ensure all room windows are secured with safety latches have been inspected and verified to have the safety latch engaged with no room window missed. 2. Statement regarding how the facility identify other residents having potential to be affected by the same preliminary fact analysis of the IJ component? a. All residents in the facility have been identified to have potential of being affected by the alleged preliminary fact of the IJ component 3. Measures the facility will take or systems to ensure the problems will be corrected and will not recur. a. The facility has initiated repairs to secure all windows in the facility with safety latches to prevent individual from going through the window. Check initiated on [DATE] and will be completed before the end of the day [DATE]. An additional permanent screw was added to all windows to enhance safety, that cannot be removed without a tool. b. The facility has initiated a q-30mins checks on all resident to ensure residents are accounted for and to ensure no resident is loitering a[TRUNCATED]