Edwardsville Operator Llc

F-F689 Accidents -Elopement policy revised August 2024 recorded a definition of elopement as follows: A situation in which a resident leaves the premises or a safe area without the facility's knowledge or supervision if necessary and this situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle. The policy recorded all residents would be assessed for elopement risk status and at-risk residents, would be care planned with interventions to address wandering and/or exit-seeking behaviors. This policy noted that at-risk residents would be monitored by staff supervision. This policy further recorded a resident with decision-making capacity, leaving the facility intentionally is considered an elopement if the facility is unaware of the resident's departure and/or whereabouts. The policy further recorded that new wandering behavior or attempted elopement would be documented in the nurses' notes and the resident's care plan would be updated to include increased monitoring.

The facility failed to provide adequate supervision and appropriate interventions to prevent Resident R1, who was diagnosed with psychiatric illness and identified, as at risk for elopement, from exiting the facility without staff awareness. For approximately 45 minutes facility staff did not know Resident R1 was missing in freezing weather until law enforcement returned Resident R1 to the facility. This deficient practice placed Resident R1 in immediate jeopardy for potentially life-threatening injury.

On 01/29/25 at 03:21 PM, Administrative Staff A was provided a copy of the Immediate Jeopardy Template and informed of the facility's failure to provide adequate supervision and appropriate interventions to prevent Resident R1 from elopement, placed Resident R1 in immediate jeopardy.

The facility completed the following corrective actions to remove the immediacy for Resident R1:

Staff conducted a headcount ensuring the safety of all residents in the facility.

Camera footage was reviewed, identified the malfunction, and effected immediate repairs on the faulty exit door.

Audited all doors and windows to ensure no similar situations existed. Reported the issue to the stated agency, physician et al.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 175245 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175245 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Edwardsville Care and Rehab 751 Blake Street Edwardsville, KS 66111

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Conducted all staff in-service How to check Doors for Lock function on 01/23/25, 01/24/25, and 01/25/25.

Level of Harm - Immediate Conducted an Ad Hoc QAPI meeting with the Executive Director, (ED) Director of Nursing (DON), and jeopardy to resident health or Medical Director (MD). The Medical Director was requested for feedback and had nothing further to add or safety suggest.

Residents Affected - Few The Surveyor verified the facility completed the above corrective actions prior to the onsite survey on 01/29/25, therefore the deficient practice was deemed past-noncompliance at a J scope and severity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 175245