Health inspection·August 7, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few where R1 would start having episodes of confusion. R1 would get agitated easily. R1 thought he was supposed to be going home to his wife. V5 said that day we had to redirect him more frequently. R1 went to the end of hall 1, took his walker, banged it up against the door and set the alarm off. V5 said he (V5) was passing medications on hall 300. I heard the Activity Aide say the alarm was off and someone is trying to get outside. V5 said he and V12 (CNA) ran to the door. It was open. V5 said R1 was about 10-15 feet from the door. on the sidewalk. (V12) and I ran out to R1. V5 said they were able to easily redirect R1 back into the building and gave him his after-dinner snack. V5 said he has been told during reports that R1 has tried to get out before by banging his walker against the door and set the alarm off. V5 said the nurse must manually reset the door alarm, after the door is opened and it alarms. V5 demonstrated how the door alarm is reset. V5 said the light could be red but not blinking if the latch is not all the way shut. To reset the alarm, you put the key in, turn it, then you make sure the latch is on the inside of the door, and push on the door to make sure it does not come open. You remove the key. the light will be red at first, then if set right, it will start blinking. V5 said you push the handle in, and the door will beep. At 4:20 PM, V5 came up to this surveyor and said the Aide yelled alarm going off, not alarm is off.On 8/7/2025 at 8/7/25 at 8:39 AM, V8 (Activity Aide) said she has been an activity aide on the Terrace unit since Mid-May. V8 said she was working on 7/3/2025 when R1 got out of the building. V8 said it was between 7:00-8:00 pm. V8 said after dinner we went to the TV room. At first, (R1) was fine, but he gets overstimulated. V8 said R1 gets mad and wants to leave. V8 said she let V5 (LPN) know that R1 wanted to leave the TV room and V5 told her to let him go down the hall and we will watch him. V8 said she saw R1 go down hall 1. She did not see him for about 5 minutes, so she asked V5 if he had seen R1. He said no. V8 said she started looking in resident rooms on hall 1. As she got to the end of the hall, she saw the exit door was opened a crack. V8 said the alarm was not sounding. V8 said she looked out and saw R1 near the end of the sidewalk by the parking lot. V8 said she had her foot holding the door open. she asked R1 what he was doing and R1 said I'm going home. V8 said she kept trying to get him to come in and he said no. V8 said she opened the exit door and yelled for help. V12 (CNA) and V5 (LPN) came out a minute later. They came out the visitor door by the terrace entrance and came around the building. V8 said it took about a minute after they came out to get R1 to come inV8 said R1 gets aggressive at times and punches at staff. V8 said she was not informed R1 was an elopement risk. I'm not aware of an elopement list for residents. V8 said after she got off work, she reported the incident. V8 said it was about two hours after the incident occurred and she does not believe V5 had reported the incident to V1 yet. V8 said I'm guessing someone turned the alarm off and did not reset it, because they got tired of hearing it. V8 said she has seen R2 try to get out. He will push on the door handle, it beeps, and staff redirect him. V8 said a resident is an elopement risk if they wander and talk about wanting to leave.On 8/7/2025 at 4:09 PM, V12 (CNA) said she was working the night R1 got out of the building. V12 said she thinks she was in with another resident providing care. She thinks she was going out of the room to get something and saw R1 outside as she was going past the window. V12 said she let V5 (LPN) know, and they both went out there immediately. V12 said the alarm was not sounding. V12 said she was not aware that R1 was exit-seeking. V12 said she had been employed at the facility for 5 months, but she floats all over the building. V12 said a resident is an elopement risk if they wander. V12 said once we saw R1, he was easily redirected back into the building. I believe he was wearing jeans and a flannel shirt and shoes. V12 said R1 was still on the sidewalk when we went out to get him.R1's progress note dated 7/03/2025 21:27 written by V5 (LPN) showed, While assisting other patients to their bedrooms and CNAs also provide care for other patients in their bedrooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The tv room staff member monitoring the patients, suddenly she heard exit door alarm sound off. She noted that a patient set the alarm off at one of the exits on the unit by opening a door while exit seeking. The patient then wandered out the door onto the sidewalk outside the door. The patient was 15 steps out the door on the sidewalk. I the Nurse was updated by the CNA, so we then both ran outside to the patient. We then redirected patient to come back into the building and he agreed. Patient had on his shoes and was using his walker with a steady gait and no injuries. Patient is confused and states where am I. Assisted patient to a recliner in the TV room, where a staff member could supervise patient's behaviors and exit seeking attempts. Patient stated where am I, and when can I go home. Offered to toilet the patient and he stated No, I don't have to use the bathroom. Patient assisted back into building by using redirection. Educated the patient on safety and educated patient that exit when opened will set off alarms. Patient unable to learn d/t diminished cognitive skills. Assisted Back to his recliner. Re-locked exit door and set alarm again and alarm is activated and functional. Will continue to monitor. Please see nurse's notes for more details. R1's progress note dated 7/2/2025 showed he was exit-seeking. R1's facility assessment dated [DATE] showed he had severe cognitive impairment, had wandering behaviors daily, used a wheelchair or walker for ambulation, and required supervision or touching assist with walking. R1's care plan initiated on 12/6/2024 showed he was at risk for wandering/Elopement.R1's Elopement Risk Assessments dated 12/6/2024, 3/12/2025, 7/7/2025 and 8/6/2025 all showed he was at risk for elopement.R1's progress note dated 7/03/2025 21:27 written by V5 (LPN) showed, While assisting other patients to their bedrooms and CNAs also provide care for other patients in their bedrooms. The tv room staff member monitoring the patients, suddenly she heard exit door alarm sound off. She noted that a patient set the alarm off at one of the exits on the unit by opening a door while exit seeking. The patient then wandered out the door onto the sidewalk outside the door. The patient was 15 steps out the door on the sidewalk. I the Nurse was updated by the CNA, so we then both ran outside to the patient. We then redirected patient to come back into the building and he agreed. Patient had on his shoes and was using his walker with a steady gait and no injuries. Patient is confused and states where am I. Assisted patient to a recliner in the TV room, where a staff member could supervise patient's behaviors and exit seeking attempts. Patient stated where am I, and when can I go home. Offered to toilet the patient and he stated No, I don't have to use the bathroom. Patient assisted back into building by using redirection. Educated the patient on safety and educated patient that exit when opened will set off alarms. Patient unable to learn d/t diminished cognitive skills. Assisted Back to his recliner. Re-locked exit door and set alarm again and alarm is activated and functional. Will continue to monitor. Please see nurse's notes for more details. R1's progress note dated 7/2/2025 showed he was exit-seeking. R1's facility assessment dated [DATE] showed he had severe cognitive impairment, had wandering behaviors daily, used a wheelchair or walker for ambulation, and required supervision or touching assist with walking. R1's care plan initiated on 12/6/2024 showed he was at risk for wandering/Elopement.R1's Elopement Risk Assessments dated 12/6/2024, 3/12/2025, 7/7/2025 and 8/6/2025 all showed he was at risk for elopement.On 8/6/2025 at 4:25 PM, V6 and V7 (maintenance) tested the alarms on the four exit doors on the memory care unit. V7 said they have not figured out what happened when R1 got out. Maybe someone went out and forgot to reset the alarm. V7 said the exit door on wing 1 is not a normal passage door. V7 said they tested all the doors the next day on the unit and the alarms worked properly. V6 pushed on the handle to the exit door on wing 1 and the alarm beeped. When he opened the door, the alarmed sounded. The wing 1 exit door opened onto a sidewalk that went to the terrace entrance parking lot. Between 4:34 PM-4:40 PM the alarms for the exit doors on wings 2, 3, and 4 were observed. All the doors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few alarmed when the door was opened. Wing 4 exit door opened to a grassy area, then gravel area, then more grass that led up to the apartments next door. V7 said he is not sure where R2 was found, but it was somewhere between the exit door and the apartments next door. V6 said the facility has ordered new dual alarms because the only one that worked properly when maintenance checked the next day was the dual alarm on wing 1. V6 said the door alarms were working, but not the secondary alarms that were in place. Waiting on new alarms to be delivered. On 8/1:32 PM, V11 (LPN) said she was the nurse working on the terrace unit on 8/3/2025. V11 said R2 wanders. He has terminal restlessness. He can be exhausted and still walk. V11 said she heard the door alarm go off for hall 4. V11 said she reset the alarm, pushed on the door and the door did not give. the red light was blinking. V11 said later, she was informed by another nurse that someone from the apartments behind the terrace called and said an older man was walking behind the terrace. V11 said she went around the building and walked the perimeter. V11 said she saw R2 walking on the sidewalk about 10-15 feet from the hall 4 exit door. V11 said she is a terrible judge of distance. V11 said it was about halfway between hall 3 and hall 4 exit doors. V11 said R2 was just walking. He had on shoes. gray lounge pants and a t-shirt. V11 said it was probably between 7:30-8:00 PM. V11 said the alarm did not go off when R2 went out. V11 said the wing 4 door alarm was not working properly. V11 said she did not know if it was due to the heat/humidity that the door stuck in the jam. V11 said it was solid in the door jam, but there was a small space between the jam and the door and for some reason it knew the door was in the jam but not far enough to alarm. V11 said she walked with R2 around the courtyard and sat on the bench for a few minutes. V11 said R2 wanted to walk again so they walked and sat on the next bench. V11 said she knocked on the window and told a staff member to bring her a wheelchair. V11 said R2 always tries to get out of building to go home. To go to dinner with his kids, or to go to work. V11 said R2 is always going somewhere. On 8/7/2025 at 10:14 AM, V9 (CNA) said she works on the terrace unit 90% of the time. I worked on 8/3/2025 on the terrace. I left at 6:00 PM. V9 said R1 and R2 are both elopement risks. R1 has said he wants to go home. V9 said she has seen R2 push on the exit doors. V9 said she was not sure if there was a list on the terrace of residents at risk of elopement. V9 said R1 and R2 both have a wander guard. The wander guard only works on the main entrance to the Terrace unit. V9 said Sunday evening she got a message saying she had to get marked off on the door again. V9 said the last one time she recalls being marked off for training on the exit doors was about a year and a half ago, adding her timing could be off a little. R2's progress note dated 8/2/2025 showed he was ambulating all over unit, undressing and setting off door alarms. Very difficult to redirect. Did take his medications tonight. Would not stay put to eat any supper. R2's 7/30/2025 BIMS evaluation showed R2 had severe cognitive impairment. R2's 7/30/2025 Elopement assessment showed he had wandering behaviors that could affect the privacy of others, and he was at risk of elopement. R2's Elopement Risk Evaluation dated 7/30/2025 showed he was at risk of elopement. R2's care plan initiated 7/30/2025 showed he demonstrates behaviors that may be interpreted as wandering, pacing, roaming, exit-seeking. Symptoms are manifested by pacing, roaming, or wandering in and out of peers' rooms. R2's progress notes dated 8/3/2025 at 10:58 AM showed he was pacing the unit for extended periods of time, anxiousness, and being easily distracted impair his ability to sit for extended periods of time.R2's progress note dated 8/3/2025 showed a skilled evaluation was done for R2 at 9:39 PM. No documentation of R2's elopement was in the evaluation, or in the progress notes on 8/3/2025.The facility's investigation for R2's 8/3/2025 incident showed typed statements from V11 and V19 (CNA) saying the alarm had been sounding. Neither statement was signed by V11 or V19. Neither statement was handwritten by V11 or V19 (V11 said in interview with this surveyor that the alarm was not sounding). The facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete policy and procedure titled Elopements and Wandering Residents, with a revision date of 12/1/2024, showed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . The policy defines elopement as occurring when a resident leaves the premises. The policy showed 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. the policy and procedure showed the procedure for locating a missing resident included a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. (e.g. internal alert code). B. The designated facility staff will look for the resident. C. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The Administrator or designee should also notify the company's corporate office. D. DON (Director of Nursing) or designee shall notify the physician and family member or legal representative. E. Police will be given a description and information about the resident; include any photos. F. All parties will be notified of the outcome once the resident is located. G. Appropriate reporting requirements to the State Survey agency shall be conducted. Event ID: Facility ID: 145024 If continuation sheet Page 5 of 5