Inspection·May 5, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm stated R3 told her he cut his wander guard off. V7 stated she had not seen R3 leave the facility but R3 always wanting to go smoke. 4/29/2025 at 10:45AM V12, Activities stated she works the front desk at times to relieve staff. V12 stated she has not seen R3 exit out the front door. V12 stated she has seen R3 hanging around the front door. Residents Affected - Few On 4/29/2025 at 11:00AM V13, Activities stated she has not witnessed R3 walk out the front door. V13 stated she has observed R3 standing in area by front door watching people enter and exit. On 4/29/2025 at 11:30am V1 stated R3 did not return to the facility until around 7:30pm with a family friend. V1 stated she was at the facility when R3 returned. On 4/29/2025 at 2:02 PM City police department dispatch stated a call came in at 3:46pm of elderly gentlemen on bench on Clear Lake and [NAME] City Avenue. On 4/30/2025 at 12:15PM V10, receptionist stated if R3 is downstairs in reception area he will wander around. V10 stated has never seen R3 attempt to exit. On 5/1/2025 at 1:41PM V14, physician stated R3 is cognitively intact and should be able to go out in the community. V14 stated R3 will get drunk. R3's progress notes dated 4/22/2025 at 16:30PM documents R3 left the facility without following facility protocol, he returned to the facility approx. 19:30 with friend. R3's Emergency Department (ED) record documents dated 4/22/2025 documents service date/time 4/22/2025 at 17:13pm and discharge service date and time as 4/22/2025 at 19:10PM. R3's ED record documents R3 was brought to the emergency department by Emergency Medical Services (EMS) after they found R3 wandering around in public. Record documents R3 reportedly eloped from his nursing facility and went to the liquor store and got himself a pint of 40 proof vodka. The report documents R3 reported he drank about half of the pint and was out on a walk looking for something to eat when the ambulance found him and brought him to the hospital. R3's report document alert and orientated to person, place time and situation. No focal neurological deficits observed. Report documents medical decision making rationale: presentation concerning for elderly gentleman who has eloped from his nursing home to drink. Report documents 4/22/2025 at 18:58PM patient facility has been contacted and willing to take R3 back. Report documents R3 has a friend with him in the department who is comfortable transporting him. Report documents R3 is able to ambulate appropriately and is eating occult tray without difficulty, and is alert orientated and answering questions appropriately. Will discharge back to the facility. Report document stable and R3 given educational materials on alcohol abuse. R3's progress notes dated 4/22/2025 at 19:15 documents R3 is on q 15 minutes checks. R3's progress notes dated 4/23/2025 at 13:58 documents the Interdisciplinary team (IDT) and R3 placed on 1:1 due to him leaving unsupervised. R3's notes document R3 stated, I removed the ankle device from my leg. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact with a Brief Interview Mental Status (BIMS) of 14. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145160 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 145160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care on the Hill 555 West Carpenter Springfield, IL 62702 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 R3's Wander Risk Scale dated 2/28/2025 documents score of 9 (9-10 at risk to wander) Level of Harm - Minimal harm or potential for actual harm R3's undated exit seeking profile documents medical alerts: cognitive impairment. Residents Affected - Few R3's ss-elopement/unauthorized leave risk review dated 11/29/2024 documents a score or 1 (combined 6 or more points indicates possible elopement risk) R3's SS-Elopement/Unauthorized Leave Risk Reviews dated 2/25/2025 documents a score of 7 (a combined score of 6 or more points indicates possible elopement risk) R3's risk reviews documents R3 is an elopement risk with goal not to leave facility unattended. R3's risk review documents intervention to identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is looking for something? Does it indicate the need for more exercise? Intervene as appropriated, intervention; wander alert. R3's SS-Elopement/Unauthorized Leave Risk Review dated 4/22/2025 documents a score of 11 (a combined score of 6 or more indicates at risk to elope). R3's risk review documents an elopement risk/wanderer with goal will not leave the facility unattended. Risk review interventions; identify pattern of wandering: is wandering purposeful, aimless, or escapist? Am I looking for something: Does it indicate the need for more exercise? Intervene as appropriate with intervention: Wander Alert R3's Care Plan dated 11/27/2024 documents R3 is an elopement risk, have a wonder guard on right ankle. R3's care plan documents the following interventions: 12/15/2024 staff to keep door alarms on as per facility policy, provide safe, structured daily routine and environment to decrease/prevent wandering, observe for thirst, hunger, pain, discomfort or need for toileting frequently and provide needed assistance, encourage to do simple exercises, encourage participation in simple activities, complete elopement risk assessments upon admission if triggered by wandering risk assessment then upon quarterly, with significant changes in condition and/or prn, wander guard to right ankle. 4/23/2025 1:1 supervision On 5/5/2025 at 9:37AM V1, Administrator stated the facility does not have a policy on making rounds every 2 hours. V1 stated it is expected and standard of care for the facility. The facility policy Management of Missing Resident, Elopement, and Risk Reduction Strategies dated last revised 04/2023 documents policy guidelines: The facility strives to promote resident safety and protect the rights and dignity of the residents. The policy documents the facility maintains a process to assess all residents for risk for elopement, implement risk reeducation strategies for those identified as an elopement risk, and institute measure for resident identification at time of admission. The policy defines elopement- is the ability of a cognitively impaired resident, who is not capable of protecting himself or herself from harm, to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. The policy defines wandering as refers to a cognitively impaired resident's ability to move about inside the facility aimlessly, but often without clear purpose and without regard to ones personal safety. The policy fails to define elopement/ wandering for a cognitively intact person. The policy documents the preadmission evaluation process includes a wandering and elopement history and whether the resident can safely be cared for at the facility. The policy documents an Elopement Risk Assessment is completed on all residents at time of admissions, quarterly and with any increase in exit seeking or wandering behaviors. The policy documents a facility approved risk evaluation tool or scoring system is utilized and the evaluation is based on various risk factors that may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145160 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 145160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care on the Hill 555 West Carpenter Springfield, IL 62702 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 precipitated and elopement event, the risk tool includes a defined parameter which, when reached, indicates and increased risk and prompts strategies, as described below. The policy documents the risk evaluation and new resident observation addresses the resident's mobility and psychologically, behavioral, physical and cognitive functions. specific risk factors may include: a history of wandering prior to admission or finding the resident lost in the facility after admission. Details of the wandering history may include when the wandering occurs, if more common during daytime or night time hours, the usual traffic pattern, if purposeful (e.g. need for food, toileting, exercise), if exit seeking and other triggers such as pain, noise or odors. Problems noted in the resident's adjustment to the facility such as stating a desire to go home, looking for children, attempting to attend functions that are based on past schedule. Interference with risk reduction strategies, including an expressed displeasure with wander bracelet or an attempt to remove it. Behavior problems, including those where the resident is not easily redirected or managed when he or she is agitated or aggressive. The policy documents actual wandering behavior, including exit seeking (the resident is intent on leaving the unit or facility, looking for exits, and hovering exits waiting for the opportunity to leave with someone, or pushing on a door) The policy documents risk reduction measures as interventions that may be used for residents identified as high risk for elopement include: a. frequent monitoring of the resident's whereabouts to assure he or she remains in the facility (e.g. every 15 minute checks 1:1 monitoring) b. room placement close to common areas such as the nurse's station and away from exits. c. promoting activities that are in full view of staff members d. alternative activities to maintain the interest level of the wanderer e. implementation of wander bracelet or other electronic alert systems f. transfer to a more suitable or more secured unit/facility, if necessary g. notification by nurse to physician and family for changes in behavior, such as increasing insistence or attempts to leave. h. environmental controls such as: the physical plant is secured to minimize the risk of elopement through a. functional alarm system for egresses and stairwells b. safety locked or keypad entry that restrict access to dangerous areas c. restricted window openings to six inches to allow for ventilation but prevent resident exit d. elevator controls (if multi-story equipped) e. adaptation of the environment with way finding cues and landmarks; brightly lit uncluttered paths with rest areas (indoors/outdoors); decorations that provide positive distractions and also act (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145160 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 145160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care on the Hill 555 West Carpenter Springfield, IL 62702 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 as deterrents. Level of Harm - Minimal harm or potential for actual harm The policy documents additional resident and family involvement and education. Verification of control systems; if an electronic surveillance system is in place, door alarms are tested weekly( at a minimum) for proper functioning and the testing is documented, door alarm codes are changed routinely, resident electronic monitoring sensors(e.g. bracelets/pendants) are checked every shift for placement and daily for proper functioning and documented in the resident record, Treatment Administration Record< Medication Administration Record, or a specifically designed log, a signing sign out system is implemented , which requires responsible parties to sign resident out when leaving and noting and expected return time. Residents Affected - Few The policy documents creation of elopement risk binder for each resident at risk to include a close up photograph taken on the day of admission, one photograph is maintained in resident record and one is placed in the elopement risk binder, with a description of the resident (e.g. height, weight, hair and eye color), which can be provided through any resident face sheet, and is maintained at the reception desk or facility accessible designated area The policy documents photographs are updated as required to reflect changes in a resident's appearance and at least annually. The policy documents a verification process is conducted to determine the location of each resident after a fire/elopement drill, resident activity, outing etc. The policy documents when a resident has been found the administrator or designee notifies all stat, search teams, police, hospitals friends and family that resident has been located, the resident's care plan is updated including: additional measures such as an electronic monitoring device if not in current use, 15 minute safety checks or 1:1 supervision, request to transfer to a more secure facility determined by continues need for supervision, if the resident is placed on an increased supervision, safety checks are documented in the resident record each shift for the duration of the increased supervision, a missing resident form is completed, and all staff involved sign the form, the form is forwarded to the regional nurse consultant and regional director of operations policy documents documentation of all elopement attempt and events are documented in the resident record to include circumstances and precipitating factors, interventions utilized to return the resident to the unit, resident response to interventions, results of the evaluation upon the resident return and the condition of the resident, care rendered, incident report, indicating when resident returned and condition of the resident, complete a new elopement risk assessment, additional risk reduction strategies implemented, plan of care updated to reflect resident specific safety concerns and interventions. review and update elopement risk binder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145160 If continuation sheet Page 5 of 5