Inspection·February 23, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents requiring special attention or services, such as wandering, confused, non-alert, or intellectually disabled residents. On 2/14/24, at 1:00pm, R2 is lying in bed awake, talking insensibly. V6 Agency Certified Nursing Assistant/CNA is seated in the room with R2. On 2/14/24, at 1:05pm, V6 CNA stated the following: I am her one on one. I am an agency CNA. I heard that during the fire (R2) got out and was over at the apartments inside someone's apartment for about 45 minutes. I think she heard the alarm, and it was her natural instinct to get out. I did not work that day but worked the day after. She is not really a wanderer. She walks back and forth out in the hallways but had never tried to leave before that I know of. She would stop at the exit doors and look out. She will push on the bar, but when it alarms, she'll step back. On 2/14/24, at 2:15pm, V4 Environmental Services Director stated that the exit doors automatically unlock when the fire alarms go off. R2's Elopement Risk Assessment, dated 1/25/24, documents R2 has a diagnosis of Dementia, has the physical ability to leave the building, spends time on the first floor or wanders between floors and units, is a risk to elope at this time and placement on the Elopement Risk Protocol is indicated. R2's Minimum Data Set/MDS assessment, dated 1/22/24, documents R2 is severely cognitively impaired, wanders, and requires supervision or touching assistance for ambulation. R2's Fall Risk Assessment, dated 2/8/24, documents R2 is disoriented x (times) three at all times, has balance problems while standing and walking, jerking or unstable when making turns, requires use of assistive device, and is at risk for falling. R2's current Care plan includes: R2 is an elopement risk/wanderer related to Dementia, ambulatory, and recent history of attempt to elope on 2/9/24 and additional comorbidities. R2 is an elopement risk/wanderer related to history of wandering off property at home prior to admission to facility, Dementia, ambulatory, and additional comorbidities. R2's Progress Note, dated 2/9/24 at 3:54am by V7 Licensed Practical Nurse/ LPN, documents: Resident was wandering and exit seeking during fire incident. Alarms and locks on doors were checked and intact during initial attempt to exit. Resident redirected away from door. When staff went to assist other resident's, staff eventually noticed resident was not in area. Staff began to look for resident. Management informed staff that resident was noted by police in residential apartment across the street. Resident assisted back to facility for cares, assessments, and monitoring. Full body assessment completed, and 15 minute checks initiated. All notifications were notified. On 2/15/24, at 1:55pm, this writer viewed the path out the exit door that R2 eloped from. The sidewalk has a slight downward slope and there is a high curb to step down into the side street. On 2/16/24, at 2:38pm and on 2/21/23 at 10:19am, V11 CNA stated the following about the night of the fire: I saw (R2) in another resident room, R2 got out of there and was redirected, but I didn't see (R2) try to get out. When the fire alarms sound the exit doors get disabled, I guess. (R2) moves very quickly. V11 continued to state that no one was assigned to monitor the wanderers. Our main thing to do when the fire happened was to get everybody out of their rooms. (R2) was in my group. (R2) is a wanderer so have to keep a close eye on her and pay attention. (R2) has pushed on exit doors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145248 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 145248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550 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 before; she pushes on everything. Level of Harm - Immediate jeopardy to resident health or safety The facility's Daily Assignment Sheet dated 2/8/24 documents the third shift nurse assigned to R2's (B) Hall was V7 Agency Licensed Practical Nurse/LPN; R2 was assigned to V10 and V11 CNA's group of residents. Residents Affected - Few On 2/16/24, at 5:26pm, V7 Agency LPN, confirmed V7 was working on B Hall the night of the fire. V7 stated the following: V12 LPN was giving lots of orders and seemed to be taking charge. No one was assigned to watch the wanderers. (R2) wanders around the building. I noticed (R2) went to one of the exit doors. I didn't see her push it. I checked the door, and it was locked, and the fire alarms were sounding. Afterwards they said that eventually when it switches to the generator the doors unlock. V7 stated If it is a known thing that these (exit) doors unlocked then most definitely wanderers should be supervised. I don't think staff knew that. Not sure they have the staff for that though because they have a lot of elopement risk residents so doors should be watched. On 2/20/24, at 1:50pm, V1 Administrator confirmed the fire alarm sounded on 2/09/24 at 12:01am. This writer viewed the camera footage of R2 exiting the facility during the fire emergency with V1 Administrator. R2 was pacing the hall, going in/out of resident rooms, and standing by and looking out the exit door several times. At 12:32am R2 slipped out the exit door at the end of B hall. At 12:45am V11 CNA noticed R2 was missing. At 12:48am V1 announced to staff a resident was over at the apartment (per police notification). Staff took off running out the door including V1 Administrator and V11 CNA. At this time, V1 stated that a policeman came up to V1 in the front lobby area and informed V1 a resident was over at Apartment 10; the owners had called police. Police didn't know who the resident was. At 12:50am V1 came back in from outside the exit door then at 12:52am R2 was seen escorted back into facility at the B Hall exit door then placed in a wheelchair upon entrance. On 2/20/24, at 2:22pm, V12 LPN confirmed V12 worked on A Hall the night of the fire and stated the following: The nurse who was the Registered Nurse/RN was who was to be in charge. So (V21 RN) was in charge and they were reporting to (V21) what we were to do and (V21) was relaying it back to us. Not aware if anyone was put in charge of wanderers. They said afterwards that when the fire alarms go off the exit doors become unlocked. I did not know that before the fire, but it was only my second day. There could have been someone to monitor wanderers, but there is not a lot of staff at night to assign someone. There is an emergency plan at the nurses' station. I think it said that B wing nurse should be in charge, but not that someone should be in charge of the wanderers. On 2/20/24, at 2:47pm, V21 RN confirmed V21 was working on A Hall the night of the fire and is an Agency nurse. V21 stated the following: I was not specifically in charge for the emergency. From my understanding the fact that they had the Director of Nursing/DON (V2) there (V2) would have been in charge of everything. On 2/21/24, at 9:30am, V10 CNA stated the following regarding the night of the fire: I originally had (R2) in my group, but due to a call off I took a different group of residents. The exit doors unlock once the fire alarms go off, 15 seconds later. I suspected it beforehand but didn't know for sure until afterwards. No one was designated to watch the wanderers specifically. V10 stated that (R2) is confused and that it is unsafe for (R2) to be outside without supervision. On 2/21/24, at 11:13am, V2 Director of Nursing/DON stated the following: After I got here, I would have been considered the person taking charge. V2 confirmed (R2) is a wanderer. (R2) was in her room when I got here. (V7 LPN) and I got (R2) out of (R2's) room and (V7) took (R2) to the nurse's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145248 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 145248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550 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 - Immediate jeopardy to resident health or safety Residents Affected - Few station. After that I don't think I saw (R2) again. No one was assigned to specific wandering residents. No one was assigned to watch exit doors, but they were in sight from nurse's station. (R2) did not have 1:1 during the fire. V2 is unaware that the facility's Emergency Operations Plan-Fire Alarm/Detection System policy documents that supervision is to be assigned to the wanderers during a facility fire emergency. The surveyor confirmed by observation, record review, interview that the Immediate Jeopardy was removed on 2/9//24, but noncompliance remains at Level Two because additional training is needed to evaluate the implementations and effectiveness of actions taken, due to concerns during observations when clearing the immediacy. Prior to the survey date, the facility took the following actions to correct the noncompliance. 1. On 2/9/24 R2 was immediately placed on 15 minute checks. R2's Elopement Risk Assessment and Care plan were reviewed and updated accordingly. 2. On 2/9/24 all staff were educated on the Facility's Elopement policy. 3. On 2/9/24 all staff were educated on the Facility's Code Pink Guidelines. 4. On 2/9/24 all staff were educated on the Facility's Code Red Guidelines. 5. On 2/9/24, all Resident's Elopement Assessments were reviewed and updated accordingly, and all Residents at Risk Plan of Cares were reviewed and updated accordingly based off the individual Elopement Assessment. 6. On 2/9/24 an Elopement drill was completed. B. R9's Elopement Risk Assessment, dated 1/13/24, documents R9 has dementia, physical ability to leave the building, spends time on the first floor or wanders between floors or units, frequently checks status of facility exits and/or stairways, verbalizes a serious/strong intent to leave the facility (pacing, packing belongings, etc.), at risk to elope and should be placed on the Elopement Risk Protocol. R9 is at high risk. On 2/16/24, at 11:48am, V15 and V16 CNAs were unable to locate the Wandering Resident binder at the A Hall nurse's station. On 2/16/24, at 11:50am, V17 LPN located the Wandering Resident binder in a cabinet drawer at the B Hall nurse's station. On 2/16/24, at 11:55am, V14 Social Service Director/SSD found the A Hall Wandering Resident binder in a cabinet drawer of the A Hall nurse's station hidden under a [NAME] of computer paper. On 2/16/24, at 11:56am V1 Administrator stated the Wandering Resident binders are not where they are supposed to be. They are to be left out and not moved. On 2/16/24, at 2:30pm, the Resident Wandering binders from A Hall, B Hall, and the front reception desk include a list of wanderers dated 1/22/24. These three binders' lists are not consistent with one another, contain residents who are no long wanderers and/or have been discharged , and are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145248 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 145248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Morton 190 East Queenwood Road Morton, IL 61550 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 incomplete as they do not include R9. Level of Harm - Immediate jeopardy to resident health or safety On 2/20/24, at 12:42pm, V14 SSD confirmed R9's Elopement Risk Assessment, dated 1/13/24, documents R9 is a high risk for elopement and is to be placed on the Elopement Risk protocol. V14 stated R9 should have been placed on the Elopement list on 1/13/24 and was not. V14 stated the wanderers should be on the list and have their facesheet and photo in each binder. V14 confirmed the current Wandering Resident list dated 1/22/24 is inaccurate. V14 confirmed that the 1/22/24 list in the binders were all different, but I fixed them. V14 stated But then yesterday when I came in the Wandering Resident binders were all different again. I found that they had been messed with. The B Hall binder was missing R2's information (no photo or face sheet), and another resident's information was also missing. The A hall binder was missing one resident. The B Hall binder was in a drawer today. The staff are to leave the Wandering Resident binders on the desk in full view, not in a drawer. Residents Affected - Few On 2/20/24, at 1:15pm V2 Director of Nursing/DON stated they do not have an Elopement Risk protocol per say- it just means that wanderers will be monitored, care plans updated, and they will be placed on the Wandering Resident list in the binders. On 2/21/24, at 9:30am, V10 CNA stated, I don't believe anyone has shown them (Wandering Resident binders) to me if we do have them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145248 If continuation sheet Page 5 of 5