Inspection·September 12, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few his car. V1 said the visitor told her he saw a resident come outside and walk behind the building, toward a wooded area. V1 said she searched there and still could not locate R1. V1 said multiple police officers and dogs arrived and continued to search the area. V1 said she received a phone call approximately one hour and forty minutes later that R1 had been found. V1 said the second-floor dementia unit is a locked unit and everyone needs a key card to activate the security pad for the elevator. The security pad was not working last Sunday (9/7) and that is the only way R1 could have got outside. It has been broken a couple of weeks now. V1 said currently, she sits at the nurse's station and watches the elevator when staff aren't there. V1 said she should have been watching the elevator when R1 got out, but she was up and down on other floors that morning. The visitor that observed R1 wandering in the parking lot was attempted to be interviewed but could not be reached during this survey. On 9/11/24 at 10:52 AM, V4 (RN-Registered Nurse) stated she was notified that R1 was outside of the building alone by V5 (CNA) during the breakfast meal on 9/7/25. V4 stated she ran to a window and saw R1 wandering in the parking lot. V4 said she immediately called the DON and reported the elopement. V4 said no one was watching the second-floor elevator or the first-floor front desk. V4 stated the elevator usually needs a key card to open the doors but it hasn't been working for a few weeks. V4 said there is usually a receptionist at the front door, but no one was working that day. V4 said we are supposed to have someone watching the doors to keep residents from getting out. V4 said R1 must have just pushed the elevator, got on, and walked out the front door all by himself. R1 is not fully alert or oriented. He does not speak English and only understands yes or no questions. On 9/11/25 at 11:08 AM, V5 (CNA) said she was feeding a resident breakfast on Sunday in a second-floor room when she looked out the window and observed R1 outside. V5 said she immediately notified V4 (RN). V5 said R1 appeared confused and was wandering around the parking lot. V5 said the key card for the second-floor elevator hasn't been working for a while. On 9/11/25 at 11:25 AM, V2 (Assistant Director of Nurses) stated she was just arriving to the facility on Sunday when the police were leaving. V2 said she was told R1 had got out and the police eventually located him near the intersection of a large, local hospital. V2 said she did the incident investigation and interviewed R1with a translator. R1 said he was trying to find his mother. V2 said R1 is on a lot of psychiatric medications and has a pretty low cognitive status. V2 said her investigation results showed R1 opened the elevator and got on it alone. V2 said she was sure he was able to get on it alone. V2 verified the key card was not working and hadn't worked for almost a month. V2 said a front desk person doesn't start until 9 AM each day and the front door is unlocked around 6 or 7 AM daily. On 9/11/25 at 11:45 AM, V6 (Elevator Security Vendor) stated he has worked on the facility's second floor card access system for years. V6 said he was at the facility a few weeks ago and told staff the system has failed. It is a 30 plus year old system and it can't be patched back together anymore. V6 said the electronic key card system control board can't be repaired anymore. V6 said he repeatedly sent a quote for a new system and never heard anything back until this past Sunday (9/7, day of the elopement). That was when his emails were finally acknowledged, and they agreed to go ahead to fix the system. V6 said right now the second-floor elevator is a fail safe set up which means it will still open when the key card is not working. That prevents anyone from getting trapped in case of an emergency. V6 said right now, anyone can get on or off that elevator. There is no security system in place. V6 said we are still waiting on the parts to be shipped in. The facility provided a quotation invoice dated 8/18/25 from V6's security company. The quote stated, Replace card access system that controls the elevator buttons on the 2nd floor and the stairwell door on that floor. System has to be designed as fail safe. Needs to be interfaced with the existing fire alarm system for emergency release. The quote was blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145434 If continuation sheet Page 2 of 4 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 145434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge Healthcare Center 700 Jenkisson Lake Bluff, IL 60044 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 under the client signature date section. The facility provided a receipt dated 9/9/25 (two days after R1 eloped) showing a downpayment for the 2nd floor elevator was processed by V6's security company. On 9/11/25 at 1:00 PM, V7 (Maintenance Staff) stated the second-floor security pad hasn't been working for a couple of weeks now. V7 said an outside company does all the repairs on that. The outside company has been notified, and the part is on order. It won't be here for several more days. On 9/12/25 at 10:57 AM, V9 (local police officer) stated he got a call on 9/7/25 related to a missing elderly person from the subject facility. It was reported the resident had dementia. V9 said he responded to the call along with several colleagues. The DON (V1) said she called us about 10 to 15 minutes after realizing the resident was missing. V9 said they checked the immediate area with trained dogs. V9 said he went inside and asked V1 how did this happen. V1 answered the missing resident resides on the second floor and the security pad system was broke. She was in the process of trying to get it fixed. V9 said R1 was only found after a random passerby saw him walking in the road. She thought he looked confused or lost so she called the local police department and reported it. That police department responded to the area and sent out notice of a missing person too. V9 said that is when we realized that sounded like our guy. V9 said he took R1 back to the subject facility and V1 confirmed his identity. V9 stated there was no one manning the front desk and he could not find any staff when he initially arrived. V9 stated he rode the elevator up to the second floor with V1. At no time did V1 need a key card to operate the elevator up or back down. V9 stated fellow co-workers mentioned later to him that they have responded to calls in the past at the same facility. Co-workers said they have never needed anything special to go on or off the dementia unit floor. V9 said there are railroad tracks right behind the facility that run all the way parallel to the busy highway, where R1 was found. V9 said they were so worried R1 may be hit by a train that they called the railroad line and confirmed none were scheduled for that day. V9 said the area where R1 eventually was found was by the same tracks. V9 said R1 was found in the road walking the wrong way in traffic. The road is a heavily traveled four lane highway. V9 stated it is the facility's job to keep these people safe and if someone gets out like that, they are not doing their job. The local police department's report dated 9/7/25 and authored by V9 stated R1 was located at 9:35 AM and the exact address of the intersection was provided in the report. The report showed R1 was walking southbound IN the northbound lanes. A google map search from the facility to the intersection showed it was an approximately two-mile walk. On 9/11/25 and 9/12/25, this surveyor was able to freely exit the second-floor dementia unit during the entire survey without using any key card security device. R1's care plan showed a focus area for risk for wandering/elopement due to an elopement event on 9/7/25. The initiation date and interventions were dated 9/8/25. The facility's undated Missing Person/Elopement Policy states: Safety of all residents is the primary care standard at (subject facility). Impaired judgement, perception, and thought processes of cognitively impaired persons make the residents at a higher risk for elopement into unsupervised or unsafe areas. Precautions, procedures, staff, and visitor education have been put in place to maximize resident safety. The Immediate Jeopardy that began on 9/7/25 was removed on 9/12/25 when the facility took the following actions: 1. The facility policy on Elopement Risk: The Policy and Procedure for Elopement Risk residents will be used to identify the potential for residents to exit unsupervised from the facility. The Elopement Risk Assessment will be completed by Social Service Department upon admission, quarterly and with change of condition. This policy has been revised on September 12, 2025. 2. R1. Social Service Unauthorized Departure / Elopement Risk Assessment has been done on 9/8/2025. R1 had a room change to room [ROOM NUMBER] (closer to nursing station) to close monitor. On 9/7/2025, R1 was placed on hourly safety checks. 3. All residents at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145434 If continuation sheet Page 3 of 4 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 145434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claridge Healthcare Center 700 Jenkisson Lake Bluff, IL 60044 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 FORM CMS-2567 (02/99) Previous Versions Obsolete risk will be reviewed and a revision of the Elopement Book and care plan update will be completed by the Social Service Department. Residents with Elopement Risk will be monitored on an individualized basis dependent on their risk assessment. Social Service will do continued education for all staff on elopement risk residents and any changes to the care plan will be done at the time the elopement risk book is updated with any changes in residents' appearance and condition. This will be completed by September 16, 2025.4. Starting today nonscheduled floor staff have been assigned to stay at the 2nd floor desk to monitor the elevator and to prevent residents from entering the elevator. The nonscheduled staff will be required to fill in a sign-in sheet to ensure the area is covered 24 hours a day. This process will continue until the repair of the elevator safety system has been completed. The elevator repair time is estimated for the week of September 15, 2025. 5. On September 12, 2025, in-services began on the Elopement Risk policy and procedures and elopement risk book to educate all staff including nursing (Nurses and CNAs), Administration, Front Desk, Dietary, Activities, Housekeeping, Maintenance and Laundry. The above staff will continue to be in-serviced on following the Elopement Risk policy and procedures, the Elopement Risk book, and the plan for nonscheduled staff monitoring the elevator. This will be completed prior to the start of their shift, via group in-service or one on one in-service, by nursing administration. All in-servicing will be completed by September 16, 2025.6. Effective today random audits of the sign-in logs will be completed every shift by the DON or her designee. This process will continue until the elevator security system is fixed. The Medical Director has been informed and will be involved in the Quality Assurance. Progress will be reviewed and discussed at the quality assurance meeting to ensure corrections are achieved and permanent. Event ID: Facility ID: 145434 If continuation sheet Page 4 of 4