Inspection·September 16, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few number was provided. Discharge instructions were gone over and POA understood. All belongings sent with patient.R2's MDS (Minimum Data Set), 7/9/25, documents R2 has severe cognitive impairment and ambulates with supervision.R2's Care Plan, dated 8/22/25, documents the following: Resident got out of the facility via 200-hall door. Staff placed resident on 15-minute checks. Starting 8/25/25, resident placed on 30-minute checks. R2's Elopement Assessment, dated 8/22/25, documents R2 is ambulatory, independent with wheelchair mobility, has cognitive impairment, and a history of wandering - elopement care plan initiated. R2's Elopement Investigation, dated 8/22/25 at 7:35 PM, documents the following: Patient got out the 200-hall door. Patient was found by another patient's family member on the street behind the facility. No behaviors prior to elopement. No changes in mental status. Contributing factors - Alzheimer's Disease, Dementia. No mood indicators present. Recent event, trauma, new diagnosis or other stressors/losses. Recent change in medications or new medications added. Abnormal lab values in the past 30 days. Immediate intervention - 15-minute checks. Interventions effective.The Final Report to IDPH (Illinois Department of Public Health), dated 8/22/25, documents the following: On 8/22/25, R2 exited the facility without staff knowledge while her son was visiting in the building. Staff immediately initiated the elopement protocol, and the resident was located nearby and safely returned to the facility without injury. The resident was assessed by nursing staff, family and Physician were notified, the care plan was updated, staff were re-educated on elopement prevention, door/alarm systems were verified to be functioning. Resident remains safe in the facility with enhanced monitoring in place. On 9/12/25 at 11:20 AM, V3, R2's Son, stated on that Friday 8/22/25, he had come to the facility to pick up R2's laundry, he saw R2 in the hallway, he went into her room, gathered her laundry and changed her bedding. V3 stated when he came out of R2's room he did not see her. V3 stated he went out and put R2's clothes in his truck and came back inside the facility. V3 stated he asked V4, LPN (Licensed Practical Nurse), where R2 was, they looked for her but could not find her. V3 stated he was going to the nurse's station by the door R2 exited out of and heard the alarm screaming. V3 stated the alarm could not be heard from the 100/300 hall nurse's station until he came closer to the 200-hall door exit. V3 stated he and V4 went outside to the fenced in courtyard and did not see her. A young lady called and stated the facility had a patient out on the road behind the facility. V3 stated they went to that area and R2 was standing in the road in front of a vehicle, where two ladies were with R2. V3 stated he tried to get R2 to walk back to the facility, but she was so weak, he had to go and get his truck from the parking lot, drive it to where R2 was and physically place her in the truck. V3 stated the gate to the fenced in area outside the 200-hall door was not locked or latched. V3 stated when he asked about this, he was told that they could not lock/latch it because it was illegal due to it preventing residents from exiting in the event of a fire. V3 stated he had decided at that time to take R2 home to live with him, they had several care concerns, and this just placed it over the top. V3 stated prior to R2 getting out of the building she was in the hospital with a UTI (Urinary Tract Infection) and was very weak. V3 stated since R2 had been at home with him and his wife, her skin has cleared up and she is doing great. V3 stated he believes R2 had tried to go out with the smokers before and they put one of them ankle bracelets on her.On 9/12/25 at 1:10 PM, V2, DON, stated V3 was at the facility visiting R2 and was gathering her dirty laundry. V2 stated V3 took R2's clothes out to his truck in the parking lot, came back to R2's room and she was not in her room. V2 stated V3 notified V4, and a resident stated she had just seen R2 on the 300 hallway, so they were headed down that hallway, then they heard the 200 hall exit door alarm sounding so they went to that door, looked outside and didn't see anyone. V2 stated V3 and V4 then went out the courtyard gait outside the 200 hall exit door, to the left towards the front of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 building, didn't see her. V2 stated a family member told them she was at the back of the facility. V2 stated they found her at the back of the facility, R2 couldn't make it back into the building so V3 got his truck and drove her back to the facility. V2 stated R2 was being treated for a UTI at the time she eloped. V2 stated it was determined that it was approximately 3 minutes from the time R2 was missing, until she was found. V2 stated R2 did not have any injuries. V2 stated R2 was normally confused but hadn't exited or attempted to exit the building prior to 8/22/25, that she is aware of. V2 denied concerns with the alarms, she can hear it from her office, which is located across from the 100/300 hall nurse's station. V2 stated the latch to the courtyard gait off of the 200 hall exit door was broken and has been fixed. V2 stated V3 asked her why it wasn't latched, and she told him because they weren't required to.On 9/12/25 at 2:08 PM, V4, LPN, stated R2 had been in the hospital, was weak, and was using her wheelchair. V4 stated the morning of 8/22/25, R2 was doing much better, she was using her walker and going to activities. V4 stated she had just finished her evening med pass, unsure of exact time, and V3 had come into the facility and stopped at the 100/300 hall nurse's station where she was and they were talking about how well R2 was doing, V3 stated they talked about 2-3 minutes as they were walking down the 200 hall towards R2's room with R2 walking in front of them. V2 stated V3 went into R2's room, did his thing, getting R2's laundry/linen. V3 then came out of R2's room and said, I guess mom disappeared on me. At that same time there was a resident sitting there and said R2 had just headed down the 300 hall, so V3 and V4, went to the 300 hall, searched every room, the dining room and were heading back towards the 200 hallway and when they reached a little ways down the 200 hall where the ice machine is, they started to hear an alarm but couldn't tell where it was coming from. V4 stated the alarm was not sounding normally, it wasn't loud at all, and she couldn't hear it until she got closer to the 200-hall door exit. V4 stated V3 was with her the entire time. On their way to the 200-hall door, V6, CNA, was on the hallway passing out meal trays, V4 told V6, R2 was missing and instructed her to go down the 400 hallway and then outside that door to search. V4 stated she and V3 went out and searched the courtyard along the fence line heading towards the front parking lot, front of the facility, they made it to the front entrance and as they were coming back into the facility, she heard staffing paging her over the intercom and she was told a family member stated R2 was on the street behind the facility. When V3 and V4 got to R2, she was with V6, a bystander and there was a USPS van that had pulled into the street to block any traffic from getting through. V4 stated R2 had not made any attempts to exit prior to that. V4 stated R2 would make comments that her car was out in the parking lot, and she needed to go to it and they would tell her, V3 has your car and R2 would say okay but would never try to exit the building or go towards the doors. V4 stated she is not sure how long the 200 hall exit door alarm was sounding because she couldn't hear it from the 100/300 hall nurses' station until she went down the 200 hall, it was not sounding loud enough to hear it. V4 stated she isn't sure how long it was from when R2 was missing until she was found. On 9/16/25 at 8:20 AM, V7, Maintenance Director, stated the 200-hall door alarm was acting up yesterday 9/15/25 and it had to be reset, but is working fine now. V7 stated they are changing the door alarms to an audible voice instead of a beeping noise that will state over the intercom which door alarm is sounding. V7 thinks this is to be installed next week. V7 stated he tests the alarms routinely and denied any problems with them. On 9/16/25 at 8:25 AM, V1, Administrator, acknowledged that the 200-hall door alarm could not be heard from the 100/300 hall nurse's station. V1 stated they have a nurse stationed at the 200 hall nurses' station at all times, so the alarm can be heard. V1 stated if the nurse isn't at the 200 hall nurses' station, they have therapy control it, the department managers do rounds, and the CNAs should be cautious and aware. V1 stated there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 isn't a lot of time in between when staff aren't there. On 9/16/25 at 1:33 PM, V10, R2's Physician, stated R2 is confused and has Alzheimer's Disease, the plan would not be to have her outside by herself. V10 stated V3 was at the facility and then went outside, so this could have caused R2 to go searching for V3. V10 stated R2 was found and returned to the facility pretty quickly.The Elopement Prevention Policy, dated 5/16/24, documents the following: It is the policy of this facility to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. A licensed nurse will complete the Elopement Risk Assessment upon admission to the facility. An interim plan of care for minimizing the risk for elopement will be initiated upon the risk determination. Revision of the Elopement Risk Assessment will be completed quarterly, upon a resident's significant change of condition, when elopement behaviors occur and as needed, determined by the IDT (Interdisciplinary Team). The Immediate Jeopardy that began on 8/22/25 was removed on 9/16/25, when the facility took the following actions to remove the immediacy:IMMEDIATE JEOPARDY REMOVAL OF IMMEDIACY PLANDeficiency Summary:The facility failed to ensure door alarms were loud enough to be heard from nursing stations and failed to ensure the exit gate latch was in working order to prevent elopement. This resulted in R2, with a diagnosis of Alzheimer's Disease, eloping from the facility and being found in the roadway, creating risk for serious harm.1. Corrective Action for Residents Affected R2 was immediately returned safely to the facility and assessed for injury by nursing staff; no injuries were noted. Completed on 8/22/2025 V4, LPN. Thorough body assessment completed for any injury 8/22/2025 V4, LPN. The physician and family were notified immediately of the incident. 8/22/2025 V4, LPN. All door alarms were checked 8/22/2025 V4, LPN and 9/16/2025 V7, Maintenance Director. All facility gates were checked 8/22/2025 V4, LPN and 9/16/2025 V7, Maintenance Director. Door alarms checked by outside vendor All components for the door monitor voice announcement system ordered on August 28th. 2. Identification of Other Residents at Risk Elopement observations for residents at risk were completed: care plans reviewed and if updated if needed. 9/16/2025 V2, DON. All exit doors and alarms were tested for sound, function, and audibility from all nursing stations; any malfunctioning or inaudible alarms were immediately ordered to be repaired or replaced. 9/16/2025 V7, Maintenance Director. All exterior gate latches were inspected and repaired to ensure secure closure. 8/26/2025 V7, Maintenance Director.3. Systemic Changes to Prevent Recurrence Staff will be positioned by the door alarm until scheduled maintenance is completed. All components for the door monitor voice announcement system are assembled, programmed, and ready to install. This will be interconnected to the 200/400 Patio door to this new system. The installation of this system is scheduled for tomorrow, September 17. A policy review of missing residents completed without any changes 9/16/2025 V1, Administrator Policy review on elopement policy without any revision 9/16/2025 V1 Administrator A policy review of door alarm policy reviewed without any revision 9/16/2025 V1, Administrator Education provided to all staff (nursing, maintenance, ancillary staff) on elopement policy, missing resident policy and door alarm policy on 9/16/2025, including response procedures when an alarm sounds. V2, DON, V1, Administrator and V15, Dietary Manager.4. Monitoring to Ensure Compliance Administrator or designee will conduct weekly audits of door alarm function and audibility for four weeks, then monthly for three months. Maintenance Director will maintain daily door alarm checks when on duty Results will be reported monthly to the QAPI committee for review and ongoing oversight. Any alarm malfunction identified will result in immediate repair and staff re-education if necessary.5. Completion Date All corrective actions will be completed 9/16/2025 Event ID: Facility ID: 145465 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 145465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure its courtyard gait latch was in proper working order when reviewing for mechanical equipment in working order. This failure has the potential to affect all 50 residents residing in the facility.Findings Include:On 9/12/25 at 11:20 AM, V3, R2's Son, stated on that Friday 8/22/25, R2 had exited the facility without staff and he and V4, LPN (Licensed Practical Nurse) went outside to the fenced in courtyard and did not see her. A young lady called and stated the facility had a patient out on the road behind the facility. V3 stated the courtyard gate to the fenced in area outside the 200-hall door was not locked or latched. V3 stated when he asked about this, he was told that they could not lock/latch it because it was illegal because it could prevent residents from exiting in the event of a fire. V3 stated he had decided at that time to take R2 home to live with him, they had several care concerns and this just placed it over the top. On 9/12/25 at 1:10 PM, V2, DON (Director of Nurses), stated the latch to the gait off of the 200-hall exit door was broken and has been fixed. V2 stated V3 asked her why it wasn't latched, and she told him because they weren't required to.R2's Progress Note, dated 9/3/25 at 2:32 PM, documents the following: This nurse spoke to (V3), and he stated he was going to discharge his mother home to his house on 9/5/25. (V3) stated he feels that if he takes her home, she would be safer, and he wouldn't have to worry about her. (V3) stated he didn't feel safe with the facilities back fence being open.The Safety and Supervision of Residents Policy, dated 12/31/25, documents the following: Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified in an ongoing basis through a combination of employee training, employee monitoring, and reporting processes, reviews of safety and incident/accident report, and a facility-wide commitment to safety at all levels of the organization.The Resident Census Report, dated 9/12/25, documents there are 50 residents residing in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145465 If continuation sheet Page 5 of 5