Health inspection·July 19, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision for a severely cognitively impaired resident identified as an elopement risk for one of three residents (R1) reviewed for elopement. This failure resulted in R1 following ancillary staff out of the facility, taking public bus transportation, and wandering throughout the city unattended for greater than three hours. This past compliance occurred on 7/6/24. Findings include: R1's Elopement Risk Assessment, dated 5/3/24, documents that R1 is at risk to elope and should be placed on the elopement risk protocol and a care plan for elopement is indicated. R1's Brief Mini Mental Status, dated 6/21/24, documents a score of 3, indicating that R1 is severely cognitively impaired. R1's current care plan documents that R1 requires the support, care and services of a long-term care facility and has been determined by community assessment to be able to access the community with supervision. This form documents that upon the outcome of the community survival skills assessment it is determined that R1 requires supervision when accessing the community and R1 is agreeable to only access the community with supervision present. R1 is at risk for elopement. Interventions are 15-minute checks, assess for fall risk, coordinated with dialysis, so R1 is not left unattended during or after dialysis. Distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. If R1 is wandering near the entrance or exit door, please re-direct R1 away from entrances or exits. Check and observe R1 in the facility. R1's Progress Notes, dated 7/6/24, documents that V6 (Registered Nurse/RN) went to give R1 his noon medications at 11:30am. R1 could not be located within the facility. R1 was last seen during morning medication pass. At 1:13pm, V4 (R1's Family) reported to the facility that R1 was in the community and V4 will be returning R1 to the facility. R1 returned to the facility at 1:30pm. On 7/12/24 at 9:00am, R1 was unable to form a sentence. R1 was asked where he went on 7/6/24. R1 stated Uncle. R1 was asked how he got there, he said Bus. Then how did you get home? And R1 stated Brother. R1 was becoming agitated and refused to answer any questions. R1 was observed ambulating around the facility independently. On 7/12/24 at 1:00pm, V1 (Administrator) verified that no special interventions are put into place for residents that are assessed as elopement risks. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145811 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 145811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Peoria Heights 1629 East Gardner Lane Peoria Heights, IL 61616 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)