Inspection·September 11, 2023

F 0656 in common area. Level of Harm - Minimal harm or potential for actual harm On 9.9.23 at 12:15pm V9 said she last saw R1 in the dining room .5 hours prior to R1 being found outside on the ground. Residents Affected - Few On 9.9.23 at 2:26pm V2 (CNA) R1 assigned CNA said he don't know where R1 was, he did not see R1 before R1 was found on the ground. V2 said R1 was not assigned to his care. On 9.11.23 at 9:50am V4 (Director of Nursing) said the facility cannot restrict the resident's movement. V4 was asked what interventions was in place to prevent R1 from leaving out the exit door. V4 replied the R1 had the wander guard. V4 was asked was it effective if R1 was able to leave out the facility. V4 said no. On 9.11.23 at 12:15pm V10 (administrator) said during her investigation V3 informed her that her (V3), V7, and V9 were all at the nurse station charting when the alarm sounded, the alarm displayed what door was alarmed. V3 went down the hall, V7 followed her to the exit door and V9 came behind them. During the facility tour the exit door was not observed in a common area, where R1 is care planned to be kept when he is awake. It is reasonable to believe that R1 left the common area went down hall, turned the corner, and went out the exit door, without staff being aware when they were at the nurse's station charting. Facility policy titled person centered plan of care last revision January 2023 denotes in-part Person centered care: integrated health care services delivered in a setting and manner that is responsive to the individual and their goals, values and preferences, in a system that empowers patients and providers to make effective care plans together. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145852 If continuation sheet Page 2 of 6 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 145852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Vista Prospect Heights 700 East Euclid Avenue Prospect Heights, IL 60070 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 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 interview and record review the facility failed to supervise and monitor a resident with identified to be an elopement risk, wandering behavior, and poor safety awareness from exitingh the facility without staff knowledge. This affected one of three residents (R1) reviewed for supervsion and elopement risk. This failure resulted in R1 exiting the facility via wheel chair through an exit door without staff knowledge. R1 was eventually found outside past the exit door on the ground after falling from the wheelchair. R1 was sent to the local hospital for evaluation Findings include: R1 face sheet denotes R1 has diagnosis of vascular dementia, unsteady on feet, history of falling, difficulty walking. R1 MDS dated 6.4.2023 section C denotes in-part attempt to conduct brief interview 0 is noted for No- resident rarely /never understood. Section C0700 denotes staff assessed R1 to have short term memory problems, and long-term memory problems. Cognitive skills for daily decision making- 2 are denoted for moderately impaired. 1 is denoted for yes there is evidence of acute change in mental status. One is denoted for inattention (behavior continuously present, does not fluctuate). One is denoted for disorganized thinking (behavior continuously present, does not fluctuate). Section E for behavior denotes Wandering- 3 (behavior of this type occurs daily). One is denoted that wandering places the resident at significant risk of getting to a potentially dangerous place (stairs, outside of facility). Two is denoted that R1 behavior has gotten worst compared to prior OBRA assessment. Facility final report to the department dated 7.6.23 denotes in-part, date of incident 7/4/ 2023 time of incident 2:40 PM. R1 name is listed. Location of incident immediately outside the exit door. Type of incident elopement and fall. Current resident diagnosis type 2 diabetes with diabetic chronic kidney disease, vascular dementia with other behavior disturbance generalized, arthritis and atherosclerotic heart disease. Description of incident initial report resident self-propelled self in wheelchair and pushed the exit door. Alarm sound. Staff responded and noted resident lying on sidewalk. Alert and oriented to self which is baseline. Sent to ER for evaluation. Final report to follow within 5 days. Final report 7/6/ 2023 resident returned to facility on the evening of 7/4/2023. All X-ray results perform in the ER were negative. Return from facility with orders to apply antibiotic ointment to facial abrasions. All exits on first floor were verified immediately to be functioning. In service conducted on elopement. Root cause of elopement seeking resident noted to be more anxious and agitated sense gradual dose reduction of antipsychotic medication. Order has been received to restart a low dose of Risperdal 0.25 milligrams at bedtime. Clinical team met and discussed with trust account representative the benefit of placing resident on the memory care unit and permission receive. Physician notified, family representative notified, sent to hospital, update residents' elopement and assess, update resident care plan to include interventions. R1 progress note dated 7.4.23 at 4:01pm completed by V6 denotes observed by staff RN and CNA lying prone on the ground with arms outstretched and head turned to the right with left cheek resting on the ground. On assessment, moderate amount of sanguineous drainage noted on the ground under left side of face. Resident left in place and 911 called while staff remained at side. Resident unable to describe event but denied pain. Vital signs as follows: BP 131/79, HR 90, RR 16, SPO2 97% on room air. Paramedics arrived and assessed resident before transferring to stretcher and transporting to ED for evaluation. PCP (primary care physician) notified. Attempts made to reach first and second (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145852 If continuation sheet Page 3 of 6 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 145852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Vista Prospect Heights 700 East Euclid Avenue Prospect Heights, IL 60070 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 emergency contacts without success. Unable to leave voicemail for either. Financial contact notified of change in condition and transfer to hospital. On 9.11.23 at 10:49am V12 (social worker) she completed R1 quarterly assessment dated 6.4.23 for section E-behavior. V12 said R1 has behaviors of wandering. V12 said she would not describe that R1 wandering getting worst but R1 started wandering into other resident's rooms. V12 said R1 is at risk for elopement. On 9.9.23 at 2:39pm V3 (certified Nursing Aide) she was in the room caring for a resident on her assignment, when she came out the room the heard the alarm and she went to the exit door (near room [ROOM NUMBER]) she opened the exit door and saw R1 laying on the ground. V3 said V1 came to the area right after her. V3 said she saw R1 laying on the ground. V3 said she did not do any vitals on R1. She did not move R1. V3 said she was not assigned to R1 and that V2 was assigned to R1 for that shift. V2 said she last saw R1 in the dining room around 2:30pm. V3 said R1 likes to wander, R1 likes to wander everywhere. On 9.11.23 at 8:59am V10 (Administrator) said she conducted the investigation for R1 elopement. V10 said she received a call at 2:48pm on 7.4.23 from V9 (Nurse) informing her that R1 had gone outside the exit door near the physical therapy room. V10 said she went to the scene and observed R1 laying on his stomach with his face to the side. V10 said the medics arrived quickly to take R1 to the hospital. V10 said she immediately began to check all the exit doors for proper functioning. V10 said all the doors that had alarms were working properly, and the door that had the electronic wandering device alarms were working properly. V10 said V3 (CNA), V7 (CNA), and V9 (Nurse) and V2 (CNA) was standing at the nurse's station when she interviewed them. V10 said V3 said she at standing at the nurse's station charting when she heard the alarm sound, V9 check the display screen verified the door that was alarming, V3 ran to the exit door near room [ROOM NUMBER] and V7 followed right behind her. V9 (Nurse) came right after. V10 said V3 was on the scene first. V10 said she could not get any information from V2. V10 said V2 was the assigned CNA to work with R1 for that shift. V10 said V2 told her that he was not working with R1 on 7.4.23 but V2 could tell her who he was working with on 7.4.23. On 9.9.23 at 12:50pm V6 (Director of Quality) said on 7.4.23 she had taken a break and when she returned inside the facility, she was informed that the alarms were going off on the skilled unit. V6 said she went to the skilled unit, to the exit door, she observed V9, V3, and a therapist outside with R1. V6 said R1 was laying on the ground in prone position with his face turned to the ground. V6 said she observed abrasion to R1 face and drainage. V6 said she assessed R1, and R1 was not responding appropriately to her satisfaction, V6 said R1 baseline was communicating few words at times. V6 said no one moved R1, V6 said V9 was sent to get the paperwork together while she stayed with R1. V6 said staff had already summons 911. V6 said V10 conducted the investigations and interviewed the staff. On 9.9.23 at 12:15pm V9 (Nurse) said she was the half nurse for 7/4/23. V9 said as the half nurse she would come in at 11:00am, she does the wound care, she does the admission paperwork, and she would pass the 12:00pm and 3:00pm medication to the residents on the high end of the unit. V9 said starting with room [ROOM NUMBER]. V9 said R1 was not assigned to her care, she just responded to the alarm. V9 said she did not get a report from V1 when she left for the day. V9 said she was not aware that V1 had left for an emergency. V9 said V3 arrived to R1 first, and she followed. V9 said R1 was observed laying on the ground kind of on his side with his face to the side. V9 said she did not move R1, 911 picked R1 up from the ground. V9 said R1 vital signs were assessed by V3. V9 said R1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145852 If continuation sheet Page 4 of 6 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 145852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Vista Prospect Heights 700 East Euclid Avenue Prospect Heights, IL 60070 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 wheelchair was there, not sure of location or position. R1 had a little blood on his face. V9 said she last saw R1 about 30 minutes prior to finding R1 on the ground outside. V9 said R1 is at risk for elopement. On 9.1.23 at 12:43pm V1 (Nurse) said she worked that morning on 7.4.23 on the skilled unit but had to leave early for an emergency at 10:40am. V1 timecard requested, facility failed to present V1 timecard during this survey. On 9.9.23 at 2:26pm V2 (Certified Nursing Aide) said R1 was not assigned to him. V2 said he do not know the last time he saw R1. V2 said he was coming out the trash room when V3 summons him to come to the area where R1 was laying. V2 then said he don't remember anything from that day. V2 said he don't remember what assignment he had. V2 said he don't remember who he was caring for when he had to dump the trash in the trash room. V2 said he don't know if it was a lady or man. V2 said he has been working for the facility for two years, and when he comes on duty he gets his assignment from the front desk, that how he knows where he's scheduled to work and what assignment he has. The facility assignment sheet was reviewed and V2 was informed that his name is listed to be assigned to R1. V2 continued to say he was not assigned to care for R1. V2 was asked if he was interviewed by the administrator during this investigation for R1 elopement, V2 continued to say he don't remember information from that day. V2 was asked did he care for R1 when R1 returned from the hospital on 7.4.23, V2 continued to say R1 was not assigned to R1, and he don't remember anything from that day. Facility assignment sheet dated 7.4.23 denotes that V2, V3, and V7 were the certified nursing aides assigned to work the skill care unit. V2 assignment was rooms 106-2 through 117. R1 room was assigned to V2. V2 timecard denotes V2 was on duty from 2:00pm until 12:00 midnight for the 7.4.23 evening shift. Using reasonable person concept, it is reasonable to believe R1 aide did not know he was assigned to R1's care, thereby not providing monitoring to R1 and knowing R1 whereabouts. On 9.9.23 at 11:35am V5 (Nurse) said she was not in the building when R1 eloped, V5 said when she pulled into the parking lot for her shift, she R1 on the ground and everybody standing around R1. On 9.9.23 during this survey tour with V8 (maintenance staff) it was observed that the exit door near room [ROOM NUMBER], opens to the outside. The exit door did not have a door alarm, the door did not have a 15 second delay when pushed open, the door opens immediately when pushed. The exit door did have an electronic wander device alarm system that activates when V8 cross the thrush hold with an electronic wander device in his hand. The sound did not emit at the door, the alarm sounds at the nurse station. Which is 98-100 feet away. Measured by V8 on 9.11.23. When exiting the door there is a concrete slab and then there a 3.5-inch step down to the sidewalk. R1 fall off the 3.5 in step on to the sidewalk in his wheelchair. On 9.11.23 at 11:30am V11 (scheduler) said V1 informed her manager that she will leave early on 7.4.23. V11 said V1 should have had a replacement. V11 said she was not aware that V1 was leaving early, V11 said she did not find a replacement for V1. V11 said the aides should know what resident assignments they have, and they should know where their residents are. On 9.11.23 at V4 (Director of Nursing) said she developed R1 plan of care for elopement on 7.5.23 when she returned to duty. V4 said R1 did not have a care plan in place for elopement on 7.4.23. V4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145852 If continuation sheet Page 5 of 6 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 145852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Vista Prospect Heights 700 East Euclid Avenue Prospect Heights, IL 60070 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 said R1 should have had a plan of care in place on 12.12.22 when R1 was identified to be at risk for elopement and the electronic wandering device was put in place. V4 said staff can round on R1 every two hours. R1 plan of care for safety reviewed with V4 denoting R1 should have frequent checks, and toilet as needed, if not sleeping keep him in common area. V4 said frequent checks means for the staff to see R1 every hour. V4 said the facility can not keep R1 in the common area/ dining room because he has a right to move around. V4 was asked what plan you had in place for R1 to ensure that he does not elope, V4 said frequent checks and keeping R1 in the common area. When asked if the interventions were effective if R1 was found outside on the ground, V4 said the interventions were not effective. V4 said she initiated R1 elopement care for R1 on 7.4.23. V4 said R1 has a history of wandering, and his wandering behaviors increased after his medication was changed recently. Review of R1 physician order sheet denotes R1 Risperdal 0.25 milligrams at bedtime was discontinued on 6.15.23. Request was made to review V1 and V9 timecards, several times during the survey, the facility failed to present the timecards during the survey. During this survey, surveyor could not establish what Nurse was assigned to R1's care when R1 was found outside on the ground on 7.4.23. Using a reasonable person concept, it is reasonable to believe R1 felt pain, sadness was scared when he fell to the ground after eloping from the facility on 7.4.23. R1 elopement assessment dated [DATE] denotes R1 is at risk for elopement, R1 has history of wandering off, getting lost etc. Patient at risk for elopement. Patient MD with order for electronic wander device placement. Facility policy titled Elopement with last revision date on 10/22 denotes in part it is the policy of this community to implement all possibles measures to protect/minimize any residents who attempts to elope. Elopement for purposes of this policy and procedures, is defined as a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. This situation presents a risk to the resident health and safety. If a resident is found to be at risk for elopement, the resident care plan will include interventions for the prevention of elopement. The resident's picture will be located at stations or reception areas to alert staff of the possible risk elopement. Facility policy titled Accidents/falls with last revision date 10/2022 denotes in-part the facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. R1 plan of care with initiated date on 11/29/22, with intervention revision on 7.3.23 denotes in-part 7.2.23 frequent checks and toilet him (R1) as needed, if not sleeping keep him in common area. R1 plan of care for elopement shows initiated date of 7.5.23, after R1 eloped on 7.4.23. R1 elopement risk assessment dated 12.12.22 denotes R1 was an elopement risk and has a history of wandering off. R1 MDS dated 6/2023 denotes R1 has behavior of worsening elopement. The facility did not develop an individualized plan of care for elopement for over 6 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145852 If continuation sheet Page 6 of 6