Health inspection·February 6, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to answer call lights timely for 3 of 9 (R1, R13, R17) residents reviewed for dignity in the sample of 28. Findings include: 1. On 1/29/25 at 1:35 PM, R2 stated that R1 was crying a couple of weeks ago because she was so upset about how long it was taking for staff to come in and help her. On 1/29/25 at 1:45 PM, R1 stated that she believes the facility is short staffed because you have to wait for help. R1 stated that it can take over an hour to get help. R1 stated about 2 weeks ago, I was crying because no one would come and answer my light and I needed to go to the bathroom. That night I waited for 2 hours. R1's Face Sheet, print date of 2/4/25, documents R1 was admitted on [DATE] with diagnoses of a history of a Heart Attack and Chronic Obstructive Pulmonary Disease. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is cognitively intact and is dependent on staff for toilet and sit to stand transfers and is occasionally incontinent of urine and always continent of bowels. 2. On 1/30/25 at 1:00 PM, R17 stated that she believes they are short staffed because it takes a long time for the call light to be answered. V23, R17's sister, stated that she does not think there is enough staff. V23 stated, It was about 2 weeks ago (R17) called me and told me she had her light on for a very long time and no one would come and help her. She needed her catheter tubing moved because she could not roll her wheelchair. I called over here. I had to try 5 times before someone would pick up the phone. Finally, someone answered. I told them my sister needed help and he told me that was a long walk for him because he was down on the rehab unit. I then decided just to drive over here. I live across town. I came and helped my sister. R17's Face Sheet, print date of 2/3/25, documents that R17 was admitted on [DATE] with diagnoses of Parkinson's Disease and Urinary Retention. R17's MDS, dated [DATE], documents R17 is cognitively intact, dependent on staff for toileting and dressing, requires substantial/ maximal assistance with transfers and bed mobility, is occasionally Page 1 of 8 146026 146026 02/06/2025 Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711

F 0550 incontinent of urine, and frequently incontinent of bowel. Level of Harm - Minimal harm or potential for actual harm 3. On 2/4/25 at 2:05 PM, R13 stated that the facility is short staffed. She has had to wait as long as 2 hours to be taken to the bathroom before. I am usually continent but when it takes 2 hours, I have an accident and it makes me feel dirty, stinky, and crappy. At night they are in such a hurry, they flip you around like a sack of potatoes so I don't even use my call light for the bed pan. I wear an incontinent brief and a pad and I go in them. Residents Affected - Few R13's Face Sheet, print date of 2/3/25, documents R13 was admitted on [DATE] and has diagnosis of hemiplegia and hemiparesis following a stroke. R13's MDS, dated [DATE], documents R13 is cognitively intact, is dependent on staff for toileting and transfers, and is occasionally incontinent of urine and always continent of bowels. The Resident Council Minutes, dated 1/27/25, documents, Residents asking about call lights - (V2, Director of Nurses) explaining our staffing issue due to the transition - New company will allow agency CNA (Certified Nurses Aide) and Nurses. The policy Call Light System, dated 12/20/11, documents, 2. Respond promptly when the call light is activated. 146026 Page 2 of 8 146026 02/06/2025 Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 educate residents on safety protocol and supervising dining for 6 of 7 residents (R2, R7, R8, R9, R10, R11) reviewed for accidents and supervision in the sample of 28. Finding include; 1. On 1/29/25 at 8:15 AM, V3, Registered Nurse (RN), stated R2 went to (Department Store) a couple of weeks ago. She called a cab, put her coat on, got her purse, and when the cab came she went out and left. We went and got her. On 1/29/25 at 9:30 AM, V2, Director of Nurses (DON), stated R2 is cognitively intact, she called a cab, got her coat and purse, and went to (Department Store). During a shift change rounds, the aide was told by R2's roommate (R1) that R2 had went to (Department Store). I was notified that she was not in the building, I looked at the camera and it showed her getting into a cab at 1:55 PM. I called the cab company and they told me they picked R2 up and took her to (Department Store). They told me they were familiar with her and had taken her to (Department Store) multiple times at her previous residence. I tried to call the son and there was no answer so I called the police. I had them go over to the (Department Store) and they found her. I went to the (Department Store) to pick her up. She was there doing banking. She said she did not realize that she needed to sign out and let someone know she was leaving. I did talk to the son and let him know what happened. He said that sounds like Mom. She does her banking at (Department Store) and goes often. She knew where she was going and how to get there by calling a cab. She was walking with a steady gait and no assistive devices. I have since educated her that she needs to sign out and let staff know where she is going. On 1/29/25 at 1:35 PM, R2 stated that she did not realize that she had to sign out and let someone know if she wants to leave the building. R2 stated she needed to go to (Department Store) because she needed to do her banking. R2 stated she is very familiar and capable with calling a cab and going by herself. She was never afraid or in danger. R2's Face Sheet, print date at 2/3/25, documents R2 was admitted on [DATE] and has diagnoses of Congestive Heart Failure and Atrial Fibrillation. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is moderately cognitively impaired and requires partial to moderate assist with mobility. R2's Elopement Risk Assessment, dated 12/9/24, documents R2 is not at risk for elopement. R2's Nurses Note, dated 1/7/2025 3:41 PM, documents, Resident last seen by this writer around 1:30 PM in her room sitting on her bed on the phone. Between 215-245 CNA (Certified Nurses Aide) notified this writer resident's roommate said resident had called a cab and left in the cab. This writer immediately went to resident's room and verified what roommate had told CNA. This writer went directly to DON's (Director of Nurses) office to notify resident had allegedly left in a cab. R2's Nurses Note, dated 1/7/2025 3:00 PM, documents, Resident left the building via cab service and went to (Department Store) to purchase a gift card for someone that she was going to gift money to. 146026 Page 3 of 8 146026 02/06/2025 Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some BIMS (Brief Interview of Mental Status) noted at 15 (indicates cognitively intact). Resident had a Winter coat on and ambulated without difficulty with a steady gait. Assisted back to facility with facility van without difficulty. Resident stating that her son knows that she has purchased gift cards that have went to others that may have scammed her money. Noted that resident has her own cell phone for use. Call to Son and he states that his mother travels all the time by herself and is capable of leaving on her own and has purchased thousands of dollars for unknown people and has depleted most of her accounts. Son states that he will bring her another new phone and new Power of Attorney papers that will require a Dr signature and assessment for capacity of executive decision making abilities. Resident is alert and oriented x 4 with no distress noted upon returning to facility. The Elopement Prevention and Response Policy, dated 2/19/21, documents, Assessment and Identification of Residents at Risk for Elopement. An Elopement Risk Assessment will be completed on every resident on the day of admission / readmission. 2. On 1/29/25 from 8:20 AM to 8:50 AM, the breakfast meal was observed at intervals of 10 minutes or less. The dining room is split into two dining rooms. The main dining room and the back half is for residents that require assistance. From the assisted dining room staff can not see the entire main dining area. V7 CNA and V8 CNA are assisting residents in the assisted dining room. The main dining room has no nurse or CNA supervising the meal continuously. R7, R8, R9, R10, and R11 all are seated and eating their breakfast in the main dining room. On 1/29/25 at 8:50 AM, V3 Registered Nurse (RN), stated that usually nursing staff is in the dining room passing medications and CNA's are in here to supervise. V3 stated, I am not going to lie. Staffing has been an issue lately. V3 agreed there is not nursing staff present and there should be. R7's Face Sheet, print date of 2/3/25, documents that R7 was admitted on [DATE] and has diagnoses of Dysphagia and hemiplegia and hemiparesis affecting the right dominant side. R7's Minimum Data Set (MDS), dated [DATE], documents R7 is cognitively intact and requires set up or clean up assist for eating. R7's Physician Order, dated 11/8/24, documents, Mechanical Soft texture, thin consistency related to dysphagia. R8's Face Sheet, print date of 2/3/25, documents that R8 was admitted on [DATE] and has diagnoses of Alzheimer's Disease and Dementia. R8's MDS, dated [DATE], documents that R8 is severely cognitively impaired and requires set up or clean up assistance with dining. R8's Physician Order, dated 1/31/24, documents, Mechanical Soft diet, Mechanical Soft texture, Thin consistency, for difficulty chewing. R9's Face Sheet, print date of 2/3/25, documents that R9 was admitted on [DATE] and has diagnoses of Dementia, Dysphagia, and Anorexia. R9's MDS, dated [DATE], documents that R9 is moderately cognitively impaired and requires set up or clean up assistance with dining. 146026 Page 4 of 8 146026 02/06/2025 Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711

F 0689 R9's Physician Order, dated 1/13/25, documents regular diet, thin consistency. Level of Harm - Minimal harm or potential for actual harm R10's Face Sheet, print date of 2/3/25, documents R10 was admitted on [DATE] and has a diagnosis Diabetes. Residents Affected - Some R10's MDS, dated [DATE], documents R10 is severely cognitively impaired and requires set up or clean up assistance with dining. R10's Physician Order, dated 8/9/24 documents Heart Healthy Diet Precautions Regular texture, thin consistency. R11's Face Sheet, print date of 2/3/25, documents R11 was admitted on [DATE] and has a diagnosis of Diabetes. R11's Skilled Nurses Note, dated 1/30/25, documents R11 is alert and orientated to person, place, and thing. R11's Physician Order, dated 1/24/25 documents Heart Healthy Diet Precautions Regular texture, thin consistency, 2000 Fluid Restriction. The facility, undated, Assisted Dining Considerations, fails to document the need for Nursing staff to be present in the dining room. 146026 Page 5 of 8 146026 02/06/2025 Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient staff were available to provide needed care in a timely manner and supervision. This failure has the potential to effect all 109 residents residing in the facility. Findings include: 1. On 1/29/25 at 1:35 PM, R2 stated that R1 was crying a couple of weeks ago because she was so upset about how long it was taking for staff to come in and help her. On 1/29/25 at 1:45 PM, R1 stated that she believes the facility is short staffed because you have to wait for help. R1 stated that it can take over an hour to get help. R1 stated about 2 weeks ago, I was crying because no one would come and answer my light and I needed to go to the bathroom. That night I waited for 2 hours. R1's Face Sheet, print date of 2/4/25, documents R1 was admitted on [DATE] with diagnoses of a history of a Heart Attack and Chronic Obstructive Pulmonary Disease. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is cognitively intact and is dependent on staff for toilet and sit to stand transfers and is occasionally incontinent of urine and always continent of bowels. 2. On 1/30/25 at 1:00 PM R17 is visiting with V23, R17's sister. R17 stated that she believes they are short staffed because it takes a long time for the call light to be answered. V23 stated that she does not think there is enough staff. V23 stated, It was about 2 weeks ago (R17) called me and told me she had her light on for a very long time and no one would come and help her. She needed her catheter tubing moved because she could not roll her wheelchair. I called over here. I had to try 5 times before someone would pick up the phone. Finally someone answered, I told them my sister needed help and he told me that was a long walk for him because he was down on the rehab unit. I then decided just to drive over here. I live across town. I came and helped my sister. R17's Face Sheet, print date of 2/3/25, documents that R17 was admitted on [DATE] with diagnoses of Parkinson's Disease and Urinary Retention. R17's MDS, dated [DATE], documents R17 is cognitively intact, dependent on staff for toileting and dressing, requires substantial/ maximal assistance with transfers and bed mobility, is occasionally incontinent of urine, and frequently incontinent of bowel. 3. On 2/4/25 at 2:05 PM, R13 stated that the facility is short staffed. She has had to wait as long as 2 hours to be taken to the bathroom before. I am usually continent but when it takes 2 hours, I have an accident and it makes me feel dirty, stinky, and crappy. At night they are in such a hurry, they flip you around like a sack of potatoes so I don't even use my call light for the bed pan. I wear an incontinent brief and a pad and I go in them. R13's Face Sheet, print date of 2/3/25, documents R13 was admitted on [DATE] and has diagnosis of 146026 Page 6 of 8 146026 02/06/2025 Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711

F 0725 hemeplegia and hemiparesis following a stroke. Level of Harm - Minimal harm or potential for actual harm R13's MDS, dated [DATE], documents R13 is cognitively intact, is dependent on staff for toileting and transfers, and is occasionally incontinent of urine and always continent of bowels. Residents Affected - Many 4. On 1/29/25 from 8:20 AM to 8:50 AM, the breakfast meal was observed at intervals of 10 minutes or less. The dining room is split into 2. The main dining room and the back half is for residents that require assistance. From the assisted dining room staff can not see the entire main dining area. V7 CNA and V8 CNA are assisting residents in the assisted dining room. The main dining room has no nurse or CNA supervising the meal continuously. R7, R8, R9, R10, and R11 all are seated and eating their breakfast in the main dining room. On 1/29/25 at 8:50 AM, V3 Registered Nurse (RN), stated that usually nursing staff is in the dining room passing medications and CNAs are in here to supervise. V3 stated, I am not going to lie. Staffing has been an issue lately. V3 agreed there is not nursing staff present and there should be. R7's Face Sheet, print date of 2/3/25, documents that R7 was admitted on [DATE] and has diagnoses of Dysphagia and hemiplegia and hemiparesis affecting the right dominant side. R7's Minimum Data Set (MDS), dated [DATE], documents R7 is cognitively intact and requires set up or clean up assist for eating. R7's Physician Order, dated 11/8/24, documents, Mechanical Soft texture, thin consistency related to dysphagia. R8's Face Sheet, print date of 2/3/25, documents that R8 was admitted on [DATE] and has diagnoses of Alzheimer's Disease and Dementia. R8's MDS, dated [DATE], documents that R8 is severely cognitively impaired and requires set up or clean up assistance with dining. R8's Physician Order, dated 1/31/24, documents, Mechanical Soft diet, Mechanical Soft texture, Thin consistency, for difficulty chewing. R9's Face Sheet, print date of 2/3/25, documents that R9 was admitted on [DATE] and has diagnoses of Dementia, Dysphagia, and Anorexia. R9's MDS, dated [DATE], documents that R9 is moderately cognitively impaired and requires set up or clean up assistance with dining. R9's Physician Order, dated 1/13/25, documents regular diet, thin consistency. R10's Face Sheet, print date of 2/3/25, documents R10 was admitted on [DATE] and has a diagnosis Diabetes. R10's MDS, dated [DATE], documents R10 is severely cognitively impaired and requires set up or clean up assistance with dining. R10's Physician Order, dated 8/9/24 documents Heart Healthy Diet Precautions Regular texture, thin 146026 Page 7 of 8 146026 02/06/2025 Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711

F 0725 consistency. Level of Harm - Minimal harm or potential for actual harm R11's Face Sheet, print date of 2/3/25, documents R11 was admitted on [DATE] and has a diagnosis of Diabetes. Residents Affected - Many R11's Skilled Nurses Note, dated 1/30/25, documents R11 is alert and orientated to person, place, and thing. R11's Physician Order, dated 1/24/25 documents Heart Healthy Diet Precautions Regular texture, thin consistency, 2000 Fluid Restriction. On 1/29/25 at 11:09 AM, V16 CNA, stated I think we have enough staff. At the longest it will take about 10 to 15 minutes to answer a call light. There are times when you have to hurry your care because there is just to much to do. On 1/29/25 at 11:12 AM, V17 Licensed Practical Nurse (LPN), stated, Usually I work the 200 hall and we have 3 aides and that is just not enough. Those residents require the (full mechanical lift) and (partial mechanical lift). You play catch up all shift late with medications, late with treatments. The aides are playing catch up too. Residents have to wait longer and they stay in bed longer. On 1/29/25 at 11:26 AM, V7 CNA, stated usually there are 2 CNAs on each hall. Taking residents to the bathroom takes longer, longer call light times, passing the food out on the hall takes longer so the food is cold. On 2/5/25 at 10:00 AM, V5 Assistant Director Of Nurses (ADON) stated the facility does not have a staffing policy. I staff per state guidelines but I go a little bit above because we do have a high rate of call offs which leave me a buffer for 2 call offs. Before the ownership change, the agency was not sending us staff. They also did not have a lot of agency CNAs that they could send us. So the last week we were relying on our staff so if we did have a call off that really did put us in a bind. That was due to agency not being able to fill our open shifts. We would have our nurse managers and supervisors come in and help. Other non direct care staff would come in and help were they could, pass ice, meal trays, push wheelchair, engage with residents. The facility written census, dated 2/5/25, doucments, (the facility) 1/29/25 In house census = 109 146026 Page 8 of 8