Health inspection·March 5, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few that the resident may have wandering/elopement tendencies and the question is answered yes. R1's Elopement Risk assessment dated [DATE] documents a score of 7 which also identified R1 as a high risk for elopement. R1's baseline care plan dated 9/10/23 documented R1 was at risk for elopement. Interventions listed were: Ask family about elopement history, observe for wandering behaviors and intervene as needed, photo taken and added to elopement book, Social Services notified for behavior management and inform staff of elopement risk. The same care plan documented an update dated 9/13/23 noting (R1) to be at risk for Elopement, Resident walked a block and a half and was found on the ground. No injuries noted. Was taken to a local hospital to get evaluated and returned. On 9/13/23 the following interventions were listed: Resident will be redirected to Courtyard for outdoor walks, stop signs placed on all exit doors, Redirect and play country music (Likes [NAME]). R1's Nurses note dated 9/13/23 at 9:47 AM documented, 9:20am call received from (name of city) police department. Resident on [NAME] Street in ditch. Police sent resident (name of local hospital) ER (Emergency Room) for eval (evaluation) and treatment. Resident last seen at 9:10 am in dining room drinking coffee. No door alarms went off in between these times. (V16/Family Member) POA (Power of Attorney) and V5/Physician) called and made aware. On 2/21/24 at 8:21am, V16 (Family Member) stated the only way the police knew who (R1) was when they found him, was that she had put his name on his socks. R1's Resident Incident report dated 9/13/23 documented in part, Narrative of incident phone call received from (Name of City) police department resident on [NAME] Street in ditch. 9:20am Resident seen at 9:10am in dining room drinking coffee . Narrative of investigation: IDT Interdisciplinary Team) met and root cause of elopement is that resident has dementia and appears he followed a visitor out per camera review . Resident was last seen in dining room drinking coffee at 0910 (9:10am) when facility administrator was alerted by (Name of City) police that resident had been located on [NAME] Street (which is 1 block and ½ away) in a ditch with a noted abrasion to resident right knee, Management staff and nurse (V14/ Licensed Practical Nurse/LPN) ran to scene of incident and spoke with (R1), EMT (Emergency Medical Technician) and police officer. (R1) reported, I was just walking back to (Hometown), I love you, and I told them I just live down the block. Temperature was around 80 degrees and was wearing a short sleeved t-shirt and jeans . R1's Local hospital emergency room notes dated 9/13/23 at 10:47am, document [AGE] year old gentleman with a history of dementia. He has a history of agitation. He walked away from the nursing facility this morning. He was found down in the grass. States he stumbled and fell. No loss of consciousness. He is brought in by EMS (Emergency Medical Services), the patient was stable at the time. No witnessed abnormal behavior. Denies chest pain or shortness of breath. No seizure-like activity. His blood pressure was normal on their arrival. The last blood pressure they obtained was lower when he got here to the emergency department. He was found to have an abrasion on his left knee. He does not have any pain in his knee. He thought he fell on his bottom. The same document also noted found to be hypotensive. Medication is reviewed. EKG (electrocardiogram) shows prolonged QT interval. He is on 2 antipsychotropics. IV (intravenous) fluids were initiated, Monitoring continued. Pressure has improved. Lactated Ringer's given as a bolus. No need at this time for pressor agents. He is showing no signs of decompensation or sepsis. Lab studies reviewed. Blood pressure has responded to fluid bolus and he is at 110 systolic. Will be discharged at this time. On 2/21/24 at 1:00 PM, V1 (Administrator) said that a picture of R1 was added to the elopement book (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146032 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 146032 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Rehab & Healthcare 602 East Jackson Du Quoin, IL 62832 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 and put at the nurses station along with the business office, with a physical description, mental emotional status, BIMS score, language spoken and home address when he was admitted on [DATE]. V1 also said that staff was informed of R1's elopement risk. V1 said that she was not aware that R1 was gone and received the call from the police department that R1 had been found on [NAME] street, (which is a block and a half from the facility) and that they were transporting him to a local emergency room. V1 said herself and another staff got in their cars and drove to where he was found. V1 said that when she got back to the facility, she immediately began an investigation. V1 said they reviewed the tapes and saw where R1 went out with visitors. V1 said they also did another risk assessment on R1 when he returned in which R1 scored a 7 which is high risk. On 2/22/24 at 2:00 PM, V3 (Licensed Practical Nurse/LPN) said she was the nurse on duty when R1 eloped. V3 said she had last seen R1 around 9:10 AM drinking coffee in the dining room. V3 said that the alarm never went off or they would have went running. V3 said that V1 and V4 (MDS Coordinator) went to where the police found R1. V3 said that when R1 returned, R1 only had a scrape on his left knee. V3 said that upon R1's return, he was put on every 15 minute checks for 3 days. On 2/22/24 at 2:30 PM, V4 (MDS Coordinator) said that she got in her car and went to where R1 was found, which was just around the block from the facility. V4 said when she arrived, the ambulance drivers already had R1 on the gurney and was going to take him to the local emergency room. V4 said she was here when R1 returned and he was still confused but was at his baseline. V4 said R1 had a scrape to his knee but was otherwise was fine. The surveyor confirmed through interview and record review that the facility took the following actions, which were initiated on 9/13/23 and completed on 9/13/23 to remove the Immediate Jeopardy: The facility completed an elopement assessment upon admission on [DATE] and completed a subsequent elopement assessment on 9/13/23. The care plan was updated and does identify the resident (R1) was at risk for elopement with new interventions put in place. On 9/13/23, interventions were reviewed and new interventions put into place: 1. Resident will be redirected to courtyard for outdoor walks. 2. Signs placed on all exit doors to ensure the safety of our residents, please ensure the door closes behind you, please do not allow residents or people you don't know, to exit the facility. For questions, please speak with Administration or nurse. 3. Play country music for resident. The facility completed Elopement inservicing with all staff on 9/13/23. This was completed by V1 (Administrator) and former Director of Nurses/DON. All staff absent during the time of the inservice, were inserviced prior to their next scheduled shift. Residents at risk for elopement have been reviewed to ensure person-centered interventions were in place and in the care plan, to address elopement behaviors and to decrease risk. This was completed on 9/13/23. Vulnerable residents requiring supervision were identified and training was completed on Supervision and not leaving residents unattended in potentially unsafe locations. This was completed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146032 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 146032 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Rehab & Healthcare 602 East Jackson Du Quoin, IL 62832 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 9/13/23 by former DON and V1. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146032 If continuation sheet Page 4 of 4