Inspection·October 2, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few transfers.The Psychiatric Nurse Practitioner Visit Notes dated 8/29/25, document R1 reports feeling more depressed for one week. The Notes document staff suspect it could be due to family and staff talking to him about his behaviors. His appetite and sleep are so-so. Reports ongoing suicidal ideations. When asked if he had a plan, he stated That's my business, not yours. When educated on notifying staff of any worsening thoughts or development of plan, he stated I told you it's my business. If l want to do it, I'll figure it out somehow. The Notes document R1 denies homicidal ideations or audio-visual hallucinations and staff are aware of his statements and will continue to monitor closely.R1's Psychiatry Visit Notes dated 9/15/25 document staff reported R1 has new behavior of exit seeking with multiple attempts over previous week and R1 confirmed to practitioner that he would continue to exit seek as he does not want to be at facility.On 9/23/25 at 11:41 AM, V6, R1's friend, stated that on Friday night of 9/5/25, he received a phone call from the facility stating they believed R1 had gotten out of the facility and someone in the community had called reporting they had seen him. V6 could not recall the exact time of the call but stated it was dark outside and he was already in bed. V6 stated that approximately an hour after he received the first call, R1 called from facility stating he was back. V6 stated that R1 stated to V6, R1 had to go home to feed the dog, and he didn't want to be in the facility anymore. V6 stated R1's residence prior to living at the facility was an apartment approximately 45 miles north that was right behind the railroad tracks. V6 stated R1 has stated to V6 previously that he would just follow the tracks home. V6 stated R1 knew the exit code because it had been posted on the door for years. V6 stated staff (Unknown) told him where R1 had been found indicating R1 had to travel over uneven, bumpy, railroad tracks to get to the location R1 was found. V6 stated if R1 fell out of the wheelchair he would not have the strength to pull himself back in. On 9/23/25 at 1:15 PM near the area R1 was found there was an audible sound of a railroad train traveling down railroad tracks and a train was observed traveling through the crossing at moderate speed. No warning lights or barriers were present at the crossing. On 9/24/25 at 11:20 AM, R1 was at the front entrance of the facility demanding to be let out to go home. At 3:00 PM on 9/24/25, R1 stated he does not remember much about the night of 9/5/25. R1 stated he knew he wanted to go home to feed his dog [NAME] and stated it was very dark, and it was getting cold.On 9/25/25 at 12:10 PM, V12, Certified Nurse Aide (CNA), stated on Friday September 5th at 10:05 PM she received a call from V14, Registered Nurse (RN), to initiate a head count with suspicion of a missing resident. V12, CNA, stated V12 completed the head count on the skilled side and ran up to the front entryway where V15 CNA stated someone called to report that there was a person rolling around in the street in a wheelchair that may live here and that R1 was missing. V12 CNA stated at that time the two nurses on duty, V14 RN, and V16 RN, pulled up in parking lot. One was in a car, and the other was pushing R1 in his wheelchair. V12 CNA stated that one nurse pushed him back in the wheelchair, while the other used the car headlights to see due to no lights on the road, and it was very dark that night. When R1 was inside facility he stated to V12 CNA that he was going home to feed his dog, but it got cold outside. V12 stated R1 was wearing grey sweatpants, and a thin long sleeve zip up jacket. V12 stated R1 stated no one let him out, he just held the handle down for a few seconds and door opened but R1 was unable to recall when he left or how long he had been outside. V12 CNA stated R1 was found near railroad tracks approximately 0.3 miles from the facility and one tenth of a mile away from the highway. V12 CNA stated she began her shift at 6:00 PM that night and doesn't remember hearing any alarms that evening. V12 CNA stated staff should be able to hear the front door alarm. V12 CNA stated R1 has often made statements to her that he doesn't want to be here, and he wants to go home.On 9/24/25 at 11:05 AM V5, Maintenance Director stated all doors have alarms if opened and the alarm sounds in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146037 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 146037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Meadows Senior Living 400 West Washington Chrisman, IL 61924 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 the area of open door as well as sends a notification to the alarm panel. V5 demonstrated doors/hallways that wander guards would trigger an alarm which included the front entrance (door #9). V5 stated the facility added a mag lock about 2 weeks ago which is essentially a video doorbell that can be opened remotely. V5 stated that he recoded the front door about a week ago.On 9/24/25 at 11:29 AM, V11 CNA stated that on 9/5/25 she was the only aide working on R1's hallway. R1 was very restless that evening so she got him up from bed and watched him roll toward the front hallway around 9:00 PM. V11 denied hearing any alarm but stated that another staff member (unknown) had turned the front door alarm off due to multiple visitors coming in that evening and not enough staff to monitor front area. V11 stated at approximately 9:40 PM, the nurse received a phone call from a local resident stating R1 was in her area. V11 stated no one had known R1 left the facility and without the call from the town resident, she is unclear when they would have noticed.The Timecard Report dated 9/5/25 documents between the hours of 9:00 PM and 10:00 PM there was one CNA and one nurse for 37 residents on R1's unit.On 9/24/25 at 11:53 AM V9 RN stated that on 9/5/25 she worked 2:00 PM to 6:00 PM until V14 RN arrived and took over. V9 stated R1 received medication from her at 5:30 PM in his room. V9 stated she noticed over the last week R1's behavior had changed notably. V9 stated R1 usually stayed to his room, but lately she noticed R1 sitting in the chapel near the front entrance staring outside. V9 stated when she returned on 9/7/25, the codes to the front door had been changed and the sign on the door with code had been removed.The Facility Investigation File dated 9/6/25 includes one written statement from V14 RN. V14's undated written statement documents that at 9:55PM she received a call from a local town resident stating she had observed someone in a wheelchair in the road near her home that she believed was a resident of the facility. A head count was initiated and R1 was found to be missing. R1 was last been seen heading toward the front hallway in a wheelchair around 9:00 pm. Upon R1's return, no injury was found, and a wander guard was placed on R1's right ankle. The statement documents notifications were made to V1 Administrator, V16 Supervisor, and V6 R1's Representative.At 3:15 PM on 9/24/25, V1 Administrator, stated that she did investigate the incident and that R1 previously had been assessed to go outside on R1's own and the night of 9/5/25, R1 was just checking things out so he did not elope.No assessment or physician order documented in R1's Medical Record documents R1 is able to leave the facility unattended.On 9/25/25 at 10:22AM V8, Nurse Practitioner, stated R1's Parkinson's Disease affects his cognition and safety awareness. V8 stated R1 has intermittent moments of clear speech and memory recall, however his baseline is confused and R1 has no safety awareness. V8, stated R1 is impulsive and has stated on many occasions that he wants to go home. V8 stated R1 has advanced cardiac disease and recently had an internal defibrillator replaced. V8 stated R1 had an unresponsive episode on 8/27/25 due to cardiac issues and has high potential for another. V8, stated R1 would sit outside facility at times but always had staff supervision and should not have ever been outside alone. V8, stated the potential for R1 to have been harmed or have succumbed to the elements during his elopement was highly likely. V8 stated V8 was not notified of the elopement.The facility document entitled Elopement and Search Policy dated 02/2014 documents all nursing personnel are responsible for knowing whereabouts of assigned residents, residents are not permitted to leave the building alone unless a physician order is present, and all personnel are responsible for promptly responding to the location of an alarm to determine the cause. The policy states if elopement occurs, the physician and resident representative are to be notified, and a report is to be sent to the Illinois Department of Public Health (IDPH).The Immediate Jeopardy that began on 9/5/25 was removed on 9/25/25 when the facility took the following actions to remove the immediacy:On 9/5/25, an alert band was placed on R1 to ensure his safety. On 9/6/25, a new elopement evaluation was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146037 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 146037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Meadows Senior Living 400 West Washington Chrisman, IL 61924 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 completed for R1, and R1 was placed on 15-minute monitoring checks for 3 days to monitor exit-seeking behavior. On 9/7/25, V4 Social Service Director completed an audit of all wandering residents, and no issues were identified.Training for all staff was initiated on 9/25/2025 by V2 Director of Nursing and V5 Maintenance Director. Training included identifying exit-seeking behaviors, placing wander alert band immediately when identified at risk, physician orders, and where to locate the wander guard bands. The training also included the location of wander guard exit doors, and alarm panels, immediate response to a door alarm or wander guard alarm and completing safety checks indoors and outdoors to ensure that all residents are safe. The training included The Door Alarm and Missing Person and Elopement Policy and Procedures. The Missing Person and Elopement Policy and Procedures were reviewed 9/25/2025 by the Corporate Clinical Director. Care Plans were reviewed and revised as necessary by V4 Social Services Director to update interventions as appropriate on 9/25/2025.On 9/25/25, V5 Maintenance Director began audits of all exit doors with plans to conduct audits five days a week for six weeks, and then weekly to ensure proper function of all door alarms. On 9/25/25, V2 started audits of all residents at risk for wandering and will continue the audits on a weekly basis for six weeks to be sure Elopement Assessments and Care Plans are up to date with accurate information and interventions are in place. On 9/30/25 at 2:00 PM V2 stated V5 and V2 will bring the audits to the Quality Assurance meetings to be reviewed by the interdisciplinary team weekly, monthly, and quarterly. This was also confirmed with V1 and V5.The facility presented an abatement plan to remove the immediacy on 9/26/25 at 2:29 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned 9/26/25 at 3:51 PM. The facility presented a revised abatement plan to remove the immediacy on 9/26/25 at 4:51 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned 9/29/25 at 9:27 AM. The facility presented a revised abatement plan to remove the immediacy on 9/29/25 at 10:40AM. The survey team reviewed the abatement plan and was able to accept the plan to remove the immediacy. The abatement plan was approved on 9/29/25 at 11:01 AM. Event ID: Facility ID: 146037 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 146037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Meadows Senior Living 400 West Washington Chrisman, IL 61924 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure a resident's medical record included an elopement event for one of three residents (R1) reviewed for elopement in the sample list of five. R1's admission Record dated 9/23/25 documents R1 admitted to facility 8/28/2019. The admission Record documents R1's medical diagnoses include Congestive Heart Failure with presence of Cardiac Pacemaker, Age-Related Cognitive Decline, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Abnormalities of Gait and Mobility, Lack of Coordination, Parkinson's Disease Without Dyskinesia, Need for Assistance with Personal Care, Unsteadiness on Feet, and Insomnia.R1's Minimum Data Sheet (MDS) Section C dated 8/15/25 documents R1 has moderate cognitive impairment.R1's undated Care Plan documents R1 has confusion and a cognitive communication deficit, R1 is high risk for falls, has a history of falls with major injury, and staff have observed R1 turning off safety alarms. The Care Plan documents R1 has psychosocial well-being issues with reported feelings of isolation, has diagnoses of Major Depressive Disorder, and Insomnia, is at moderate risk for abuse related to dependence on others, displays inappropriate behaviors, has impaired cognitive function, and has suicidal ideations.On 9/23/25 at 11:41 AM, V6, R1's friend, stated that on that Friday night of 9/5/25, he received a phone call from the facility stating that they believed R1 had gotten out of the facility and that someone in the community had called reporting they had seen him. V6 could not recall the exact time of the call but stated it was dark outside and he was already in bed. V6 stated that approximately an hour after he received the first call, R1 called from the facility stating he was back. R1 stated to V6 that he had to go home to feed the dog and that he didn't want to be in facility anymore. V6 stated R1's residence prior to living at the facility was an apartment approximately 45 miles north that was right behind the railroad tracks. V6 stated R1 has stated to V6 previously that he would just follow the tracks home. V6 stated R1 knew the exit code because it had been posted on the door for years. V6 stated staff (Unkown) told him where R1 had been found indicating R1 had to travel over uneven, bumpy, railroad tracks to get to the location R1 was found. V6 stated if R1 fell out of the wheelchair he would not have the strength to pull himself back in. R1's medical record does not document notification to V6 on 9/5/25.The Facility Investigation File dated 9/6/25 includes one written statement from V14 RN. V14's undated written statement documents that at 9:55PM she received a call from a local town resident stating she had observed someone in a wheelchair in the road near her home that she believed was a resident of the facility. A head count was initiated and R1 was found to be missing. The statement documents R1 was last seen heading toward the front hallway in a wheelchair around 9:00 pm. The statement documents upon R1's return, no injury was found, and a wander guard was placed on R1's right ankle. The statement documents notifications were made to V1 Administrator, V16 Supervisor, and V6 R1's Representative.R1's undated Care Plan documents Elopement risk was added on 9/6/25 by V4 Social Services Director (SSD) with a goal of R1 will not leave facility without being escorted by family or staff. R1's Physican Order Sheet dated 9/23/25 documents a new order for monitoring wander guard functioning started on 9/8/25.R1's Psychiatry Visit Notes dated 9/15/25 document staff reported R1 has new behavior of exit seeking with multiple attempts over previous week and R1 confirmed to practitioner that he would continue to exit seek as he does not want to be at facility.R1's medical record does not document any incident on the night of 9/5/25. On 9/24/25 at 3:20 PM V2 Director of Nurses, stated she was not aware there was no documentation for R1 on the event on 9/5/25. The Facility Medical Record Policy, undated documents physicians, nursing staff, and other healthcare professionals are responsible for making timely and accurate entries. Nursing documentation shall include notations of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146037 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 146037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Meadows Senior Living 400 West Washington Chrisman, IL 61924 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 0842 Level of Harm - Minimal harm or potential for actual harm incidents including notification to medical doctor and resident representative.The Facility policy titled Accidents & Incidents dated 6/1/2007 documents staff must document in the clinical record a descriptive summary of an incident and any associated interventions including resident response to interventions, as well as complete incident report by end of shift. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146037 If continuation sheet Page 6 of 6