Inspection·October 29, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (R2's) primary diagnosis is Alzheimer's disease. Currently she is generally awake, alert and pleasant, however she is adamant about going home, she cannot understand why she is here at the facility. (R2) is becoming increasingly forgetful and in addition she has had a problem with anger outburst and very hostile behaviors which previously were out of character for her. R2's Skilled Nursing admission Documentation, dated 10/8/2024, documents alert to person only and confused. (R2) was assessed independent with bed mobility, transfers, eating and toilet use. A note documents: resident alert to self, able to make needs known. Resident anxious this morning, carrying her purse saying she needs to leave, becoming agitated. PRN (As Needed) Ativan administered and effective. Ambulates independently, with steady gait. R2's Nurse Progress Note, dated 10/10/2024 at 2:03 PM, documents (R2) continues to seek exit today and asking for (V12) and husband able to redirect at this time. R2's Nurse Progress Note, dated 10/11/2024 at 1:01 AM, documents (R2) had an episode prior to HS (bedtime) that was long lasting where she was exit seeking and yelling out for her daughter, staff unable to redirect easily and PRN Ativan was given. She calmed after about an hour and the PRN dose was effective. Closely monitored by memory care staff. R2's admission Minimum Data Set (MDS) dated [DATE], documents resident understood and understands. Brief Interview for Mental Status (BIMS) score of 5 (severely cognitively impaired.) Physical, verbal, and other behavioral symptoms (hitting or scratching self, pacing, rummaging or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Rejection of care occurred 1 to 3 days. Change in behavior or other symptoms were worse. No mobility devices. R2's Nurse Progress Note, dated 10/14/2024 at 2:00 PM, documents completed the admission MDS and assessment with (R2). (R2) is confused as to time, place and situation. (R2) was able to answer the MDS questions without issues. The questions about her history were a little more confusing for her. She is new to the facility and is on the unit. She packs her belongings every day and waits for (V12) to pick her up. (R2) was able to talk about her past and growing up. We will continue to try to get her involved in activities. R2's Nurse Progress Notes, dated 10/15/2024 at 6:40 PM, documents (R2) returned to facility via EMS via stretcher. (R2) alert and oriented to self. Speech clear. No injuries observed from previous incident. (V8), Medical Director notified of (R2's) return. R2's admission Assessment, dated 10/15/2024 at 6:40 PM documents elopement risk assessment walk in room supervision on and off unit, moderately impaired decisions regarding tasks of daily life, behaviors include: prior exit seeking, packing belongings, repeatedly opening doors/settings off alarms of secured doors, resisting redirection from staff and verbalizing statements about leaving. Contributing diagnoses include Alzheimer's disease, depression and anxiety disorder. Interventions documented include ID bracelet on, clothing marked with identification and frequent checks. R2's Nurse Progress note, dated 10/15/2024 9:42 PM, documents frequent checks on resident. V7, CNA Written Statement, dated 10/15/2024 at 5:15 PM, documents I was on the hall working and was last in contact with (R2) around 4:00 PM. She asked about going home and I instructed her we would have dinner in about 30 minutes if she could wait. I then checked on another resident and then moved onto another resident and escorted her to the bathroom where I then began to change her. I was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 2 of 11 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 notified of (R2) being gone around 4:45 PM. Level of Harm - Immediate jeopardy to resident health or safety V4, LPN Written Statement, dated 10/15/2024 at 5:44 PM, documents this nurse had just finished med pass on a (different hall than R2 resided) hall, med cart parked at nurse's station when phone rang. (V9), Unit Aide answered phone at 5:40 PM. (V9) informed this nurse that police were on the phone and (R2) was in their custody, they had found her in a field and (V9) transferred the call to Administrator's office. This nurse immediately went to Administrator's and DON's offices to notify them. This nurse then went to (the hall R2's room was located) hall, head count performed. All residents accounted for except (R2). Residents Affected - Few V9, Unit Aide Written Statement, dated 10/15/2024 at 6:00 PM, documents I, (V9) was passing supper when the phone rang at 4:50 PM. I answered the call from the local police department who stated they found one of our residents in a field. I made the resident's nurse aware the Administrator the police were on the phone. R2's Care Plan, updated 10/16/2024 documents focus: the resident is at risk for elopement posing a safety concern. Goal: the resident will not leave the facility without a responsible person accompanying them. Interventions: develop a plan for immediate action if elopement occurs. Educate the family and engage resident in activities such as folding washcloths/towels, washing tables in dining room to give a sense of purpose. Have photo and description readily available. Implement continuous monitoring and whereabout tracking preform elopement risk assessment on admission and quarterly secure exits, windows and potential escape routes changing codes to locked unit train staff of elopement prevention and immediate response. V1, Administrator typed statement dated 10/16/2024, documents this writer was informed around 4:30 PM on 10/15/2024 from the local Sherriff's Office that someone had called the sheriff's department about a person that was observed at the corner South Grand and [NAME] Street. Resident had been sent to local hospital Resident did return from hospital at 6:40 PM. Hospital stated no injuries. This writer also spoke with (V12) to keep her updated and told her (R2) had returned from hospital. Prior to (R2's) returning to the facility, facility provided POA information at 5:07 PM on the 15th. This writer informed the Medical Director of incident that same day. Investigation continues. 10/16/2024 left message for IDPH (Illinois Department of Public Health) to return my call. Informed my receptionist of this. On 10/15/2024 Administrator had maintenance screw all the windows on (hall R2 resides on) hall to only open 2-3 inches. There was a window left open in a vacant room. On 10/16/2024, DON and Administrator surveyed the area where (R2) was observed at. Maintenance and Administrator also surveyed the grounds of the facility with no real findings. Spoke to (V14) at 11:00 AM on 10/16/2024, Assistant Director of Nurses at hospital to thank her and the hospital for the assistance with (R2). On 10/17/2024 at 9:00 AM, R2's door was closed. Upon opening R2's bedroom door she was observed sitting on her bed with a black purse next to her. R2 told the State surveyor she wanted to go home, and she doesn't belong here, and she didn't know where her family was. R2 didn't recall being outside or at a hospital within the last few days and she was alert to name only at that time. No identification bracelet on. On 10/17/2024 at 11:20 AM, V3 Social Service Coordinator stated that (R2) was initially admitted on [DATE], (R2) was very confused and thought this was a doctor's office and as soon as she was seen by the doctor she could go home. (R2) is severely cognitively impaired and wanders up and down the memory locked unit hall from one door to the other and constantly tries to get out of the locked unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 3 of 11 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 V3 didn't see or assess (R2) on 10/15/2024 and wasn't told (R2) was exhibiting behaviors on that day. Upon admission, (R2's) family told her (R2) is no longer safe to be at home because her husband is frail with a heart condition and can't take care of (R2) anymore and she was afraid (R2) would leave the house unsupervised and would get harmed in some way. (R2's) family voiced they were afraid she would get out of the facility and get harmed in some way. On 10/17/2024 at 12:20 PM, V4, LPN (Licensed Practical Nurse) stated she worked on 10/15/2024 and was assigned to (R2) from 6:00 AM to 6:30 PM. V4 states she works with 1 CNA (Certified Nurse Aide) on the memory care locked unit and she is also assigned to other residents on three additional halls so although she is the assigned nurse to the locked unit, she is not back on the locked unit at all times when she is off the unit administering medications to other residents there is 1 CNA assigned to the unit for 11 residents who are very active and multiple residents are ambulatory and have behaviors and it is hard for her and the CNA to keep track of the residents let alone her being off the unit and leaving 11 residents with 1 CNA. Staffing has been like that for the year she has worked at the facility and even though she doesn't agree with it, it's how her schedule is set for the day to be assigned to multiple halls. V4 recalled she administered morning medication to (R2), and she took it, but she didn't recall seeing (R2) after that. V4 left the locked unit between 3:25 PM - 3:30 PM to pass evening medications on other halls and didn't recall seeing the resident at that time. V4 found out the resident was not at the facility at approximately 4:50 PM on 10/15/2024 because she was on a hall passing evening medications and overheard (V9) talking to the police on the phone and when (V9) transferred the call to (V1), (V9) told her that (R2) was in police custody, and she was found walking in a field. When she found out (R2) eloped she went to the locked unit she went and did a head count she noted the window (in R2's room) was wide open and a recliner was propped up against the window as well. All residents were accounted for at that time except for (R2). V4 didn't know how (R2) got out of the facility or if (R2) went out the window. V4 stated she never observed (R2) playing with the windows on the locked unit or anything like that. On 10/17/2024 at 1:30 PM, V7, CNA stated he worked on 10/15/2024 from 6:00 AM to 6:30 PM and was assigned to (R2) on the locked unit. V7 was the only CNA assigned to the locked unit with (V4), LPN and when (V4) had to administer medications to residents on other hall V7 was the only employee assigned to the locked unit. V7 stated he was getting residents ready for supper and that consists of toileting residents and washing their hands. V7 assisted (R2) to the bathroom and the last time V7 saw (R2) was at 3:00 PM. V7 stated he didn't know (R2) was not at the facility until (V4), LPN came and told him to do a head count of residents because the police called and reported (R2) was found walking in a field and was in police custody. V7 assisted with the head count and (V4) showed him a window in room [ROOM NUMBER] was wide open and a recliner was propped up against the window. V7 stated there are 4 or 5 residents that are exit seekers and several are transferred via sit to stand lifts, so they need 1:1 care he has to stay there with them. V7 stated he didn't hear any door alarms while he was caring for the residents in the bathroom. While he provides 1:1 care he tries to make sure all residents are safe prior to going into the bathroom but he's only 1 person and can't leave a resident on the toilet alone so he does the best he can. No other staff are there to keep an eye on the residents when he is providing 1:1 care to a resident. V7 stated he was familiar with (R2) and her wanting to always go home but she was calmer the day of 10/15/2024, she still voiced she wanted to go home but she wasn't hanging out at the exit door like she has in the past. V7 stated (R2) is alert to name only and she is extremely confused at all times. When she exit seeks and says she wants to go home V7 tells her let's eat the next meal and go from there to redirect her. V7 recalled what (R2) wore on 10/15/2024, it was pants with a t-shirt with a sweater over (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 4 of 11 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 the t-shirt and house shoes. Level of Harm - Immediate jeopardy to resident health or safety On 10/17/2024 at 11:40 AM, V10, Activities/Unit Aide stated she worked on the locked unit on 10/15/2024 and left at 3:00 PM and (R2) was on the unit at that time because she recalled saying bye to her. V10 was familiar with (R2) and stated (R2) always says she's going home and she's always packing her bag. V10 stated (R2) looks out the windows often but she never saw her playing or attempting to open a window. Residents Affected - Few On 10/17/2024 at 11:05 AM, V2, DON stated that (R2) was admitted on [DATE] and ever since then she has wanted to go home every minute of every day. V2 knew (R2) wanted to go home prior to her eloping from the facility. (R2) was initially admitted to the facility on the memory care locked unit due to her diagnoses of dementia and early onset Alzheimer's disease. V2 stated (R2's) family was concerned (R2) would leave the facility without anyone knowing and get harmed in some way. Prior to (R2) eloping the facility she expected staff to encourage (R2) in social activities on the unit, assist with activities and monitor for worsening behaviors. After (R2) returned from the elopement she expected staff to reassess her elopement risk to see if it changed and she wasn't aware staff didn't document a reassessment of (R2's) elopement risk. Interventions that were added to (R2's) care plan after she returned to the facility included in-servicing staff on how to prevent future elopements, educate family, involve the resident in folding wash cloths and towels, 15-minute checks for 72 hours and increase monitoring of resident as needed. Staff working on the memory care locked until on 10/15/2024 reported seeing (R2) last at 4:00 PM that day. She was aware after the police called the facility at approximately 4:40 PM that the resident was found walking in a field behind the hospital, she didn't know how the resident got out of the facility. After she was aware (R2) eloped she had the memory care locked unit do a head count to ensure all other residents were there and the nurse noted a window (in R2's room) was wide open and there was a recliner pushed against the windowsill. On 10/17/2024 at 1:10 PM, V2 stated an elopement risk assessment should be completed after a resident elopes to see if the elopement risk has changed. There is no initial care plan done upon a resident's admission and a MDS is done at days 4 and 14 then a care plan is documented at day 21 after a resident is admitted . The memory care unit is a locked unit for confused residents and there is 1 nurse and 1 CNA assigned to the unit. The nurse is also assigned to other halls as well so she's not always on the unit, but the assigned CNA is always on the unit. There are 11 residents that reside on the locked unit with 4 of the 11 residents are ambulatory and V2 didn't know how many residents exit seek or set door alarms off. (R2) was readmitted the same day she eloped which was 10/15/2024. (V2) was not at the facility when (R2) was readmitted to the facility via EMS but she knew (R2) didn't sustain any injuries. On 10/16/2024 at 1:30 PM, V5, Maintenance Man stated he just started working as the maintenance man at the facility, before that he worked in the kitchen. V5 was aware a resident was found in a field a few days ago but didn't know how she got out of the facility. The Administrator asked him to screw all the windows shut so they only open approximately 2 inches one day after (R2) was readmitted to the facility. On 10/17/2024 at 10:50 AM, V1, Administrator stated she was here at the facility on 10/15/2024 from approximately 8:00 AM to 6:30 PM. She was not aware (R2) was missing from the facility until the police called the facility at approximately 4:30 PM on 10/15/2024 and they stated the resident was found walking in a field near the local hospital. V1 stated doesn't know how (R2) got out of the facility or what time she left the facility. (R2) was seen by a staff member at 3:00 PM on 10/15/2024 and that was the last time staff saw here before she eloped. After V1 was notified that the resident was not at the facility staff did a head count on the memory until and during that it was noted a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 5 of 11 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 window in (R2's room) was found wide open with a recliner pushed up again the heat register. V1 and other staff don't know if (R2) went out the window to get out of the facility but since then they have screwed the windows shut on the memory unit so the windows only open 2 inches so residents cannot go out the window. (R2) was transported via EMS to the hospital and then back to the facility at approximately 6:30 PM on 10/15/2024 with no injuries. (R2's) has a low BIMS score and has diagnosis of dementia and early onset Alzheimer's disease. V1 stated R2 was found wandering in a field 0.6 mile from the facility. Review of the streets surrounding the facility showed there were multiple cars driving by a curvy busy country road with no sidewalks and deep ditches on both sides of the road. There was also a pond within 150 feet of where the resident was found. (R2) was initially admitted to the facility on [DATE] and since then she's stated she wants to go home and that's why she's on the memory locked unit because she doesn't have safety awareness and to be kept safe. When (R2) states she wants to go home she expects staff to redirect her. Since she returned to the facility staff have (R2) on 15-minute checks for 72 hours and all residents every 2 hours for 72 hours. On 10/18/2024 at 8:46 AM, R2 was observed sitting on her bed dressed with house shoes on. She was packing her clothes into a plastic hospital bag and stating to call her family because she needs to go home today. No identification bracelet on. On 10/18/2024 at 9:00 AM, R2 was observed sitting on her bed her house shoes were under the bed and she now had tennis shoes on. R2 again stated tell them I am going home today and to call her family. No identification bracelet on. On 10/18/2024 at 10:48 AM, V8, Police Officer who responded to the 911 call stated no report was made for this incident because he saw it as a medical situation. 3 police officers responded to an elderly woman (R2) walking in a bean field behind the local hospital on [DATE] at 4:31 PM. The resident stated her last name and police dispatch called the local nursing home and they stated the resident resided at the facility and they didn't know she was missing. The resident was pleasantly confused at that time and had notable dementia. V8 couldn't recall what (R2) was wearing or if she had shoes on or not. (R2) was transferred to the local hospital via EMS at that time. No police report was documented because this was considered a medical transport issue. On 10/18/2024 at 9:05 AM, V6, Medical Director stated that (R2) is alert to person only and has poor safety insight. (R2) has diagnoses including dementia and early onset Alzheimer's disease. (R2) is not safe to be outside by herself due to poor safety awareness due to being confused and has anxiety often. V6 stated (R2) never wanted to be at the facility and her family told her once the doctor sees her, she can go home, and she continues to say she wants to go home. V6 didn't know how (R2) eloped from the facility but thinks she followed a family out the locked door and went out the main door of the facility. V6 wasn't aware there was a window left wide open in room [ROOM NUMBER] on the locked unit after the resident eloped. On 10/25/2024 at 2:00 PM, V1, Administrator stated (R2) now has a Electronic wandering bracelet on her ankle. V1 stated the facility had the electronic wandering system in place when (R2) was initially admitted to the facility but no one put the Wander Guard bracelet on her. V1 expected staff to assess all new residents for elopement risk and if they are determined to be an elopement then an electronic monitoring bracelet should be applied within hours of the resident being admitted to the facility. The memory care locked unit doors are not equipped for the electronic system, but all other exit doors to the facility are protected so if (R2) had the electronic wandering bracelet on, the alarm would have sounded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 6 of 11 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 Facility's Undated and Untimed Final Investigation documents (V2) was notified on 10/15/2024 at or around 4:30 PM that the local Sheriff's Office had responded to a call regarding an individual in the area of South Grand and [NAME] Street In Nashville, Illinois. This individual was identified as (R2) a memory care resident of the facility. Sheriff's Deputies transported (R2) to the local hospital per department policy, Facility investigation began Immediately and (State Survey Agency) and the facility Medical Director were notified. Facility shared pertinent medical Information regarding the resident with local hospital, including the power of attorney Information on file at the facility, at or around 5:07 PM on 10/15/2024. The resident's family was immediately notified of the elopement and was notified again when (R2) returned to the facility at 6:40 PM on 10/15/2024. The results of the investigation are as follows: (R2) was observed by staff safe and secure in her assigned room on the locked memory care unit of the facility at 4:00 PM on 10/15/2024. Following the notification by the Sheriff's Department of the discovery of the resident at 4:30 PM, the facility conducted a search of the memory care unit and discovered a window ajar in an unoccupied resident room on the unit. While a conclusive determination cannot be made with the evidence at hand, It Is suspected that (R2) exited the facility by 1 of the 2 methods: 1. Following the check on (R2) 4:00 PM she may have at some point entered the unoccupied room on the locked memory care unit and was able to open a window and exit the facility. 2. (R2) followed a visitor through the unit's secured door, with the visitor not being aware that she was a resident. She was then able to exit the facility. A search of the facility grounds and the area that the resident was found revealed no additional findings. (R2) sustained no injuries as a result of the elopement. Facility staff have been reeducated on elopement policies and procedures. The door codes to enter the locked memory care unit of the facility have been changed and distributed to staff. A new notification system has been Implemented for families to utilize to gain entry to the locked memory care unit with posted Instructions at the entrance. The facility maintenance department as inspected all windows along the locked memory care unity of the facility as has modified their operation to only allow for the window to open 2-3 Inches, per life safety codes. (R2's) care plan was updated to reflect her current status and to include the use of a Wanderguard device which was Implemented Immediately. Beginning on 10/15/2024 all memory care residents were put on 15-minute checks to continue for a period of 72 hours. Upon the expiration of the 72 hours, (R2) wlll continue to be on 15-mlnute checks while other residents will be on 2 hour checks for a continued period of-14 days and then QA Team will review. All residents of the memory care unit were reevaluated for elopement risk and statuses were updated accordingly. Elopement policies and procedures, and this incident in particular will be included in the next QA meeting to be held on 10/20/2024. R2's Hospital Emergency Department documentation dated 10/15/2024, documents chief complaint: patient presents with altered mental status. [AGE] year-old female patient resident of local nursing home for the past 5 days only with a past medical history of dementia, high blood pressure, high cholesterol and anxiety who was found wandering in a field in heavy clothing with house shoes and socks, carrying one shoe in her hand. Patient was found by a passerby who noted that patient was confused so 911 was called. Police found out that patient was a resident of local nursing home and patient was not able to say where she lived. EMS transported to ER for evaluation. We called nursing home to request paperwork and information about contacting family. We called (V12) for more information and found out that patient was just placed into the nursing home on Friday, and she had been trying/wanting to leave ever since. Previously patient was at home being cared for by her [AGE] year-old frail husband. (V12) not able to come to ER because she was taking the patient's husband to the ER for another health matter. Physical exam: awake, alert, confused, asking about parents and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 7 of 11 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 her missing daughter. Neurological: mental status: she is alert. Mental status is at baseline. She is disoriented and confused. Psychiatric: perception is normal, she is inattentive. Thought content is delusional. Cognition and memory is impaired. She exhibits impaired recent memory and judgement is impulsive and inappropriate. Medical Decision Making: [AGE] year-old patient with dementia found wandering in a field several blocks from nursing home where she is a new resident in the locked dementia unit. Patient found walking by a passerby and when patient was confused, they called 911. Patient checked over with no physical abnormality noted. Patient ambulatory with steady gait and had no complaints of pain, nausea, dysuria, fever or any other complaints. Patient was disoriented which (V12) confirms is her baseline. Problems addressed: confusion: chronic illness and dementia. Risk details: called patient's (V12) to discuss findings and the decision to discharge. (V12) unable to come get patient because she is with patient's husband in another ER right now. Decision made to use EMS for transport due to high elopement risk via other means as evidenced by her escape from locked unit in the nursing home and her baseline severe dementia confusion. The facility's Elopement Prevention Policy, dated 1/1/2024, documents the facility will implement individualized interventions to strive to prevent elopement. We define elopement as follows: a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. Procedure: upon admission, quarterly, and after an elopement event or attempt, and with a change in condition, each resident will undergo a comprehensive elopement risk assessment using a validated tool. Assessment results will be documented in the resident's medical record and used to develop an individualized care plan for residents identified to be at risk for elopement. The interdisciplinary Team (IDT) will work with the resident and/or family to identify and implement appropriate individualized elopement prevention interventions based on assessment findings to reduce the risk of elopement while maximizing dignity and independence. Interventions may include but are not limited to electronic monitoring/alarm system, environmental modifications, protected list of names and photographs of those at risk for elopement, psychosocial interventions, regular rounds, resident/family education, staff interventions, and structured group activities. Communicate interventions during shift report and daily clinical rounds to the caregiving team. Review and revise the elopement plan of care admission, quarterly and after an elopement event or attempt and with a change in condition. The IDT will educate residents and their families about fall risks and prevention strategies. Analyze elopement incident date to identify trends and develop quality improvement initiatives. Provide regular training for all staff on elopement prevention, risk assessment, and post-elopement event management. Ensure staff competency through ongoing education and practical assessments. The QAPI Committee will review elopement incidents and outcomes regularly to ensure compliance with the policy and identify areas for improvement and implement quality improvement projects based on data analysis and feedback from staff and residents. The Immediate Jeopardy that began on 10/15/24 was removed on 10/29/2024, when the facility took the following actions to remove the immediacy: Proposed Removal Plan: The following actions have been taken to abate the risk of future elopements: • The issue has been determined to have the potential to affect all memory care residents and any other residents within the facility that have been identified as an elopement risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 8 of 11 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 (R2) was evaluated at local hospital following the elopement and again upon returning to the facility on [DATE]. No injuries were observed at that time. (R2's) responsible party, attending physician, and State Survey Agency were all notified on 10/15/2024. Residents Affected - Few • All residents on the memory care unity were placed on 15-minute checks for a period of 72 hours, beginning on 10/15/2024. At the expiration of the 72 hours, residents were placed on a 2-hour check, with the exception of (R2) remained on 15-minute checks, for a time period of 14 days and QA team will review to see if any changes need to be made. • (R2) care plan was reviewed and updated to assess exit seeking triggers and none were identified. The care plan was updated to include the use of a electronic monitoring device. • The electronic monitoring device, which is present on all exterior doors of the facility, was tested and determined to be in working order. The electronic monitoring alert system was tested and determined to be functioning properly and the electronic monitoring bracelet was placed on the resident. These items were all completed on 10/15/2024. • &nbs[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 9 of 11 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview and record review the facility failed to ensure adequate staffing for the memory care locked unit. This failure affects all 11 residents residing on the unit (R1, R2, R3, R4, R5, R22, R23, R24, R25, R26 and R27.) Reviewed for elopement on the sample list of 27. Findings include: On 10/24/2024 at 12:36 PM, V28, LPN (Licensed Practical Nurse) stated she works 6:00 PM to 6:00 AM and has been assigned to the a hall on the memory care locked unit. There is one CNA (Certified Nurse Aide) assigned to the hall with her and she is also assigned to 18 residents on a different hall, 1 resident on one hall and 4 residents on another hall. When she is off taking care of the residents on the other halls there is one CNA for 11 residents on the locked unit and that is not safe, not even during the night shift because the residents have dementia and Alzheimer's disease, and they have behaviors including wandering and even trying the locked doors and setting the locked door alarms off. V28 estimated she is not on located on the memory care hall for 4-5 hours during the 12-hour shift, so the CNA is working alone while she is not on the hall. 10/24/2024 at 1:15 PM, V21, RN (Registered Nurse) stated she works 6:00 AM to 6:00 PM and is assigned to the memory care locked unit often. V21 has to leave the locked unit to provide care to other residents who reside on two additional halls. When she is off the locked unit providing care to other residents there is one CNA assigned to the unit for 11 high acuity residents who have dementia and Alzheimer's disease, and they all need assistance with ADLs including being toileted so when she is off the unit and the one CNA is toileting a resident no staff are watching the other 10 residents. Some residents have behaviors like wandering and setting off door alarms and other residents' sundown at various times of the day so it's not safe to have one staff on the unit because no one is able to keep an eye on the other residents when that one CNA is providing 1:1 care to a resident. On 10/17/2024 at 12:20 PM, V4, LPN stated she works 6:00 AM to 6:30 PM. V4 states she works with one CNA on the memory care locked unit and she is also assigned to other residents on three additional halls, so although she is the assigned nurse to the locked unit, she is not back on the locked unit at all times when she is off the unit administering medications and treatments to other residents there is 1 CNA assigned to the unit for 11 residents who are very active and multiple residents are ambulatory and have behaviors and it is hard for her and the CNA to keep track of the residents let alone her being off the unit and leaving 11 residents with 1 CNA. Staffing has been like that for the year she has worked at the facility and even though she doesn't agree with it its how her schedule is set for the day to be assigned to multiple halls. V4 stated it is not safe to have one CNA with 11 high acuity dementia/Alzheimer's disease patients because they all need 1:1 assistance with ADLs including toileting and when the CNA is toileting a resident the other 10 residents are not supervised and that is not safe practice. On 10/17/2024 at 1:30 PM, V7, CNA stated he works 6:00 AM to 6:00 PM and is often assigned to the memory care locked unit. V7 is the only CNA assigned to the locked unit with (V4), LPN and when (V4) has to administer medications to residents on other halls V7 was the only employee assigned to the locked unit. V7 stated getting residents ready for meals consists of toileting them and washing their hands. V7 stated there are 4 or 5 residents that are exit seekers and several are transferred via sit to stand lifts so they need 1:1 care he has to stay there with them while they are on the toilet so no one is supervising the other 10 residents while he is toileting a resident and that is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 10 of 11 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 146043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Gardens of Nashville 485 South Friendship Drive Nashville, IL 62263 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 0725 Level of Harm - Minimal harm or potential for actual harm safe staffing because it takes at least 10-15 minutes to toilet each resident which is a lot of time that the other 10 residents are not being supervised. While he provides 1:1 care he tries to make sure all residents are safe prior to going into the bathroom but he's only 1 person and can't leave a resident on the toilet alone so he does the best he can. No other staff are there to keep an eye on the residents when he is providing 1:1 care to a resident. Residents Affected - Some On 10/24/2024 at 12:05 PM, V26, CNA stated she works on the memory care locked unit 6:00 AM to 6:00 PM and is the nurse for multiple other halls as well. When the nurse leaves the hall to provide care to other residents, she is the only staff on the hall and that is not safe. There are 11 residents on the memory care locked unit and several of them walk, wander and set off door alarms and when she is toileting one resident she can't keep an eye on the 10 other residents. V26 stated she is very vocal to administrative staff that this is not safe staffing for the acuity of the hall but they don't listen to what she says because nothing has changed. On 10/24/2024 at 12:10 PM, V18, CNA stated she doesn't work the memory care locked unit often but when she does, she is the only assigned CNA and when the nurse leaves the hall to assist other residents, she doesn't feel it is safe for residents because a lot of residents on that unit walk and others have sporadic behaviors. All 11 residents need assistance with toileting, and you can't keep an eye on other residents when you are toileting a resident. V18 doesn't find the current staffing to be a safe situation because anything can happen while she toileting another resident. On 10/17/2024 at 11:05 AM, V2, DON stated the nurse assigned to the memory care locked unit is also assigned to residents on three additional halls so the nurse is not always on the locked unit but there is a CNA on the unit at all times. There are several residents on the unit that are ambulatory, and all residents have either dementia or Alzheimer's disease and most of them are at elopement risk. V2 didn't know how many of the residents on the locked unit that try to elope or set the door alarms off. On 10/25/2024 2:15 PM. V1, Administrator stated she doesn't know exactly the nurse staffing assignments because the DON does the nurse scheduling, and she doesn't know the acuity of the memory care locked unit, but it doesn't sound safe to have 1 CNA on the unit and no staff to supervise the other residents when staff have to take care of a resident 1 on 1. The facility owners are looking at the staffing patterns and are seeing if changes need to be made. The Facility's Assessment Policy, dated 11/2022, documents evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet. The Facility's Staffing Policy, revised December 2011, documents a minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care provided by registered nurses. Registered nurses and licensed practical nurses employed by the facility in excess of these requirement may be used to satisfy the remaining 75% of the nursing and personal care time requirements. The minimum staffing ratios shall be 3.8 hours of nursing an personal care each day for a resident needing skilled care and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. The facility shall schedule nursing personnel so that the nursing needs of all residents are met. The number of staff who provide direct care who are needed at any time in the facility shall be based on the needs of the residents, and shall be determined by figuring the number of hours of direct care each resident needs per day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146043 If continuation sheet Page 11 of 11