Health inspection·February 17, 2026

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few At 6:11 AM V9 DON notified V1 Administrator of the incident. At 7:06AM, V14 Certified Nurse Assistant (CNA) located R1 in a restaurant parking lot and at 7:07AM, V14 CNA called 911. On 2/8/26 at 7:16AM, EMS arrived on scene and transported R1 to the local hospital for evaluation.R1's Hospital Records dated 2/10/26 document R1 arrived at the Emergency Department at 7:23AM on 2/8/26. The Hospital Records document R1 was hypothermic with a temperature of 94.8 degrees Fahrenheit (F), with frostbite to bilateral great toes and additional digits related to environmental exposure, discoloration of bilateral hands, abrasions to bilateral knees, a hematoma to the forehead, a comminuted fracture through the distal neck and head of the proximal phalanx of the left great toe extending to the articular surface, and that R1 was disoriented and complaining of back pain. The Records document R1 was found with no coat and no shoes on.V14 Certified Nurses Aide's (CNA) statement dated 2/8/26 documents on 2/8/26 at 5:40AM V14 entered through the front entrance of the facility for her shift and noticed a bedside table sitting by the door. While completing morning vital signs, V14 noted that R1 was not in his room and alerted V8 Licensed Practical Nurse at that time. V14 found R1 at a local restaurant and placed her coat over his shoulders and called 911. The statement documents that R1's family arrived around the same time as V14 at the restaurant parking lot.The Facility Investigation File documents on 2/8/26, time unknown, V8 Licensed Practical Nurse (LPN) stated she last saw R1 at 11:00PM in his room in bed. The File documents V8 denied hearing any door alarms throughout the night and stated she was alerted to a missing resident around 5:30AM.R1's Progress Notes dated 2/9/26 document the Interdisciplinary Team (IDT) met following R1's unauthorized leave and the root cause was determined to be confusion/wandering behavior.The Facility Final Report dated 2/13/26 documents R1 was hospitalized with frostbite to toes and bilateral feet, hypothermia, Urinary Tract Infection (UTI), and fracture to the left great toe. The Report documents R1 was reassessed for risk of elopement and community survival skills and R1's Plan of Care was updated to reflect current risk of elopement and associated behavioral needs.The Google Map Application dated 2/17/26 documents the distance from the facility to the location R1 was found is 0.6 miles.The World Weather Forecast Temperature Charts dated 2/7/26 and 2/8/26 for the facility location document the temperature at 11:00PM on 2/7/26 was 25 degrees F with a real feel of 16 degrees F and the temperature at 7:00AM on 2/8/26 was 27 degrees F with a real feel of 15 degrees F.The Facility Daily Assignment Sheet dated 2/7/26 third shift, documents V8 LPN and V15 LPN were the nurses on shift between the hours of 10:00PM and 6:00AM. The Daily Assignment Sheet documents V16 CNA, V17 CNA, V18 CNA, and V19 CNA were the Certified Nursing Assistants for the third shift on 2/7/26 between the hours of 10:00PM and 6:00AM. The Facility Daily Assignment Sheet dated 2/8/26 first shift, documents V14 CNA worked from 6:00AM to 2:00PM.On 2/11/26 at 12:55 PM V14 CNA confirmed V14's statement dated 2/8/26. V14 stated V14 noted R1 missing the morning of 2/8/26 after arriving for the day shift and V14 alerted V8 LPN that R1 was not in his room.On 2/8/26 at 8:00AM, V15 Licensed Practical Nurse (LPN) stated that he was the overnight nurse for the other wing and stated he was completing wound rounds at end of the shift when he was alerted there was a Code Pink (Missing Resident).Attempts were made during the survey to contact V8 LPN, V16 CNA, V17 CNA, V18 CNA and V19 CNA night shift staff.On 2/10/26 at 1:15PM V10 Hospital Registered Nurse stated that R1 sustained a hematoma with skin tear to the right forehead area, bilateral foot frostbite involving great toes and additional digits due to environmental exposure, and fracture to left proximal phalanx great toes requiring a surgical shoe. V10 stated R1 was currently being treated for a Urinary Tract Infection with Intravenous Antibiotics. On 2/10/26 at 2:05 PM V6, Facility Nurse Practitioner, stated that R1 could have suffered kidney failure, hypothermia, loss of limbs, falls, fractures, heart attack, and ultimately death from being unattended outside of facility. V6 stated R1 has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 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 146148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Hickory Point 565 West Marion Avenue Forsyth, IL 62535 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 poor cognition, is extremely hard of hearing, has poor vision, and has no safety awareness.At 11:50AM on 2/10/26, V1 Administrator, and V2 Regional Operations Director, stated that the facility does not have cameras and that through interviews and witness statements, R1 was identified as last seen around 11:00PM on 2/7/26 and was not identified as missing until 6:05 AM the following morning on 2/8/26. V1 and V2 stated R1's family was notified and family found R1 at approximately 7:00AM.On 2/10/26 at 9:55AM, V4, R1's Family Member, stated on 2/8/26 at 6:55AM she was notified by facility staff that R1 was missing. V4 stated at 7:00AM, V4 and V4's spouse found R1 crouched down by a wall at a restaurant on the way to the facility wearing a T-shirt, sweatshirt, jeans and socks. V4 stated R1 did not have a coat, hat or shoes on. V4 stated R1, complained he was cold, and the wind was very bad. V4 stated R1 had a visible knot on his forehead and R1's left-hand fingers were blue. R1 stated he had been a bad boy and that he had wandered into the hallway looking for help when he wandered out. V4 stated R1 stated that he fell several times that night. V4 stated that R1 required a walker to walk, but the facility did not have one for R1, so he did not have any walking aid when found at the restaurant that morning. V4 stated upon admission to local emergency room, R1 was found to have frostbite to the left index finger and right and left great toes, and R1's left great toe was broken and at this time, amputation of frostbit extremities is still a possibility. V4 stated R1 was also found to have a urinary tract infection at the hospital that R1 did not have at the time of admission to the facility five days prior. V4 also stated that R1 was found in clothing from the day prior, and R1's hearing aides were in R1's ears but not charged, R1's dentures were in place, and R1 did not have his glasses on. V4 stated V4 believes R1 was never assisted to bed that evening prior. V4 also stated that after admission to facility on 2/2/26, R1 had fallen in the facility. On 2/10/26 at 11:30 AM, V5 Receptionist stated there is an elopement alert binder at the front desk that identifies residents who are at risk of elopement. V5 stated there is always someone at the front desk from 8AM to 8PM seven days a week and prior to leaving shift, the outside front door is locked so no one can enter, and the inside exit door is alarmed a with code.On 2/10/26 at 9:00AM the restaurant parking lot where R1 was found, 0.6miles from the facility, was noted to be located at the intersection of two major highways. The policy titled Code Pink-Missing Resident/ Elopement, dated 11/2017, documents the facility maintains a process to assess all residents for risk for elopement, implement risk reduction strategies for those identified as an elopement risk, and institute measure for resident identification at the time of admission.The Immediate Jeopardy that began on 2/7/26 was removed on 2/8/26 when the facility took the following actions to remove the immediacy:1.) R1 was reassessed for risk of elopement and community survival skills and R1's Plan of Care was updated to include R1's current risk of elopement and associated behavioral needs by V12 SSD on 2/8/2026. The facility has a plan to have R1 on one to one observation when R1 returns.2.) On 2/8/26, V11 Maintenance Director reviewed the incident and confirmed door alarms/system functional status.3.) The elopement binder was reviewed and updated on 2/8/2026, completed by V12 SSD, V13 SSD, V21 MDS, V9 DON and V1 Administrator.4.) Code Pink Education and Rounding Expectations were provided to 100% of staff on 2/8/2026, completed by V22 Human Resource Director, V20 CNA Scheduler, V9 DON, V3 ADON, & V1 Administrator.5.) All residents were assessed for risk of elopement and community survival by V12 SSD, V13 SSD, V21 MDS, and V8 admission Nurse on 2/8/2026.6.) All residents will be reevaluated for elopement risk at admission, readmission, quarterly, annually, and significant change or incidentally if at risk behaviors are identified. This will be on-going. SSDs assigned this responsibility as of 2/8/26. Audit will be reviewed by the administrator or designee for six weeks.7.) On 2/8/2026 100% of staff were in serviced regarding wandering/exit seeking behavior, and when to provide/implement increased supervision to a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 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 146148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Hickory Point 565 West Marion Avenue Forsyth, IL 62535 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 resident exhibiting these behaviors by V3 ADON, V9 DON, V20 CNA Scheduler, V1 Administrator, and V22 Human Resources Director (HRD).8.) On 2/8/2026 100% of staff were in serviced regarding door alarms as required safety measure and must never be turned off, silenced, or disabled. These alarms help prevent unauthorized leave. Any alarm issues must be reported immediately to the charge nurse and maintenance, and staff are expected to respond promptly when alarms sound. The front door entrance door alarm may be disabled from approximate times of 8 am to 8 pm only when the door is being monitored by staff. Staff in-serviced by V9 DON, V22 HRD, V3 ADON, and V1 Administrator.9.) An Elopement drill was conducted on 2/8/2026 at 2:25 PM by V9 DON & V1 Administrator.10.) A plan for in-servicing was implemented which includes elopement policy, wandering/exit seeking behavior and door alarms to occur upon hire and remain ongoing by V22 HRD.11.) On 2/8/2026 Agency staff were in-serviced by the agency platform regarding Code Pink and Rounding Expectations prior to working at the facility. 12.) An ADHOC Quality Assurance (QA) meeting was completed with the IDT regarding the Elopement Policy and Procedure on 2/8/2026.13.) The QA committee will review policy and procedure as part of the Quality Assurance Process on 2/11/26.14.) Elopement will be reviewed during each quarterly meeting for four meetings.The facility presented an abatement plan to remove the immediacy on 2/11/26 at 3:59 p.m. The survey team reviewed the abatement plan and was able to accept the plan to remove the immediacy. The abatement plan was approved on 2/13/26 at 10:10 a.m. Event ID: Facility ID: 146148 If continuation sheet Page 4 of 4