Inspection·September 27, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that the information on the Practitioner Order for Life Sustaining Treatment Form (POLST) matched the physician's order for life sustaining measures or had a physician's order for life sustaining measures in 4 of 4 residents (R23, R33, R48, R155) reviewed for advance directives in the sample of 42. Residents Affected - Some Findings include: 1. R23's POLST, dated 12/4/22, documents R23 wishes to be a do not resuscitate (DNR). R23's Physician Order Sheet (POS), dated 12/4/21, documents an order for R23 to be a full code. 2. R33's POLST, dated 5/13/22, documents R33 wishes to be a DNR. R33's POS, fails to document a physician's order for R33 to be a DNR. 3. R48's POLST, dated 4/22/22, documents R48 wishes to be a full code. R48's POS, dated 7/15/22, documents R48 is a DNR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 2 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide treatment in accordance with professional standards of care for a fall resulting in injury for 1 of 16 residents (R65) reviewed for quality of care in the sample of 42. This failure resulted in R65 falling and sustaining a fractured arm which was not treated for two days. Residents Affected - Few Findings include: R65's Physician Order Sheet for September 2022 documents R65 is a [AGE] year-old female with diagnoses of unspecified dementia with behavioral disturbances, elevated white blood cell count, unspecified abnormalities of gait and mobility, other lack of coordination, muscle weakness, cognitive communication deficit and auditory hallucinations. On 9/23/2022 at 10:58 AM, R65's was residing on the dementia unit. R65 had a soft cast to her right arm. R65's Care Plan dated 8/15/2022 documents (R65) has dementia with behaviors. On 9/23/2022 at 10:59 AM, V38, Registered Nurse stated, (R65) is on the dementia unit and has poor safety awareness. She is easily confused. R65's Progress Notes dated 8/29/2022 at 4:16 PM, documents Resident had witnessed fall, playing game in dayroom with other residents, resident began walking backwards and tripped over her own feet and tried to catch herself and landed on her Right wrist, resident did not hit her head. Right wrist swelling noted. PRN (as needed) Acetaminophen administered, wrapped in ace wrap, Ice pack placed alternating on/off for 20 minutes. MD (Medical Doctor) notified, received orders to wrap/immobilize, and get STAT (right away) x-ray. R65's Progress Note dated 8/29/2022 at 8:00 PM, documents x-ray technician here at this time, x-ray done. R65's X-ray Report dated 8/29/2022 document R65 had an acute fracture of the distal radius and ulna styloid of the wrist. (2 long bone fractures close to the wrist). R65's Progress Note dated 8/30/2022 at 5:41 AM, documents Resident's bruise to Right side of eye is healing well, no swelling or redness to resident Left Knee, resident had a fall on 8/29 resulting in a Right wrist injury, resident denies any pain or discomfort at this time, this writer notices that Right wrist swollen with some redness and dark blue bruising, continuing to wait on results of x-ray related to wrist injuries. R65's Progress Notes dated 8/30/2022 at 11:25 AM, documents Edema continues to be noted to right wrist. Pain noted to area with movement. Resident currently has an ace wrap in place to area. Current x-ray results pending at this time. Resident also continues to have swelling to Left knee at this time. Resident denies pain to area. MD (Medical Doctor) previously made aware of knee. Resident able to ambulate normally and expresses no pain. Family in at this time to sit with resident. R65's Progress Notes dated 8/30/2022 at 2:29 PM, documents Power of Attorney (POA), Medical Doctor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 3 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0684 has been made aware of fracture. Level of Harm - Actual harm R65's Progress Notes dated 8/31/2022 at 11:13 AM, documents Assistant Director of Nursing (ADON) in unit at this time and advises Nurse to send resident out to ER (Emergency Room) to be further evaluated. Resident wrist continues to have swelling and is painful with movement. Movement to area currently limited and radial pulse very faint. This Nurse contacted ems (Emergency Medical System) at 11:17 AM to send to ER (Emergency Room) for evaluation of fracture to area. POA (Power of Attorney) contacted and made aware of concerns. Residents Affected - Few On 9/22/2022 at 8:58 AM, V2, Director of Nursing (DON), stated, If a STAT (Immediately) x-ray was ordered I would expect the turnaround time to be minimum of 3 hours. I would expect staff after three hours to be following up with the lab and finding out where the results are. Typically, the form is faxed back to us at the nurse's station. I would expect the x-ray company to call us to alert us of any critical care including a fracture. I reviewed the notes and saw that there was a delay in reporting the fracture for (R65). I am not sure what exactly happened and why it was not caught earlier. On 9/23/2022 at 10:06 AM, V36, Former Assistant Director of Nursing (ADON), stated, I use to be the ADON but no longer work in the facility. I remember (R65) she was in the dementia unit and had poor safety awareness and was really confused. I remember I came in on a Wednesday morning and (V2, Director of Nursing) told me (R65) had a previous fall a few days later and then she just walked away. (V2) told me they took and x-ray, but she was not sure if there was any injury. I talked with the nurse, and she told me nobody got an x-ray. I went and checked on (R65) her wrist was swollen, and she had a low pulse, so I wanted them to send her (R65) next door to the hospital to get an x-ray. I sent her out and then she had two fractures. When I told (V2) she just told me 'I guess we will just take the tag for that one.' On 9/23/2022 at 11:07 AM, V37, Medical Director stated, I am not sure when I got the x-ray results or when I was notified of (R65) having pain and swelling in her wrist. The facility is usually good about notifying me. I have another patient I cannot talk. The Change of Condition Policy with a revision date of 12/02 documents, The resident is involved in any accident or incident that results in an injury including injuries of unknown source notification will be made within twenty-four hours of a change occurring in residents' condition or status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 4 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to implement range of motion (ROM) programs to maintain or prevent a decrease in mobility of the joints for 4 of 4 residents (R23, R34, R48, R50) reviewed for ROM in the sample of 42. Findings include: 1. On 9/20/22 at 09:52 AM, R23 was observed with limited ROM and an inability to fully raise her arms and legs. R23's Face Sheet, undated, documents R23 has a diagnosis of Muscle Weakness and Patella Fracture. R23's Minimum Data Set (MDS), dated [DATE], documents R23 has impairment in ROM one side of the upper and lower extremities. R23's Activities of Daily Living (ADLs) skills analysis/restorative programs, dated 5/20/22, document R23 has impairment in ROM in the left upper extremity with a mild risk of contracture development. R23's Physical Therapy (PT) Discharge summary, dated [DATE], documents PT recommends R23 participates in a restorative therapy program to maintain current functional gains. Restorative range of motion program for generalized strengthening and endurance by participating in restorative therapy program by patient. R23's Occupational Therapy (OT) Discharge summary, dated [DATE], patient is currently able to raise arms above head and raise arms straight out from shoulders. With a restorative nursing program, patient will be able to maintain participation in daily activities by performing the following restorative nursing interventions: active ROM and allow resident to assist as possible, keep hands in position to maintain support of joint. 2. On 9/20/22 at 11:25 AM, R34 was observed with limited ROM to her upper and lower extremities with an inability to fully raise her arms and legs. R34's Face Sheet, undated, documents R34 has a diagnosis of Muscle Weakness. R34's ADL Skills Analysis/Restorative Programs, dated 7/6/22, documents R34 has mild impairment in ROM with mild risk for contracture development. 3. On 9/20/22 at 9:59 AM, R48 was observed with limited ROM in both of her upper and lower extremities with an inability to fully raise her arms and legs. R48's Face Sheet, undated, documents R48 has a diagnosis of Muscle Weakness. R48's Monthly Summary of Care, dated 8/22/22, document R48 is not receiving restorative services. 4. On 9/21/22 at 10:44 AM, R50 was observed with limited ROM to her upper and lower extremities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 5 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0688 with an inability to fully raise her arms and legs. Level of Harm - Minimal harm or potential for actual harm R50's Face Sheet, undated, documents R50 has a diagnosis of Muscle Weakness. Residents Affected - Some On 9/21/22 at 1:35 PM, V2, Director of Nurses (DON), states R23, R34, R48 and R50 are not on a ROM program. On 9/22/22 at 2:30 PM, V2, DON, states she would expect a resident with limited ROM be on a ROM program. The Range of Motion (Passive and Active) policy, dated 3/2009, documents the purpose of ROM is to prevent contractures, to maintain normal range of motion, to increase joint motion to the maximum possible range, to maintain and build muscle strength, to stimulate circulation, to prevent deformities and to prevent contracture from becoming worse if they are already present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 6 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 - Minimal harm or potential for actual harm Residents Affected - Few 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 implement progressive interventions and provide supervision to prevent falls for 1 of 16 residents (R65), reviewed for falls in the sample of 42. Findings include: R65's Physician Order Sheet for September 2022 document R65 is a [AGE] year old female with a diagnosis of Unspecified dementia with behavioral disturbances, Elevated white blood cell count, unspecified abnormalities of gait and mobility; Other lack of coordination; muscle weakness; cognitive communication deficit. On 9/23/2022 at 10:58 AM, R65's room was on the dementia unit. R65 had a cast on her arm. R65's Care Plan dated 8/15/2022 documents (R65) has dementia with behaviors. R65's Care Plan with a revision date of 8/31/2022 documents, Resident at risk for falling related to recent illness/hospitalization and new environment. On 9/22/2022 at 2:41 PM, V2, Director of Nursing (DON), stated, I would expect all interventions for falls to be on the Care Plans. R65's Progress Notes dated 8/18/2022 at 12:50 PM, document, Certified Nursing Assistant (CNA) witnessed resident fall to floor extremely hard hitting face against ground and causing a CNA witnessed resident fall to floor extremely hard hitting face against ground and causing a very small skin tear to right frontal lobe. Resident assisted self from floor prior to Nurse arrival without help. Resident able to follow all commands, Range of Motion, Within normal Limits and denies any pain. Resident did hit head and has a small skin tear noted. Area was cleansed and dry dressing applied. Resident has been placing furniture in front of bathroom door stating 'I'm keeping the man out.' Hallucinations have been noted since admission date and currently has new medication orders in place. Resident eating at this time and still continues to deny pain. Current vitals 100/59, 71 pulse, 96% on RA, and 98.5 temp. Neurological checks have been put into place. POA (Power of Attorney) and MD (Medical Doctor) NP (Nurse Practitioner) made aware. R67's Care Plan does not have any interventions documented on her plan for this fall. R65's Progress Notes dated 8/18/2022 at 9:01 PM, Bruise forming where resident had unwitnessed fall. Measuring 5 centimeters (cm) x 3 cm. Light purple/red in color. R65's Evaluation Note Report for 8/1/2022 to 9/23/2022 does not document any intervention for her fall on 8/18/2022 in her Care Plan. R65's Progress Notes dated 8/19/2022 at 12:49 PM, document, Root Cause analysis related to fall on 8/18: CNA was walking with resident, resident stumbled due to shoes not fitting properly and resident fell. Intervention: Residents family contacted to bring resident some shoes that fit properly. This intervention was not documented in R65's Care Plan and there were no notes to document if the family had brought in any shoes. R65's Progress Notes dated 8/29/2022 at 4:16 PM, Resident had witnessed fall, playing game in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 7 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 - Minimal harm or potential for actual harm Residents Affected - Few dayroom with other residents, resident began walking backwards and tripped over her own feet and tried to catch herself and landed on her Right wrist, resident did not hit her head. Right wrist swelling noted. PRN (As needed) Acetaminophen administered, wrapped in ace wrap, Ice pack placed alternating on/off for 20 minutes. MD notified, received orders to wrap/immobilize, and get STAT (right away) x-ray. R65's Progress Note dated 8/29/2022 at 8:00 PM, x-ray technician here at this time, x-ray done. R65's Care Plan does not document any interventions for this fall. R65's Progress Note dated 8/30/2022 at 5:41 AM, Residents bruise to Right side of eye is healing well, no swelling or redness to resident Left Knee, resident had a fall on 8/29 resulting in a Right wrist injury, resident denies any pain or discomfort at this time, this writer notices that Right wrist swollen with some redness and dark blue bruising, continuing to wait on results of x-ray related to wrist injuries. R65's Problem Evaluation Notes Report dated 9/22/2022 Root cause analysis related to fall on 9/21/2022. Resident was ambulating independently from day room to resident room; stumbled and fell. Intervention: Resident encouraged to allow staff to assist with ambulation. (R65 is on the dementia unit). This was not documented on her Care Plan. The Accident/Incident Prevention Policy undated documents, When a resident has been identified as a high risk for accident/incidents, interventions will be put into place per the individual resident assessment and care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 8 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to monitor food intake, assess insidious weight loss and effectiveness of interventions, and implement progressive interventions based upon this assessment to prevent continued weight loss for 1 of 5 residents (R75) reviewed for nutrition and weight loss in the sample of 42. This failure resulted in R75's severe weight loss of 28.41% in 3 months. Residents Affected - Few Findings include: R75's Undated Face Sheet, documented diagnoses of encephalopathy, dementia, anorexia, hypoglycemia, dysphagia (swallowing problems), congestive heart failure (CHF) and pain. R75's Care Plan, dated 8/31/2021, documents R75's current body weight was 109 pounds. R75's Care Plan documents R75's acceptable body weight is 114-146 pounds. The Goal documents Resident will achieve desired weight of 114-146 pounds. R75's Approaches documented the following approaches with the following start dates: Pureed diet start 9/22/21; Encourage oral intake of food and fluids start 8/13/21; Monitor/record weight weekly, notify physician and family of significant weight change start 8/13/21; and provide supplement of high protein supplement with fortified pudding at all times start 8/13/21. R75's Nurse's Note, dated 5/15/2022 at 6:42 PM documents resident arrived via ambulance at 5:37 PM. Resident was transferred 3 assist from stretcher to bed by EMS (emergency medical services) and staff. NG (nasogastric) feeding tube, 8 FT in place with Jevity 1.5 Cal 45 ml (milliliters)/hr (hour) continuous. No s/s (signs and symptoms) of pain or discomfort noted during assessment. R75's Nurse's Note, dated 5/16/2022 at 2:15 PM documents Hospice nurse removed NG tube per family and order from MD (physician). Resident tolerated removal well. R75's Practitioner Order for Life-Sustaining (POLST) form dated 5/16/2022, had no documentation in the section regarding medically administered nutrition section. This section was not completed. R75's Significant Change Minimum Data Set (MDS), dated [DATE] documents R75 is severely cognitively impaired, no swallow disorder, height 66 inches weight 97 pounds. R75's MDS documents R75 requires extensive assistance with one-person physical assist for eating. R75's MDS documents R75 had no weight loss and was on a mechanically altered diet. R75's Physician's Order Sheet (POS), dated 5/16/2022 documents pureed diet as tolerated, comfort feedings if pt (patient) alert enough. R75's POS dated 5/25/2022, documents Megestrol (Megace appetite stimulate) 125 mg (milligrams)/5 ml every day. R75's Progress Note, dated 6/8/2022 at 11:02 AM documents, resident alert and very talkative during breakfast. With help of staff resident consumed around 30% of breakfast and drank approximately 1 cup of water and half apple juice. Within 5 minutes of resident telling aide 'no more,' resident had small emesis (vomit) that resulted in what she had eaten and drank. R75's POS, dated 6/8/2022 documents high protein supplement with meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 9 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0692 R75's Progress Note, dated 6/12/2022 at 6:30 PM, documents, Resident refused meds and a drink of water this shift. CNA (Certified Nurse Aide) tried to feed resident at dinner, and she also refused to eat and drink. Level of Harm - Actual harm Residents Affected - Few R75's Progress Note, dated 6/14/2022 at 3:18 PM documents, Resident ate about 5% of breakfast and drank 1 cup apple juice and refused all drinks and food for lunch. R75's Monthly Weight dated, 6/15/2022, documents R75 weighed 111.6 pounds. R75's Progress Note, dated 6/17/2022 at 1:02 PM, documents, Resident ate 1 pudding for breakfast with 2 cups ice water and refused all food for lunch but drank 1 cup water. R75's Progress Note, dated 6/20/2022 at 6:03 PM, documents, Poor appetite for supper, refused to let staff feed her. R75's Progress Note, dated 6/21/2022 at 6:45 PM, documents, Resident has refused all meals from help or staff. R75's Monthly Weight dated, 7/1/2022, documents R75 weighed 108 pounds. R75's Monthly Weight dated, 8/2/2022, documents R75 weighed 92 pounds. R75's Progress Note, dated 8/7/2022 at 8:52 AM, documents, Resident ate about 50% of breakfast and drank 25% of liquids this morning. Staff encouraged resident to drink more of her liquids, resident continued to put blanket on top of her head and refused to drink anymore. Writer of this note will continue to encourage fluids during all mealtimes. R75's Dietitian Assessment, dated 8/9/2022 at 5:09 PM documents, on a Pureed diet as tolerates with High Protein Supplement. Fortified Pudding at meals. Intakes poor. Refuses assistance at meals and refuses food and fluids. On Megace which can stimulate appetite. Weights: (8/2): 92, (7/1): 108, (5/4): 97, and (2/1): 111. Current weight is down 16# (14.8%) x/1 month and down 19# (17.1%) x/6 months. Below IBW Range 114-146. Body Mass Index: 14.85 (Underweight). History of edema, on (2) diuretics (Diagnosis CHF). Potential risk for weight changes and dehydration. Fluids encouraged and dietary offers 15+ servings/day. Skin free of open areas. No new labs to review. On Iron Supplement. Estimated Needs: 1260 calories (30 kilo-calories per kg), 1260 cc (cubic centimeters) fluids (1 cc per kilo-calories), and 42-50 gram protein (1.0-1.2 injury factor). History of weights up and down. Monitor. R75's Progress Note, dated 8/9/2022 at 4:55 PM, documents, this nurse left voicemail to resident's family to return call to facility in regards to unplanned weight loss. R75's POS dated, 8/10/2022 documents weekly weight related to unplanned weight loss. R75's Care Plan, dated 8/10/2022 documents resident has unplanned weight loss. Goal resident will have no weight changes +/- 2 pounds during this quarter. Approaches monitor weight, serve diet as ordered R75's Medication Administration Record (MAR), dated 8/10/2022 documents she weighed 93 pounds. R75's Dietitian/Quarterly Assessment, dated 8/16/2022 at 1:45 PM documents, on a Pureed diet with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 10 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0692 Level of Harm - Actual harm Residents Affected - Few High Protein Supplement. Comfort feedings if alert. Fortified Pudding at meals. Intakes poor. Refuses assistance at meals and refuses food and fluids at times. On Megace which can stimulate appetite. Weights: (8/2): 92, (7/1): 108, (5/4): 97, and (2/1): 111. Current weight is down 16# (14.8%) x/1 month and down 19# (17.1%) x/6 months. Below IBW Range 114-146. Body Mass Index: 14.85 (Underweight). History of edema, on (2) diuretics (Diagnosis CHF). Potential risk for weight changes and dehydration. Fluids encouraged and dietary offers 15+ servings/day. Skin free of open areas. Labs (4/27/22): Glucose 60(L), Sodium 134(L), Potassium 5.0, Blood Urea Nitrogen 57(H), Creatinine 1.9(H), Total Protein 6.5, Albumin 3.2(L), Hemoglobin 9.5(L), and Hematocrit 28.2(L). On Iron Supplement. Estimated Needs: 1260 calories (30 kilo-calories per kg), 1260 cc fluids (1 cc per kilo-calories), and 42-50 gram protein (1.0-1.2 injury factor). History of weights up and down. Monitor. R75's MDS, dated [DATE] documents R75 is severely cognitively impaired, no swallow disorder, height 66 inches weight 92 pounds. R75's MDS documents R75 is totally dependent with one person physical assist for eating has had no weight loss and is receiving mechanically altered diet and feeding tube (nasogastric or abdominal). R75's MAR, dated 8/17/2022 documents she weighed 94 pounds. R75's Progress Note dated, 8/22/2022, documents, resident continues with poor appetite. Resident did however take around 4 bites of breakfast but then told aide that she was full and done eating. Half cup water drank. R75's MAR, dated 8/24/2022 documents she weighed 94 pounds. R75's Progress Note dated, 9/1/2022 at 6:56 PM, documents, Poor appetite continues. Resident stated she wanted some candy or cookies, but when given some soft candy resident refused saying 'I'm not hungry'. R75's Progress Note dated, 9/6/2022 at 1:04 PM, documents, resident ate approximately 5-6 bites of breakfast and 5-6 bites of lunch, 1 cup of apple juice for breakfast with half cup of water, and for lunch 1 cup apple juice. R75's Dietitian Assessment, dated 9/7/2022 at 5:20 PM documents, on a Pureed diet with High Protein Supplement. Comfort feedings as alert. Fortified Pudding at meals. Intakes poor. Refuses assistance at meals and refuses food and fluids at times. On Megace which can stimulate appetite. Weights: (9/6): 86, (8/2): 92, (6/15): 111.6, and (3/1): 108. Current weight is down 6# (6.5%) x/1 month, down 25# (22.9%) x/3 months, and down 22# (20.4%) x/6 months. Below IBW Range 114-146. Body Mass Index: 13.88 (Underweight). History of edema, on (2) diuretics (Diagnosis CHF). Potential risk for weight changes and dehydration. Fluids encouraged and dietary offers 15+ servings/day. Skin free of open areas. No new labs to review. On Iron Supplement. Estimated Needs: 1170 calories (30 kilo-calories per kg), 1170 cc fluids (1 cc per kilo-calories), and 39-47 gram protein (1.0-1.2 injury factor). Continue with diet Rx and encourage intakes. Monitor. R75's MAR, dated 9/7/2022, documents R75 weighed 87 pounds. R75's Progress Note dated, 9/8/2022 at 8:55 PM, documents, resident refused all meals this day stating 'I'm not hungry.' Resident would hold head down and staff could only get resident to take few sips of a drink. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 11 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0692 R75's MAR, dated 9/14/2022, documents R75 weighed 86 pounds. Level of Harm - Actual harm R75's Progress Note dated, 9/20/2022 at 8:12 PM, documents, resident continues with poor appetite for all meals this day. Approximately 5% total eaten this day with resident also denying most fluids. Family (who is aware of resident's decline and not eating) has called up to check on resident and was told no change in eating habits. Residents Affected - Few On 9/20/2022 at 12:15 PM, staff were feeding R75 pureed food with fortified pudding and fortified milk. R75 sat in a geri chair with her head was half way under the blanket. Staff encouraged her to eat and drink. R75 ate less than 5% of the meal. On 9/21/2022 at 8:50 AM staff pureed food with fortified pudding and fortified milk. R75 sat in a geri chair, her head was under the blanket. Staff encouraged her to eat and drink. R75 ate less than 5% of the meal. On 9/21/2022 at 12:30 PM, staff were feeding R75 pureed food with fortified pudding and fortified milk. R75 sat in a geri chair, her head was laying against the chair and half under the blanket. Staff encouraged her to eat and drink. R75 ate less than 5% of the meal. R75's Progress Note dated, 9/21/2022 at 1:01 PM, documents, Appetite continues to be poor with aide of staff. Resident took around 5-6 bites for breakfast and same for lunch. Fluids encouraged with taking very little sips. Resident continued to hang down and again encouraged to lift head to eat and drink Resident would lift head a little but kept wanting head covered stating she was cold. On 9/21/2022 at 1:35 PM V24, Certified Nurse's Aide (CNA) and V11, CNA transferred R75 to bed using a full body lift to weigh R75. R75's weigh was 79.9 pounds. V24 and V11 stated they are familiar with R75, she doesn't ever eat well but lately R75 is eating less and less they feed her at all meals as much as she will eat. V24 and V11 both stated they don't offer R75 snacks in between meals because no one told them to do that. R75's Electronic Medical Record dated 6/15/2022 documents she weighed 111.6 pounds and 9/22/2022 documents she weighed 79.9 pounds which resulted in R75 had a 28.41% weight loss in 3 months. R75's EMR during this time period has no documentation R75's physician was notified of the significant weight loss and no additional interventions/recommendations were added from the licensed dietitian and R75's care plan was not updated during this time. On 9/21/2022 at 2:00 PM, V6, Licensed Practical Nurse (LPN), stated R75 was on weekly weights in the past and then her weight was stable so they discontinued her weekly weights and reordered weekly weights in August 2022. V6 stated she documents the weekly weights in the computer. V6 stated R75 was on hospice for one day in May 2022 but the family didn't want her on hospice so it was discontinued. R75's Progress Note dated, 9/21/2022 at 6:04 PM, documents, Notified family of weight loss and continued poor appetite. Discussed options and conditions. Family would like to see if resident is a candidate for G (gastrostomy) -Tube placement. MD (physician) notified of weight loss and continued poor appetite, gave OK for GI (gastrointestinal) consult. R75's Progress Note dated, 9/21/2022 at 8:51 PM, documents, resident ate 50% of meal during dinner. Resident consumed all her mashed potatoes and chocolate pudding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 12 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0692 Level of Harm - Actual harm Residents Affected - Few On 9/21/2022 at 3:20 PM, V2, Director of Nursing (DON), stated R75 is on dietary supplements ordered by the physician of fortified foods and staff feed her as much as she will eat. V2 stated every day is different with R75, some days she eats more than others. V2 stated she expects staff to document in the nurse's notes when R75 doesn't eat well. V2 stated she didn't know if staff document meal intake for R75. V2 stated the Dietary Manager does a weight report that documents 5% or more weight loss in a month and she reviews it. V2 stated the Registered Dietitian (RD) comes in weekly to review residents that have weight loss. V2 stated R75's physician recommended hospice but (R75's) family doesn't want her to be on hospice. V2 stated R75's physician would be responsible to discuss a G-Tube with R75's family and she wasn't sure if it was discussed or not. V2 stated R75 had an NG tube when she was readmitted from the hospital in May 2022, but they had to discontinue it because the facility doesn't allow NG tubes at the facility. On 9/22/2022 at 9:00 AM, V2, DON stated staff are not documenting how much R75 eats per meal. V2 stated if she doesn't eat well for a meal V2 expected staff to document that in the nurse's notes. V2 stated she doesn't know if staff are offering R75 comfort food/snack between meals, but they should and if R75 eats the snack staff should document how much of the snack she ate in the nurse's notes. R75 was on weekly weights in the past but she gained weight and the weekly weights were discontinued and were reordered in 8/2022. V2 stated R75 was on hospice for a few days but her family didn't want her on hospice, so it was discontinued. V2 stated she expected staff to follow the facility weight monitoring policy. On 9/22/2022 at 1:00 PM, V2 stated she called R75's POA to update her on R75's weight loss and asked if she wanted R75 to have a G-Tube if her physician would clear her for surgery and the POA stated she would agree to a G-Tube. On 9/22/2022 at 1:55 PM, V40, R75's Power of Attorney (POA) stated she wanted R75 to have a G-Tube for a long time. V40 stated R75 was hospitalized in May 2022, and she was readmitted to the facility a few days later with a naso-gastric tube. V40 stated R75's NG tube was removed at the facility the next day she was readmitted staff took her NG tube out because she couldn't stay at the facility with it. V40 stated she asked multiple staff about R75 getting a G-Tube, but it fell on deaf ears, no one wants to do their job. V40 stated the DON called her in the evening on 9/21/2022 and told her R75 was losing more weight and asked her if she would be ok with R75 getting a G-Tube and she said yes. On 9/23/2022 at 9:00 AM, V34, Licensed Dietitian, stated R75 she comes to the facility every two weeks. V34 stated R75 is on Megace to increase her appetite and on high protein supplement of fortified milk and pudding. V34 stated the facility doesn't document how much the residents eat so it's hard to tell how many calories she's getting. V34 stated she talks to staff when she is at the facility to see how much residents are eating. V34 stated R75 has a history of not eating well. V34 stated her weight was stable a few months ago and now she's losing weight again. V34 stated she hasn't recommended a G-Tube for R75 and she didn't have a reason why she hasn't recommended it. V34 stated she expected staff to feed R75 between meals and a bedtime snack to ensure she is getting as many calories as possible. V34 was not aware R75's current weight is down to 79.9 pounds. The facility's Weight Monitoring Policy, revised 6/2021 documents, Objective to consistently assess residents for significant weight loss or gain. Procedure record weight in the proper place in the resident's clinical record, weekly and monthly weights are recorded by dietary in Electronic Medical Record (EMR.) Licensed staff will notify the physician of the following: 5% loss in a 30-day period, 7.5% loss in a 90-day period, 10% loss in a 180-day period. Notification to the physician must be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 13 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0692 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documented, and also whether or not new orders were received. Families/POA must be notified of significant weight loss. The weight committee will review all residents with significant weight losses and other residents of concern and refer to the RD (registered dietitian) as needed. The RD will review significant weight losses and any other residents referred by the weight committee on a monthly basis and make recommendations to physician as necessary. Residents that are confined to bed may be weighed with a lift scale. Responsible staff include licensed staff, CNAs, food service supervisor and the RD. Event ID: Facility ID: 145728 If continuation sheet Page 14 of 15 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 145728 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to wear personal protective equipment (PPE) appropriately to aid in the prevention and spread of the Coronavirus (COVID-19). This failure has the potential to affect all 104 residents residing in the facility. Residents Affected - Many Findings include: 1. On 9/20/22 at 9:09 AM, V1, Administrator, states they have had a staff member test positive for COVID over the weekend, the facility is now in outbreak status. On 9/20/22 at 9:20 AM, V5, Licensed Practical Nurse (LPN) was observed at the nurses station with no eye protection on. On 9/20/22 at 9:20 AM, V6, LPN, was observed at the nurses station with eye protection on the top of her head, not covering her eyes. On 9/21/22 at 12:10 PM, V9, Dietary Assistant, was observed in the 300 hall dining room/kitchenette serving the lunch meal with no eye protection on. On 9/21/22 at 12:30 PM, V12, Housekeeper/Laundry, was observed outside of room [ROOM NUMBER] with her mask down below her nose and no eye protection on. On 9/21/22 at 12:35 PM, V10, Certified Nurses Assistant (CNA), and V11, CNA, were observed in the 200 hall dining room feeding residents with no eye protection on. The COVID-19 Policy, dated 5/27/20, page 3, documents When community transmission levels are substantial or high, employees must wear a well-fitted face mask and eye protection. On 9/21/22 at 1:22 PM, The Community Transmission Rate COVID Data Tracker for [NAME] County, where the facility is located, is High. On 9/22/22 at 2:30 PM, V2, Director of Nurses (DON), states she would expect staff to wear their masks and eye protection at all times in the resident areas. The Updated guidance for nursing homes and other licensed long-term care facilities by the State of Illinois/The Illinois Department of Public Health, updated 3/22/22 documents the following: page 8 - When community transmission levels are substantial or high, at a minimum, health care personnel must wear a well-fitted mask at all times and eye protection while present in resident care areas. The Resident Census and Conditions of Residents (CMS Form 672), dated 9/20/22, documents there are 104 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 15 of 15