Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to staff enough Certified Nursing Assistants (CNA) to provide
care to the residents for 5 of 8 residents (R3, R36, R54, R79, R80) reviewed for adequate staffing in the
sample of 35. This failure has the potential to affect all 102 residents residing in the facility.
Findings include:
1. On 10/4/23 at 1:54 PM, R54 stated the facility needs more CNAs, especially on the weekends. R54
stated a lot of times they only have one CNA on her hall. R54 stated her roommate is at risk for falls and
when her alarm goes off, she (R54) will turn her call light on to get help for her roommate. R54 stated no
one comes so she (R54) has to call the nurse's station on her phone to get help.
R54's filed a grievance, dated 2/28/23, documenting that there are low staff on the weekends. The
corrective action from the facility was they have hired eight nurse aides, changed the schedule to spread
staffing out throughout the weekend more effectively with a team effort from all department heads to assist
with scheduling and staffing on the weekends.
R54's Minimum Data Set (MDS), dated [DATE], documents R54 is cognitively intact.
2. During the group meeting on 10/4/2023 at 3:00 PM, R80 stated the staff that are here are great and they
work hard but the truth of the matter is we need more staff. R80 stated It's really bad at nights. I am not sure
what is going on in the world, but the truth of the matter is we need more staff working here. I am not sure
what has happened, but it is not enough, and I think some of the staff get burnt out because they do not
have enough help and then quit. I do not like to complain but they need more help. Our needs are not
always met because there is not enough help.
R80's MDS dated [DATE] document R80 was cognitively alert for decision making of activities of daily
living.
3. During the group meeting on 10/4/2023 at 3:00 PM, R36 stated, My biggest complaint is that they need
more help. Especially in the evenings. I have to wait and wait for staff because there is not enough help. I
need help getting to the bathroom and I have had accidents for waiting for staff to come and help me. They
need more help here it really is a big problem at nights.
R36's MDS dated [DATE] document she is cognitively intact for decision making for activities of daily living.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
145728
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
10/06/2023
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 0725
Level of Harm - Minimal harm
or potential for actual harm
4. During the group meeting on 10/4/2023 at 3:00 PM, R3 stated, This is a great place to live if you have to
be in a nursing home. My biggest complaint is that they need more help. Especially in the evenings. I have
to wait and wait for staff because there is not enough help. I need help getting to the bathroom and I have
had accidents for waiting for staff to come and help me. They need more help here, it really is a big problem
at nights.
Residents Affected - Some
R3's MDS dated [DATE] document she is cognitively intact for decision making for activities of daily living.
5. During the group meeting on 10/4/2023 at 3:00 PM, R79 stated there is not enough help especially at
night. The facility needs more staff because resident needs are not being met during the night.
R79's MDS dated [DATE] document she was cognitively alert and orientated for decision making of
activities of daily living.
On 10/3/23 at 2:23 PM, V7, Licensed Practical Nurse (LPN), stated all of healthcare needs more staff, a lot
quit during COVID and never came back.
On 10/3/23 at 2:30 PM, V5, LPN, stated they have staff, but they call off, so it causes the CNAs that do
come in to have to do extra work.
On 10/4/23 at 2:35 PM, V13, CNA/Shift Coordinator, stated they decide how many CNAs are needed on
each hallway and each shift by reviewing the census and acuity/needs of the residents. V13 stated if there
are call offs, she will work the floor or call another CNA in to work. V13 stated if they have call offs and can't
replace them, they work short and make it work.
On 10/4/23 at 2:35 PM, V2, Director of Nurses (DON) stated call offs are a problem with CNAs.
On 10/5/23 at 8:10 AM, V14, CNA, stated they are short on CNAs on day shift and it's hard to care for the
facility. V14 stated the facility is hiring but they don't show up.
On 10/5/23 at 8:15 AM, V15, CNA, stated some days they are short on CNAs and when they are short it
makes it harder to provide care. V15 stated they have a lot of call offs or staff that don't call or show up for
their shift.
On 10/5/23 at 8:18 AM, V16, CNA, stated they are short on CNAs, and it makes it hard to provide care to
the residents. V16 stated the facility just doesn't have enough CNAs.
The Staffing policy, dated 9/18, documents staffing shall be based on the number, acuity, and diagnoses of
the residents in the facility in accordance with the facility assessment, and shall be determined by figuring
the number of hours of nursing time that each resident needs on each shift of the day.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145728
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145728
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/06/2023
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to ensure residents' drug regimen was free for
unnecessary psychotropic drug use for 1 of 5 residents (R13) reviewed for unnecessary psychotropic
medications in the sample of 35.
Findings include:
On 10/6/2023 at 10:50 AM, R13 was sitting in television area, R13's facial features would slightly twitch/jerk
as she was sitting in her wheelchair watching the dancing on the television.
On 10/6/2023 at 9:05 AM, V20, Registered Nurse (RN) stated, I know (R13) has some lip smacking and
facial twitches. I do not think it is getting worse. I have been here for about 8 months now. I am not aware of
her having any behaviors.
On 10/6/2023 at 9:11 AM, V10, RN stated, When (R13) was in the Memory Care Unit I provided care for
her. She has some facial twitching in her neck and face. I am not aware of her having any behaviors. There
were times she refused her medication but no behaviors that I can think of.
R13's Physician Order Sheet (POS) document a diagnosis of Unspecified dementia, unspecified severity
with anxiety, type 2 diabetes mellitus with diabetic neuropathy, shortness of breath, emphysema,
conversion disorder with seizures or convulsions, constipation, unspecified abnormalities of gait and
mobility, cognitive communication deficit, muscle weakness, gastro-esophageal, hypertension, pain, vitamin
deficiency, long term care use of aspirin, depression.
R13's POS documents an order for quetiapine 25 milligrams (mg), amount 1 tablet oral. Diagnosis of
Dementia in other diseases classified elsewhere mild, with anxiety at bedtime, 8:00 PM.
R13's Care Plan does not address quetiapine or the use of psychotropic medication.
R13's Minimum Data Set, dated [DATE] documents R13 has memory problems, moderately impaired for
decision making. Mood: Little interest in doing things; No behaviors, and document R13 was receiving
antipsychotic, antidepressants, and hypnotic medications.
On 10/5/2023 at 2:32 PM, Behavior Tracking was requested for R13.
On 10/5/2023 at 3:31 PM, V1, Administrator stated, We do not have any behavior tracking for (R13). (R13)
came into the facility with the quetiapine and remember some issues with the family wanting her on the
medication. There is no behavior tracking for (R13).
R13's Progress Notes dated 6/7/2023 at 10:40 AM, documents Resident currently having Tardive
Dyskinesia. Resident is sitting in wheelchair and states not feeling well. Involuntary twitching movement
noted in intervals.
R13's admission Note dated 4/17/2023 at 4:16 PM, document, admitted to the facility via private car
accompanied by daughter from Home. She is alert and oriented. She is here for long term placement
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145728
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145728
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/06/2023
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 0758
in memory care for worsening Dementia.
Level of Harm - Minimal harm
or potential for actual harm
The Pharmacy Note To Attending Physician/ Prescriber, Pharmacist Recommended does reduction to
Quetiapine 25 milligrams (mg): take ½ tablet (12.5) at bedtime. The Physician (V21) disagreed and
marked an x in the box, Behavior interventions continue to be attempted, except in emergency situations,
and are included in the plan of care. However, dose reductions at this time would likely impair resident's
function or increase distressed behavior while continuing to pose a danger to the resident or others as
supported by the following CLINICAL RATIONALE AND EVIDENCE OF THE FOLLOWING SYMPTOMS:
Nothing was documented in this area.
Residents Affected - Few
The Facility Psychopharmacological Drug Usage Procedure with a revision date of 09/08 documents, A
Psychopharmacological Drug is any medication used for managing behavior, stabilizing mood, or treating
psychiatric disorders. This includes the following types of drugs: antipsychotic, antidepressants, anti-anxiety
meds, and sedatives/hypnotics. Documentation of behaviors and conditions requiring the use of these
medications must be done on a routine basis, as well as medication response and adverse consequences.
Unsuccessful reductions of medication must be substantiated by documentation, including rationale from
the physician as to why the medication cannot be reduced further.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145728
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145728
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/06/2023
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 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to obtain urine cultures to ensure that the
appropriate antibiotic was utilized or necessary to treat urinary tract infections (UTIs) for 4 of 4 residents
(R12, R57, R65, R91) reviewed for antibiotic stewardship in the sample of 35.
Residents Affected - Some
Findings include:
1. The Facility Infection Control Log documents R12 had a UTI, and the hospital stated the culture was
negative.
R12's Progress Note, dated 3/16/23 at 1:47 PM, documents report was called from the hospital and R12
would be returning to the facility and was treated for an abnormal urinalysis (UA), but the urine culture
came back negative but R12 would be continuing three more days of antibiotics.
R12's Progress Note, dated 3/20/23 at 12:12 PM, documents R12 completed the antibiotic on 3/19/23
related to an abnormal UA/UTI.
R12's Physician Order Sheet (POS), documents an order dated, 3/16/23, for Cefdinir 300 milligrams (mg)
twice daily (BID) with an end date of 3/19/23.
2. The Facility Infection Control Log documents R57 had two UTIs with no organism identified on the log.
R57's Progress Note, dated 4/17/23 at 3:06 PM, documents the root cause analysis related to a fall on
4/16/23 was that R57 attempted to get herself out of bed and fell. The intervention is as follows: Hospice in
the building to assess resident, resident is anxious and fidgety. Resident is moving around in chair. Hospice
Nurse states that he suspects that the resident has a UTI and will be starting her on an antibiotic.
R57's Progress Note, dated 9/4/23 at 6:16 PM, documents that the facility talked with R12's family and they
do not want the resident catheterized to obtain a urine specimen because it wouldn't be comfortable for
R12, who is on hospice. Called hospice care nurse and received a new order for Cipro 500 mg BID for 10
days.
R57's POS, documents an order dated, 4/18/23, for Cipro 500mg BID with an end date of 4/27/23.
R57's POS, documents an order dated, 9/4/23, for Cipro 500mg BID with an end date of 9/15/23.
There was no documentation in R57's record that a urine culture was obtained prior to the antibiotics
ordered on 4/18/23 and 9/4/23 to ensure the antibiotic was necessary or susceptible to the
organism/infection.
3. The Facility Infection Control Log documents R65 had a UTI, resulted at the urologist, results not
available.
R65's Progress Note, dated 10/21/22 at 5:59 PM, documents R65 was out for a urology appointment,
during the appointment the catheter was changed, and a UA was obtained with no findings noted.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145728
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145728
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/06/2023
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 0881
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
R65's Progress Note, dated 10/24/22 at 11:42 AM, documents Urologist called and stated R65 had a UTI
and started resident on Macrobid 100mg BID for 7 days.
R65's POS documents an order, dated 10/24/23, for Macrobid 100mg BID with an end date of 10/31/22.
There was no documentation in R65's medical record what the results of the UA/Urine culture results were
to ensure that the antibiotic was necessary or was susceptible to the antibiotic prescribed.
4. The Facility Infection Control Log, documents R91 had a UTI and there was no documentation on the log
that a urine culture was obtained or that an organism was identified.
R91's Progress Note, dated 9/5/23 at 1:40 PM, documents the hospice nurse came to see the resident.
New orders received to start Macrobid 100mg BID for 7 days for UTI.
R91's last urine culture report, dated 8/10/23, documents normal skin flora.
There was no documentation that a urine culture was obtained prior to R91 starting the antibiotic on 9/5/23
to ensure the antibiotic was necessary or was susceptible to the organism/infection.
On 10/6/23 at 9:20 AM, V4, Infection Control Preventionist, stated she would expect that a UA/Urine culture
would be obtained prior to the initiation of an antibiotic for a UTI to ensure the antibiotic is necessary and if
so, the antibiotic prescribed is susceptible to the organism.
The Antibiotic Stewardship policy, dated 12/18/19, documents the purpose of the program is to reduce
inappropriate use of antibiotics, improve resident outcomes and lessen adverse events.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145728
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
FAQ · About this visit
Common questions about this visit
What happened during the October 6, 2023 survey of MANOR COURT OF MARYVILLE?
This was a inspection survey of MANOR COURT OF MARYVILLE on October 6, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MANOR COURT OF MARYVILLE on October 6, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiatin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.