Inspection·December 13, 2023

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 fall interventions to prevent accidents/falls for 1 of 3 residents (R4) reviewed for supervision to prevent accidents in the sample of 7. Findings include: R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, idiopathic peripheral autonomic neuropathy, chronic pain, abnormalities of gait and mobility, lack of coordination, muscle weakness, and muscle spasms. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was cognitively intact and used wheelchair for mobility. The MDS did not further evaluate R4's functional abilities. R4's Care Plan initiated 1/7/19 documents, (R4) at risk for falling r/t (related to) impaired mobility, use of psychoactive medications, use of diuretic medication, dx (diagnosis) of htn (hypertension), dx of insomnia, and dx of neuropathy. R4's Fall Report dated 1/31/23 documents R4 had an unwitnessed fall in the bathroom while trying to reach for a grab bar next to the toilet. The interventions added were therapy evaluation and application of new cushion and (non-slip pad) to wheelchair. R4's Fall Risk assessment dated [DATE] documented R4 was at high risk of falls. R4's Progress Note by V25, Registered Nurse (RN) on 12/11/23 at 6:30 PM documents, found pt (patient) sitting on floor in the bathroom no call light on and brake wasn't locked on the w/c (wheelchair) pt (patient) states she isn't injured no sores bruises noted to hip. Pt states that she wheeled into bathroom and slide out of w/c on to the floor. R4's Fall Report dated 12/11/23 documents R4 had unwitnessed fall wheeling into bathroom from wheelchair. R4 did not sustain any injuries. The intervention added was therapy evaluation for wheelchair positioning and cushion. On 12/13/23 at 9:35 AM, R4 stated she was transferring herself from her wheelchair to the toilet the other night when the pad on her seat slid out from the chair and she fell. On 12/13/23 at 9:37 AM, V24, Director of Rehab, entered R4's room with a cushion and (non-slip pad). V24 stated the previous (non-slip pad) might have been displaced, but she has a new one to place in R4's chair. R4 stated she had never seen that (non-slip pad) in her wheelchair before. On 12/13/23 at 1:15 PM, V1, Administrator, stated he expects the Facility to implement and follow progressive interventions and feels they always do. The Facility's Accidents and Incidents Policy dated 8/2014 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. All accidents/incidents need to be investigated to determine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 2 of 5 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 12/13/2023 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 0689 the possible cause, to assist in future recurrences. All staff should be part of the identification of and intervention process to assist in fall prevention. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 3 of 5 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 12/13/2023 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 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 observation, interview, and record review, the Facility failed to ensure staff appropriately use PPE (Personal Protective Equipment) to prevent the spread of infectious disease including COVID-19. This has the potential to affect all 93 residents living in the Facility. Residents Affected - Many Findings include: 1. On 12/12/23 at 7:15 AM, there was a sign on the door of the Facility entrance documenting Positive Covid Cases and Masks Are Required In The Building. An additional copy of the sign was placed on the door leading into the residential part of the Facility. On 12/12/23 at 7:24 AM, V5, Registered Nurse (RN), was working at the medication cart on Bounce Back Lane without a mask. On 12/12/23 at 7:30 AM, V6, Licensed Practical Nurse (LPN), and V7, V8, and V9, Certified Nurse Aides (CNAs), were all working in the Memory Lane unit and were not wearing masks. On 12/12/23 at 12:58 PM, V7, CNA, stated she was not wearing a mask because there was no COVID in that unit. On 12/12/23 at 8:35 AM, V3, Minimum Data Set (MDS) Coordinator/ Licensed Practical Nurse (LPN), provided a list of residents that have tested positive for COVID since the outbreak began on 10/28/23. V3 stated R1 was the only resident isolated at that time. V3 stated residents must isolate for ten days after a positive COVID test result. The Facility's List of COVID Positive Residents documents R1 tested positive for COVID on 12/5/23. 2. On 12/12/23 at 10:04 AM, V13, CNA, exited room [ROOM NUMBER] with a surgical mask worn around her neck. The mask was not covering her nose or mouth. On 12/12/23 at 10:24 AM, V13, CNA, entered room [ROOM NUMBER] and spoke with R4 while still wearing the mask around her neck. On 12/12/23 at 10:26 AM, there were two signs on R1's door documenting Contact and Droplet precautions. There was a rack on the door containing gowns, masks, and gloves. V13, CNA, entered R1's room wearing a surgical mask. V13 was not wearing a gown, gloves, N-95 mask, or protective eyewear. On 12/12/23 at 10:28 AM, V3, entered R1's room wearing appropriate PPE and pointed to the sign on R1's door. V13, CNA, stated, I don't think (R1) has COVID. V13 stated Nobody told me. On 12/12/23 at 2:30 PM, V3, stated she expects staff to wear surgical masks any time they go beyond the double doors to the patient care area in the Facility. V3 stated if staff are going into a COVID positive room, they need to wear N-95 masks, gowns, and gloves. On 12/13/23 at 9:25 AM, V1, Administrator, stated he expects staff to wear surgical masks in all patient care areas and wear appropriate PPE in COVID positive rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 4 of 5 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 12/13/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The Facility's COVID-19 Policy revised 8/28/23 documents, Facility will follow current CDC (Centers for Disease Control)/CMS (Centers for Medicare and Medicaid Services) recommendations regarding masking while in an outbreak. The policy adds, Any residents that are determined to have new onset of symptoms will have the following initiated: Contact/Droplet precautions (N95 respirator) with eye protection will be initiated. Staff will wear N95 respirators, eye protection, gowns and gloves when caring for residents with COVID-19. The Facility's Resident Census and Conditions of Residents Form, CMS-672, dated 12/12/23 documents there are 93 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 5 of 5