Health inspection·July 5, 2024

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 initiate progressive interventions to prevent falls after a resident had a fall with a fracture for 1 of 4 residents (R1) reviewed for falls in the sample of 11. Findings include: On 7/3/24 at 1:15 PM, V15 Certified Nursing Assistant (CNA) and V16 CNA provided incontinent care for R1. R1 was able to bring her own legs up onto the bed after sitting on side of bed and laying down. There was a healed scar on R2's right knee from previous surgery (no surgery after recent fall). R1 did not appear to have any pain when lifting her legs onto bed before incontinent care started. R1's undated Care Plan documents her diagnoses as: Unspecified Fracture of Left Patella, Cerebrovascular Accident (CVA), Hypertension (HTN), Dysphagia; Chronic Kidney Disease (CKD)-Stage 3, Unspecified Dementia, Urinary Tract Infection (UTI) on 4/4/24, Rash and other Non-Specific Skin Eruption (1/18/24), Dysuria, Hemiplegia Affecting Left Non-Dominant Side, and Major Depressive Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and is dependent for toileting hygiene, positioning and transfers, she does not walk and is dependent for wheel chair (w/c) mobility and she is always incontinent of bowel and bladder. R1's Progress Note dated 05/02/2024 at 6:03 AM documents, Resident found on the floor near bed laying underneath her covers. When this nurse ask resident what happen, she stated that I just fell out of the bed. Resident is c/o (complaining of) pain to her left knee, also c/o back pain and stated that she did hit head. Some bruising was also noted under residents left eye. Resident was sent to (local hospital) for treatment and evaluation. All parties have been notified. R1's Progress Note dated 5/02/2024 at 6:52 AM documents, Report received from (hospital staff) with (local hospital). Resident has a small fracture noted to L (left) Kneecap and will return with an Immobilizer. Follow up with Ortho. Will return to facility shortly. R1's Care Plan dated 5/5/21 documents, Resident at risk for falling R/T (related to) recent illness/hospitalization and new environment, orthostatic hypotension, TIA (Transient Ischemic Attacks) , femur fracture, impaired cognition, vision loss, CVA. The goal for this care plan documents, Resident will have decreased risk for injury related falls this quarter. Page 1 of 5 145728 145728 07/05/2024 Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062

F 0689 Interventions for this care plan include: Level of Harm - Minimal harm or potential for actual harm 7/10/23: When resident in high traffic areas, offer/assist resident into chairs from wheelchair. 5/6/21: Orientate resident to room, surrounding areas, and use of call light system. Residents Affected - Few 5/6/21: Encourage resident to use side rails/enablers as needed. 5/6/21: Provide resident with specialized equipment as deemed necessary per therapy 5/6/21: Assist resident with activities of interest. There was no updated interventions on care plan for most recent fall of 5/2/24 after R1's fall resulting in fractured patella (knee cap). On 7/2/24 at 10:52 AM, V8 Care Plan Coordinator, stated she was not aware R1 had a fall with a fracture on 5/2/24. She stated she checks the Events tab in residents' medical records to check for falls. She stated she tries to watch their progress notes also, but doesn't always see all progress notes. She stated R1's Care Plan was not updated with a progressive intervention after her fall on 5/2/24 and it should have been. The facility's policy, Accidents and Incidents dated 8/2014 documents, 2. All accidents and incidents should be documented, by creating and event and attaching a progress note. Progress notes will be documented in the resident record every shift until the event is closed by the DON (Director of Nursing). All accidents/incidents need to be investigated to determine the possible cause, to assist in future reoccurrences. When a resident has been identified as a high risk of accidents/incidents, interventions will be put into place per the individual resident assessment and care plan. 145728 Page 2 of 5 145728 07/05/2024 Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on record review, observation, and interview the facility failed to perform a diagnostic test in a timely manner to diagnose and treat a Urinary Tract Infection for 1 out of 7 residents (R8) reviewed for a Urinary Tract Infections. Findings include: According to the electronic health record (EHR) dated 6/27/2024. R8 EHR documents diagnose of Dementia, Type 2 diabetes, displaced of medial Condyle of left tibia closed fracture, chronic obstructive pulmonary disease, cirrhosis of liver, abnormalities of gait and mobility, muscle weakness, atrial fibrillation, cognitive communication deficit, osteoporosis, overactive bladder, gastro-esophageal reflux disease, hyperlipidemia, encephalitis, encephalomyelitis, spinal stenosis, anemia, vitamin D and B12 deficiency, depression, and anxiety. MDS (minimum data set) dated 5/14/2024 documents R8 having a BIMS (brief interview of mental status) of 15 and dependent of functional abilities and goals. Requires maximal/substantial assist with ADLs (activities of daily living). Care Plan dated 5/14/2024 documents that R8 requires substantial maximum assistance with ADLs related to dementia. The EHR review of the progress notes documented by V23, RN (Registered Nurse) on 06/23/2024 09:40 PM interview with V10, R8's spouse, at length concerning resident's confusion would like to see ensure or some shake given or medication to help with her appetite be started to help lessen confusion. On 6/26/2024 V6, LPN (Licensed Practical Nurse) documented 06:12 PM, Resident has some confusion noted for some days now. POA, (Power of Attorney) V10 has also stated to Nurse that confusion observed. Resident repeating same questions and not usually like resident. MD (Medical Doctor) has orders to collect urinary analysis/urine. On 06/27/2024 11:57 AM, V6, LPN documented that urine specimen obtained this shift due to confusion. Urine placed on main floor in lab fridge for collection. V6 documented the resident continues to show confusion this shift with staff and spouse. Urine obtained. V6 documented on 07/02/2024 at 1:58 PM, 2nd urine specimen obtained this shift for STAT collection. R8's Urinalysis dated 7/5/24 for specimen collected 7/3/24 documents the following abnormal results: Clarity: Turbid, Protein: 1+. Urobilinogen: 2+, Nitrates: Positive, Leukocytes: 1+, Bacteria: Few, Amorphous: Present, and Mucous: Present. At 10:45 AM observed V16, CNA and V15, CNA perform perineal care related to incontinence on R8. V16 wiped back (buttocks) to front (vaginal) area of R8, was unable to obtain all of stool from inner buttocks. V16 and V15 placed a new brief on R8. On 7/2/2024 at 9:20 AM, Interview with V6, LPN stated the urine was collected 6/27/2024 and that she will check it today to see if the results of urinalysis are in yet. On 7/2/2024 at 12:30 PM, V3 LPN stated about lab results of R8's urinalysis results are needed. V3 145728 Page 3 of 5 145728 07/05/2024 Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062

F 0690 stated she would check into that. Level of Harm - Minimal harm or potential for actual harm On 7/2/2024 at 1:00 PM, V2 DON (Director of Nursing) stated that the specimen was never picked up due to the lab technician was off that day and never came to get it. V2 DON stated that another urine specimen will be obtained today. Residents Affected - Few On 7/2/2024 at 2:55 PM, V10 R8's husband, stated the nurse V6, LPN came in and obtained another urine for collection this afternoon. V10 stated he noticed R8 is more confused and disoriented than normal. V10 stated the confusion and disorientation started a week ago I told V6, and she did agree. V10 stated that R8 is forgetful but not this confused. On 7/3/2024 at 11:45 AM, V22 technician stated the urine for the urinalysis was received today about an hour ago and someone will be out there to pick up the specimen sometime today. Received extension to supervisor, at the lab will follow up in 30 minutes. On 7/3/2024 At 1:32 PM, spoke to V21, Supervisor stated no orders were submitted for any labs for R8 between 6/25/2024 through 6/30/2024 at this time. Policy: It is a policy of the facility to provide means of quality diagnostic lab services for the residents. Purpose: To provide residents a means of diagnostic service promptly and conveniently. Staff Responsible: 1. Director of Nursing 2. Staff Nursing 3. Procedure: 1. Provision for Diagnostic Services a. Provision has been made for promptly and conveniently obtaining required clinical laboratory, X-ray and other diagnostic services from a clinical laboratory or diagnostic service, physician's office, 145728 Page 4 of 5 145728 07/05/2024 Manor Court of Maryville 6955 State Route 162 Maryville, IL 62062

F 0690 or hospital. Level of Harm - Minimal harm or potential for actual harm b. Residents Affected - Few All diagnostic services are provided only on the order of a Physician, a Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist (if practitioners are acting in accordance with state law, scope of practice law and facility policy). The facility will follow the standards set by the Laboratory, Radiology, or other Diagnostic service in setting the Normal, Abnormal, and Critical result reference ranges for the Labs and Diagnostics ordered. Revised: 11/28/17 145728 Page 5 of 5