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. (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 5 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 07/05/2024 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)