Inspection·November 1, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to prevent resident physical abuse for 1 of 3 residents (R54) reviewed for abuse in the sample of 39. Findings include: R54's Physician Order Sheet (POS) dated February 2024 documents a diagnosis of Alzheimer disease with late onset, wedge compression fracture vertebrae, subsequent encounter for fracture with routine healing, atherosclerotic heart disease of native coronary artery without angina pectoris, stent 1999 & 2004, unspecified dementia, unspecified severity without behavioral disturbances, psychotic disturbance and anxiety, conductive hearing loss, age related osteoporosis. R54's Minimum Data Set (MDS) dated [DATE] documents R54 was severely impaired for cognition for activities of daily living. R54's Care Plan dated 11/9/2022 documents Problem: (R54) has chosen to receive Hospice care from (Hospital) Hospice related to Alzheimer's. R54's Care Plan does not address abuse. R54's Incident Report dated 2/20/2024 at 10:15 AM, Notified by (V6, Licensed Practical Nurse), notified me that she observed a hospice aide strike resident (R54) across the head with both hands and she yelled at the hospice aide to stop, and the aide stated, 'I was pushing her head away to keep her from biting me.' 10:20 AM, V7, Hospice aide, that was identified as the alleged perpetrator was instructed not to go back into the resident care area, and a statement obtained from (V7) that stated she was providing assistance for resident and she was trying to bite me, and I insistently was pushing her way from me although I know (V6) thinks I was slapping (R54) but I wasn't'. I asked for her contact information, (V7's phone number) was given to me as a phone number and she was instructed to leave and not return until such time as I contact her and allow her back into the facility. 10:40 Resident assessed for injuries and no injuries noted. Resident unable to communicate but has no signs or distress on her face and appears calm currently. 10:55 was informed by (V6) that she notified the POA (Power of Attorney) and the Physician, no injuries were noted per assessment she stated and to her the resident does not look upset or having any distress. 10:45 AM, Notified (Local Police Department) of allegation, at approximately 11:10, an Officer came to the facility and interviewed staff and took statements from staff, information was provided about the alleged perpetrator, and case number was documented. Written statement by V6 undated documents, Call light was on and entered the room. When I entered the room (V7) slapped resident on both sides of her head simultaneously by each ear creating a 'slapping' sound. I yelled, 'Hey' Hospice CNA looked up and said, 'she bit me.' Another facility nurse and CNA came into the room. Stayed with the resident while I left to report to (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 3 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 11/01/2024 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)