Inspection·July 8, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to correctly transcribe and administer discharge orders regarding medications for 1 of 3 residents (R4) reviewed for medications in the sample of 9. Residents Affected - Few The Past Non Compliance occurred 6/10/25 to 6/24/25. Findings include: R4 's Face sheet undated documents an admittance date of 5/27/25 with pertinent medical diagnoses of Osteomyelitis of vertebra Thoracic region, Chronic Systolic (congestive) heart failure (5/27/25) and Chronic Obstructive Pulmonary Disease, Unspecified (5/27/25). R4's Minimum Date Sheet (MDS) dated [DATE] documents R4 is cognitively intact, and the medications taken are in the class of antidepressant, anticoagulants, opioids, and antibiotics. R4's Hospital Medical discharge records from area hospital dated 5/8/25 -5/27/25 documents hospitalized problems as Chronic Midline Thoracic back pain, Bacteremia due to Enterococcus, Osteomyelitis of Thoracic Spine, Pacemaker Infection-(Pacemaker removed), Suspected Heparin Induced Thrombocytopenia (HIT) in hospitalized patient and Fall. R4's hospital medical discharge records dated 5/8/25-5/27/25 documents discharge medications as Albuterol, Ampicillin 100 Milligram/Milliliter injection, Breztri Aerosphere 160-9-4.8 Microgram actuation inhaler, Carvedilol 12.5 Milligram, Ceftriaxone, Cholecalciferol, Famotidine, Ferrous Sulfate, Fluticasone Propionate, Gabapentin, Hydrocortisone 1% cream, Hydroxyzine, Lidocaine 5%, Loraepam, Methocarbamol, Ondansetron, Oxycodone, Polyethylene Glycol, Rosvastatin, Sertraline, Trazadone and Warfarin. Discharge instructions included to stop medications Cyclobenzapine, Furosemide and Spironolactone. The medication Carvedilol was stopped due to low blood pressure but resumed 5/26; Spironolactone was placed on HOLD due to low Blood pressure initially and now to worsening of her renal function. This medication will be resumed as indicated by primary care physician and cardiologist. No reasoning was included for stopping the medication Furosemide. R4's Nurse Progress notes dated 5/27/25 documents R4 was admitted to the facility from a local hospital and was sent back out to an area hospital on 5/28/25 due to complaints of Shortness of Breath (SOB). R4's Hospital Medical discharge records from local hospital dated 5/28/25-6/10/25 documents hospitalized problems as Chronic Midline Thoracic back pain, Bacteremia due to Enterococcus, Osteomyelitis of Thoracic Spine, Pacemaker Infection- (Pacemaker removed), Suspected Heparin Induced Thrombocytopenia (HIT) in hospitalized patient and Fall. R4's hospital discharge medications from area hospital dated 5/28/29-6/10/25 are documented as: Furosemide 40 Milligrams daily, Ampicillin Sodium 2 gram reconstituted solution, Carvedilol 3.125 Milligram tablet daily, Ceftriaxone 2 gram reconstituted solution, Saccharomyces Boulardill 250 Milligram capsule daily, spironolactone 25 Milligram Daily, Sertraline 100 Milligram Daily, 50 Milligram 50 Milligram at bedtime, Famotidine 40 Milligrams daily, Rosuvastatin 40 Milligram, Carvedilol 12.5 Milligram every 12 hours, Diphenhydramine 50 Milligram capsule, Budesonide-Glycopyr-formoterol 160-9-4.9 Micrograms Actuation HFA Aerosol Inhaler, Albuterol Sulfate 90 Micrograms / Actuation, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 2 of 4 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 07/08/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Cyclobenzapine 10 Milligram tablet, Ampicillin 2 gram reconstituted solution, Fluticasone Propionate 50 Micrograms/ Actuation Suspension Spray, Warfarin 4 mg Daily, Hydrocortisone 1% cream, Lidocaine 5% adhesive patch every 12 hours, Polyethylene glycol 3350 17 gras daily, Ceftriaxone 2 gram reconstituted solution, Ferrous Sulfate 325 Milligram Daily, Gabapentin 300 Milligram capsule three times/day, Hydroxzine 10 Milligram every 4 hours as needed, Ondansetron 4 Milligram tablet, disintegrating every 8 hours as needed. Lorazepam 0.5 Milligram (0.25 Milligram every 6 hours as needed, Oxycodone 15 Milligram (7.5 Milligram every 4 hours as needed). HOLD Budesonide-Glycol-Formoterol 160-9-4.8 Microgram/Actuation HFA Aerosol Inhaler until seen by Primary Care Provider (PCP); DISCONTINUE Warfarin 3 Milligram tablet Tuesday-Thursday, 4.5 Milligram Monday, Wednesday, Friday, Saturday, and Sunday. On 7/1/26 at 12:36 PM V2 Director of Nursing (DON) stated they did not have any medication errors in the past 3 months. She did review the orders after the family did complain about R4 not receiving the specific medication Furosemide and did not see the order. On 7/3/25 at 10:00 AM V20 Nurse Practitioner stated the doctor sees the residents first and the nurse practitioners come in next. They try to review medical records prior to seeing the resident but a lot of the times the medical records are not available. We do review the electronic records but that is only helpful if the information has been put into the system. That is what happened with R4. The hospital discharge medications were not entered into the system. She (V20) only became aware that the resident was not receiving Lasix after R4's son brought it to her attention. It was clearly an error. No harm was done, however, the potential for harm was present due to possible fluid overload. Fluid overload can cause lung and/or heart problems. (V20) Nurse Practitioner had not encountered this problem with the facility before and do believe staff do provide good care. On 7/3/25 at 11:30 AM R4's admission nurse (V22) Licensed Practical Nurse stated when a resident is admitted , the hospital records are reviewed with doctor or NP. The facility usually has 2 nurses review the orders to ensure all orders have been entered correctly. We also have another nurse that audit the case to ensure all medications are captured. Uncertain how all R4's medications were not transcribed. On 7/3/25 at 3:30 PM V23 Registered Nurse stated she is the auditing nurse that goes over all orders for admissions or re-admissions. V23 (RN) stated she was on vacation the day that R4 was re-admitted to the facility. It was her understanding that either the Director of Nursing of Assistant Director of Nursing would take care of auditing admissions or re-admissions. Upon her (V23's) return to work R4's was not included in the stack of admissions that needed to be reviewed. On 7/3/25 at 4:30 PM R3 Assistant Director of Nursing stated the facility already had a system in place where 2 nurses would go over the orders during admission and the auditing nurse would review all admissions the next day. That check and balance worked until the auditing nurse went on vacation and this case fell through the cracks. After I became aware of the problem, I agreed to audit the admissions or re-admissions in the absence of the auditing nurse. On 7/8/25 at 1:40 PM V1 Administrator stated the facility instituted a check and balance system to avoid any potential issues of missing medication with 2 nurses being involved in the admission process and the bridge nurse to audit admissions. We have added the Assistant Director of Nursing to that process to cover when the bridge nurse is off work. We did investigate the incident and initiated a Plan of Correction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 3 of 4 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 07/08/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm The facility's policy Medication Administration Using eMAR revised 11/11 documents the objective it to provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. Prior to the survey date, the facility took the following actions to correct the noncompliance. Residents Affected - Few This tag was corrected on 6/24/25 This Plan of Correction in response to the statement of deficiency demonstrates our good faith and desire to continue to improve the quality of care and services rendered to our residents. This plan of correction constitutes a written allegation of compliance with Federal Medicaid and Medicare requirements. The Following Plan of Corrections was developed to ensure future compliance with all medication orders upon admission. 1) Two nurses will review the discharge orders for all new admissions and readmissions together going line by line of the discharge order summary sheet. 2) The RN Bridge nurse will review all admission and readmission orders within 48 hours of admission and correct any identified issues. 3) The ADON will be clearly designated to perform the reviews of the clinical records within 48 hours of admission if the RN Bridge nurse is unavailable for any reason. 4) The Licensed staff were inservice on 6/24/25 regardig the admission process, including two Licensed nurses to review all discharge orders from hospital. 5) The ADON will perform no less than two audits of the admissions and/or readmissions weekly for no less than 4 weeks. The QAPI will include these audits when they meet monthly and determine if further interventions are necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145728 If continuation sheet Page 4 of 4