Health inspection·January 12, 2024

F 0609 result in serious bodily injury. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement abuse policies by not reporting abuse and theft allegations within the designated time frame for 2 (R4,and R30) of 3 residents reviewed for abuse in a sample of 41. Residents Affected - Few Findings include: 1. R4's face sheet documented an admission date of 2/9/23 with diagnoses including: hypertension, pulmonary hypertension, chronic kidney disease stage 3, difficulty in walking. R4's Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. On 1/9/24 at 9:39 AM, R4 said she had $100 dollars taken out of her purse. R4 said she thought another resident had taken it. R4 said she had reported it to the facility and the facility had replaced it. R4's 12/4/23 progress note documented in part .Resident reported another resident had removed her money from her room. Said the other resident was confused and went thru her things and didn't mean harm but she was aggravated that the money was lost because it was Christmas money to give to her grandkids when they came in. Search conducted in room and belongings of resident accused. Resident accused stated she didn't take it, it was her friend. She then stated she put it up for her so she wouldn't lose it but couldn't find it. Staff will continue to search . R4's 12/12/23 progress note documented Facility replaced money resident reported missing, possibly taken by resident. On 1/12/23 at 11:08 AM, V1 (Administrator) said R4 had reported the missing money. V1 said she had not reported the missing money to Illinois Department of Public Health (IDPH) because she did not think R4's money had been stolen and was going to be found. The facility's revised 11/28/19 Abuse Prohibition and Reporting policy documents the following under the section titled Misappropriation of Resident Property: 1. No person shall misappropriate or steal any resident property. Any person who becomes aware of any alleged misappropriation or theft of resident property shall report the incident to the Administrator immediately. 2. The Administrator or designee shall investigate the alleged misappropriation or theft of resident property. 3. The Administrator or designee shall be responsible for supervising the investigation and reporting the results of the investigations to IDPH. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 2 of 7 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 145841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Manor 3116 Williamson County Parkway Marion, IL 62959 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to investigate an abuse allegation of misappropriation of property for 1 (R4) of 3 residents reviewed for abuse in a sample of 41. Residents Affected - Few Findings include: 1. R4's face sheet documented an admission date of 2/9/23 with diagnoses including: hypertension, pulmonary hypertension, chronic kidney disease stage 3, and difficulty in walking. R4's Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. On 1/9/24 at 9:39 AM, R4 said she had $100 dollars taken out of her purse. R4 said she thought another resident had taken it. R4 said she had reported it to the facility and the facility had replaced it. R4's progress note dated 12/4/23 at 10:19 am by V1 (Administrator) documents in part .Resident reported another resident had removed her money from her room. Said the other resident was confused and went thru her things and didn't mean harm but she was aggravated that the money was lost because it was Christmas money to give her grandkids when they came in, Search conducted in room and belongings of resident accused. Resident accused stated she didn't take it, it was her friend. She then stated she put it up for her so she wouldn't lose it but couldn't find it. Staff will continue to search . R4's progress note dated 12/12/23 at 10:24 am by V1 documented Facility replaced money resident reported missing, possibly taken by resident. On 1/12/24 at 11:08 AM, V1 said when R4 had reported she had money missing and thought another resident had taken it, V1 had went to search the alleged resident's room. V1 said the alleged resident did not recall taking any money or where she had placed any money. V1 said R4's money was not found in the facility. V1 said a day or two later she spoke with R4's daughter to verify R4 had $100. V1 said R4's daughter verified R4 did have $100 and was planning on giving money to R4's grandchildren for Christmas. V1 said R4's money had been reimbursed to R4 from the facility. V1 said she had not completed a formal investigation because she thought R4's money would be found and returned to R4. The facility's revised 11/28/19 Abuse Prohibition and Reporting policy documents the following under the section titled Policy: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of any physical or chemical restraint not required to treat resident's symptoms. The same policy documents the following under the section titled Investigation: 1. Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes. 2. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident. 3. The Administrator shall keep copies of all notes from the interviews conducted by the Administrator or other facility interviewer in the course of the investigation. 4. The Administrator shall be responsible for supervising the investigation and reporting the results of the investigation to the Illinois Department of Public Health. 5. The Administrator shall be responsible for resident's protection from retaliation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 3 of 7 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 145841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Manor 3116 Williamson County Parkway Marion, IL 62959 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 0610 during and after the investigation. 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: 145841 If continuation sheet Page 4 of 7 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 145841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Manor 3116 Williamson County Parkway Marion, IL 62959 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 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to implement interventions to mitigate falls for 1 (R71) of 7 residents reviewed for accidents in a sample of 41. Residents Affected - Few Findings include: 1. R71's face sheet documented an admission date of 12/27/21 and diagnoses including: dementia, hypertension, weakness, dysphagia, cognitive communication deficit. R71's 10/10/23 Minimum Data Set (MDS) documented a Brief interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. R71's 10/10/23 Fall Risk Assessment Tool documented a score of 23, indicating R71 is a high fall risk. The facility's 8/10/23 through 1/10/23 Fall Log documented R71 had an unwitnessed fall in his room on 11/5/23 while trying to self-transfer from his wheelchair to his bed. R71's care plan (review date 11/4/23) documented in part . is at risk for falls r/t (related to) reduced independent mobility . and documents an intervention dated 5/16/23 of dysom (sic) (non slip padding) in wheelchair and an intervention dated 1/31/21 of anti-rollbacks to wheelchair. On 1/9/24 at 10:43 AM, R71 was observed sitting in his wheelchair in the dining room completing an activity. R71's wheelchair had an anti-rollback attached to the back of his wheelchair with one arm missing and the other arm bent at an angle unable to make contact with the wheelchair wheel. On 1/10/24 at 11:34 AM R71, was observed sitting in his wheelchair in the dining room. R71's wheelchair did not have a dycem cushion in the seat of his wheelchair. On 1/12/24 at 12:20 PM, V6 (Director of Memory Care) said on 1/11/24 R71 did not have a dycem cushion in his wheelchair when the facility checked. V6 said R71 would sometimes take the dycem cushion (non slip pad) out of his wheelchair when R71 went to use the bathroom. V6 said R71 was known to throw the dycem cushion away. On 1/11/24 at 11:01 AM, V2 (Director of Nursing/ DON) said she expected R71 to have anti-rollbacks on his wheelchair and the dycem cushion in his wheelchair as care planned. V2 said she expected any staff to complete a work order if they see any wheelchair parts not in working order. On 1/11/24 at 1:00 PM, V1 said the facility did not have a fall policy. V1 provided a revised 4/3/18 Emergencies policy documenting the procedure to care for a resident after a fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 5 of 7 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 145841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Manor 3116 Williamson County Parkway Marion, IL 62959 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 implement the facility policy and procedure for Pneumococcal Vaccinations for 1 out of 5 residents (R69) reviewed for immunizations in a sample of 41. Residents Affected - Few Findings include: R69's face sheet documents that R69 was admitted to the facility on [DATE] with diagnoses including encephalopathy, heart failure, peripheral vascular disease, and cardiomegaly. R69's Face Sheet documents a date of birth indicating that R69 is [AGE] years old. R69's Minimum Data Set (MDS) dated for 10/31/2023 documents a Brief Interview for Mental Status (BIMS) score of 12, indicating R69 has moderate cognitive impairment. RF69's Vaccination Records in the Electronic Medical Records (EMR) documents that R69 declined Pneumococcal vaccination on 8/16/2023, 8/23/2022 and 2/17/2022. This documentation was noted on Pneumococcal Vaccine Immunization Assessment/Consent forms. The Risk Assessment and Assessment for Contraindications to the Pneumococcal Vaccination sections of R69's Pneumococcal Vaccine Immunization Assessment/ Consent forms dated 8/16/2023, 8/23/2022 and 2/17/2022 are left blank including the assessment question of Is the resident currently up to date on pneumonia vaccination per CDC (Centers for Disease Control) guidelines? R69's Pneumococcal Vaccine Immunization Assessment/Consent form dated at time of admission on [DATE], had written at the bottom that resident received P23 @ (at) primary with no date of administration documented on the form. The same consent for documents: I have been educated as to the risk and benefits of pneumococcal vaccination and DO NOT want to be vaccinated. This statement is marked with an x along with R69's signature on the signature line. The Pneumococcal vaccine assessment/consent form does not distinguish if the declination was for the Pneumococcal polysaccharide vaccine (PPSV23), Pneumococcal Conjugate Vaccine (PCV) 13, PCV15, or PCV20. On 1/12/2024 at 11:30am, R69 was asked if he remembered when he had his Pneumonia vaccine before admission to the facility and R69 stated No, I don't remember. R69 stated that he takes the flu shot and would be willing to take the needed pneumonia shots. R69 was asked if he had been educated on the different types of pneumonia vaccines and R69 stated, No, I was not aware. R69 was alert to person, place, and time at the time of the interview. On 1/11/2024 at 2:20pm, V2 (Director of Nursing) stated that she does not have a vaccination log or binder, and that all the vaccination records are in the resident's Electronic Medical Record (EMR). On 1/12/2024 at 8:10am, V2 said she could not produce the dates of the pneumonia vaccination for R69 for the vaccines received prior to his admission on [DATE]. V2 said that the consents do not specify which pneumococcal vaccine was consented to or declined. V2 again said that they do not have a log documenting resident's vaccines administered and dates. The facility policy and procedure titled Pneumococcal Vaccination (Revision date 8/11/22), policy # 3.34B documents It is the policy of the facility to provide immunizations in accordance with CDC (Centers for Disease Control) recommendations. The facility policy documents under Procedure that All residents aged 65 years or more and those residents that are determined to be at high risk (those with chronic illness such as lung, heart, or kidney disease, sickle cell anemia, diabetes, recovering from illness, those in congregate living environments, with a weakened immune system, etc.) will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 6 of 7 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 145841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkway Manor 3116 Williamson County Parkway Marion, IL 62959 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few offered the pneumococcal vaccine as recommended by the CDC. Procedure step 1 documents: All residents will have their immunization status assessed at the time of admission and annually thereafter. Any vaccinations that have been received prior to admission will be recorded in the electronic health record. Procedure step 2 documents: Each resident and/or resident representative will receive education regarding the pneumococcal vaccine appropriate for them via the vaccine information sheet provided by the CDC, regarding the benefits and potential side effects of the vaccine. The CDC Immunization Schedule (https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo) documents for adults age 65 or older who have: Previously received only PPSV23: 1 dose PVC15 or 1 dose PVC20. Administer either PCV15 or PVC 20 at least 1 year after PPSV23 dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 7 of 7