Health inspection·April 4, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement interventions for a resident at risk for altered nutritional status for 1 (R83) of 3 residents reviewed for nutrition in a sample of 40. Residents Affected - Few Findings include: R83's Resident Face Sheet documented an admission date of 2/26/25 with diagnoses including: Primary osteoarthritis, unspecified hand, unspecified dementia, moderate protein calorie malnutrition, multiple fractures of ribs bilateral, pain, and tremor, unspecified-hx (history). R83's 3/5/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R83 was cognitively intact. R83's 3/5/25 MDS Section GG documented R83 required Partial/ Moderate assistance with eating, indicating helper does less than half the effort. Section S- Care Area Assessment Summary, under Care Area 12. Nutritional Status, the boxes for Column A, Care Area Triggered, and Column B, Care Planning Decision, are both marked. R83's Care Plan documented under Problem Resident Care Information with a problem start date of 2/27/25. Documented approach includes Regular diet. Set up. Plate guard and weighted utensils with an approach start date of 3/19/25. R83's Care Plan did not document R83 was at risk for weight loss or nutrition concerns. R83's 2/27/25 Occupational Therapy (OT) Evaluation and Plan of Treatment documented in part .New Goal . (R83) will improve ability to safely and efficiently perform eating tasks with Setup and Clean-up Assistance including but not limited to use of built-up utensils . and plate guard to facilitate ability to live in environment with least amount supervision and assistance and to ensure adequate nutrition and hydration . Patient Referral and History . Medical Factors . hand deformity from arthritic changes . Hand Dominance = patient is right-handed . Functional Skills Assessment . Eating . increasing arthritic changes in R (right) hand . R83's Dietitian/Admit Assessment note dated 2/27/2025 at 10:08 AM documents [AGE] year old female admitted (2/26) per progress note on a Regular Diet. Assisted at meals due to fracture. Intakes 50-75%. Weight: (2/27): 114.6 . On Vitamin C Supplement. Estimated Needs: 1560 calories (30 kilo-calories per kg (killigram)), 1560 cc fluids (1 cc (cubic centimeter) per kilo-calories), and 52-62 gram protein (1.0-1.2 injury factor). Plan: Add Diet to orders. R83's Weight Variance Report documented the following weights: 2/27/25 114.6 lbs. (pounds) 3/2/25 112 lbs., indicating a 2.6 lb. weight loss or 2.3% weight loss in 3 days 3/8/25 110 lbs., indicating a 4.6 lb. weight loss or 4% weight loss in 9 days 3/15/25 108 lbs., indicating a 6.6 lb. weight loss or 5.75% weight loss in 16 days 3/22/25 104 lbs., indicating a 10.6 lb weight loss or 9.25% weight loss in 23 days (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 2 of 6 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 04/04/2025 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 0692 4/3/25 107 lbs., indicating a 7.6 lb. weight loss or 6.63% weight loss in 35 days Level of Harm - Minimal harm or potential for actual harm An unsigned weekly weight note with a date documented of 3/19 documents that R83 has a current weight of 108 lbs on 3/15 and documents that R83 has a 5.8% or 6.6 lb weight loss in 16 days. This document further states not a significant change yet, but trending with an approach of Added adapted equipment a few days ago. Monitor. Another unsigned weekly weight note dated 3/26 documents a current weight of 104 lbs and documents last weeks approach of New adaptive equipment, monitor and documents an approach of ask for HCHPS (high calorie high protein supplement). Residents Affected - Few R83's Physician Order Report dated 3/2/25 to 4/2/25 documents an order dated 3/28/25 for High Calorie/ High Protein Supplement ordered by V7 (Nurse Practitioner). On 4/1/25 the following observations were made: 12:39 PM: R83's noontime meal tray was delivered to R83's room. R83's weighted silverware was wrapped in a paper napkin and placed on the far side of her plate. R83 had regular silverware placed beside her plate. R83's plate did not have a plate guard. R83 picked up the regular fork and started eating with difficulty holding the fork. 12:44 PM: R83 was observed feeding herself with difficulty holding the regular fork between her index and middle finger. R83's thumb joint was noted to be deformed. While trying to get food onto the fork, R83's hand would slide down the fork to the area where the fork widened, and the tines began. R83 was observed dropping a lot of the food from the fork onto her clothing protector. 12:50 PM:R83 sat her regular fork on her plate to take a bite of bread. R83 attempted 7 times at picking the regular fork back up. 12:52 PM: R83 attempted to cut a piece of brownie with regular fork and the fork kept slipping out of R83's hand. R83 picked up the regular spoon and was able to cut a piece of the brownie but dropped the piece before getting it to her mouth. R83 then piled up the plates in front of her and started licking food from her hands and the food dropped on the table. On 4/2/25 the following observations were made: 11:43 AM: R83's noontime meal was delivered with a weighted spoon and no weighted fork, a plate guard, and regular silverware. 12:00 PM: R83 was eating with a regular fork with difficulty dropping food on the table and on herself. On 4/4/25 at 9:42 AM, R83's breakfast was sitting in front of her in her room on the bedside table. R83's breakfast plate did not have a plate guard and no weighted utensils were present. R83 said sometimes staff would bring her the weighted utensils and plate guard sometimes they didn't, it just depended on the meal. On 4/3/25 at 10:58 AM, V8 (Occupational Therapist) said she would order weighted utensil for a resident if they had tremors or difficulty grasping a regular utensil and would order a plate guard to have more control with the plate to get food onto the utensil and to increase independence. V8 said R83 had trialed the weighted utensils at a facility prior to being admitted due to some tremors and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 3 of 6 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 04/04/2025 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 0692 hand weakness. V8 said she expected staff to provide all ordered assistive devices. Level of Harm - Minimal harm or potential for actual harm R83's Progress Notes documents an entry on 4/4/25 at 8:20 AM for a late entry for 4/3/25 at 12:10 PM documenting During the lunch meal, (R83) was served weighted utensils and a plate guard. CNA (Certified Nursing Assistant) returned shortly afterwards saying that (R83) requested a regular set of silverware. (R83) had weighted utensils, plate guard, and regular silverware per her request. Residents Affected - Few On 4/4/25 at 9:47 AM, V7 (Nurse Practitioner) said if a resident is not eating with adaptive equipment they could have weight loss. V7 said if therapy ordered adaptive equipment for a resident, it should be provided. V7 said that she was not aware of R83's weight loss. On 4/4/25 at 12:23 PM, V1 (Administrator) said the facility did not have a policy pertaining to assistive devices. The facility's Weight Monitoring policy with a revision date of 9/6/24 documented in part . 2. Residents are weighted weekly for the first 4 weeks following admission .5. Licensed staff will notify the physician of the following: A. 5% or more gain or loss in a 30-day period .7. Notification to the physician must be documented, and also whether or not new orders were received for either significant weight losses or gains .9. The weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to RD (Registered Dietitian) as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 4 of 6 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 04/04/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to provide pain medications per physician's orders for 1 (R251) of 2 residents reviewed for pain management in the sample of 40. This failure resulted in R251 becoming tearful and experiencing increased pain. Residents Affected - Few Findings Included: R251's Resident Face Sheet documented an admission date of 3/24/25. This same document listed diagnoses including other specified disorders of bone density and structure, other site, osteopenia of spine, rheumatoid arthritis, unspecified, unilateral primary osteoarthritis, right knee, bilateral primary osteoarthritis of hip, and primary osteoarthritis, right shoulder. R251's Care Plan documented a focus area of Problem: Dx (diagnoses) of Rheumatoid arthritis, osteoarthritis/right knee, and osteoarthritis/right shoulder puts her at risk for pain with a start date of 03/25/2025. Interventions documented included administer pain medications as ordered. Monitor for side effects with start date of 3/25/2025. R251's April 2025 Physicians Order Report documented orders for hydrocodone-acetaminophen 7.5-325 mg (milligrams). One tablet by mouth every 4 hours for pain-prn (as needed) with a start date of 3/24/2025. R251's Medication Administration History report dated 3/24/25 to 4/3/2025 documented hydrocodone-acetaminophen 7.5-325 mg. One tablet by mouth given on 4/3/25 at 1:42 AM. The same report documents R251's pain was rated at an 8 out of 10 on the pain scale before the pain medication and 0 out of 10 on the pain scale after the pain medication. On 04/03/25 08:28 AM, V2 (Infection Preventionist) and V3 (Registered Nurse/RN) were observed entering R251's room to administer AM medications. R251 was observed notifying V2 that she had asked for her hydrocodone-acetaminophen 2.5 hours ago. V2 and V3 both stated to R251 that she is scheduled for this medicine every 12 hours at 7:00 AM, she does not have an order for every 4 hours and apologized that her medication was late. R251 stated that she does have an order that she can take this pain medication every 4 hours for pain, and she last took it at 2:00 AM this morning. R251 stated to V2 and V3 that she hurts all over and rated her pain at a 7 on a 1 to 10 pain scale. R251 was observed crying when talking to V2 and V3 and while taking her medications. R251 was observed to be alert and oriented to person, place, and time. On 4/3/2025 at 8:35 AM, V3 (RN) stated R251 does not have an order for hydrocodone-acetaminophen 7.5-325MG for every 4 hours as needed. On 4/3/2025 at 9:06 AM, V2 stated R251 did have an order for hydrocodone-acetaminophen 7.5-325MG every 4 hours as needed and there was a communication breakdown between staff. On 4/3/2025 at 9:17 AM, R251 is alert and oriented to person, place, and time. R251 stated she did notify staff members at 6:00 AM this morning that she had been in pain and wanted her pain medication. R251 stated, upon waking up she is a 5 out of 10 on the pain scale is her normal and she tries to stay ahead of hurting more. R251 stated she does get her hydrocodone-acetaminophen 7.5-325MG for every 4 hours as needed and the last time she had it was around 2:00 AM this morning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 5 of 6 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 04/04/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few On 4/3/2025 at 9:52 AM, V4 (Certified Nurse Assistant/CNA) stated R251 did report to her at 6:00 AM that she wanted her pain medication. V4 stated she notified V3 (RN) while she was in report that R251 was requesting her pain medication. V4 stated that V3 did respond back to her by saying ok'. On 4/4/2025 at 8:33 AM, V7 (Nurse Practitioner) stated her expectations are for the nursing staff to administer medications based on physician's order. V7 stated that R251 did have a physician's order for hydrocodone-acetaminophen 7.5-325MG for every 4 hours as needed and scheduled every 12 hours. V7 stated that 2.5 hours after R251 requested her pain medication was not an appropriate time frame to administer the medication. The facility policy titled Pain Management (revised 3/03/22) documented under Policy: The facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy. Purpose: To identify residents experiencing pain to establish control of pain to the resident's satisfaction and to relieve related symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145841 If continuation sheet Page 6 of 6