Health inspection·April 27, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to keep a resident's fingernails trimmed to reduce the risk of impaired skin integrity for one resident (R15) out of one resident reviewed for skin conditions in a sample of 47. Residents Affected - Few Findings include: The facility's Personal Care of Residents policy revised 12/02 documents 1. Each resident shall have proper daily personal attention and/or care, including skin, nails, hair and oral hygiene, in addition to treatment ordered by the physician. R15's medical record documents a diagnosis of malignant neoplasm of skin. R15's brief interview of mental status (BIMS) documents a score of 11. A score of 8-12 indicates moderately impaired cognition. R15's medical record dated 3/29/23 documents Weekly skin check complete, scattered scabbing remains to bilateral lower extremities, bilateral upper extremities and face. Resident frequently picks at scabs. Resident instructed to refrain from removing scabs due to increased risk of infection. Resident verbalizes understanding. No reddened areas noted to buttocks, skin prep applied to right lower buttock as per order. No new skin concerns noted. R15's provider visit note dated 4/25/23 documents There is a concern from staff the patient will not allow them to cut his fingernails and he is picking skin cancer lesions on his face causing them to bleed. Upon exam, patient does have dried blood under his fingernails and agrees to have his nails filed. On 04/24/23 at 10:32 AM, R15 observed lying in bed with scattered scabbing to his face, head, bilateral hands, and bilateral legs. His fingernails have grown past the tips of his fingers and have what appears to be dried blood under his nails. During observation, R15 started picking at the scabs on his forehead with his overgrown fingernails. On 04/24/23 at 10:33 AM, V8 (Licensed Practical Nurse/LPN) stated I see they're long. I'll get them trimmed. He has skin cancer and that's what he's picking at. During interview with V8, R15 started picking at the scabs on his forehead and broke one of the wounds open. On 04/24/23 at 1:57 PM, R15 lying in bed with blood on his hands and on his pillow. R15 observed picking at an open bleeding wound to his right temple area with his left-hand fingernails. R15's fingernails are still past his fingertips and contain blood from the open bleeding wound on his right temple. On 04/24/23 at 2:00 PM, V8 stated I tried cutting his nails, but I only got a couple cut, then he refused to let us cut the rest. When he doesn't let us cut them, we have to re-approach and try again. Other than that, I'm not sure what else we can do. That's something you'll have to talk to the care plan coordinator (V9) or V2 (Director of Nursing/DON) about. R15's medical record dated 4/24/23 at 10:46 AM documented by V8 (LPN) documents Attempted to trim residents' fingernails and was able to trim left pinky nail, resident refused for this nurse to trim (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146083 If continuation sheet Page 2 of 8 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 146083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Princeton 140 North Sixth Street Princeton, IL 61356 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 0684 the rest of fingernails and for nails to be cleaned. Attempted three times. Level of Harm - Minimal harm or potential for actual harm On 04/26/23 at 11:04 AM, V9 (CPC) stated After we implement a care plan intervention, we follow up in one to two weeks to see if the care plan intervention was effective. I was not aware that he was refusing to have his nails trimmed. I don't see a follow up to the care plan intervention or an alternate intervention in his care plan to that addresses his refusals to have his nails trimmed. If I knew he refused to have his nails trimmed, we would have come up with a new intervention. Residents Affected - Few On 04/26/23 at 11:10 AM, V10 (Certified Nursing Assistant/CNA), stated I usually work down this hall and provide AM cares for (R15). He's known to refuse am cares and has been for a while. He refuses his showers, being shaving and having his nails trimmed. When the CNAs try to trim his nails, he'll start getting aggressive with us, so we started asking the nurses to do it. On 04/26/23 at 1:26 PM, V2 (DON) verified having knowledge that R15 refuses to have nails trimmed and stated We do frequent educations with him to not pick at his skin (cancer lesions) because he refuses to have his nails trimmed. We do the frequent education with him because his BIMS is 11. On 04/27/23 at 9:25 AM R15's care plan does not document frequent educations of not picking at his skin cancer lesions or his refusals to have his fingernails trimmed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146083 If continuation sheet Page 3 of 8 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 146083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Princeton 140 North Sixth Street Princeton, IL 61356 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview, observation and record review, the facility failed to ensure a resident with limited range of motion was provided appropriate treatment and services to maintain and/or prevent a further decrease for one of four residents (R74) reviewed for limited range of motion in the sample of 47. Findings include: On 04/24/23 at 11:25 AM, V12 (R74's daughter) was sitting in a chair at R74's bedside while R74 was asleep in a low bed. V12 stated she is unsure if R74 is receiving range of motion exercises at this time. On 04/25/23 at 02:15 PM, R74 was sitting in a high-back reclining wheelchair with her knees slightly bent and raised toward her chest. R74 was pleasantly confused and stated Ok when asked how she was doing. R74's call light was within her reach, and a full mechanical lift sling was in place underneath of R74. R74's Minimum Data Set Assessment (dated 02/15/23), Section G, documents the following: R74 has impairment on one side of her upper extremities; and R74 requires total dependence with transfers, dressing, eating, toilet use, personal hygiene, and bathing. R74's ADL (Activities of Daily Living) Skills Analysis/Restorative Programs form (dated 02/15/23) documents the following: Is the resident currently in a range of motion program? No, but would benefit and program will be established. R74's medical record (dated 02/15/23 - 04/20/23) has no documentation of any range of motion exercises completed. On 04/27/23 at 09:30 AM, V2 (Director of Nursing) stated a range of motion program has not been in place for R74. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146083 If continuation sheet Page 4 of 8 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 146083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Princeton 140 North Sixth Street Princeton, IL 61356 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview, observation and record review, the facility failed to ensure an indwelling urinary catheter was secured for one of two residents (R50) and failed to keep an indwelling suprapubic catheter drainage bag and tubing off the floor for one of two residents (R48) reviewed for indwelling urinary catheters in the sample of 47. Findings Include: 1. The facility's Catheter Care policy (revised 05/06) documents the following: Secure the catheter to the thigh and/or lower abdomen in men to facilitate flow of urine and prevent excessive tension on the catheter. On 04/24/23 at 11:20 AM, R50 was sitting in a chair next to her bed. An Indwelling urinary drainage bag inside of a dignity bag was hanging on the lower aspect of R50's bed. R50 stated she has an indwelling urinary catheter, and has had it, a long time. Clear urine was noted in R50's drainage tubing. R50's current Physician's Orders document the following order: Foley catheter care every shift. Monitor that Foley is draining urine to gravity and anchored to person. R50's Progress Note (dated 04/24/23) documents the following: Foley catheter noted to have fallen out of place during cares. No bleeding noted. 16F (French) Catheter inserted utilizing sterile technique. Positive yellow urine flow noted. Balloon inflated with 30 cc (cubic centimeters) of sterile water. Resident tolerated procedure fair. On 04/25/23 at 02:24 PM, R50 was lying supine in bed with her eyes closed. An indwelling urinary drainage bag was placed inside of a dignity bag and was attached to the lower aspect of R50's bed. V7 (Certified Nursing Assistant) entered R50's room to provide indwelling urinary catheter care to R50 at this time. V7 removed R50's pants and incontinence brief, and R50 had an indwelling urinary catheter in place. R50's catheter was not secured with any type of securement device. V7 confirmed R50's urinary catheter was not secured and stated, We usually have the catheters secured with a little Velcro device. It must have worked its way off. I'll have to find one. 2. The facility's Standard Precautions policy, dated 8/2009, documents, Standard Precautions will be used in the care of all residents regardless of any suspected or confirmed presence of an infectious agent. Standard Precautions are based on the principle that all, blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Handle resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents kin and mucous membrane exposure, contamination of clothing, and transfer of other infectious agents to other residents and environments. R48's Physician's orders, dated 3/26-4/26/23, document that R48 has orders for an indwelling suprapubic catheter and Ampicillin (antibiotic) 500 mg (milligrams) by mouth four times a day starting 4/22/23 and ending 5/3/23 for the diagnosis of UTI (Urinary Tract Infection). R48 Care plan, dated 4/24/23, documents, R48 has a suprapubic catheter related to urinary retention/neurogenic bladder. The care plan was updated 4/22/23 when R48's UTI was diagnosed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146083 If continuation sheet Page 5 of 8 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 146083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Princeton 140 North Sixth Street Princeton, IL 61356 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/24/23 at 01:16 PM, R48 was sitting in a dining room chair eating lunch. R48's suprapubic catheter drainage privacy bag was lying on the floor with the drainage bag partially out of the privacy bag touching the floor. R48's suprapubic catheter tubing was also on the floor. The tubing had cloudy yellow urine present in it. On 04/24/23 at 01:19 PM, V15 (Certified Nursing Assistant) stated, With (R48) sitting in the dining room chair, we have no choice but to place the bag on the floor. I'm aware that it is an infection control issues. On 04/27/23 at 10:51 AM, V2 (Director of Nursing) stated, The catheter drainage bag should never be on the floor. V2 confirmed that all the residents on the memory care unit eat in one dining room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146083 If continuation sheet Page 6 of 8 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 146083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Princeton 140 North Sixth Street Princeton, IL 61356 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 a dementia specific plan of care for one of two residents (R197) reviewed for dementia care in the sample of 47. Residents Affected - Few Findings include: The facility's How To-Write a Care Plan for Mood/Behavior and Psychotropic Meds policy, dated 3/20, documents, Problem Statement-The Problem Statement shall contain a description of the problem, statements made by the resident, the behaviors that are displayed, as well as the baseline amount of behaviors and any identified triggers. If no Mood/Behavioral issues are currently being displayed, a discussion of the mood/behavior history shall be included in the problem statement. The facility's How To-Care plan for Cognition, Vision, Hearing/Communication policy, dated 3/20, documents, Addressing Cognition, Vision, Hearing and Communication in the care plan differs from traditional care planning in that they are typically not addressed through a goal, goal, and approach format. Because there is no way to address these care areas with an appropriate goal, they should be addressed throughout the care plan through the use of approaches under the care areas impacted by this deficit. When care planning, think about how that specific resident's impairment in cognition, vision, hearing, or communication is impacting their ability in other areas. On 04/24/23 at 11:00 AM, R197 was lying in bed sleeping. On 4/25/23 at 9:26 AM, R197 was lying in bed sleeping. R197's Physician's order Report, dated 4/6/23, documents, that R197 was admitted to the facility on [DATE], and R197 has orders to receive Olanzapine (antipsychotic) 2.5 mg (milligrams) twice a day by mouth and Olanzapine 5 mg daily by mouth for the diagnosis of unspecified Dementia. On 04/25/23 at 02:00 PM, V11 (R197's Power of Attorney) was sitting on R197's bed waiting for R197 while he was out of the room. V11 stated, Since he has been on it, he sleeps a lot. Every day when I come in, he seems to be sleeping. He is here because of a fall. At 2:20 PM, R197 was wheeled in his wheelchair into the room. R197 had his head hanging down sleeping. V11 stated, See this is what I mean he's sleeping like this a lot. V11 assisted R197 to a standing position and transferred to R197's chair. R197 instantly began to fall asleep while sitting up in the chair. R197's Memory Care Screening Form, dated 3/30/23, documents that R197 is accepted to being admitted to the Memory unit with the diagnosis of Dementia. R197's Comprehensive care plan, dated 4/20/23, has no documentation of a comprehensive care plan addressing R197's diagnosis of dementia. On 04/27/23 at 11:02 AM, V14 (Memory Care Coordinator) confirmed that R197 does not have a dementia specific comprehensive care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146083 If continuation sheet Page 7 of 8 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 146083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Princeton 140 North Sixth Street Princeton, IL 61356 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview, record review and observation, the facility failed to ensure that equipment in the kitchen was clean and free of debris. This has the potential to affect all 84 residents residing in the facility. Residents Affected - Many Findings include: The facility's Bag-In-Box Juice Dispenser Procedure, dated 08/2019, documents Daily cleaning, dispensing gun: Detach the black nozzle from the dispensing gun by twisting it gently pulling down, then soak both the nozzle and dispensing gun in lukewarm water for 10-15 minutes. This form also documents that if the diffuser area (exposed when the nozzle is removed) appears to have residue, clean with a small gentle brush like a soft toothbrush. The Dining Services Department Daily Cleaning Schedule, undated, documents to clean the following equipment after each use: Oven (wipe down) inside and out. On 4/24/23 at 9:45am, a tour of the facility's kitchen was conducted with V13 (Dietary Manager). The left convection oven contained a black, burnt, crusty substance present throughout the floor of the oven, and a brownish-sticky substance was observed running down the glass of the oven door. The right convection oven contained a brown, burnt substance on the glass of the oven door. V13 verified that the convection ovens had spillage/boil over and was unsure of the last time they had been cleaned. V13 then indicated the substances on the ovens had been there for a while. V13 stated that the brown substance on the oven doors appeared to be grease. V13 then stated that maintenance is supposed to clean the ovens monthly but does not keep a log of the cleaning. The kitchen's large warmer had five cookie sheets on the shelves, which had dried food and oily substances present on them. The kitchen's warmers contained a large area of a dark brown coating on the floor. V13 stated that the warmers are used to transport meals from the main kitchen to the kitchenettes on each unit. V13 verified that the dried brown substance in the warmers was left from supper that was served on 4/23/23. V13 stated that both the convection ovens and warmers should be cleaned after each use. The juice dispensing nozzle contained a large amount of an orange, reddish, sticky build-up. V13 stated that kitchen staff does not clean the juice dispensing nozzle. On 4/24/23 at 2:00pm, V1 (Administrator), stated that the kitchen staff are supposed to clean the ovens, not maintenance. V1 also stated that the ovens and the warmers should be cleaned after each use. V1 stated that the juice nozzle dispenser should be cleaned according to the manufacturer's instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146083 If continuation sheet Page 8 of 8