Health inspection·June 16, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify the Physician and resident representative of an elopement for one of three residents (R27) reviewed for wandering in the sample of 27. Residents Affected - Few Findings include: The facility's Accidents and Incidents policy dated 8/2014, documents, All accidents and incidents should be documented, by creating an event and attaching progress notes. When completing event documentation, the Notifications needs to be done at the time of the event, waiting until the next shift cannot be done. R27's Nurses Note dated 5/31/22 at 12:01 p.m., documents, Spoke with V25(R27's family member) that R27 had wandered out of the facility on 5/30/22 at approximately (7:20 p.m.) and found by (an apartment building) and brought back by V20 (Dietary Aide) and V21(Cook). No injury noted. R27 placed on frequent checks by shift nurse and (wander management device) placed. On 6/8/22 at 11:48 a.m., V20 stated on 5/30/22 at approximately 7:45 p.m., V20 found R27 outside unattended, in the back parking lot area of the complex, walking through the grass back towards the facility. R27's Nurses Notes/electronic medical record dated 5/30/22, did not document that R27's family or Physician were notified of R27's elopement on 5/30/22. On 6/8/22 at 10:25 a.m., V2 (Director of Nursing/DON) stated that R27's medical record does not document that R27's family member or Physician were notified of R27's elopement on 5/30/22. V2 stated, I spoke with V25 when he came in the next day (5/31/22) and told him that R27 had wandered out of the facility the night before. R27's physician was never notified that I'm aware of. V2 stated that the nurse on duty at the time of the elopement (5/30/22) should have created an Event (incident report) and notified R27's family member and Physician at that time, once R27 was back in the facility and safe. Page 1 of 38 146108 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a resident centered comprehensive plan of care related to elopement risk, respiratory care, discharge, psychotropic medication use, impaired/limited range of motion and hospice services, for six of 15 residents (R4, R13, R27, R31, R40, R89) reviewed for care planning, in a sample of 27. Findings include; The facility policy, titled Care Plan Policy (revised 11/28/19), documents It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy further documents, 7. The comprehensive Care Plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. c. The resident's goals for admission, desired outcome, and preferences for future discharge. d. Discharge plans, as applicable. e. Any individual cultural considerations as known/disclosed. f. any individual considerations related to trauma as known/disclosed. 1. R31's Physician's Orders, dated 5/08/22, document R31 has the diagnosis of Congestive Heart Failure (CHF) and includes orders to check R31's weight daily related to CHF, conduct a respiratory assessment every shift, use oxygen at 3-6 Liters per nasal cannula continuously for shortness of breath related to CHF, apply CPAP (Continuous Positive Airway Pressure) at night during hours of sleep, and administer Quetiapine (anti-psychotic) 25 mg (milligrams) at bedtime. Nursing notes, dated 6/06/22, document R31 was discharged back to his home. On 6/06/22 at 11:46 am, R31 was resting in bed with his oxygen on at 6 Liters per nasal cannula. R1's current Plan of Care, dated 5/02/22, identifies that he is at risk for falling, developing pressure ulcers and needs assistance with ADLs (Activities of Daily Living); however, the Plan of Care fails to identify any respiratory care needs related to CHF, the use of antipsychotics, or discharge plans. 2. The electronic medical record Face Sheet documents R40 was admitted to the facility on [DATE] for Therapy Services with the diagnosis of Partial Traumatic Amputation Between the Knee and Ankle of Right Lower Leg. Nursing Progress Notes, dated 3/15/22, document, Spoke with resident about NOMNC (Notice of Medicare Non-Coverage) getting issued by insurance, and discussed discharge plans. Resident will discharge home on Friday with (Home Health). Nursing Progress Notes, dated 3/18/22, document R40 was discharged to his home. R40's Plan of Care, dated 2/24/22, did not contain any documentation regarding discharge planning. 3. The electronic medical record Face Sheet documents R89 was admitted to the facility on [DATE] with a primary diagnosis of Hypertension. Nursing Progress Notes, dated 06/07/2022, document R89 146108 Page 2 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0656 discharged to home with daughter in stable condition with all belongings and medications. Level of Harm - Minimal harm or potential for actual harm R89's Plan of Care, dated 5/23/22, did not contain any documentation regarding discharge planning. Residents Affected - Some 4. R27's Physician Orders dated 5/4/22 through 6/8/22, document R27 has received Seroquel (antipsychotic medication) since she was admitted on [DATE]. On 6/06/22 at 12:53 p.m. V25 (R27's family member) stated R27 lived at home with him prior to hospitalization/admission to this facility. V25 stated R27 had wandered away from their home at least three different times and got lost. V25 stated R27 is not safe to stay at home any longer due to her Dementia and severely impaired cognition. V25 stated that R27 has tried to get out the doors of the facility and stated that she wants to go home, since she was admitted on [DATE]. V25 stated, I'm sure the staff were aware of R27 getting away from me at home. V25 stated R27 has been exit seeking since the beginning of her stay at the facility. V25 stated R27 has tried to elope from here a couple of times according to staff. R27's Care Plan initiated on 5/4/22, does not address R27's history of elopement at home, wandering, exit seeking, risk for elopement or any interventions to help prevent R27 from eloping, until after she eloped on 5/30/22. Additionally, R27's current Care Plan does not address R27's Seroquel use or any interventions and goals. 5. R13's current computerized Physician orders, document R13 was admitted to Hospice on 1/6/22. R13's Care Plan last updated on 5/31/22, does not document that R13 is receiving Hospice Services or any interventions regarding the collaboration of care between the facility or R13's Hospice provider. R13's Minimum Data Set (MDS) assessment dated [DATE], documents R13 has limitation of range of motion in one side of her lower extremity. R13's Care Plan last updated on 5/31/22, does not address R13's limitation of range of motion or any interventions/goals. 6. R4's MDS assessment dated [DATE], documents R4 has limitation of range of motion in one side of his lower extremity. R4's Care Plan last updated on 5/18/22, does not document R4's limitation of range of motion or any interventions/goals. On 6/09/22 at 9:58 am, V24 (Care Plan Coordinator) stated resident specific primary care needs should be identified on a Plan of Care. V24 identified, for example, some of those care needs as: skin condition, Hospice services, fall risk, reason for admission, specialized diets, behaviors, Dementia Care, respiratory care needs, psychotropic medications, and restorative programming/range of motion. V24 stated all residents that are planning to return to home, which is the majority of their admissions, should have discharge planning included in their Plan of Care by the Social Service Coordinator. V24 stated the facility currently does not have a Social Service Coordinator, so discharge planning might be missing from some care plans. V24 confirmed that many of the resident's Care Plans might be missing some specific care needs, as she is new to her position and is working on improving the Care Plans that were in place. 146108 Page 3 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, interview and record review, the facility failed to keep a resident's fingernails trimmed and clean for one of one resident (R2) reviewed for Activities of Daily Living in the sample of 27. Findings include: The facility's Personal Care of Residents policy dated 12/2002, documents, It is a policy of the facility to provide a plan of personal care for residents. 1. Each resident shall have proper daily personal attention and/or care, including skin, nails, hair and oral hygiene, in addition to treatments ordered by the Physician. R2's Minimum Data Set assessment dated [DATE], documents R2 requires extensive assistance of staff for toilet use and personal hygiene. R2's Care Plan dated 1/28/22, documents the following: R2 requires moderate assistance of one staff for dressing and grooming; R2 has a colostomy and staff are to assist with the colostomy as needed to ensure hygiene. On 6/6/22 at 12:02 p.m. and 6/7/22 at 10:15 a.m., R2's fingernails on both hands were long and had a brown matter underneath all fingernails and around the nail bed of each finger. R2 stated staff need to cut his fingernails because R2 cannot do it independently. R2 stated he tries to take care of his colostomy independently but occasionally staff assist him. R2 stated R2 does not like his fingernails to be long like a girl or dirty. R2 stated the brown matter could be from when he takes care of his colostomy. On 6/8/22 at 10:40 a.m., V2 (Director of Nursing/DON) stated staff should be keeping R2's fingernails trimmed and clean. V2 stated R2 has a habit of digging in his stoma (artificial opening in his stomach, where bowel movements come out). V2 stated staff should definitely be helping R2 keep his hands washed and clean at all times. 146108 Page 4 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

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 interview and record review, the facility failed to document a thorough assessment was completed after a resident elopement for one of three residents (R27) reviewed for wandering in the sample of 27. Residents Affected - Few Findings include: The facility's Missing Resident policy dated 2/25/19, documents under the section, Response to Resident leaving the building: When resident returns to facility, a thorough exam should be completed, to assess for injuries. R27's Nurses Notes dated 5/31/22 at 12:01 p.m., document Spoke with V25 (R27's family member) that R27 had wandered out of the facility on 5/30/22 at approximately 7:20 p.m. and found by (an apartment building) and brought back by V20 (Dietary Aide and V21 (Cook). No injury noted. R27 placed on frequent checks by shift nurse and (wander management device) placed. R27's Nurses Note dated 5/30/22, does not document any information about R27's elopement from the facility, including a thorough head to toe assessment to ensure R27 had no injuries. On 6/8/22 at 11:48 a.m., V20 (Dietary Aide) stated V20 was sitting outside of the service door (the exit door located by the kitchen) at the end of his shift on 5/30/22. V20 stated R27 came walking towards the facility, through the grass in the back of the building. V20 stated, I have no idea where R27 came from or how she got out of the facility. I knew she needed help, so I ran inside the building and got V21(Cook) to come outside to help me with R27. I quickly tried to call nursing staff when V21 headed outside but no one answered the phone, so I went back outside to help V21 get R27. R27 was walking but appeared exhausted. It took V21 and I both taking R27 by the arms to assist her back inside to the nurse's station. R27 was worn out. I'm glad I saw her when I did, or I don't know what would have happened to her. On 6/8/22 at 10:25 a.m., V2 (Director of Nursing/DON) stated R27 eloped from the facility on 5/30/22 and was found by V20 (Dietary Aide) and assisted back into the facility and taken to R27's nurse V22 (Registered Nurse/RN) by V20 and V21 (Cook). V2 (DON) stated V22 should have documented a head-to-toe assessment of R27 when she was brought back in the building on 5/30/22 after being found outside alone. V2 stated R27's medical record has no documentation on 5/30/22, by V22, including a thorough assessment for potential injuries of R27. V2 stated due to R27's severely impaired mental status, R27 would not likely be able to report she was injured. On 6/14/22 at 5:05 a.m., V22 (RN) stated, I did not document anything on 5/30/22 in (R27's medical record) when she got out of the facility. According to V2 (DON), I should have charted R27's elopement and a head-to-toe assessment of R27. 146108 Page 5 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment/services for residents with limitations of range of motion or document rationale for the services to not be provided for two of two residents (R4, R13) reviewed for range of motion in the sample of 27. Findings include: The facility's Range of Motion (Passive and Active) dated 3/2009, states, Range of motion may be defined as the extent of movement within a given joint, which is normally achieved through the action of muscles or groups of muscles. Purpose: 1. To prevent contractures; 2. To maintain normal range of motion; 3. To increase joint motion to the maximum possible range; 4. To maintain and build muscle strength; 5. To stimulate circulation; 6. To prevent deformities; 7. To prevent contractures from becoming worse if they are already present. The facility's Active Range of Motion Program policy dated 4/2014, states, 1. MDS (Minimum Data Set) Coordinator or nurse designee completes the Contracture Risk Assessment prior to the completion of the admission MDS and quarterly thereafter and/or with significant change. 2. MDS Coordinator or nurse designee completes Section G 0400 A or B according to the RAI (Resident Assessment Instrument) guidelines. 3. After reviewing Contracture Risk Assessment and Section G0400, the MDS Coordinator or nurse designee determines if the resident would benefit from (Passive Range of Motion) and/or (Active Range of Motion). The MDS Coordinator or nurse designee develops a program that includes objective, measurable goal(s), and approaches to address the identified voluntary loss or risk for voluntary loss. The program is Care Planned and the profile is activated on Point of Care. 4.g. A quarterly note is completed reflecting periodic reevaluation by the MDS Coordinator or nurse designee and attached to the contracture assessment. A quarterly note should include documentation of the resident's participation, response to treatment, and progress towards goal. 1. On 6/06/22 at 11:40 a.m., R4 was lying in his bed on his right side with his feet hanging over the edge of the bed. R4 had a fall matt on the floor, next to his bed. R4 was confused and complained of his back and legs hurting. R4's MDS assessment dated [DATE], documents the following: R4 has severely impaired cognition; R4 requires extensive assist of staff for transfers; R4 is unable to ambulate; R4 has impaired functional limitation of range of motion to one side of the lower extremities; R4 is not receiving any Therapy services and is not receiving any range of motion services. R4's Care Plan last updated 5/18/22, documents R4 requires a mechanical stand aide for transfers with assistance of two staff and assist of one with bed mobility. R4's Care Plan does not document R4's limitation of range of motion or any interventions to prevent further decline in his range of motion. R4's computerized medical record dated 12/6/21 through 6/9/22, does not document a Contracture Risk Assessment has been completed or that R4 is receiving any services to maintain or prevent further decline in range of motion. R4's current computerized medical record also does not include any documented rationale for R4 to not have services provided for the limitation of range of motion in his lower extremity. 146108 Page 6 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. On 06/06/22 at 11:44 a.m., 6/7/22 at 1:30 p.m. and 6/8/22 at 11:00 am., R13 was lying on her back in bed with no noted independent movement. R13's Minimum Data Set (MDS) assessment dated [DATE], documents the following: R13 has moderately impaired cognition; is unable to ambulate; requires extensive assistance of two staff for transfers and bed mobility; uses a wheelchair; has impairment of functional limitation of range of motion on one side of her lower extremities; and did not receive any therapy services or restorative/range of motion programs. R13's Care plan dated 12/30/21, documents R13 was admitted to the facility after falling at home and sustaining a left hip fracture; R13 requires the use of a full mechanical lift for transfers; R13's Care Plan does not address R13's limitation of range of motion or any interventions to prevent further decline in mobility/range of motion. R13's current computerized medical record, does not document a Contracture Risk Assessment has been completed since R13 was admitted on [DATE] or that R4 is receiving any services to maintain or prevent further decline in her range of motion. R4's current computerized medical record also does not include any documented rationale for R4 to not have services provided for the limitation of range of motion in her lower extremity. On 6/9/22 at 1:20 p.m., V1 (Administrator) stated R4 and R13 do not have any type of restorative/range of motion program in place for their documented limitation of range of motion. V1 stated that any resident with a limitation of range of motion should either be on some type of service to help improve, maintain/prevent further decline in range of motion or there should be documented rationale for not having a service is in place. 146108 Page 7 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to interview the family of a confused resident to accurately assess elopement risk prior to admission, screen for supervision needs and develop an elopement care plan, failed to provide adequate supervision to prevent an elopement, failed to ensure all exit doors were secured and/or alarmed and the exit door alarm system was in working order, and failed to investigate an elopement for one of three residents (R27) reviewed for wandering in the sample of 27. These failures resulted in R27, a severely cognitively impaired resident with a diagnosis of Dementia, who is normally independent with ambulation and with a known history of eloping prior to admission to the facility, eloping from the facility on 5/30/22 and being found outside in the back of the building, walking across the grass heading towards the facility, from an unknown location. The facility was unaware that R27 was missing until V20 (Dietary Aide) observed R27 outside and notified facility staff. R27 was found and required extensive assistance of two staff members to return inside of the facility due to R27 being physically exhausted. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6/15/22, the facility remains out of compliance at a severity Level II as the facility Maintenance Director and Administrator continue to monitor all exit doors to ensure they are alarmed and functioning. Residents identified as an Elopement Risk/identified as high risk for elopement were added to Quality Assessment and Assurance/Quality Assurance and Performance Improvement plan for ongoing monitoring. The facility is also awaiting a local electronic maintenance company that has been scheduled to provide service to evaluate and repair keypad and magnetic-locking door system on the fire door leading into the assisted living. In addition to this, parts have been ordered for adding an announcer speaker to sound the front door alarm when it is breached. This installation will be scheduled as soon as parts arrive. Findings include: The facility's Missing Resident policy dated 2/25/19, states, Purpose: To provide 24-hour supervision of the resident's safety. Staff responsible: 1. Administrator 2. Maintenance 3. Director of Nursing 4. All Staff; Missing Resident: the following criteria shall be met prior to determining whether a resident is missing: The resident is not capable of making safe decisions regarding their safety and welfare and they are unattended. Procedure: All exterior doors shall be equipped with a signal that will alert staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device. 2. Residents at risk for wandering shall be assessed and addressed on the Care Plan. Immediately following the alarm signal, staff shall check the alarm panel and respond to the door indicated. Prevention: Check and test door alarms regularly, Identify and monitor residents at risk; Response to Resident Leaving the Building: Assist back to building, When resident returns to facility, a thorough exam should be completed, to assess for injuries; Missing Resident Protocol: The facility shall notify the resident's Physician and the legal representative or family member; Once the resident is found, an internal investigation will be conducted by the Administrator. R27's electronic medical record documents R27 was admitted to the facility on [DATE] with diagnoses which include, Dementia with behavioral disturbances, Cerebral Infarction with left sided weakness, Insomnia, Unsteadiness on feet, and Aphasia. 146108 Page 8 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few R27's MDS (Minimum Data Set) assessment dated [DATE], documents the following: R27 has severely impaired cognition with short and long-term memory problems, wanders daily which places R27 at significant risk of getting to a potentially dangerous place (such as stairs, outside of the facility); and R27's wandering also significantly intrudes on the privacy or activities of others. This same MDS assessment documents R27 ambulated once or twice with one staff assistance. R27's Elopement Risk assessment dated [DATE] at 3:56 p.m., and completed by V13 (Activity Director), documents R27 is not at risk for elopement. R27's Care Plan initiated on 5/4/22, does not address R27 being a risk for elopement or wandering until it was revised on 6/1/22 (after R27 eloped on 5/30/22). This same Care Plan states, Activities: R27's barriers are cognitive decline due to Dementia, physical and verbal behaviors to other residents and staff when upset about wanting to go home or see husband. R27's Behavior Tracking dated 5/10/22 through 5/30/22, does not document R27's exit seeking/wandering. R27's Progress Notes dated 5/14/22 9:50 a.m., state R27 has continual supervision in waking hours. Unable to reorient. R27 does not remember fall occurring earlier in day. R27 self ambulates often raising her voice and cussing at staff. R27's Progress Notes dated 5/15/22 at 11:05 a.m., state, R27 has to have one-on-one supervision at almost all times (due to) her behaviors and fall risk. R27's Progress Notes dated 5/16/22 at 10:19 a.m., state, R27 states, 'My husband is not here yet. You hate me and I am not listening to you. I am tired of this bulls**t. I am leaving, maybe I will die'. On 6/06/22 at 12:53 p.m., V25 (R27's Husband) stated that R27 lived at home with him prior to her hospitalization and admission to the facility on 5/4/22. V25 stated R27's Dementia was progressing, and she was no longer safe to stay at home with V25. V25 stated R27, got lost three times in our hometown after she wandered off from home. Luckily, it's a small town and people knew who R27 was. R27 even went to (her old place of employment) and walked in like she was going to work. R27 can walk independently, and I take her on a lot of walks when I'm here. R27 has tried to leave this facility at least twice, according to staff. R27 says she wants to go home so she is frequently trying to get to an exit door. I can't remember the date that she tried to elope. R27's Nursing Progress Note dated 5/31/22 and completed by V2 (Director of Nursing) states, Spoke with V25 that (R27) is an elopement risk and R27 had wandered out of the facility on 5/30/22 at approximately 7:20 p.m. and found by (the apartments down the street) and brought back by dietary staff member. No injury noted. R27 placed on frequent checks by night shift nurse and wander guard placed. R27's Nursing progress Note dated 5/31/22 at 12:42 p.m., states Nursing implemented (wander management device) this morning. On 6/8/22 at 11:48 a.m., V20 (Dietary Aide) stated V20 was sitting outside of the service door (the exit door located by the kitchen) at the end of his shift on 5/30/22. V20 stated R27 came walking towards the facility, through the grass in the back of the building. V20 stated, I have no idea where R27 came from or how she got out of the facility. I knew she needed help, so I ran inside the 146108 Page 9 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety building and got V21(Cook) to come outside to help me with R27. I quickly tried to call nursing staff when V21 headed outside but no one answered the phone, so I went back outside to help V21 get R27. R27 was walking but appeared exhausted. It took V21 and I both taking R27 by the arms to assist her back inside to the nurse's station. R27 was worn out. I'm glad I saw her when I did, or I don't know what would have happened to her. There were no alarms heard from the kitchen. The (service door exit) does not have an alarm on it. Residents Affected - Few On 6/8/22 at 10:30 a.m., V21 (Cook) stated, I was in the kitchen when V20 came running in telling me that R27 was outside by herself. V20 tried to call nursing staff for help, and I ran outside to R27. When I got to R27 she was completely exhausted. I have no idea where all she had been or how long she was outside. It took both V20 and I to hang on to R27 and help her to get back inside to the nurse. I didn't ever hear any alarms. The service door (exit by the kitchen) is not alarmed. The door that comes from the hallways to the kitchen area is unlocked by kitchen staff in the morning and not locked until approximately 8:00 p.m. at night. On 6/8/22 at 9:34 a.m., V2 (Director of Nursing/DON) stated, I was notified on 5/30/22 at approximately 8:00 p.m., that R27 had somehow gotten outside of the facility. R27 has a diagnosis of Dementia and cannot make safe decisions. Her cognition is severely impaired. I did not do any type of investigation after R27's elopement on 5/30/22. I just had nursing staff attach a (wander management device) on her clothes the next morning. R27's nurse V22(Registered Nurse/RN) did not document R27's elopement, an assessment of R27 to check for any type of injuries, or that R27's Physician or husband were notified of the elopement. I don't recall hearing R27 verbalize that she wanted to go home or that she had made attempts to leave the facility. I did call V1 (Administrator) on 5/30/22, after I was notified of R27 being found outside. We (facility staff) had been trying to find her alternative placement due to her behaviors. I did not know that R27 had a history of eloping when she was still living at home. I don't do the elopement risk assessments. Those assessments are completed by the Activity Director in this facility. The elopement risk assessment should have been completed with the assistance of R27's husband since R27 is confused. I have no idea if R27's Care Plan addressed her risk for elopement prior to 5/30/22. I have not watched any video surveillance or conducted any interviews with the staff that found (R27) outside or any other staff on duty on 5/30/22. I cannot say where she exited the building or how long she was outside. I screened R27 for admission to the facility. I don't recall reading anything about her history of elopement. I don't have any documentation of my screening that was completed prior to accepting R27. I don't recall what all I reviewed from the hospital. There is no specific form that I follow. I probably wouldn't have taken (R27 as a resident) if I had known she had a history of eloping at home. We aren't a locked unit. I absolutely would have made sure R27 had a (wander management device) in place on admission at the very least. On 6/8/22 at 9:50 a.m., V13 (Activity Director) stated R27 is very impulsive and easily becomes agitated. V13 stated, I do a lot of one on one's with R27 and at times she is very hard to re-direct. I take her for a lot of walks because that seems to keep her content. She likes to be up moving. R27 was admitted on [DATE] and I completed her Elopement Risk Assessment. I don't know why this facility has the Activity Director doing those assessments. I don't have access to residents' medical records or anything like that. I was not formally trained on completing the Elopement Risk Assessments. I don't recall involving V25 while completing R27's Elopement Risk assessment. I wasn't aware that R27 escaped from her home prior to admission. I would have made her high risk for elopement if I had known that. I don't make the decision to put a (wander management device) on residents. R27 is always telling staff she wants to go home and asking where V25 (R27's Husband) is. I know she has tried to get out the exit doors and she has done a lot of wandering since she was admitted . 146108 Page 10 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 6/8/22 at 11:20 a.m., V1 (Administrator) stated V2 notified her of R27's elopement from the facility on the night of 5/30/22. V1 stated V1 did not consider it an actual elopement because R27 was still on (facility owned property). V1 stated R27 has severely impaired cognition and is not safe to be outside of the facility without supervision. V1 stated, I thought V2 (DON) was handling the elopement issue. I told V2 to put a (wander management device) on R27 and do frequent checks. I have not completed any sort of investigation of R27's elopement on 5/30/22. I don't know what happened. V2 was responsible for the investigation at that point. We don't know what door R27 exited from or how long she was outside unsupervised. I do not have access to video surveillance and I'm not sure what is monitored by the video surveillance. I doubt the exit doors are on video. All exterior doors should be alarmed. Staff should have been aware of R27's history of elopement when she was admitted if they had interviewed V25 (R27's Husband) or properly screened R27 prior to admission. On 6/6/22, at 11:10 a.m., R27 was ambulating independently towards the nurses' station, with no staff supervision. On 6/7/22 at 9:50 a.m., R27 was ambulating independently in the main hallway. On 6/8/22 at 9:47 a.m., R27 ambulated into V2's office and sat at the table. On 6/8/22 at 10:07 a.m., R27 was up independently ambulating in the common area with only socks on her feet. A staff member assisted R27 back to the wheelchair and took R27 to her room. On 6/08/22 at 10:40 am, R27 was ambulating on the main hall of the facility with standby assistance from staff. R27 repeatedly stated get me out of this place and when am I going home. R27 had a small device attached with a clip to the hood of her sweatshirt. V2 (DON) was questioned as to what that device was. V2 stated the device was a wander guard that would alert staff if R27 passed through an exit door. V2 stated that the facility typically uses a wander guard that is placed on the resident's wrist or ankle as a bracelet, but they only have two of those devices and they are being used by other residents. On 6/8/22 at 3:30 p.m., R27 was walking outside with her husband. On 6/08/22 at 10:37 am, the facility was toured with V2 (DON) to identify all exterior doors and if they were secured and alarmed. The corridors that separate the Skilled Nursing side of the facility from the Assisted Living Side of the facility were not alarmed. V2 explained, at that time, that the only way a staff member would know if a resident went through those doors, was if they had a wander guard bracelet/alarm on. V2 then stated, R27 did not have a wander guard on when she eloped from the facility on 5/30/22, so R27 likely went through those doors into the Assisted Living portion of the facility. Once on the Assisted Living side of the building, the Service Entry door that leads to the Kitchen and another exterior door, was not locked, or alarmed. That exterior door led to the parking lot behind Assisted Living. At 10:45 am, V21 (Cook) stated that Service Entry door is unlocked and not alarmed from the time Kitchen staff arrive early in the morning, until they are gone at 8:00 pm. An additional exit door on the [NAME] Hall, which led directly to the parking lot in the front of the facility was able to be opened without an alarm sounding. V2 stated, at that time, that the exit door on [NAME] Hall should alarm when opened. The Immediate Jeopardy was identified on 6/8/22. The Immediate Jeopardy began on 5/4/22 (R27's admission date) upon admission when the facility failed to identify R27's risk for elopement and implement interventions to help prevent R27 from eloping from the facility. 146108 Page 11 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 V1 (Administrator) was notified of the Immediate Jeopardy on 6/9/22 at 8:55 a.m. Level of Harm - Immediate jeopardy to resident health or safety On 6-13-22 from 9:45 AM through 10:15 a.m., it was confirmed through interviews that V30 (Agency Licensed Practical Nurse/ Agency LPN), V31 (Physical Therapy Assistant), V32 (Occupational Therapy Assistant), and V33 (Housekeeper) had not been in-serviced as stated on the abatement plan, the facility's abatement plan was not completely executed. Residents Affected - Few On 6/14/22 at 5:00am, the same fire doors that separate the Skilled Nursing Unit from the Assisted Living Unit were not alarmed, as outlined in the Abatement Plan for F689. On 6/14/22 at 5:05 am, V22 (Registered Nurse/RN) was the only Licensed Nurse working 3rd shift. V22 was unable to reiterate any of the education provided by V2 (DON) and V1 (Administrator) regarding the Immediate Jeopardies identified the week prior. V22 was unaware of the Elopement Book, that was outlined in the Abatement Plan for F689. Upon further interview, V22 (RN) explained that R27 had attempted to elope two times the evening of 6/13/22, once out the front door and once out of the corridor that connects the Assisted Living Unit to the Skilled Nursing Unit. V22 verified that R27 was supposed to be on one-to-one supervision due to the elopements throughout the evening; however, V22 stated that the facility did not have the staff to provide 1:1 supervision and R27 was not on 1:1 supervision at the time. At 5:15 am, two additional staff, V36 (Agency Certified Nursing Assistant/ Agency CNA) and V38 (Cook) stated they had not received education as identified in the Abatement Plans. On 6/14/22 from 6:35 a.m.-6:37 a.m., The fire doors that separate the Skilled Nursing Unit from the Assisted Living Unit did not alarm on two separate instances when one visitor and one staff member V11(Registered Nurse/RN) came through those doors. On 6/14/22 at 5:21 a.m., review of the Shift Door Check sheet dated 6/13/22, did not document any of the 19 listed doors were checked to ensure they were properly functioning on the 2nd and 3rd shift. On 6/14/22, R27, R119, and R194's Care Plans had not been revised with resident specific interventions related to their elopement risk. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 6/8 and 6/9/2022 V17 (Maintenance Director) verified that all exit doors were alarmed when opened and reported findings to V1 (Administrator). 2. On 6/13/22, R27s elopement investigation from 5/30/2022 completed by V1 (Administrator). 3. On 6/9/22, R27s Care plan and interventions were reviewed and updated by V24 (Minimum Data Set/MDS Care Coordinator) and the Interdisciplinary Team. 4. On 6/9/22, V2 (Director of Nursing) In-serviced all staff on R27's Elopement Interventions. Staff members not in attendance of in-servicing held on 6/9/22 will be in-serviced prior to the start of their next shift, by phone or in person by V1 or designee. 146108 Page 12 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 5. Level of Harm - Immediate jeopardy to resident health or safety On 6/9/22, V2 (DON) and Department Heads In-serviced all staff on all residents at risk for elopement, individualized resident interventions, and monitoring needs, and Missing Resident Protocol. Staff members not in attendance of in-servicing held on 6/9/22 will be in-serviced prior to the start of their next shift, by phone or in person by V1 or designee. Residents Affected - Few 6. On 6/9/2022, V2 (DON) and V24 (MDS Coordinator) completed new Elopement Risk Assessments on all residents. On 6/15/22, the Care Plans for those residents Identified as high risk for elopement were updated adding resident specific interventions to meet the resident's needs. 7. On 6/9/2022, all nursing staff, including V2 and V24 were in-serviced on Elopement Risk Assessments needed for all new admissions, to include reviews on a quarterly basis and with significant changes. Staff members not in attendance of in-servicing held on 6/9/22 will be in-serviced prior to the start of their next shift, by phone or in person by V1 or designee. 8. On 6/9/2022, V1 (Administrator) and V2 (Director of Nursing) verified that the appropriate information on residents with exit seeking behaviors were properly placed in binders and at designated locations. All staff were in-serviced on the locations of binders. 9. On 6/9/2022, V17 (Maintenance Director) activated an alarm on fire doors directly leading to the Assisted Living Facility. 10. On 6/9/2022, V17 (Maintenance Director) in-serviced exit doors needing checked by staff every shift to assure they are alarmed and functioning. These Logs will be reviewed by the Maintenance Director and presented to the Administrator daily with issues being addressed as they occur. 11. On 6/9/22, the residents identified as an Elopement Risk/identified as high risk for elopement were added to Quality Assessment and Assurance/Quality Assurance and Performance Improvement plan by V1 (Administrator) for ongoing monitoring. 12. On 6/14/22, all staff were provided additional in-servicing on the above-mentioned trainings by the Regional Nurses along with a post-test for proof of training and understanding. 146108 Page 13 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Based on observation, interview, and record reviews conducted on 6-15-22 the facility completed all measures including the in-servicing of working staff and updating care plans for high-risk elopement residents as stated on the abatement plan. Residents Affected - Few 146108 Page 14 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure oxygen was delivered according to the Physician's order, for one of one resident (R31) reviewed with oxygen, in a sample of 27. Residents Affected - Few Findings include: The facility policy, titled, Oxygen Therapy (revised 3/16/17), documents, Objective: 1. To provide a source of oxygen to persons experiencing an insufficient supply of same. The policy further documents, Procedure: 1. M.D. (Medical Doctor) order will provide: when to use, how often, liter flow, and whether to use a cannula or mask. A Physician's Order Sheet, dated 5/08/22, documents R31 was admitted to the facility on [DATE] with the diagnoses of Chronic Obstructive Pulmonary Disease and Centrilobular Emphysema, and orders for Oxygen to be administered at 3 - 6 Liters via nasal cannula continuously for shortness of breath, with, Special instructions: baseline 3 (Liters per minute) and with activity 6 (Liters per minute) continuous. On 6/06/22 at 11:46 am, R31 was in his room resting in bed with his Oxygen on at 6 Liters per minute via nasal cannula. R31 stated he was just relaxing before lunch. On 6/06/22 at 2:10 pm, R31 was in his room in bed with Oxygen on at 6 Liters per minute via nasal cannula. At that time, R31 stated he wears his oxygen at all times at 6 Liters per minute and staff do not lower it. On 6/06/22 at 2:32 pm, V11 (Registered Nurse/RN) stated R31's oxygen is usually set at 6 Liters at all times and should be set according to the Physician's order. 146108 Page 15 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to attempt non-pharmacological interventions and obtain consent prior to initiating an antipsychotic medication, monitor targeted behaviors and complete psychotropic assessments for two of four residents (R10, R27) reviewed for psychotropic medications in the sample of 27. Findings include: The facility's Psychopharmacologic Drug Usage Procedure policy, dated 10/18/17, documents, Purpose: To provide appropriate assessment and monitoring of residents receiving these medications. To ensure residents receive gradual dosage reductions and behavioral interventions in an effort to discontinue these medications and minimize adverse consequences. Psychopharmacological medication usage must be reassessed at least every 90 days and include rationale for continuing the medication. Consent for use of Psychopharmacologic medications must be given in writing by the resident and/ or the resident's representative. This consent form will also include the educational components of: name of medication, condition/reason for its use, possible risks/ side effects of the medication, and expected outcome/ benefits of the medication. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medication response and adverse consequences. This policy also documents, Residents using psychopharmacological medications must have an initial assessment with quarterly reassessments to provide a data base for the Care Plan and Gradual Dose Reduction Program. 1. R10's current Physician Order Sheet dated 6/8/22, documents R10 has an order for Seroquel (antipsychotic medication) 25 milligrams daily and 50 milligrams at every bedtime. On 6/6/22 at 11:05 AM, R10 was observed self-propelling her wheelchair in the hall. R10 was holding a stuffed animal and had a blanket on her lap. R10 was not displaying any adverse behaviors. R10's electronic medical record does not document a consent for Seroquel, psychotropic medication assessments and does not document any interventions attempted prior to initiating R10's Seroquel. On 6/9/22 at 10:20 AM, V2 (Director of Nursing/DON) confirmed that R10 has behaviors related to Dementia and stated she isn't aware what interventions have been done prior to when she was placed on antipsychotic medications. V2 stated, I wasn't here then. R10 first started Seroquel on 8/23/21, and I cannot find a consent for that. It was then increased to two times daily on 11/24/21. If a verbal consent is obtained, it should be transferred onto a paper consent and I do not have any signed consents for (R10's) Seroquel. We only do an AIMS (Abnormal Involuntary Movement Scale). I do not have a psychotropic medication assessment for her Seroquel. 2. R27's Physician Orders dated 5/4/22 through 6/8/22, document R27 was admitted to the facility on [DATE], with an order for Seroquel (antipsychotic medication) 25 mg (milligrams) 1/2 tablet twice a day for Unspecified Dementia with behavioral disturbance. R27's Physician Orders dated 5/4/22 through 6/8/22, document R27's Seroquel was increased to 25 mg twice a day on 5/13/22. 146108 Page 16 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R27's Physician Orders dated 5/4/22 through 6/8/22, document R27's Seroquel was increased to 25 mg in the morning and 50 mg at bedtime. R27's current computerized medical record does not include the following: An assessment of R27's Seroquel use from admission or changes in Seroquel dosage; R27's target behaviors; non-pharmacological approaches that have been implemented; R27's history of prior and current use of Seroquel, including therapeutic effectiveness and any adverse consequences. R27's Observation Detail List Report dated 5/19/22, documents R27's new Physician orders for Seroquel and that V25 (R27's family member) signed the Denial of Consent for use of Medication-My signature indicates I am informed, but DO NOT consent to the use of the medication(s) listed above although I understand the reason for use and potential risks and benefits. R27's Medication Administration Record documents R27 continued to receive Seroquel 25 mg every morning and 50 mg at bedtime. R27's Behaviors Tracking dated 5/10/22 through 6/8/22, does not document daily consistent behavior monitoring by staff and does not identify R27's target behaviors for the use of an antipsychotic medication (Seroquel). R27's Behavior Tracking is not documented/completed by staff for the following days: 5/4/22-5/9/22 and 5/18/22-6/2/22. On 6/9/22 at 10:05 a.m., V2 (DON) stated that R27 has had, a couple of increases of her Seroquel dosage. V2 stated, I don't know if V25 (R27's Family) meant to sign the refusal portion of the consent or not. That might have been an accident. Regardless, it should have been fixed. V2 also stated that R27's medical record does not include assessment for the use of Seroquel or routine behavior tracking. V2 stated the Certified Nurse Aides are supposed to document whether the resident has behaviors or not on each shift. V2 stated, They have to mark no behaviors if there were none. There is not supposed to be any shift left blank. I don't know what R27's target behaviors are for using Seroquel. I can't see where that is documented in her chart. V2 also verified that R27's medical record does not include any documentation regarding non-pharmacological approaches that have been implemented; R27's history of prior and current use of Seroquel, including therapeutic effectiveness and any adverse consequences. 146108 Page 17 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on interview and record review, the facility failed to ensure bedtime snacks were given to seven of eight residents (R2, R7, R18, R26, R29, R31, & R90) reviewed for receiving an evening snack, in a sample of 27. Findings include: The facility policy, titled Snack Procedure (10/2021), documents, Objective: To provide residents snacks of nourishing quality. Procedure: Snacks of nourishing quality will be available in the kitchen, satellite pantries, nourishment rooms and/or on a snack cart or nursing ice water pass cart throughout the day. All residents should be offered a bedtime snack. The Dining Services staff will supply snacks to each nurses' station for nursing to pass. Appropriate snacks for residents on mechanical diet will be sent. Snacks that require refrigeration will be placed in the satellite pantry or nourishment room. Nursing will be informed of the location of the bedtime snacks. On 6/07/22 at 10:00 am, during the group meeting with residents, R2, R26 and R7 all stated that they are not offered a snack before bedtime. On 6/06/22 at 2:10 pm, R31 stated staff do not offer him a snack before bedtime. R31 went on to say that he would enjoy a small snack if offered. On 6/06/22 at 1:45 pm, R18 stated she has never been offered a bedtime snack during her stay at the facility. On 6/07/22 at 1:02 pm, R90 stated the staff do not offer snacks before she goes to bed. On 6/07/22 at 2:05 pm, R29 stated staff have not offered her a snack before bed, but she would probably enjoy that. On 6/09/22 at 10:13 am, V23 (Dietary Manager) stated snacks are always available to residents and the CNAs (Certified Nursing Assistants) are supposed to go room to room and offer residents a snack. 146108 Page 18 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to cover, label, and date pans filled with cooked chicken, cooked pork and cooked rice, and failed to maintain the temperature of milk below 41 degrees Fahrenheit. These failures had the potential to affect all 30 residents within the facility. Findings Include: reside within the facility. The facility's Food Storage and Labeling Procedure dated 10/2021 documents, Objective: To provide staff with guidelines for food storage and labeling of foods. Food Storage: Keep all food covered in a resealable bag or container or the original container, if applicable. Labeling of Refrigerated Foods: The label should include: 1. Product Name: Even if you can see the product/leftover through the plastic wrap or lid, you must label the container or re-sealable bad with the product name. 2. Date: Document the date that the product is placed in the refrigerator. 3. Discard Date: Count seven days from the date you are placing the item in the refrigerator. Staff initials: Every label must include the initials of the staff member preparing the item/leftover to be refrigerated. The facility's Food Temperatures-Measuring Procedure dated 08/2019 documents, Objective: To provide guidelines for testing food temperatures and the proper temperatures for food preparation and holding. Proper Food Preparation/Holding Temperatures: 41 degrees Fahrenheit for cold handling (cold foods/milk). On 06/06/22 at 10:45 AM, the walk-in refrigerator contained an uncovered, unlabeled, undated, 12 inch by 20 inch by 4 inch metal steam table pan filled with chunks of pork that were covered in frost. This walk-in refrigerator also contained an uncovered, unlabeled, undated, 12 inch by 7 inch by 6 inch metal steam table pan of rice and an uncovered, unlabeled, undated, 6 inch by 10 inch by 4 inch metal steam table pan of chicken pieces. On 06/06/22 at 11:19 AM, V21 (Cook) stated, All foods in the refrigerator should labeled, covered and dated. On 06/06/22 at 12:00 PM, V7 (Cook) took the temperature of the individual glasses of milk. This temperature read 58 degrees Fahrenheit. The thermometer in the dining room refrigerator read 60 degrees Fahrenheit, which contained the gallons of milk used to fill these glasses of milk. V7 also took the temperature of a gallon of milk in this refrigerator. This temperature read 58 degrees Fahrenheit. 146108 Page 19 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Many Based on observation, interview, and record review, the facility failed to properly screen a resident prior to admission to determine safety needs, failed to administer, operate and implement policies and procedures in a manner that ensured the safety of residents identified as an elopement risk, and failed to have the ability to implement an effective Abatement Plan for Immediate Jeopardies identified during survey. These failures have the potential to affect all 30 residents residing in the facility. Findings include: The facility policy, titled, Job Description Administrator (revised 11/28/17), documents, Job Function: Responsible for directing the overall operation of the facility's activities with current applicable federal, state, local and corporate standards, guidelines and regulations ensuring the highest degree of quality resident care is provided at all times. Supervises: Department Heads and Office Staff. Reports To: Regional Manager. Primary Responsibilities: 1. Assure that the goals of the Nursing Home are being met - the provision of quality resident care in a highly respectful, highly regulated, well managed, and caring environment and billing collection for these services. 2. Complete duties as assigned by supervisor. The policy also documents that the Administrator is responsible for Developing and implementing Plans of Correction. The policy identifies that the Administrator is part of the Admissions Determination Committee, which includes, a. Have final say on whether Resident is to be admitted ; b. If necessary, complete the admission paperwork. The facility policy, titled Job Description Director of Nursing (revised 04/03/18), documents, Primary Responsibilities: 1. Implement and monitor Facility Policies and Procedures to ensure that the facility is in compliance with all Federal and State Minimum Standards as they apply to nursing and medical services. reside within the facility. The State Survey team entered the facility on 6/06/22 for an annual Certification Survey. On 6/06/22, V19 (Regional Nurse/RN) joined V1 (Administrator) to assist in the survey process for the week. On 6/08/22, V39 (Licensed Nursing Home Administrator) joined V1 and V19 for survey assistance and remained present throughout the survey. During the course of the survey, Immediate Jeopardies at F880 and F886 were identified on 6/08/22 and at F689 on 6/09/22. The Abatement Plans for F880, F886 and F689 outlined that staff would receive education and training regarding the Immediate Jeopardy findings and the facility's plan to correct the immediacy of the issues identified by 6/09/22. V40 (Regional Nurse) arrived on 6/13/22, to assist V1, V19 and V39 with the Immediate Jeopardy Abatement Plans. R27's electronic medical record documents R27 was admitted to the facility on [DATE] with diagnoses which include, Dementia with behavioral disturbances, Unsteadiness on feet, and Aphasia. R27's Elopement Risk assessment dated [DATE] at 3:56 p.m., and completed by V13 (Activity Director), documents R27 is not at risk for elopement. R27's Care Plan initiated on 5/4/22, does not address R27 being a risk for elopement or wandering. 146108 Page 20 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 6/06/22 at 12:53 p.m., V25 (R27's Husband) stated R27 lived at home with him prior to her hospitalization and admission to the facility on 5/4/22. V25 stated R27's Dementia was progressing, and she was no longer safe to stay at home with V25, as R27 had wandered off from their home on three separate occasions. V25 stated, R27 has tried to leave this facility at least twice, according to staff. R27 says she wants to go home so she is frequently trying to get to an exit door. I can't remember the date that she tried to elope. R27's Nursing Progress Note dated 5/31/22 and completed by V2 (Director of Nursing/DON) documents, Spoke with V25 that R27 is an elopement risk and R27 had wandered out of the facility on 5/30/22 at approximately 7:20 p.m. and found by the apartments down the street and brought back by dietary staff member. No injury noted. R27 placed on frequent checks by night shift nurse and wander guard placed. On 6/8/22 at 9:34 a.m., V2 (DON) stated she was notified on 5/30/22 at approximately 8:00 p.m., that R27 had left the facility and was found by dietary staff. V2 stated she did not do any type of investigation after R27's elopement on 5/30/22 and was unaware of how R27 exited the facility without staff knowing or how long R27 was even gone. V2 stated, I did call V1(Administrator) on 5/30/22, after I was notified of R27 being found outside. We (facility staff) had been trying to find her alternative placement due to her behaviors. I did not know that R27 had history of eloping when she was still living at home. I don't do the elopement risk assessments. Those assessments are completed by the Activity Director in this facility. The elopement risk assessment should have been completed with the assistance of R27's husband since R27 is confused. I have no idea if R27's Care Plan addressed her risk for elopement prior to 5/30/22. I have not watched any video surveillance or conducted any interviews with the staff that found R27 outside or any other staff on duty on 5/30/22. I cannot say where she exited the building or how long she was outside. I screened R27 for admission to the facility. I don't recall reading anything about her history of elopement. I don't have any documentation of my screening that was completed prior to accepting R27. I don't recall what all I reviewed from the hospital. There is no specific form that I follow. I probably wouldn't have taken (R27 as a resident) if I had known she had a history of eloping at home. We aren't a locked unit. I absolutely would have made sure R27 had a (wander management device) in place on admission at the very least. On 6/09/22 at 8:55 am, the State Survey team notified V1 (Administrator) that another Immediate Jeopardy had been identified due to the facility's failure to properly screen R27 prior to her admission, identify that R27 was an elopement risk, failure to implement interventions to prevent the 5/30/22 elopement and failure to investigate the elopement after it occurred. A final Abatement Plan for F-Tag 689 (Accidents/Supervision) was completed and signed by V19 on 6/09/22 at 3:21 pm. The Abatement Plan documented that all staff would receive education/training regarding door alarms, education on who is an elopement risk and how to identify those individuals, and which doors were to be alarmed by staff, with instructions on the monitoring of those doors by 6/09/22. Additionally, on 6/09/22, the Survey Team attempted to determine if the facility had completed the requirements as outlined in the Abatement Plan for the Immediate Jeopardies identified at F880 and F886. The Abatement Plans indicated that R30 and R8 would be placed on Contact Isolation effective 6/08/22. On 6/09/22 at 2:00 pm, R8 and R30 had yet to be placed on Contact Isolation. On 6/13/22 at 9:00 am, four staff members, V30 (Agency Certified Nursing Assistant/ Agency CNA), V31 (Physical Therapy Assistant), V32 (Certified Occupational Therapy Assistant), and V33 (Housekeeping) that were working stated during interviews that they had yet to receive any education regarding the Immediate Jeopardies found at F689, F880 & F886, the week prior. The fire doors that separate the 146108 Page 21 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Skilled Nursing Unit from the Assisted Living Unit, were not alarmed as outlined in the Abatement plan for

F689. At 10:00 am, the fire doors that lead to the front entrance of the facility were not alarmed. The Plan of Care for the three residents identified as an elopement risk (R27, R94 & R119) had not been updated with resident specific interventions, including frequency of supervision by staff. On 6/13/22 at 11:32 am, V1 (Administrator) stated she was unaware V30 and V33 would be working in her facility on 6/13/22, and that was why they had not yet been educated. V1 was uncertain as to why V31 and V32 had not been educated. On 6/14/22, at 5:00 a.m., the same fire doors that separate the Skilled Nursing Unit from the Assisted Living Unit were not alarmed, as outlined in the Abatement Plan for F689. On 6/14/22 at 5:05 am, V22 (Registered Nurse/RN) was the only Licensed Nurse working 3rd shift. V22 was unable to reiterate any of the education provided by V2 (DON) and V1 (Administrator) regarding the Immediate Jeopardies identified the week prior. V22 was unaware of the Elopement Book, that was outlined in the Abatement Plan for F689. Upon further interview, V22 (RN) explained that R27 (who had been the focus of F689 for eloping on 5/30/22) had attempted to elope two times the evening of 6/13/22, once out the front door and once out of the corridor that connects the Assisted Living Unit to the Skilled Nursing Unit. V22 verified that R27 was supposed to be on one-to-one supervision due to the elopements throughout the evening; however, V22 stated that the facility did not have the staff to provide 1:1 supervision and R27 was not on 1:1 supervision at the time. At 5:15 am, two additional staff, V36 (Agency Certified Nursing Assistant/Agency CNA) and V38 (Cook) stated they had not received education as identified in the Abatement Plans. On 6/14/22 from 6:35 a.m.-6:37 a.m., the fire doors that separate the Skilled Nursing Unit from the Assisted Living Unit did not alarm on two separate instances when one visitor and one staff member V11(Registered Nurse/RN) came through those doors. On 6/14/22 at 6:50 am, Therapy Staff set off the front door alarm attempting to enter the facility. That staff member then turned around and left without entering the building and the alarm continued to sound for four minutes, with no staff response. After four minutes, the alarm was then turned off by the same Therapy Staff member that had attempted entrance, and she went into the Therapy Department. On 6/14/22 at 7:08 am, the fire doors that lead to the front entrance of the facility were not alarmed, again. On 6/14/22 at 8:35 am, V1 (Administrator) was interviewed regarding concerns identified upon entering the facility 6/14/22. V1 indicated resident Care Plans had not been revised with resident specific interventions related to elopement, as indicated in the facility's F689 abatement plan, because she had not had time to meet with the IDT team to do so. V1 stated, she again was unaware that agency staff V36 (Agency CNA) that would be working 3rd shift 6/13/22 and that was why V36 had not been educated regarding the Immediate Jeopardies. V1 went on to say she didn't even know what staffing agency V36 was working for. V1 then stated V22 had contacted her the evening of 6/13/22, informing her that R27 had attempted to exit the building multiple times. V1 instructed V22 to have staff provide 1:1 supervision with R27 during the night, as they had enough staff to do so. V1 was informed at that time, there was no observation of R27 with 1:1 staff supervision that morning. V1 was advised that both sets of fire doors were found to be unalarmed, after staff had been educated to alarm those doors as a part of their Abatement Plan for F689. V1 then admitted that they were relying on staff and/or visitors to manually alarm those doors each time they were used. The State Survey team then discussed concerns regarding 3rd shift staff not responding to the front door when it alarmed for four minutes at 6:50 am that morning. V1 went on to say she was aware that staff were unable to hear the front door alarms sound through the fire doors when they were closed. At that point, V1 confirmed that if the fire doors at the entrance of the facility were not alarmed, any resident with a wander guard on could exit through those doors and once the fire 146108 Page 22 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many doors close behind them, staff would not be able to hear the alarm of the front entrance doors if the resident eloped. V1 indicated that had not been taken into consideration when the decision was made to keep the front entrance fire doors closed to be alarmed. On 6/14/22 at 10:05 am, the front door alarm was set off with the fire doors at the Skilled Unit entry way closed. The alarm sounded for five minutes, with no staff responding. The Surveyor then went onto the skilled unit with the fire door closed and confirmed that staff working on the skilled unit cannot hear the front door alarms if they sound. At that point, V1 (Administrator), V19 (Regional Nurse), V39 (Licensed Nursing Home Administrator) and V40 (Regional Nurse) began developing another plan regarding which doors should be alarmed/closed again. 146108 Page 23 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to develop and implement a plan of action to correct identified quality of care related deficiencies and follow up on resident care areas identified as a concern, through the Quality Assessment & Assurance Committee. This failure has the potential to affect all 30 residents living in the facility. Findings include: The facility's QAPI (Quality Assurance and Performance Improvement) Plan, effective 4/01/22, documents, (The facility) is committed to providing quality care to the customers it serves, in a home-like atmosphere. We attempt to deliver and maintain customers' functional status at the highest practicable physical, mental and psycho-social well-being; to promote human dignity; to provide person centered care that offers legitimate choices and control to customers to ensure quality of life; protect human dignity; and encourage staff engagement, competency and empowerment to better serve our customers and their families. We view QAPI as an integral role in management of our facility and board functions. Thou outcome of our QAPI program can be measured through the high level of resident and family satisfaction and the quality of care and life experienced by all at (the facility). In our organization, the outcome of QAPI is the quality of care and the quality of life for our residents. Our organization uses QAPI to make decisions and guide our day-today operations. Our QAPI program focuses on our organizations systems and processes, rather than on the performance of individuals. We strive to identify and improve system gaps, rather than place blame. Our organization sets goals for performance improvement and measures progress towards those goals. Our organization supports performance improvement by encouraging our employees to support each other, as well as to be accountable for their own professional performance and practice. Our organization maintains a culture that encourages, rather than punishes, employees who identify errors or system breakdown. The QAPI Plan further documents, QA&A Committee Reports to the executive leadership and Governing Body and responsible for: 1) Meeting, at a minimum, on a quarterly basis; more frequently if necessary 2) Coordinating and evaluating QAPI program activities 3) Developing and implementing appropriate plans of action to correct identified quality deficiencies 4) Regularly reviewing and analyzing data collected under the QAPI Program and data resulting from drug regimen review and acting on available data to make improvements 5) Determining areas for PIP (Performance Improvement Projects) and Plan-Do-Study-Act (PDSA) rapid cycle improvement projects 6) Analyzing the QAPI program performance to identify and follow up on areas of concern and/or opportunities for improvement. On 6/09/22 at 11:41 AM, V1 (Administrator) stated she started her position within the facility in 11/2021. V1 stated the facility has not has a QAA meeting since she started her position. V1 stated the QAA Committee had planned to meet in March of 2022, but that meeting was canceled. V1 stated there were multiple areas identified that needed to be discussed in March 2022 meeting, that the Board has not had the opportunity to follow up on or develop an improvement plan for. V1 identified the following areas as known concerns for the facility and the residents, that still need to be addressed: 1.) Use of Psychotropic Medications and the need for GDRs (Gradual Dose Reductions), obtaining appropriate referrals from the hospital, staff not documenting significant resident events according to protocol/policies, staff monitoring and documenting resident behaviors, poor staff retention, CNAs (Certified Nursing Assistants) professionalism during resident care and the dining process and timing, as the residents feel they have to wait too long to receive their food once they enter the dining room. V1 stated these are just some of the concerns that have come up since she started in November 2021, but no corrective action plan has been developed with the QAA Committee since being identified. 146108 Page 24 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0867 The Resident Census and Condition Report, dated 6/07/22, and signed by V24 (Minimum Data Set/Care Plan Coordinator) documents 30 residents currently reside in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 146108 Page 25 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) meetings were held at least quarterly. This failure has the potential to affect all 30 residents residing in the facility. Residents Affected - Many Findings include: The facility's QAPI (Quality Assurance and Performance Improvement) Plan, effective 4/01/22, documents The QA&A Committee Reports to the executive leadership and Governing Body and responsible for: 1) Meeting, at a minimum, on a quarterly basis; more frequently if necessary. The facility's QAA Committee Meeting Minutes sign in sheets, provided by V1 (Administrator), document there were only two quarterly QAA meetings held in the past four quarters. Those documented meetings occurred on 7/20/21 and 10/26/21. On 6/09/22 at 12:28 pm, V1 (Administrator) stated the facility did not hold quarterly QAA meetings for the first and second quarter of 2022. The Resident Census and Condition Report (Centers for Medicare and Medicaid/CMS 672), dated 6/07/22, and signed by V24 (Minimum Data Set/Care Plan Coordinator) documents 30 residents currently reside in the facility. 146108 Page 26 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety Based on observation, interview, and record review, the facility failed to ensure all employees were screened upon entrance to the facility for COVID-19 (Coronavirus Disease 2019) every day before their scheduled work shift, failed to remove a symptomatic employee from work immediately and quarantine this employee, and failed to isolate residents who are unvaccinated or not up to date with the COVID-19 vaccination immediately after exposure to COVID-19 positive employees. These failures resulted in V4 and V6 (CNAs/Certified Nursing Assistant) continuing to provide direct care to all of the residents within the facility for three to five days after exhibiting symptoms of COVID-19 and eventually testing positive for COVID-19. These failures have the potential to affect all 30 residents within the facility, which is located in a high COVID-19 transmission area according to the Centers for Disease Control and Prevention (CDC) COVID-19 data tracker. Residents Affected - Many These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6-15-22, the facility remains out of compliance at a severity Level II as the facility continues to screen employees prior to their shift for COVID-19, test employees and residents who are symptomatic of COVID-19 immediately, remove employees from the facility immediately who have symptoms of COVID-19, isolate residents who are not up to date with the COVID-19 vaccination or are unvaccinated and have direct contact with anyone who is COVID-19 positive, in-service staff concerning the COVID -19 Screening Check List for Visitors, Vendors and Employees, and continue to audit employee screen forms for accuracy and to ensure staff are not working while symptomatic. Findings include: Form 672 dated 6-7-22 documents 30 residents reside within the facility. The CDC COVID-19 Data Tracker dated 6-2-22 through 6-7-22 documents COVID-19 Community Level of contracting COVID-19 as High for Peoria County, Illinois (the county the facility is within). The facility's COVID-19 policy dated 1-19-22 documents, The infection control program at this facility recognizes novel Coronavirus (COVID-19) as a highly contagious virus and has a focus to reduce the risk of unnecessary exposures among residents, staff, and visitors. Measures are based on guidance from the Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and state and local authorities. Interventions focus on prevention of exposure, early detection of symptoms, effective triage, and isolation of potentially infectious residents. Screening: All people upon entering the facility must self-screen at designated area for signs and symptoms of COVID-19 based on the most current recommendations of CMS, CDC, and State Department of Public Health. Documented screening forms will be kept for at least 30 days. Facility will use the CDC COVID-19 Data Tracker Website to carefully monitor the color-coding, which depicts county community transmission levels. Staff who are not moderately to severely immunocompromised may return to work after ten days or may return to work after seven days if asymptomatic or have mild to moderate symptoms that are improving and fever-free for 24 hours. Must have one negative test completed within 48 hours before work shift begins or rapid antigen test prior to shift. Exposure Definition: Exposure is defined as being within six feet of a person with confirmed COVID-19 infection or having unprotected direct contact with infectious secretions or excretions of the person with confirmed COVID-19 infection. 146108 Page 27 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 2-2-22 documents, Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: A positive viral test for SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus), symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection or a higher-risk exposure (for healthcare personnel (HCP). Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2. The facility's COVID-19 Screening Checklist for Visitors, Vendors, and Employees dated 1-7-22 documents that if any visitor, vendor, or employee is experiencing any of the following symptoms, they are to be restricted from entering the building: fever, chills, fatigue, diarrhea, congestion, runny nose, nausea/vomiting, headache, sore throat, new/worsening cough, muscle/body aches, new loss of taste of smell, and shortness of breath, or difficulty breathing. The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus) Spread in Nursing Homes & Long-Term Care Facilities Website dated February 2, 2022 documents, Manage residents who had close contact with someone with SARS-CoV-2 Infection: Residents who are not up to date with all recommended COVID-19 (Coronavirus Disease 2019) vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP (Health Care Personnel) caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure if they do not develop symptoms. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure if a viral test is negative for SARS-CoV-2 and they do not develop symptoms. On 06/06/22 at 2:00 PM, V6 (Certified Nursing Assistant/ CNA) stated, I was not tested for COVID-19 until 6-3-22 when I tested positive for COVID-19. I started feeling sick on Monday (5-30-22) and for the rest of the week. I had a runny nose, chills and a mucousy cough. I brought a space heater to work because I was chilling so bad. I did not do the pre-screening for COVID before my shifts. The screening is located in another building and that door is locked, so I cannot get to the screening. I took care of all of the residents in the building every day I worked last week. On 06/06/22 at 2:15 PM, V4 (Certified Nursing Assistant/CNA) stated, I tested myself for COVID-19 using a (Brand Name Covid 19 Antigen Rapid Test) rapid test on Saturday (6-4-22) around 10:30 AM when I went out to my car for break. The test came back positive. I had worked since 2:00 AM that morning. I worked until 2:00 PM that day and worked Sunday from 2:00 AM through 2:00 PM and worked Monday starting at 4:00 AM. On Monday (6-6-22) around 8:05 AM V2(Director of Nursing/DON) came in and swabbed me for COVID-19 again, and the rapid test V2 obtained was positive for COVID, so I was sent home. I had worked with all of the residents on every shift that I worked on Saturday, Sunday, and Monday. V6's Time and Attendance Employee Punch History dated 5-30-22 through 6-2-22 documents V6 worked on 5-30-22 from 10:03 PM through 6-1-22 at 6:08 PM, 6-1-22 from 10:15 PM through 6-2-22 at 6:20 AM, 146108 Page 28 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0880 and 6-2-22 from 10:10 PM through 6-3-22 at 6:08 AM. Level of Harm - Immediate jeopardy to resident health or safety V4's Time and Attendance Employee Punch History dated 6-4-22 through 6-6-22 documents V4 worked on 6-4-22 from 2:04 AM through 2:03 PM, 6-5-22 from 1:58 AM through 2:01 PM, and 6-6-22 from 3:59 AM through 8:05 AM. Residents Affected - Many The facility's COVID-19 Screening Checklists for Visitors, Vendors, and Employees dated 5-1-22 through 6-4-22, do not include any screening checklists for V6 (CNA). The CDC COVID-19 webpage dated 5-24-22 documents: Vaccines: Primary Series: Doses of Pfizer-BioNTech given three to eight weeks apart. Fully Vaccinated: Two weeks after final dose in primary series. Boosters: One booster for most people at least five months after the final dose in the primary series. Second booster of either Pfizer-BioNTech or Moderna COVID-19 vaccine for adults ages 50 years and older at least four months after the first booster. Up to Date: Immediately after getting all boosters recommended for you. The facility's COVID-19 Vaccine Resident Tracking documents R8's initial COVID-19 vaccination two doses were finished on 10-30-21 and R8 refused the Pfizer boosters. This same tracking documents R30 refused the COVID-19 vaccinations. On 6-6-22 at 8:45 AM and 6-7-22 at 3:10 PM, R30 was lying in his bed in his room. R30 was not in isolation at these times. R30 stated he does not want the COVID-19 vaccination. On 6-6-22 at 12:10 PM, R8 was self-propelling her wheelchair up the hallway and into her room. R8 stated that she does not want a COVID-19 booster and has not been in isolation. R8 was not in isolation at this time. On 6-7-22 at 3:10 PM, R8 was in bed in her room. R8 was not in isolation at this time. On 06/06/22 at 2:30 PM, V2 (DON) stated, I did not know that V4 had symptoms of COVID-19, or that V4 was not screened for COVID-19 symptoms prior to her shifts. V4 should not have worked while having symptoms of COVID-19. All employees are supposed to screen themselves for COVID-19 prior to working their shifts and immediately upon entering the facility. R8 and R30 have not been put in isolation. The Immediate Jeopardy was identified on June 7, 2022 at 11:08 AM. The Immediate Jeopardy began on May 30, 2022, when the facility failed to screen, remove and test an employee V6 (CNA) for COVID-19 who was having active symptoms of COVID, resulting in V6 continuing to work with all residents from 5-30-22 through 6-3-22 (when V6 tested positive for COVID-19). V1 (Administrator) and V19 (Regional Nurse) were notified of the Immediate Jeopardy on 6-8-22 at 11:00 AM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 (Administrator) and V2 (Director of Nursing) were in-serviced on 6-8-22 by V19 (Regional Nurse) on COVID-19 testing requirements, screening employees prior the start of their shift, testing employees immediately who have symptoms and sending them home following the CDC/IDPH Guidance, ensuring COVID-19 POC (Point of Care) and PCR (Polymerase Chain Reaction) testing supplies are available for 146108 Page 29 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many all licensed nurses on each shift and, ensuring licensed trained staff are performing the COVID-19 Testing and reviewing the manufacturer's directions for COVID-19 testing, and ensuring all residents who are unvaccinated or not up to date with COVID-9 boosters were isolated immediately after exposure to COVID-19. 2. V1 and V2 initiated all staff in-servicing on 6/7/2022, concerning the COVID -19 Screening Check List for Visitors, Vendors and Employees. Staff not currently working will be in-serviced prior to the beginning of their next scheduled shift. 3. Staff were actively screened prior to their scheduled shift by the front desk receptionist during normal business hours and by a licensed nurse assigned to the long hall on off hours including on second shift, third shift, and the weekend. Employees reporting or exhibiting any symptoms of COVID-19 were tested and sent home immediately. 4. Adequate testing supplies were located for licensed nurses to access during all shifts in the nurse's medication preparation room. 5. All licensed nurses were trained on the testing kits manufactures guidelines on how to appropriately use the POC (Point of Care) antigen rapid testing device, including when to follow-up with PCR test. 6. Employees are to report to the nurse immediately upon the onset of any signs or symptoms that occur during their shift and will then be COVID-19 tested, sent home, and the licensed nurse will report this or anyone testing positive to V1 and V2. 7. All residents who are unvaccinated or not up-to-date with the COVID-19 vaccinations were placed in isolation after being exposed to COVID-19. 8. V2 completed an audit on 6-7-22 and 6-8-22 to ensure that staff currently working were not symptomatic for COVID-19. 9. Facility wide testing was completed on 6-7-22 and no residents tested positive. One employee in dietary tested positive, who did not have a high- risk exposure to any resident and was sent home immediately. 10. All screening forms were being reviewed by the front desk receptionists or licensed nurses at the time of completion. On 6-9-22 at 2:00 PM, R30 was self-propelling up the hallway in her wheelchair and R8 was lying in bed. Neither R8 nor R30 were in contact/droplet isolation precautions. Due to R8 and R30 not being placed in isolation precautions as stated in the facility's abatement plan, the facility's abatement plan was not completely executed by 6-8-22 as documented by the facility. On 6-13-22 from 9:45 AM through 10:15 AM, V30 (Agency LPN), V31 (Physical Therapy Assistant), V32 (Occupational Therapy Assistant) and V33 (Housekeeper) stated that they had not been educated or in-serviced regarding anything within the past two weeks including COVID-19 pre-screening prior to work, performing COVID-19 testing, reporting signs and symptoms of COVID-19 immediately, and removing staff immediately with any signs and symptoms of COVID-19. 146108 Page 30 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many On 6-14-22 from 5:05 am to 5:15 am, V22 (Registered Nurse/RN) could not reiterate any education provided by Administrative staff in the last week and V37 (Agency Certified Nursing Assistant) and V38 (Cook) stated they had not received any education or in-servicing regarding COVID -19 pre-screening prior to work, performing COVID-19 testing, reporting signs and symptoms of COVID-19 immediately, and removing staff immediately with any signs and symptoms of COVID-19. Based on observation, interview, and record reviews conducted on 6-16-22 the facility completed all measures on the abatement plan to remove the immediacy by 6-15-22. 146108 Page 31 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to designate a qualified Infection Preventionist. This failure has the potential to affect all 30 residents residing in the facility. Residents Affected - Many Findings include: 672, dated 6-7-22 documents 30 residents reside within the facility. The facility's Infection Preventionist Job Description dated 04/2022 documents, Job Function: Responsible for the facility infection prevention and control program which is designed to help prevent the development and transmission of communicable diseases and infections. On 06/06/2022 at 1:00 PM, the facility could not provide documentation that any employee of the facility had completed an Infection Preventionist Nursing Home Training Course Infection Course between the dates of 11-16-21 through 6-6-22. The facility was unable to provide documentation on who the facility's Infection Preventionist was. On 06/06/22 02:19 PM, V2 (Director of Nursing/DON) stated, The facility has not had an Infection Preventionist that I am aware of since I started in November, 2021. I just finished an Infection Preventionist course today. On 06/08/22 at 11:05 AM, V1 (Administrator) stated, I did not even know that the facility needed an Infection Preventionist. 146108 Page 32 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0886 Perform COVID19 testing on residents and staff. Level of Harm - Immediate jeopardy to resident health or safety Based on record review and interview, the facility failed to test an employee who had symptoms of COVID-19 immediately, failed to follow the COVID-19 rapid tests manufacturer's recommendations for accurate testing, failed to ensure COVID-19 testing supplies were readily available for staff to obtain testing on the designated testing days, and failed to utilize trained licensed staff to obtain the staff's COVID-19 tests. These failures resulted in one positive COVID-19 staff member V6 (Certified Nursing Assistant/CNA) working with residents due lack of testing supplies readily available upon entrance to the facility, and then testing positive for COVID-19. This also resulted in another staff V4 (Certified Nursing Assistant/CNA) continuing to provide direct care to all of the residents for two days after a nurse failed to follow the rapid COVID-19 test manufacturer's recommendations by not waiting the allotted time to complete a COVID-19 test resulting in the nurse erroneously reading the result as negative. These failures have the potential to affect all 30 residents within the facility. Residents Affected - Many These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6-15-22, the facility remains out of compliance at a severity Level II as the facility continues to screen employees prior to their shift for COVID-19, test employees and residents who are symptomatic of COVID-19 immediately, remove employees from the facility immediately who have symptoms of COVID-19, in-service staff concerning the COVID -19 Screening Check List for Visitors, Vendors and Employees, in-service all licensed nurses on the testing kits manufacture's guidelines on how to appropriately use the antigen rapid testing device, and continue to audit employee screen forms for accuracy and to ensure staff is not working while symptomatic. Findings include: Form 672 dated 6-7-22 documents 30 residents reside within the facility. The facility's Infection Control Communicable Disease Testing policy dated 3-15-22 documents, The facility shall conduct testing of residents and staff for the control or detection of communicable disease in the following situations: The facility is experiencing an outbreak. The facility is directed by the department or the certified local health department where the chance of transmission is high, including, but not limited to, regional outbreaks, pandemics, or epidemics. COVID-19 Testing: c. Facility may utilize rapid point of care tests if available and appropriate. Trained licensed staff will be utilized to obtain the tests. Routine testing for unvaccinated facility staff only will be based on the extent of the virus in the community using the level of community transmission in the past week. High (red)-minimum of twice a week testing. Facility staff will include employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents. Facility will prioritize those individuals who are in the facility on a weekly basis. Any staff that has a fever or exhibit symptoms will be tested. The (Brand Name) COVID-19 Antigen Rapid Test Manufacturer's Instructions dated 12/2021 for use document, A positive result must show both a c (control) line and a t (test) line. A positive result means that viral antigens from COVID-19 were detected and the individual is positive for COVID-19. Persons who test positive should self-isolate and seek follow up care with their Physician or healthcare provider as additional testing and public health reporting may be necessary. The t line may be faint and is evidence of a positive test. 146108 Page 33 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0886 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many The (Brand Name) COVID-19 Card Rapid Test Manufacturer's Instructions dated 12/2020 document, Peel off adhesive liner from the right edge of the test card. Close and securely seal the card. Read result in the window 15 minutes after closing the card. In order to ensure proper test performance, it is important to read the result promptly at 15 minutes, and not before. False negative results can occur if test results are read before the 15 minutes. On 06/06/22 at 2:00 PM, V6 (Certified Nursing Assistant/CNA) stated, I was supposed to test myself for COVID-19 last Thursday (6-2-22) at 10:00 PM but there were no rapid COVID tests available for me to test. All of the tests were locked up in V2's (Director of Nursing/DON) office. I worked that night from 10:00 PM through 6:00 AM (6-3-22). V2 came in at 6:00 AM on Friday (6-3-22) and I tested positive for COVID. I was sick all last week. I started feeling sick on Monday (5-30-22) and for the rest of the week. I had a runny nose, chills and a mucousy cough. I brought a space heater to work because I was chilling so bad. On 06/06/22 at 2:15 PM, V4 (Certified Nursing Assistant/CNA) stated, I tested myself for COVID-19 using a (Brand Name Covid 19 Antigen Rapid Test) rapid test on Saturday (6-4-22) around 10:30 AM when I went out to my car for break. That test requires three drops of solution. The test came back positive. I had worked since 2:00 AM that morning. I took the test into V3(Licensed Practical Nurse/LPN) and showed her it was positive. V3 took a different rapid test and re-tested me and (V3 told me it was negative and to go ahead and work. I worked until 2:00 PM that day and worked Sunday (6-5-22) from 2:00 AM through 2:00 PM and worked Monday (6-6-22) starting at 4:00 AM. On Monday (6-6-22) around 8:05 AM, V2 (DON) came in and said that the test V3 swabbed me with (on 6-4-22) had a positive result. V3 (LPN) had put my test result card in V2's office box. V2 noticed the test was positive and had me re-test. The rapid test V2 obtained on me was positive for COVID, so I was sent home. I had worked with all of the residents on every shift I worked on Saturday, Sunday, and Monday. I have had the Pfizer COVID vaccine and I have been boosted. V6's (CNA) Time and Attendance Employee Punch History dated 5-30-22 through 6-2-22 documents V6 worked on 5-30-22 from 10:03 PM through 6-1-22 at 6:08 AM, 6-1-22 from 10:15 PM through 6-2-22 at 6:20 AM, and 6-2-22 from 10:10 PM through 6-3-22 at 6:08 AM. V4's (CNA) Time and Attendance Employee Punch History dated 6-4-22 through 6-6-22 documents V4 worked on 6-4-22 from 2:04 AM through 2:03 PM, 6-5-22 from 1:58 AM through 2:01 PM, and 6-6-22 from 3:59 AM through 8:05 AM. On 06/06/22 at 1:45 PM, V3 (LPN) stated, V4 took a rapid COVID test out to her car and tested herself on (6-4-22). V4 brought the test to me showing me she had a faint line indicating she was positive for COVID. V4 had used the (Brand Name) antigen rapid COVID test. The staff are able to use either the (Brand Name A) rapid test or the (Brand Name B) COVID antigen rapid test. I took a (Brand Name B) test and re-tested V4. I waited five minutes to read the test and it was negative. I told V4 she was negative and let her stay at work. I took V4's test and placed it in a biohazard bag and placed it into V2's (DON) office box. I put all COVID tests that are done over the weekend in V2's box. The staff are able to test themselves for COVID. On 6/7/22 at 10:20 a.m., V10 (Housekeeper) stated she is tested for COVID-19 twice a week, and she is allowed to swab herself and wait about 15 minutes for results. On 6/7/22 at 10:30 a.m., V11 (Certified Nursing Assistant/CNA) stated she is tested for COVID-19 on Mondays and Thursdays, and she swabs herself. V11 stated, Whoever the nurse is will let us know if 146108 Page 34 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0886 there is an issue with the test, like if it's positive. Level of Harm - Immediate jeopardy to resident health or safety On 6/8/22 at 10:36 a.m., V12 (Certified Nursing Assistant/CNA) stated she is tested for COVID-19 twice a week and she swabs herself. V12 stated, I wait about five minutes for the results (of the COVID-19 test) then go to the floor. Residents Affected - Many On 6/7/22 at 10:25 AM, V9 (Certified Nursing Assistant/CNA) stated, Right now, we are testing two times a week due to having some positive cases. I get here between two and four in the morning, and I get off at two in the afternoon. I am due to test today and I normally do that whenever V2 (DON) gets here. She is here now but I have not tested today. V2 will usually send a message and let us know when are to go to her office and test. When I am tested, I swab myself, and then V2 confirms the results. On the weekends, the on-duty nurse gets the test for me, and I swab myself and then the nurse verifies the results. On 06/06/22 at 2:30 PM, V2 (DON) stated, I did not know that V4 (CNA) had tested herself and was positive. V4 should have gone home as soon as, she was positive. I also did not know that (V3) did not do the COVID rapid test right by waiting 15 minutes before reading the result. When I got to work, I noticed (V4's) COVID test had a line showing it was positive, so I had (V4) do another test on that following Monday and it was positive. (V4) should not have worked while having symptoms of COVID-19 and while testing positive for COVID-19. (V6) did not have a COVID-19 rapid test available for her to test herself, and I live over 45 minutes away from the facility and was not going to come in to get a test for her. The employees are supposed to test every Monday and Thursday. The Immediate Jeopardy was identified on June 7, 2022 at 11:00 AM. The Immediate Jeopardy began on June 2, 2022, when the facility failed to have COVID-19 tests readily available to test V6 for COVID-19, as per the facility's scheduled test days to test facility staff, resulting in V6 continuing to work with all residents and testing positive for COVID-19 the following morning on June 3, 2022, and V4 continuing to work with residents for two days after testing positive for COVID-19 on June 4, 2022. V1 (Administrator) and V19 (Regional Nurse) were notified of the Immediate Jeopardy on 6-8-22 at 11:00 AM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 (Administrator) and V2 (Director of Nursing/DON) were in-serviced on 6-8-22 by V19 (Regional Nurse) on COVID-19 testing requirements, screening employees prior the start of their shift, testing employees immediately who have symptoms and sending them home following the CDC/IDPH Guidance, ensuring COVID-19 POC (Point of Care) and PCR (Polymerase Chain Reaction) testing supplies are available for all licensed nurses on each shift and, ensuring licensed trained staff are performing the COVID-19 Testing and reviewing the manufacturer's directions for COVID-19 testing, and ensuring all residents who are unvaccinated or not up to date with COVID-19 boosters were isolated immediately after exposure to COVID-19. 2. V1 and V2 initiated all staff in-servicing on 6/7/2022, concerning the COVID -19 Screening Check List for Visitors, Vendors and Employees. Staff not currently working will be in-serviced prior to the beginning of their next scheduled shift. 146108 Page 35 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0886 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many 3. Staff were actively screened prior to their scheduled shift by the front desk receptionist during normal business hours and by a licensed nurse assigned to the long hall on off hours including on second shift, third shift, and the weekend. Employees reporting or exhibiting any symptoms of COVID-19 were tested and sent home immediately. 4. Adequate testing supplies were located for licensed nurses to access during all shifts in the nurse's medication preparation room. 5. All licensed nurses were trained on the testing kits manufacture's guidelines on how to appropriately use the POC antigen rapid testing device, including when to follow-up with PCR test. 6. Employees are to report to the nurse immediately upon the onset of any signs or symptoms that occur during their shift and will then be COVID-19 tested, sent home, and the licensed nurse will report this or anyone testing positive to V1 and V2. 7. All residents who are unvaccinated or not up-to-date with the COVID-19 vaccinations were placed in isolation after being exposed to COVID-19. 8. V2 (DON)completed an audit on 6-7-22 and 6-8-22 to ensure that staff currently working were not symptomatic for COVID-19. 9. Facility wide testing was completed on 6-7-22 and no residents tested positive. One employee in the dietary department tested positive, who did not have a high- risk exposure to any resident and was sent home immediately. 10. All screening forms were being reviewed by the front desk receptionists or licensed nurses at the time of completion. On 6-9-22 at 2:00 PM, R30 was self-propelling up the hallway in her wheelchair and R8 was lying in bed. Neither R30 nor R8 was in contact droplet isolation precautions. Due to R8 and R30 not being placed in isolation precautions as stated in the facility's abatement plan, the facility's abatement plan was not completely executed by 6-8-22 as documented by the facility. Therefore, the immediacy could not be removed on 6-8-22. On 6-13-22 from 9:45 AM through 10:15 AM, V30 (Agency Licensed Practical Nurse/Agency LPN), V31 (Physical Therapy Assistant), V32 (Occupational Therapy Assistant) and V33 (Housekeeper) stated that they had not been educated or in-serviced regarding anything within the past two weeks including COVID-19 pre-screening prior to work, performing COVID-19 testing, reporting signs and symptoms of COVID-19 immediately, and removing staff immediately with any signs and symptoms of COVID-19. On 6-14-22 from 5:05 am to 5:15 am, V22 (Registered Nurse/RN) could not reiterate any education provided by Administrative staff in the last week and V37 (Agency Certified Nursing Assistant/Agency CNA) and V38 (Cook) stated they had not received any education or in-servicing regarding COVID -19 pre-screening prior to work, performing COVID-19 testing, reporting signs and symptoms of COVID-19 immediately, and removing staff immediately with any signs and symptoms of COVID-19. Based on observation, interview, and record reviews conducted on 6-16-22, the facility completed all measures to remove the immediacy for F886 by 6-15-22. 146108 Page 36 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure a resident's call light was in working order at all times for one of twelve residents (R24) reviewed for call lights in the sample of 27. Residents Affected - Few Findings include: The facility's Call Light policy, dated 1/2004, documents, If the call light is defective, report immediately to maintenance. Check room frequently until call light is repaired. Fill out a maintenance work request form stating room number and take to maintenance immediately. The facility's Maintenance policy, dated 2/25/19, documents, It is the facility's policy to provide its' residents with an adequate maintenance service within the facility and maintaining Public Health rules and regulations. Any items that directly affects resident care will be given top priority and will be attended to as quickly as possible by appropriate maintenance worker. On 6/7/22 at 10:30 AM, R24 attended the Resident Council group meeting and stated that his call light in his room does not work. R24 stated that R24 has told staff and, They come down and wiggle it and say it's working but then it goes back to not working. On 6/8/22 at 9:50 AM, R24 was sitting in his room on the edge of the bed. R24 stated that his call light stopped working on Friday (6/3/22). R24 stated, I told a couple certified nursing assistants and when they came in, they would wiggle it and it might work one time but then goes right back to not working. I can't remember the names of staff I have told but I did tell more than one nursing assistant about this. At this time R24 hit his call light two times and it did not alarm or light up outside of his room. On 6/8/22 at 10:00 AM, V16 (Registered Nurse/RN) confirmed that R24's call light was not alarming. V16 then went into R24's room and wiggled the call light cord to push it back into the wall mount. V16 stated she was not aware of the issue and confirmed there is no work order for R24's call light to be fixed. On 6/8/22 at 10:05 AM, V2 (Director of Nursing/DON) confirmed that the call light should have been fixed immediately upon it being discovered not functioning. V2 stated, I was not made aware. V17 (Maintenance Director) was not aware and does not have a work order to fix R24's call light. 146108 Page 37 of 38 146108 06/16/2022 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on record review and interview, the facility failed to ensure the Nursing Aides were provided with annual Dementia management training. This failure has the potential to affect all 30 residents within the facility. Findings include: Form 672, dated 6-7-22 documents 30 residents reside within the facility. The Facility's current CNA (Certified Nursing Assistant) Listing documents the following CNAs (V4, V5, V9, V26, V27, V28, V29) have worked for the facility for over one year. These same CNAs employee files did not contain evidence that these CNAs had the required annual Dementia management training. On 6-10-22 at 9:30 AM, V1 (Administrator) stated that V4, V5, V9, V26, V27, V28, and V29 have not received the annual Dementia management training. 146108 Page 38 of 38