Health inspection·May 19, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to assess one resident (R6) for self-administration of medications of 16 residents reviewed for medications in the sample of 40. Residents Affected - Few Findings include: Facility Policy/Self-Administration of Medications dated/revised 12/02 documents: Self-administration preference shall be noted in the resident's record. If the resident chooses to self-medicate, the interdisciplinary team shall meet and assess the resident's ability to self-medicate. This includes the resident's cognitive, physical, and visual ability to carry out this responsibility. The storage and documentation of self-administered medications shall be the responsibility of the nursing staff. Facility staff, with the direction of the Director of Nursing, shall exercise program oversight with guidance of residents in self-administration of medication. All medications used by the resident shall be properly recorded by the facility staff at the time of use on self-administration record. The MAR will indicate self-administration. The clinical record shall record the resident's response to the program. Current Physician's Order Report indicates R6 has diagnoses that include Unspecified Respiratory Disorder and Alzheimer's Disease. Physician Orders include orders for: Ipratropium-albuterol solution for nebulization 0.5mg-3mg (milligram)/3ml (milliliter) inhalation, four times per day as needed for wheezing/shortness of breath. Albuterol sulfate solution for nebulization 2.5mg/3ml (0.083%) inhalation three times per day. Ipratropium-albuterol solution for nebulization 0.5mg-3mg/3ml, amount 1 vial inhalation as needed three times per day. Current Medication Administration Record (MAR) indicates R6 received albuterol sulfate 2.5mg/3ml three times per day via nebulizer from 5/1/23 through 5/18/23. Page 1 of 22 146108 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Current Comprehensive Assessment indicates R6 could not be interviewed for cognitive patterns due to R6 is rarely/never understood, has mild memory impairments and is modified independent. On 5/16/23 at 11am, R6 was in her room and stated she uses the nebulizer sometimes. Nebulizer machine was on the bedside table and had the medication chamber, mouthpiece and tubing were all connected. The medication chamber contained a small amount of clear liquid. On 5/17/23 at 1:45pm, R6's nebulizer chamber still contained liquid. On 5/18/23 at 9:50am, R6's nebulizer chamber had even more liquid than on the previous days of observation. At that time V10 (Licensed Practical Nurse/LPN) was questioned about R6's nebulizer. V10 stated that the liquid in the nebulizer chamber is Albuterol (bronchodilator), the medication used in the nebulizer. V10 stated that R6 wants to do it herself, so the nurses just put the medication in the chamber and R6 will use it when she wants. V10 stated she did not put the liquid into the chamber and didn't know when or who filled the chamber. Physician Order Report and Care Plan does not include orders for R6 to self-administer medications, including nebulizers. On 5/19/23 at 10:45am V2 (Director of Nursing/DON) stated she found the assessment form for residents who want to self-administer medications, but it had not been completed prior to R6 self-administering inhalation medications. V2 acknowledged the policy should have been followed. 146108 Page 2 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0610 Respond appropriately to all alleged violations. 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 ensure a thorough investigation of an allegation of employee to resident abuse for one resident (R23) and failed to ensure thorough investigations were completed for two residents (R29, R140) with injuries of unknown origin of three residents reviewed for abuse in the sample of 40. Findings include: 1) Nurse Progress Note for R29, dated 3/29/23 at 2:12pm indicates swelling noted to right wrist, painful to touch; X-ray ordered. Radiology Report dated 3/29/23 indicates R29 had a non-displaced fracture of distal right (fracture). Serious Injury Incident Report (initial and final) for R29, dated 3/31/23 indicates date of last fall was 2/3/23 with no injury. Report indicates R29 experiences tremors and muscle spasms due to disease processes, striking forearms and wrist(s) against hard surfaces. Report indicates Incident Category as Right Wrist Fracture not Injury of Unknown Origin. The Current Care Plan did not include interventions to protect R29 from injury related to tremors and muscle spasms until wrist fracture on 3/30/23. No documentation was found or presented to indicate R29 had behaviors of striking forearms and wrists against hard surfaces. No documented interviews were provided as part of the incident file. A thorough investigation of R29's right wrist fracture was not included with the Incident Report. The only document that was part of the investigation was one page of brief, handwritten notes documented by V2 (Director of Nursing/DON). On 5/18/23 at 3:20pm V1 (Administrator) stated the incident was an injury of unknown origin and thought they had identified the source of R29's injury. V1 stated she was unaware of the extent of the investigation or lack of documented interviews. 2) Nurse Progress Note dated 4/13/23 at 7:32pm indicates R140 was admitted from assisted living dementia care unit. admission Skin assessment dated [DATE] at 6:51pm indicates no skin alterations; no petechiae (red/purple). Nurse Progress Note dated 4/15/23 at 10:53am indicates R140 was assessed to have top of left foot and up to ankle was a 12cm (centimeter) x 9.5cm black-blue bruise; top of right foot, along outer side of right foot up to right ankle was a 12cm x 11cm black-blue bruise; swelling to bilateral feet and ankles. Note indicates R120 reported moderate pain to affected areas. Note indicates X-rays were 146108 Page 3 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0610 ordered at that time. Level of Harm - Minimal harm or potential for actual harm Nurse Progress Note dated 4/16/23 at 9:31am indicates likely 5th metatarsal bone fracture. Residents Affected - Few Nurse Progress Note dated 4/16/23 at 3:52pm indicates possible hairline fracture on left ankle. R140 was transferred to the hospital and admitted overnight for Urinary Tract Infection. Nurse Progress Note dated 4/20/23 10:48am indicates R140 has bruising to bilateral ankles and feet, bruising noted to back of both knees possible cause from (mechanical lift) net. Event Report dated 4/15/23 at 1:55pm indicates R140 has bruising and swelling to bilateral feet and ankles. Report indicates Cause unknown. R140 had a fall 4 days ago, it is possible a fall injury. Serious Injury Incident Report (final) dated 4/21/23 at 12pm indicates R140 sustained a 5th metatarsal fracture - does not identify injury as unknown origin. Incident Report Summary indicates hospital X-ray results showed no acute fracture. It was discovered that (R140) had two incidents of being lowered to the ground prior to (admission to the facility). No documented interviews were provided as part of the incident file. A thorough investigation of R140's right severe bilateral extremity bruising, and swelling was not included with the Incident Report. The only document that was part of the investigation was one page of brief, handwritten notes (timeline) documented by V2 (DON). No investigation was done to investigate the potential that the injuries were sustained during mechanical lift transfer as documented in nurse notes dated 4/20/23. On 5/18/23 at 3:20pm, V1 (Administrator) stated the incidents were an injury of unknown origin and thought they had identified the source of R29 and R140's injuries. V1 stated she was unaware of the extent of the investigation or lack of documented interviews. Facility Policy/Abuse Prohibition and Reporting dated/revised 3/18/19 documents: Investigations: 1. Interviews with all involved parties or potential witnesses will be completed. At least one interviewer shall take notes. 2. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, person making the allegations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident. 3. The Administrator shall keep copies of all notes from the interviews conducted by the Administrator or other facility interviewer in the course of the investigation. 4. The Administrator shall be responsible for supervising the investigation and reporting the results to the State Agency. 146108 Page 4 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0610 Level of Harm - Minimal harm or potential for actual harm 3. On 5/17/23 at 2:40 PM R23 stated A CNA made me get out of bed one night to use the toilet and when I fell, she kept saying I did it on purpose. She said I (resident made air quotes) put myself on the ground. I told her (CNA) my leg would buckle and that I wanted to use the bedpan and she brought the lift in and sat me up and said stand up, so I did. When I stood up my leg buckled so I let myself slide very slowly to the ground. Residents Affected - Few R18's Event Report dated 3/9/23 at 11:15 PM documents CNA alert this nurse (V9/LPN) to room where resident sitting on floor beside her bed with head on mattress resident report dizzy angry with CNA (V6) for make her get out of bed to go to the bathroom. On 5/18/23 at 11:30 AM, V2 (DON) stated, I have no knowledge of resident saying someone made her get confirmed the event report contained the allegation that a CNA made resident get out of bed. On 5/18/23 at 1:00 PM, V1 (Administrator) stated, I was not informed of R18 saying a staff member made her get out of bed when she did not want to. I would have investigated it immediately as an allegation of abuse. 146108 Page 5 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some 8. R4 On 5/17/23 at 11:00 AM, R4 was sitting in a wheelchair in the dining room for lunch with oxygen infusing at 2L (liters) via a nasal canula and had pressure relieving boots to his bilateral lower legs. On this same date at 1:30 PM, R4 was lying in bed, eyes closed, and oxygen infusing at 2L via nasal canula. On 5/18/23 at 10:00 am, R4 was sitting in a wheelchair in his room watching television. R4 had pressure relieving boots to his bilateral lower legs and oxygen infusing at 2L via nasal canula. On 5/18/23 at 10:00 am, R4 confirmed his weight fluctuates up and down and stated he has been trying to lose weight because he needs to, his heart doctor would be glad, and his physician is aware and helping him. R4 stated he has been in the hospital multiple times for having trouble breathing, having severe migraines, an infection in the bone in his left little toe requiring surgery, and just finished his IV (intravenous) antibiotics last night. On 5/18/23 at 11:48 AM, V2 (Director of Nursing/DON) stated R4 has circulatory issues in his lower extremities, has multiple wounds due to this, has osteomyelitis, and just completed the IV antibiotics for the infection last night. The POS for R4, dated 5/17/23 documents R4 is on a regular diet and there are no other special diets or supplement orders for R4. The Monthly Weight Report for R4, documents R4's weight fluctuations as follows: 1/17/23 at 226.0 pounds; 1/26/23 at 242.3 pounds; 2/1/23 at 243.5 pounds; 3/2/23 at 236.8 pounds; 3/15/23 at 257.2 pounds; 3/21/23 at 249.2 pounds; 4/1/23 at 254.0 pounds; and 5/1/23 at 250.5 pounds which is a weight increase of 24.5 pounds since 1/17/23. The RD (Registered Dietician) readmission Review for R4, dated 4/28/23, documents R4 was admitted to the hospital on [DATE] with a diagnosis of UTI (urinary tract infection), A-fib (atrial fibrillation), and Sepsis. During R4's hospitalization, he received a bone biopsy of his left lateral foot that indicated osteomyelitis and surgery of left 5th toe. R4 returned to the facility on 4/26/23. This same review documents R4 with significant weight gain of 7.3% in one month and potential for changes in weight related to hospitalization and history of significant weight gains. Intakes may have varied during hospital admission. R4's current Care Plan does not include a weight loss, hospitalization, or oxygen care plan. On 5/17/23 at 2:10 pm, V4 (Care Plan Coordinator/Minimum Data Set Coordinator/Infection Control Preventionist) confirmed R4's current Care Plan does not include a plan of care for R4's fluctuation in weights, multiple hospitalizations or an oxygen care plan, and stated she will get the areas added to R4's Care Plan. 9. R35 146108 Page 6 of 22 146108 05/19/2023 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 On 5/16/23 at 11:00 AM and 5/17/23 at 11:49 AM, R35 was lying in bed on his left side with a chest tube exiting R35's right chest. R35 appears thin and frail with dry lips and oral cavity. R35 stated, I think I have been losing weight. On 5/17/23 at 11:49 AM, R35 was lying in bed on his left side with a chest tube drain to his right chest with oxygen infusing at 3L (liters) via nasal cannula. R35 stated he gets Chemotherapy on Tuesdays, Wednesday, and Thursdays for his lung cancer, but the chemotherapy is on hold for now and does not know when it will start back up. R35 stated he gets antibiotics and medications through his IV (peripheral intravenous line). On 5/17/23 at 3:06 PM, V2 (DON) stated R35 has stage IV lung cancer with metastasis in multiple areas of his body. V2 stated R35 has been in the hospital multiple times for thoracentesis and was recently in the hospital with pneumonia, and the hospital put in a chest tube to drain the fluid. V2 stated R35's cancer doctor felt R35 was too week for chemotherapy at this time and put it on hold, and R35 is being followed by the local cancer center. The Physician's Orders for R35, dated 3/16/23 through 5/17/23, documents physician orders for oxygen 3L/min (3 liters per minute) per nasal cannula. Monitor coccyx, cleanse and apply [NAME] zyme every shift and prn (as needed). D/C (discontinue) when healed. Monitor for s/s (signs and symptoms) of infection from chest tube; report to PCP (primary care physician) for increased pain, swelling, warmth, redness, pus, fever, or red streaks leading from area every shift. Right chest tube drains daily if symptomatic, do not drain more than 1,000 ml (milliliters) everyday prn. The Monthly Weight Report for R25 documents on 4/17/23, R35 weighed 158.2 pounds. And on 5/9/23, R35 weighed 136.4 pounds, resulting in a 13.78% weight loss in less than one month. The RD Note for R35, dated 5/12/23 documents R35 readmission from a local hospital with a diagnosis of pleural effusion and pneumonia to his left lower lobe with a history of malignant neoplasm of lung. The recent weight for R35 on 5/9/23 was 136.4 pounds which indicates a 13.5% weight loss since residents' recent hospital visit. The RD Note for R35, dated 4/21/23 documents R35 has the Potential for weight changes r/t (related to) hx (history) of minimal PO (by mouth) intake and hx of significant weight loss. The RD Note for R35, dated 3/29/23, documents R35 receives chemotherapy at local cancer center for cancer. Noted resident refused many meals during hospital stay per speech eval (evaluation). R35's weight on 3/21/23 at 148.2 pounds; weight on 3/16/23 at 150.8 pounds; weight on 3/2/23 at 165.8 pounds, weight on 2/28/23 at 163.8 pounds. Significant weight loss since prior admission, which is likely r/t limited dietary intake and meal refusals at the hospital. Potential for weight changes r/t recent hx of minimal PO intake and significant weight loss since last admission. On 5/19/23 at 1:25 PM, V2 (DON) stated R35 has Stage 4 lung cancer with metastasis, and R35's cancer doctor is holding R35's chemotherapy right now due to him being so weak. V2 stated R35 has had multiple hospitalizations and thoracentesis (fluid removal from the chest cavity) done multiple times. V2 stated R35 had 1970 ml pulled of fluid removed in March and another 1610 ml and 1850 ml in April on two different occasions. The Doctor is aware of the fluctuations of R35's weight and feels some of the weight issues have to do with the fluid. V2 DON also stated R35 is also weak and doesn't always eat all of his meals if he is feeling poorly. 146108 Page 7 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0656 Level of Harm - Minimal harm or potential for actual harm On 5/17/23 at 2:09 PM, V4 (Care Plan Coordinator/Minimum Data Set Coordinator/Infection Control Preventionist) confirmed R35's current Care Plan does not include R35's Cancer status, chemotherapy, chest drain, IV, or significant weight loss. V4 stated she did not get the areas added on R35's Care Plan. Facility Policy/Care Plan Policy dated/revised 6/1/22 documents: Residents Affected - Some 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. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative as applicable. The comprehensive care plan will describe, at a minimum, the following: --The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. --The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. --The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment. Based on observation, interview the facility failed to develop care plans for multiple care areas and services for nine residents (R4, R6, R18, R20, R23, R28, R29, R35, R140) of 16 residents reviewed for care plans in the sample of 40. Findings include: 1. R6 Current Physician Orders for R6 include orders for: Ipratropium-albuterol solution for nebulization 0.5mg-3mg (milligram)/3ml (milliliter) inhalation, four times per day as needed for wheezing/shortness of breath. Albuterol sulfate solution for nebulization 2.5mg/3ml (0.083%) inhalation three times per day. Ipratropium-albuterol solution for nebulization 0.5mg-3mg/3ml, amount 1 vial inhalation as needed three times per day. Current Medication Administration Record (MAR) indicates R6 received albuterol sulfate 2.5mg/3ml three times per day via nebulizer from 5/1/23 through 5/18/23. 146108 Page 8 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0656 Level of Harm - Minimal harm or potential for actual harm On 5/16/23 at 11am, R6 was in her room and stated she uses the nebulizer sometimes. Nebulizer machine was on the bedside table and had the medication chamber, mouthpiece and tubing were all connected. The medication chamber contained a small amount of clear liquid. On 5/17/23 at 1:45pm R6's nebulizer chamber still contained liquid. Residents Affected - Some On 5/18/23 at 9:50am R6's nebulizer chamber had even more liquid than on the previous days of observation. At that time, V10 (Licensed Practical Nurse/LPN) was questioned about R6's nebulizer. V10 stated that the liquid in the nebulizer chamber is Albuterol (bronchodilator), the medication used in the nebulizer. V10 stated that R6 wants to do it herself, so the nurses just put the medication in the chamber and R6 will use it when she wants. V10 stated she did not put the liquid into the chamber and didn't know when or who filled the chamber. Care Plan was not developed to include self-administration of medications, including nebulizers for R6. 2. R28 On 5/16/23 at 10:15am, R28 was sitting in a reclining chair in her room. R28 able to make eye contact when approached and shook head No when attempt made to verbally communicate. R28 had a frustrated, distressed facial appearance while trying to communicate. 5/18/23 at 9:40am, R28 was in bed, with a Hospice Nurse at bedside. At that time the Hospice Nurse stated R28 can understand but has profound hearing impairment. Hospice Nurse stated R28 communicates best with paper and black marker. Hospice Nurse stated she was told by the facility staff to communicate in writing with R28. Hospice Nurse then asked R28 if she was in pain by writing on a yellow pad with a black marker. R28 was able to read the question and shook her head No. On 5/18/23 at 12:17pm, V10 (LPN) stated R28 can communicate by reading lips, yelling loudly into right ear or by writing. R28's care plan did not include a communication or hearing impairment problem and did not identify the methods of communication identified by staff. 3. R29 Physical Therapy Discharge summary dated [DATE] indicates discharge recommendations for R29 include: Fitness Program - walk with staff when appropriate; restorative program established/trained. Summary Recommendations Prognosis is Current Level of Function - Excellent with strong family support, Excellent with consistent staff support. On 5/16/23 at 11:10am, V18 (Family) stated R29 had been walking with the walker but hasn't been for a while now. At that time, a walker with an arm tray on the right side of the walker was at R29's bedside. V18 stated the arm tray/support was put on the walker after R29 had the cast put on so he 146108 Page 9 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0656 could still walk. Level of Harm - Minimal harm or potential for actual harm On 5/18/23 at 12:55pm, V11 (Physical Therapy Assistant/PTA) - is stated R29 is on a Fitness Program now and V12 (Rehab Aide) took over. V11 stated that R29 should walk down to the therapy room and then ride the bike. V11 stated, It's been a while now since he came down here - longer than a month ago. V11 stated only V12 is responsible for walking R29 - not the CNAs. V11 stated V12 has been educated on the therapy and exercise program for R29. V11 stated V12 has her own computer where she documents dates and times of R29's participation. Residents Affected - Some No care plan was developed to include restorative therapy for R29. 4. R140 Psychotropic Medication Consent dated 4/15/23 indicates consent was signed for R140 to receive Seroquel (antipsychotic) 25mg (milligrams) daily for diagnosis of anxiety with agitation. Current Physician Order Report indicates R140 has orders to receive Seroquel (start date 4/13/23) 25mg (milligrams) each evening for Unspecified, Moderate Dementia with Anxiety. Current Care Plan/Behavioral Symptoms dated initiated 5/9/23 indicates R140 tends to scream and holler when cares a are being given. No care plan was developed and/or implemented to address psychotropic/antipsychotic medications (Seroquel) administered to R140. 5. R18 R18's Physician Order Sheet dated May 2023 documents 16 FR (French) catheter with 10 cc (Cubic Centimeter) balloon for Neurogenic Bladder. R18's Physician Order for Life Sustaining Treatment Dated 3/17/23 documents Attempt Cardiopulmonary Resuscitation. R18's admission Nurse's Notes dated 3/18/23 documents Resident and family state that resident is here for therapy with plans to return to Assisted Living. R18's Care Plan dated 5/9/23 does not contain any information regarding R18's indwelling urinary catheter, Advance Directives, or her plans to discharge. On 5/18/23 at 9:06 AM, V3 (LPN/Infection Preventionist/Care Plan Coordinator) confirmed the information was not on R18's Care Plan. 6. R20's R20's Treatment Administration Record dated May 2023 documents Apply medi honey to sacral wound and cover with a hydrocolloid dressing every three days and as needed. R20's Physician Order for Life Sustaining Treatment dated 7/20/22 documents Attempt Cardiopulmonary 146108 Page 10 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0656 Resuscitation. Level of Harm - Minimal harm or potential for actual harm R20's Care Plan dated 7/21/22 did not contain any information regarding R20's sacral wound or her Advance Directives. Residents Affected - Some On 5/18/23 at 9:06 AM, V3 (LPN/Infection Preventionist/ Care Plan Coordinator) confirmed the information was not on R20's Care Plan. 7. R23 R23's Physician Order Sheet dated May 2023 documents Toe-Touch Weight Bearing to RLE (Right Lower Extremity). R23's Physician Order Sheet dated May 2023 documents Letrozole 2.5 mg (milligram) once daily for Malignant neoplasm of central portion of breast. The 2022 Physician Desk Reference for Medications documents Letrozole is a hormone-based chemotherapy. R23's Physician Order Sheet dated May 2023 documents Flush PICC (Peripherally Inserted Central Catheter) (right arm) with 10 ml (milliliters) NS (Normal Saline) before and after IV (Intravenous) ATB (Antibiotic) administration. R23's Care plan dated 2/25/23 did not contain any information regarding R23's weight bearing status of her right leg, her oral chemotherapy medicine or her PICC line. On 5/17/23 at 2:00 PM, V2 (Director of Nursing/DON) stated, I didn't know R23 was on maintenance chemotherapy. On 5/18/23 at 8:50 AM, V3 (LPN/Infection Preventionist/ Care Plan Coordinator) confirmed the information regarding R23's weight bearing status, PICC line and chemotherapy medications were not on her care plan. 146108 Page 11 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review the facility failed to revise a nutrition and wound Care Plan for one (R4) of 16 residents reviewed for Care Planning in the sample of 40. Residents Affected - Few Findings include: On 5/17/23 at 11:00 am, R4 was sitting up in a wheelchair with pressure relieving boots to his bilateral lower extremities. On 5/17/23 at 1:30 pm and on 5/18/23 at 1:30 pm, R4 was lying in bed with pressure relieving boots to his bilateral lower extremities. The current Care Plan for R4, documents (R4) has pressure ulcer to left heel with osteomyelitis of both feet. The Interventions include: Administer antibiotics as ordered. Monitor for side effects. Educate (R4) and family/representative on precautions needed related to osteomyelitis and handwashing. Monitor labs and/or cultures as ordered. The Wound Management Detail Report for R4, dated 3/29/23, documents Wound to left heel Closed/Resurfaced and left heel 1.4 x 4.0 pink epithelial tissue with dry scattered scabbed areas, area dark purple ecchymosis (bruising) vs (versus) DTI (deep tissue injury). On 5/18/23 at 10:00 am, R4 stated he does not have any other wounds than the ones on his toes. On 5/18/23 at 1:50 pm, V19 (Registered Nurse/RN) performed wound care to R4 wounds to right lateral ankle and toes to left foot. V19 RN raised R4's left leg revealing no wounds to R4's left heel. On 5/19/23 at 2:30 pm, V20 (RN Wound Nurse) stated R4's left heel wound resolved in March and R4 does not currently have any wounds to his heels. On 5/17/23 at 2:35 pm, V4 (Care Plan Coordinator/Minimum Data Set Coordinator/Infection Control Preventionist, CPC/MDS/ICP) confirmed R4's Care Plan should have been revised indicating R4's left heel wound was resolved. The facility's Care Plan policy and procedure, revised 06/01/22, documents In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into, and updated summary provided to the resident and his or her representative, if applicable. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (minimum data set) assessment. 146108 Page 12 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 continue a restorative mobility program as recommended by Physical Therapy for one resident (R29) of 16 residents reviewed for mobility in the sample of 40. Residents Affected - Few Findings include: Physical Therapy Discharge summary dated [DATE] indicates discharge recommendations for R29 include: Fitness Program - walk with staff when appropriate; restorative program established/trained. Summary Recommendations Prognosis is Current Level of Function - Excellent with strong family support, Excellent with consistent staff support. On 5/16/23 at 11:10am, V18 (Family) stated R29 had been walking with the walker but hasn't been for a while now. At that time, a walker with an arm tray on the right side of the walker was at R29's bedside. V18 stated the arm tray/support was put on the walker after R29 had the cast put on so he could still walk. On 5/18/23 at 12:55pm, V11 (Physical Therapy Assistant/ PTA) stated that R29 is on a Fitness Program now and V12 (Rehab Aide) took over. V11 stated that R29 should walk down to the therapy room and then ride the bike. V11 stated It's been a while now since he came down here - longer than a month ago. V11 stated only V12 is responsible for walking R29 - not the CNA's. V11 stated V12 has been educated on the therapy and exercise program for R29. V11 stated V12 has her own computer where she documents dates and times of R29's participation. On 5/18/23 at 1:10pm, V12 (Rehab Aide) stated she had not walked R29 since he got the cast on his arm because I didn't know if I should be walking him. I'll find out. I probably should have asked before. Maybe I could walk him if the arm tray is on his walker. V12 stated she was aware R29 had an arm support on his walker to support his arm that was in a cast. On 5/18/23 at 1:30pm, R29 was being assisted with the sit-to-stand lift from a wheelchair into bed. R29 had difficulty supporting weight on both legs during the transfer. At that time, V13 (Certified Nurse Assistant/CNA) stated R29 has been leaning more lately and has declined in his ability to stand. V14 (CNA) stated that R29 used to be able to stand and pivot with his walker but hasn't in a while because he's declined. Fitness Program tracking indicates the last time R29 walked was on 3/3/23. Progress Notes dated 3/31/23 indicate a cast was placed on R29's right wrist on that date. On 5/18/23 at 3:10pm, V11 (PTA) stated she took R29's arm support off the walker because he came back today without the cast. V11 stated she did put the arm support on the walker with the intent for R29 to still be able to use the walker and walk. V11 stated that V12 should have at least been 146108 Page 13 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0676 Level of Harm - Minimal harm or potential for actual harm trying to walk R29 and stated she wasn't aware R29 hadn't been walking, even prior to when the cast was put on. On 5/18/23 a policy for restorative therapy was requested from V1, Administrator and V2 (Director of Nursing/DON). No policy was provided. Residents Affected - Few 146108 Page 14 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to monitor the weight of a new admission for one resident (R18) of four residents reviewed for nutrition in a total sample of 40. This failure caused R18's significant weight loss to be undetected therefore not treated. Residents Affected - Few Findings Include: R18's Medical Record documents she was admitted on [DATE] after a fall at home. R18's Medical Record documents on 3/17/23 R18 weighed 103 pounds. R18's medical record documents the next weight being done on 4/3/23 at 101 pounds. R18's medical record documents on 4/11/23, R18 was 102.4 pounds and on 4/17/23 R18 was 99.6 pounds. On 5/18/23 V4 (LPN/Infection Preventionist) stated R18 should have been weighed on 3/24/23 and 3/31/23. When R18 went from 102.4 pounds to 99.6 pounds in one week, we should have reweighed her. On 5/18/23, V16 (Registered Dietician) stated, I was not aware that (R18) had any weight loss or problems. I assessed her when she first came in on 3/29/23 but have not assessed her since then. I have been trying to reach out to the facility for the past couple days to get any weight concerns, and no one has gotten back to me. On 5/18/23, V4 (LPN/Infection Preventionist) weighed R18, and she was 95.4 pounds. V4 confirmed that neither she nor V2 (Director of Nursing/DON) were aware of any issues regarding R18's weight, therefore, the Registered Dietician has not reassessed the resident, nor has her family or doctor been notified of the significant weight loss. The Facility's Weight Monitoring Committee Policy dated 03/11 documents It is the policy of this facility to appropriately monitor the weights of the residents as needed and monitor intake to improve health status whenever possible. Purpose: to assure each resident is monitored by measurement of weight and intake on a periodic basis to assess and improve health status whenever reasonably possible. The Facility's Weight Monitoring Committee policy documents The weight monitoring meeting should be held in conjunction with the Infection Control Meeting held each week. The day prior to the Weight Monitoring meeting the shift coordinator will obtain a list of weights which are required for the meeting. Residents to be reviewed in the weight committee should be new admissions for four weeks plus admission weight and monthly weight, anyone assigned to daily weighs and residents with a new tube feeding. 146108 Page 15 of 22 146108 05/19/2023 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. Based on observation, interview, and record review, the facility failed to provide an appropriate indication for use, failed to monitor behaviors and failed to provide target behaviors on a consent for an antipsychotic medication for two residents (R23 and R140) with a diagnosis of Dementia receiving antipsychotic medications of five residents reviewed for unnecessary medications in the sample of 40. Findings include: 1. Psychotropic Medication Consent dated 4/15/23 indicates consent was signed for R140 to receive Seroquel (antipsychotic) 25mg (milligrams) daily for diagnosis of anxiety with agitation. Current Physician Order Report indicates R140 has orders to receive Seroquel (start date 4/13/23) 25mg (milligrams) each evening for Unspecified, Moderate Dementia with Anxiety. Current Care Plan/Behavioral Symptoms dated initiated 5/9/23 indicates R140 tends to scream and holler when cares a are being given. No care plan was developed and/or implemented to address psychotropic/antipsychotic medications (Seroquel) administered to R140. No behaviors were identified in R140's progress notes reviewed from 4/13/23 (admit) through 5/19/23. On 5/16, 5/17, 5/18 and 5/19, 2023, R140 was observed at random times throughout those dates. At all times of observation, R140 was calm, appropriate, and accepting of care. On 5/18/23 at 11am, V3 (Social Service Director/SSD) stated she is not aware of any behaviors displayed by R140 except she doesn't like to have cares done sometimes. V3 stated she has never observed or been told of any other behaviors for R140. On 5/18/23 at 2:30pm, V2 (Director of Nursing/DON) stated there is no behavior monitoring for R140. 2. R23's Current Physician Order Sheet documents Escitalopram 20 mg (milligrams) daily, Fluphenazine 5 mg twice daily and Alprazolam 0.25 mg twice daily. R23's Unsigned Psychotropic Medication Consent dated 2/2/23 documents Escitalopram 20 mg (milligrams) every day to decrease depression. R23's Medical Record did not contain any signed or unsigned consents for Fluphenazine 5 mg twice daily or Alprazolam 0.25 mg twice daily. R23's current Care Plan does not identify any target behaviors for any of R23's psychotropic medications. R23's care plan does not have any non-pharmacological interventions listed for any behaviors for psychotropic medications. 146108 Page 16 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0758 Level of Harm - Minimal harm or potential for actual harm On 5/18/23 at 9:30 AM, V2 (DON) confirmed that R23 had no target behaviors identified in her medical record nor did she have any behavior tracking or consents for the use of psychotropic medications. Stated, It looks like we are just monitoring for the side effects of psychotropic medications, no behaviors. Facility Policy/Psychopharmacologic Drug Usage procedure dated 10/18/17 documents: Residents Affected - Few Psychopharmacologic medication usage must be addressed in the care plan, including appropriate goals, likely medication effects and potential for adverse consequences. Consent for use of psychopharmacologic medications must be given in writing by the resident and/or 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 outcomes/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. 146108 Page 17 of 22 146108 05/19/2023 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 ensure monitoring of high temperature sanitization of dishes. This failure has the potential to affect all 38 residents who receive meals from the kitchen. Findings include: Facility Policy/Dish Machine High Temperature Recording Procedure dated (Adopted 08/19) documents: Hot Water is used for sanitizing in High Temperature Dish Machines, not chemical sanitizer. Therefore, it is important to record wash temperatures and final rinse temperatures Three Times per Day. ABC: After all, three meals, before you wash meal dishes, Check and record dish machine wash and final rinse temperatures. Procedure: 1. Record temperatures on a High Temperature Dish Machine Temperature Log. 2. Goal temperatures are located on the metal plate located on the front of the dish machine. Appropriate temperatures are as follows: Wash Temperature: 150-160 degrees F. Final Rinse Temperature: 180 degrees or higher. 3. Do not wash dishes from meals until you have checked the dish machine temperatures. Staff will test the dish machine periodically with 180-degree Fahrenheit test strips for accuracy. On 5/16/23 at 10:20am, V15 (Dietary Aide) was putting dirty breakfast dishes through the high heat dish machine. At that time, V15 stated he had not put test strip through the machine yet I didn't get here till 9 (am). V15 then placed a 180-degree test strip on a whisk and put it through the dish machine. The strip turned from blue to orange, the dish machine displayed digital temperature display of 156 degrees. Two Dish Machine Test Strip Logs were displayed on the bulletin board directly behind the dish machine. One of the logs had two dates 4/22/23 and 4/23/23 with strips attached. The High Temperature Dish Machine Temperature Log dated May 2023 did not have following dates entered at the time the dishwasher test strip was tested: May 8, 9th not entered for entire day. May 10th missing dinner (lunch) and supper. May 11th missing supper. May 15th missing dinner and supper. 146108 Page 18 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0812 Level of Harm - Minimal harm or potential for actual harm On 5/18/23 at 9:50am, V5 (Dietary Manager) stated V15 was only checking the digital temperature display on the dish machine, he was not used to using the strips. V15 should have checked and confirmed the digital temperature with the test strip prior to putting dishes through the dish washer. He's been educated now on the correct process. Residents Affected - Many V15 stated both logs should include the digital display as well as the test strip result for each meal service. Resident Census and Conditions of Residents dated 5/16/23 indicates there are 38 residents in the facility who receive meals from the kitchen. 146108 Page 19 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow an Antibiotic Stewardship Program, this failure has the potential to affect all 39 residents who currently reside in the facility. Residents Affected - Many Findings Include: The Facility's Antibiotic Stewardship Policy dated 12/18/19 documents It is the policy of the facility to follow an Antibiotic Stewardship Program, including the core elements as outlined by the CDC (Center for Disease Control). The Facility Antibiotic Stewardship policy documents Antibiotic use will be calculated on a monthly basis for QAPI (Quality Assurance and Performance Improvement). The CDC (Center for Disease Control) website documents As of November 2017 each (long term care) facility must have had an antibiotic stewardship program in place as part of their infection prevention and control program. The Antibiotic Stewardship program must include the use of antibiotic use protocols and a system to monitor antibiotic use. The Facility's unfinished Core Elements of Antibiotic Stewardship in Nursing Homes adopted 11/28/2017 documents Tracking Monitoring Antibiotic Prescribing, use and Resistance: 7. Does your facility monitor one or more measures of antibiotic use a. Adherence to clinical assessment documentation (signs/symptoms, vital signs, physical exam findings) b. Adherence to prescribing documentation (dose, duration, indications) c. Adherence to facility-specific treatment recommendations d. Performs point prevalence surveys of antibiotic use e. Monitors rates of new antibiotic starts/1,000 resident days f. Monitors antibiotic days of therapy/1,000 resident days. January 2023 through May 2023 Monthly Antibiotic/Infection Control Logs did not include clinical symptoms for antibiotic use, no calculations for QAPI (Quality Assurance and Performance Improvement), no point prevalence surveys to include where the resident's infection originated, and no facility specific treatments started prior to antibiotic use. On 5/18/23 at 10:00 AM, V4 (LPN/Infection Preventionist) confirmed that the monthly infection control logs from January 2023-May 2023 do not include signs and symptoms of infections. V4 confirmed monitoring did not include any point prevalence surveys to include if the infection was acquired in the community, hospital or the facility. V4 stated We have no facility specific treatments or recommendations for physicians. I just track what is prescribed. I don't know how to calculate antibiotic use for QAPI meeting. I don't feel like I have been trained very well on what I am doing. The Resident's Census and Condition Report dated 5/16/23 documents 39 residents currently reside in the facility. 146108 Page 20 of 22 146108 05/19/2023 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review the facility failed to administer vaccinations per CDC (Center for Disease Control) guidelines for five residents (R16, R18, R23, R24 and R29) of five residents reviewed for immunizations in a total sample of 39. Residents Affected - Some Findings Include: The Facility's Immunizations policy dated 06/2017 documents It is the policy of the facility to provide immunizations in accordance with CDC (Center for Disease Control Control) recommendations, resident consent, and physician orders. Purpose: to reduce the overall incidence of influenza by offering immunizations to all residents and to reduce the overall incidence of pneumococcal pneumonia by providing the pneumonia vaccines to residents 65 years or older and to others at high risk. The Facility's Immunizations policy documents If a resident or responsible party refuses an immunization it should be documented in the permanent medical record on the Resident Immunization Record. The resident will be offered to receive the vaccine annually. R16's Medical Record documents Flu Immunization: 12/29/2021. R18's Medical Record did not document any information regarding R18's Pneumonia vaccination status. R23's Medical Record did not document any information regarding R23's Pneumonia vaccination status. R24's Medical Record did not document any information regarding R24's Pneumonia vaccination status. R9's Medical Record did not document any information regarding R9's Pneumonia vaccination status. On 5/18/23 at 1:45 PM, V2 (Director of Nursing/DON) stated, I don't know anything about these vaccinations, that information should be documented and it isn't. 146108 Page 21 of 22 146108 05/19/2023 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 interview and record review, the facility failed to ensure CNAs/Certified Nursing Assistants received twelve hours of required continuing competency training annually. This failure has the potential to affect all 39 residents residing in the facility. Findings include: The Administrator provided a binder that includes facility in-services that have been completed for 2023. None of these in-services document the 12 hours of required training for CNAs (Certified Nursing Assistants). There was no documentation for 2022 included in the binder. On 5/18/23 at 12:45 pm, V2 (Director of Nursing/DON) stated that she started working at the facility in the fall of 2022 and does not know if the required CNA training was completed in 2022 and has not yet completed the training for 2023. On 5/18/23 at 12:49 pm, V1 (Administrator) stated she only has in-service documentation for the CNAs that have been completed since she started working at the facility late last year and is unable to locate any of the required CNA training for 2022 and has just recently started the training for 2023. The Resident Census and Condition of Residents (Centers for Medicare and Medicaid Services/CMS 672) form dated 5/16/23 documents 39 residents reside in the facility. 146108 Page 22 of 22