Health inspection·October 8, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a call light was within reach for four of four residents (R1, R2, R3, R4) reviewed for accommodation of needs in the sample of ten. Residents Affected - Some Findings include: The facility's Call Light policy dated 01/2004 documents, Objective: To respond to resident's request and needs. Offer further services before leaving resident's room. Be sure call light is within reach before leaving the room. 1. On 10-6-23 from 7:30 AM through 8:35 AM R1 was sitting in her wheelchair in her room. During this time R1's call light was on the floor next to the right side of R1's wheelchair. R1 stated, I cannot reach my call light on the floor. 2. On 10-6-23 from 7:30 Am through 8:35 AM R2 was lying in bed on her right side. During this time R2's call light was laying on the floor beside the right side of R2's bed and out of R2's reach. On 10-6-23 at 8:40 AM V9 (CNA/Certified Nursing Assistant) stated, The last time someone took care of (R2) was on third shift around 6:00 AM. I am not sure how long (R2's) call light has been on the floor. 3. On 10-6-23 from 7:20 AM through 8:15 AM R3 was lying in bed on his back. During this time R3's call light was laying on the floor on the right side of his bed and was out of R3's reach. R3 stated, My call light is always on the floor. On 10-6-23 at 8:20 AM V7 (CNA) and V8 (CNA) both stated they were taking care of R3 and had not attended to R3 since 6:00 AM when they made rounds with the third shift CNA's. V7 verified that R3's call light should not have been on the floor. On 10-7-23 from 2:25 AM through 4:00 AM R3 was lying in bed on his back. During this time R3's call light was laying in the chair next to R3's right side of the bed and out of R3's reach. On 10-7-23 at 4:00 AM V17 (CNA) verified that R3's call light was not within his reach from 2:25 AM through 4:00 AM. 4. On 10-6-23 from 7:25 AM through 8:35 AM R4 was lying in bed on her back and R4's call light was on the floor behind her headboard. At 8:35 AM R4 stated, I do not know how long my call light was on the floor. All I know is I could not reach it. The staff never brush my teeth. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 146108 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)