Health inspection·March 12, 2025

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 record review and interview the facility failed to follow physician's order to follow-up with gastroenterology following a resident who ingested a hazardous chemical for one of seven residents (R1) reviewed for accidents in the sample of eight. Residents Affected - Few Findings include: The facility's Special Needs policy dated 11-28-17 documents, To address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. If necessary, the facility will assist residents in making appointments with a qualified person or facility and arranging for transportation to and from such appointments. The facility will communicate relevant information with outside providers to ensure safe, continuous care of the resident. Medical conditions will be monitored and managed to prevent complications. The attending physician will assume responsibility for the overall care and treatment of the resident's medical conditions. RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) will participate in the management of medical conditions by following physician orders, assessment of residents, and reporting changes in condition to the resident's physicians. R1's emergency room Provider Notes dated 2-14-25 and signed by V9 (emergency room Physician) document, Chief Complaint: (R1) present with accidental ingestion. (R1) presents to ED (Emergency Department) from (facility) after drinking about six oz (ounces) of a cleaning chemical, BNC-15 one step disinfectant cleaner, about 30 minutes ago. Accidental ingestion of caustic alkali (highly corrosive bases that can cause severe burns and damage to living tissues). (R1) has a history of Dementia. Chemical was left sitting on the counter. (R1) did not appear to do this in an attempt to harm himself but did not understand what he was doing. Discharge Instructions: Four to six hours observation. Strict NPO (Nothing by Mouth). GI (Gastro-intestinal) referral for EGD (Esophagogastroduodenoscopy) per poison control. R1's Progress Notes dated 2-15-25 at 1:08 AM and signed by V4 (LPN/Licensed Practical Nurse) document, (R1) arrived back from (local) hospital via AMT (Advanced Medical Transport). (R1) alert to baseline. Denies any pain at this time and ROM (Range of Motion) to baseline. (R1) has orders to follow-up with gastroenterology and to return (to emergency room) if resident exhibits any symptoms. R1's Electronic Medical Record dated 2-14-24 through 3-7-25 documents no evidence R1's follow-up with gastroenterology or EGD being completed. On 3-7-25 at 1:00 PM V11 (R1's Family Member) stated, We (R1's Family) want (R1) to go to the gastroenterology follow-up to make sure (R1) does not have any internal injuries from the chemical. I am Page 1 of 7 146108 146108 03/12/2025 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0684 not sure why the facility has not made the appointment yet. Level of Harm - Minimal harm or potential for actual harm On 3-7-25 at 2:30 PM V2 (Director of Nursing) stated, (R1's) follow-up appointment with gastroenterology was missed and did not get scheduled. Residents Affected - Few 146108 Page 2 of 7 146108 03/12/2025 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 provide adequate supervision for cognitively impaired residents and keep hazardous disinfectant, alcohol gel, and hazardous odor eliminating spray secured and out of the reach of cognitively impaired, self-mobile residents for seven of seven residents (R1, R2, R3, R4, R5, R6, R7) reviewed for accidents in the sample of eight. These failures resulted in, on 2-14-25 R1, a cognitively impaired resident, obtaining a bottle of hazardous disinfectant (BNC-15), R1 ingesting the hazardous disinfectant, and R1 requiring emergency room services for treatment. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3-10-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The facility's Housekeeping Policy dated 1-2023 documents, Purpose: To assure proper housekeeping and facility cleanliness and to have proper guidelines for housekeeping standards. Supplies and Equipment: Cleaning supplies should be kept in locked cupboards or rooms for the protection of the residents. The Chemical BNC-15 Manufacturer's Safety Data Sheet/MSDS dated 4-1-21 documents, (32 ounce) BNC-15 (Disinfectant). Hazard Statements: Harmful if swallowed. Causes severe skin burns and serious eye damage. Response: Immediately call a poison center or physician. If on skin: Rinse cautiously with water for several minutes. Take off immediately all contaminated clothing and shoes. Rinse with water or shower for at least 15 minutes. Ingestion: Rinse mouth. Do not induce vomiting. Storage: Store locked up. Toxicology Information: Skin Contact: Pain, redness, blistering, and possible chemical burn. Ingestion: Damage or chemical burns to mouth, throat and stomach, pain, nausea, vomiting and diarrhea. The Manufacturer's Fresh Odor Eliminators Spray Safety Data Sheet dated 11-9-22 documents, Precautions for Safe Handling: Store at normal room temperature away from reach of small children. Keep container closed. Ingestion: Do not induce vomiting unless directed to do so by medical personnel. Never give anything by mouth to an unconscious person. If potentially dangerous quantities of this material have been swallowed, call a physician immediately. Acute Toxicity: Exposure to solvent vapor concentrations from the component solvents in excess of the stated occupational exposure limits may result in adverse health effects such as mucous membrane and respiratory system irritation and adverse effects on the kidneys, liver, and central nervous system. Symptoms may include headache, nausea, dizziness, fatigue, muscular weakness, drowsiness, and in extreme cases, loss of consciousness. Repeated or prolonged contact with the preparation may cause removal of natural fat from the skin resulting in dryness, irritation, and possible non-allergic contact dermatitis. Solvents may also be absorbed through the skin. Splashes of liquid in the eyes may cause irritation and soreness with possible reversible damage. The Manufacturer's Spectrum Advance Hand Sanitizer Gel dated 7-23-24 documents, Storage: Keep 146108 Page 3 of 7 146108 03/12/2025 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some containers tightly closed in a dry, cool and well-ventilated place. Store locked up. Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Remove contact lenses, if applicable, and continue flushing. If symptoms persist, call a physician. Skin Contact: In the case of skin irritation or allergic reactions see a physician. Inhalation: Move to fresh air. Get medical attention immediately if symptoms occur. If breathing has stopped, contact emergency medical services immediately and give artificial respiration. Ingestion: If swallowed do not induce vomiting. Clean mouth with water and afterward drink plenty of water. Never give anything by mouth to an unconscious person. Consult a physician if necessary. Most important symptoms/effects: Burning sensation. Itching. Rashes. Hives. Coughing and/or wheezing. May cause breathing difficulties if inhaled. The facility's current Centers for Medicare and Medicaid Services Form 802 documents R1-R7 have the diagnoses of either Alzheimer's or Dementia and can either self-propel a wheelchair or self-ambulate. R1's current Face Sheet documents R1 is an [AGE] year-old with the diagnoses of Dementia, mild, with Anxiety, Dysphagia, Anxiety Disorder, Alzheimer's Disease, Insomnia, Restlessness, and Agitation. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired. R1's Progress Notes dated 2-14-25 at 7:06 PM and signed by V3 (RN/Registered Nurse) document, This writer was sitting at nurses' station when another resident (R8) alerted me to Stop him (R1). (R1's) going to drink that. This writer then stood up to see (R1) sitting in wheelchair at nurses' station with lid to purple disinfectant cleanser labeled BNC-15 in hand and liquid coming from (R1's) mouth. (R1) then asked for water and the writer immediately notified (R1's) nurse (V4/LPN/Licensed Practical Nurse) and located MSDS (Material Safety Data Sheet) for BNC-15 in MSDS manual in cabinet at nurses' station and followed sheet advice for ingestion of BNC-15. R1's Progress Notes dated 2-14-25 at 7:31 PM and signed by V4 (LPN) document, (V3) came up to writer and stated that (R1) was possibly observed drinking cleanser. (R1) alert to baseline not showing any signs of distress at this time. (V2/DON/Director of Nursing) immediately notified. EMS (Emergency Medical Services) called for further evaluation and MSDS sheet for cleanser (R1) ingested sent with paramedics. All emergency contacts were attempted to be notified with no response. Voicemail left to return call back to facility. (R1) taken to (local) hospital. R1's emergency room Provider Notes dated 2-14-25 and signed by V9 (emergency room Physician) document, Chief Complaint: (R1) present with accidental ingestion. (R1) presents to ED (Emergency Department) from (facility) after drinking about six oz (ounces) of a cleaning chemical, BNC-15 one step disinfectant cleaner, about 30 minutes ago. Accidental ingestion of caustic alkali (highly corrosive bases that can cause severe burns and damage to living tissues). (R1) has a history of Dementia. Chemical was left sitting on the counter. (R1) did not appear to do this in an attempt to harm himself but did not understand what he was doing. Discharge Instructions: Four to six hours observation. Strict NPO (Nothing by Mouth). GI (Gastro-intestinal) referral for EGD (Esophagogastroduodenoscopy) per poison control. R1's Report of Incident dated 2-14-25 and signed by V1 (Administrator) documents, On 2-14-25 around 7:07 PM, (V1) was notified by (V2) that the nurse on duty reported to her that (R1) long-term resident with a history of advanced Dementia was reported by (R2) to have something (R1) shouldn't have. 146108 Page 4 of 7 146108 03/12/2025 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Nurse (V3) stated that she was sitting at the nursing station when another resident (R8) said to her You better take that from (R1). (R1) is going to drink it. The nurse reports to have looked over the countertop and saw (R1) sitting in his wheelchair with the lid of a bottle of disinfectant in his hand. The nurse states (R1) did not have the bottle of cleaner in his hand, only the sprayer lid, which she reports (R1) took out of his mouth. (V3) immediately notified the nurse assigned to (R1) and they immediately assessed (R1). (R1) has advanced Dementia, very poor hand dexterity, and is unable to communicate clearly, therefore the clinical decision was made to error on the side of caution and send (R1) to the ER for evaluation since no one could say with certainty that (R1) did not ingest the disinfectant. The bottle was around 90 percent full. EMT transported (R1) to (hospital) emergency room where they observed (R1) for around four and a half hours and then returned (R1) to the facility around 2:00 AM on 2-15-25 with orders to follow-up with gastroenterology. R2's MDS assessment dated [DATE] documents R2 is severely cognitively impaired. R3's MDS assessment dated [DATE] documents R3 is moderately cognitively impaired. R4's MDS assessment dated [DATE] documents R4 is severely cognitively impaired. R5's MDS assessment dated [DATE] documents R5 is severely cognitively impaired. R6's MDS assessment dated [DATE] documents R6 is severely cognitively impaired. R7's MDS assessment dated [DATE] documents R7 is severely cognitively impaired. R8's MDS assessment dated [DATE] documents R8 is cognitively intact. On 3-7-25 from 9:45 AM through 11:00 AM a two-ounce bottle of fresh odor eliminators spray was located on top of a handrail in the middle of the hallway and two eight-ounce bottles of spectrum advanced hand sanitizer gel were sitting on top of a cart located in the hallway outside of room [ROOM NUMBER]. There were no staff present during these times, and R2 was walking aimlessly up and down the hallway. On 3-7-25 at 11:10 AM R2 was at a cart located in the hallway outside of room [ROOM NUMBER]. There were two eight-ounce bottles of spectrum advanced hand sanitizer gel and a box of tissues sitting on top of the cart. R2 was standing in front of this cart, pulling tissues out of the box, and placing them on top of the cart. R2 then picked up one bottle of the alcohol gel and sat it back down. On 3-7-25 at 11:15 AM R8 was lying in bed. R8 stated, On (2-14-25) I saw (R1) take the lid off of a cleaner and drink the cleaner. (R1) had the nozzle to the cleaner in his other hand. I was yelling at the nurse look! Look! Look! (R1) is drinking that! The nurse sent (R1) to the hospital and (R1) had to have his stomach pumped. On 3-7-25 at 10:05 AM V4 (LPN) stated, I was (R1's) nurse and was not at the desk when (R1) had drank the disinfectant. Another nurse told me (R1) drank the disinfectant. (V3) came into to me and reported it to me. I called (V2/Director of Nursing) and asked how much (R1) drank and I told (V2) I was not sure. (R1) had the cap off the disinfectant and drank some of it. There was at least a half of a cup of the disinfectant missing out of the container. I called 911 and all emergency contacts. I found the Safety Data Sheet and sent it with EMS. (R1) was being observed the entire time until the ambulance came. I did not rinse (R1's) mouth or skin. I just observed (R1) until EMS arrived. 146108 Page 5 of 7 146108 03/12/2025 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 3-7-25 at 10:30 AM V7 (RN) stated, (R1) is extremely confused and would not know if he was drinking a chemical. (R1) gets up late every day and self-propels his wheelchair around the facility, using his hands to propel the wheelchair. (R1) is not aware of his surroundings. On 3-7-25 at 10:40 AM V5 (Housekeeper) stated, For some reason (V6/RN) would always ask me for the BNC-15 disinfectant. There were several days before (R1) got ahold of the disinfectant that (V6) would get the disinfectant when I was not aware and leave the disinfectant on top of the nurses' desk. No staff would be around when the disinfectant was being left on top of the nurses' desk. Every time I would find the disinfectant, I would lock it up. I would tell (V6) the disinfectant must be locked up. I know residents can drink the cleaners. That is why the cleaners have to be locked up at all times. On 3-7-25 at 11:56 AM V10 (Housekeeping Supervisor) stated, (V6/RN) asked for a chemical that day and was refused the chemical BNC-15. (V6) would ask for this chemical frequently and was the only nursing staff that would ask for that chemical. (V6) worked that day and (V6) left the BNC-15 chemical on top of the nurses' station and did not lock the chemical back up. All chemicals are to be locked up at all times and the housekeeping cart is to be always visible to keep residents from getting to the chemicals. (R2) observes the housekeeping carts frequently and could try to open a housekeeping cart. Staff should always pay attention to their surroundings. On 3-7-25 at 12:10 PM V6 (RN) stated, On 2-14-25 I got the disinfectant (BNC-15) to clean up a spill that had happened on the nurses' desk and floor. I got busy that day and I forgot to lock the disinfectant back up after I used it. I got told that was part of the reason why I was terminated. On 3-7-25 at 1:00 PM V11 (R1's Family Member) stated, (R1) has no idea what he is doing and is not safe around chemicals. On 3-7-25 at 2:40 PM V3 (RN) stated, On 2-14-25 around 7:00 PM, I heard (R8) yelling, Stop him (R1)! Stop him! I saw (R1) had the top off the chemical BNC-15 and had the tube that goes down into the chemical in his mouth, licking the chemical off the tube. (R8) yelled, (R1) drank that! I saw a very light purple liquid in (R1's) mouth and running out of (R1's) mouth. The BNC-15 chemical is a purple color. The bottle had about four to six ounces missing out of it. I immediately told (V4) and (R1) was sent to the hospital. Whoever left the chemical on top of the nurses' desk should know better. All chemicals should be locked up at all times. On 3-7-25 at 2:30 PM V2 (Director of Nursing) confirmed that all chemicals should be always locked up. V2 also confirmed R1-R7 are cognitively impaired and either self-propel a wheelchair or self-ambulate throughout the facility. The Immediate Jeopardy started on 2-14-25 when V6 (RN/Registered Nurse) left a bottle of BNC-15 hazardous disinfectant unsecured on top of the nurses' desk and R1, a cognitively impaired resident, obtained the bottle of BNC-15, ingested the disinfectant, and required emergency room services for treatment. V1 (Administrator), V2 (Director of Nursing), and V13 (Regional Manager) were notified of the Immediate Jeopardy on 3-10-25 at 10:30 AM. On 3-12-25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 146108 Page 6 of 7 146108 03/12/2025 Manor Court of Peoria 6900 North Stalworth Peoria, IL 61615

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 1. On 3-10-25 department heads conducted a facility wide walk through to assure all chemicals and hazardous materials were securely stored and out of reach of the residents. On 3-12-25 this surveyor conducted a facility wide walk through to assure all chemical and hazardous materials were securely stored in the housekeeping carts, clean storage utility room, and out of reach of the residents. 2. On 3-10-25 a list of identified residents who are cognitively impaired and self-mobile was placed as the nurses' station by V2 (Director of Nursing). 3. On 3-10-25 all care plans of residents who are cognitively impaired and self-mobile were revised. 4. On 3-10-25 V1 (Administrator), (V2 (Director of Nursing), and V14 (Human Resource Director) in-serviced all staff on which residents are cognitively impaired and self-mobile, where to find the list that indicates residents who are cognitively impaired and self-mobile, proper securement of chemicals and all other hazardous materials, location of the SDS (Safety Data Sheets) and how to read a SDS sheet. All new employees will be in-serviced by V14 prior to their first shift. 5. On 3-10-25 an audit tool was developed and implemented by V1 to track compliance of proper storage of chemicals and all other hazardous materials. 146108 Page 7 of 7