Inspection·May 20, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few appear to be in any distress or having breathing issues. V10 said [R1's] lung sounds were diminished, and she messaged V14 Physician about a chest x-ray, which was ordered. V10 said the x-ray was not a stat order and the x-ray company said they would be in the following day [5/12/2025] to do the x-ray. V10 said non stat x-rays are done in about 24 hours normally. V10 said [R1] had lost his upper dentures about a month ago and only had his bottom denture which was a partial. On 5/19/2025 at 1:00PM, V6 RN said on 5/12/2025 [R1's] family approached her about him sleeping in the dining room and asked what the x-ray showed. V6 said she explained she didn't have any x-ray results because it wasn't done over the weekend. V6 said she went to check on [R1] and he was sleeping in the chair. V6 said his lung sounds were diminished with audible congestion. V6 said she called [V14] regarding transfer to the hospital for evaluation and [V14] was ok with transfer. On 5/19/2025 at 4:17PM, V7 Licensed Practical Nurse (LPN) said [R1] was sent out on 5/12/2025 because he was having increased lethargy and some crackles. V7 said [R1's] oxygen saturation was 98% prior to leaving with paramedics on 5/12/2025. On 5/19/2025 at 3:05PM, V14 (Physician) said [R1] did have a foreign body in his airway or above it that needed to be removed. V14 said he wasn't close to serious harm or death with slightly abnormal breath sounds, stable vital signs, and was still oxygenating. On 5/20/2025 at 8:36AM, V18 Fire Department Lieutenant read the report for the 5/12/2025 at 9:18AM for [R1]. V18 said [R1] was picked up for difficulty breathing and was classified as emergent, but not critical or unstable. V18 said two oxygen saturations were documented one at 96% on room air and another at 89% and 3 liters of oxygen via nasal cannula was started. V18 said [R1] was arousable with sternal rub initially and then was following commands and tracking with his eyes. V18 said [R1] had bilateral rhonchi noted and difficulty breathing. V18 said they gave [R1] a GCS (Glasgow Coma Scale) of 10. V18 said if someone can follow commands, they would still have a gag reflex and artificial airway placement would be contraindicated. V18 said a GCS of 8 or less would indicate intubation would be appropriate. V18 stated [R1's] vitals were listed as 97.9 temperature, 95 heart rate, 154/76 blood pressure, 22 respiratory rate. On 5/20/2025 at 10:15AM, V2 Director of Nursing (DON) said [R1] requires assistance with oral care and would not be responsible for them himself. V2 said staff should report missing dentures. V2 said abnormal breath sounds should be followed up on and assessed by nursing staff. R1's Search Vitals Results 5/5/2025 to 5/20/2025 show vitals of 98.1 temperatures, 68 heart rate, respiratory rate of 22, blood pressure of 105/51, and an oxygen saturation of 97% on 5/12/2025 at 8:34AM. R1's current care plan shows [R1] has generalized muscle weakness, fatigue, poor activity tolerance, and decreased mobility [dated 11/8/2024] . and approach of mouth care: staff will assist with oral care as needed. [R1] has top and bottom dentures. R1's hospital records shows resident was transferred from the facility to [a local area hospital] for foreign body aspiration on 5/12/2025. Hospital records state the resident has been gurgling over the past couple of days and CT chest showed the dental denture within the pharynx. Therefore, the patient was transferred to [another local area hospital] to receive a higher level of care. R1's hospital procedure notes state on 5/12/2025 [R1] was brought to the operating room and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 2 of 4 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few monitoring anesthesia care with sedation was administered. Time out performed. The pharynx was examined with a Glide laryngoscope and thick secretions were suction. The intact dental appliance was visible in the hypopharynx, and it was removed without trauma with a [NAME] forceps. The hypopharynx and larynx were inspected and found to be free of mucosal trauma or other foreign bodies. The patient was turned over to anesthesia to transport back to his room. There were no complications. The dental appliance was given to the patient's son who verified that it was fully intact. R1's 5/12/2025 hospital records show [R1] was noted to have pneumonia and was started on antibiotic therapy related to pneumonia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 3 of 4 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 146193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to address the loss of a resident's denture and formulate a plan for replacement. This applies to 1 of 3 (R1) in the sample of 3 reviewed for denture care. Residents Affected - Few The findings include: On 5/20/2025 at 11:13AM, V9 Social Services Director said [R1's] upper denture was reported missing on 4/13/2025. V9 said she investigated the missing dentures on 4/14/2025 and they were unable to find the missing upper denture for [R1]. V9 said when residents are admitted to the facility it is explained to them the facility is not liable for missing or lost items unless the facility is liable. V9 said she was unaware if the facility was going to pay for the lost dentures or not. On 5/20/2025 at 10:15AM, V2 Director of Nursing (DON) said [R1] requires assistance with oral care and would not be responsible for them himself. V2 said staff should report missing dentures. The facility failed to provide documentation of any conversation with [R1's] family regarding the lost dentures and replacement/payment agreement prior to the initiation of the survey on 5/19/2025. The Loss Control/Damage Report (Form #NH-553) shows the investigation was began on 4/14/2025 for a missing upper denture plate which was identified on 4/13/2025 and the report was signed off on 4/15/2025. The report does not indicate a resolution or liable party for missing dentures. The facility provided copy of the admission Agreement contact states. W. Indemnification: The Resident will defend, indemnify and hold the Facility harmless from any and all claims, demands, suit and actions made against the Facility by any person resulting from any damage or injury caused by the Resident to any person or property of any person or entity (including the Facility), except in the case of negligence of the Facility's employees and agents. The facility provided Loss/Damage of Dentures revised 6/1/2022 states, the facility shall not be held responsible for replacement/cost of repair of dentures unless the loss or damage is determined to be the result of negligence on the part of the facility, or loss and/or damage occurs when the resident has provided dentures to the facility for safekeeping. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146193 If continuation sheet Page 4 of 4