Inspection·February 1, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 01/29/24 at 11:20 AM, V4 (Family Member) said that R1 hit her call light to ask for assistance with going to the toilet and that one of the staff told R1 to just go to the bathroom in her incontinence brief and that she would clean it up later after R1 was done. V4 (Family Member) stated that this occurred around 01/04/24 when R1 was admitted . On 01/30/24 at 1:40PM, V2 (Director of Nursing/DON) said he was told that staff has told residents to go bathroom in their incontinence brief instead of using the toilet. V2 said he dealt with the incident right away. V2 said that the staff were educated right away. V2 said that this happened about a month ago. 2. R2's Face sheet, undated, documents R2 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus with unspecified complications, Nontraumatic subdural hemorrhage, Constipation, Dysuria, Anxiety disorder, Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, Weakness, Muscle weakness (generalized), Unspecified dementia with other behavioral disturbance, Unsteadiness on feet, and Cerebral infarction. R2's Care Plan, dated 10/31/23, documents Resident Care Information and Interventions of: Bowel and bladder: Bathroom Continent/Incontinent Toileting, Incontinence Products- wears underwear, Safe resident handling procedure-Transfer method stand pivot transfers with one assist. Orientate resident to room, surrounding area, and use of call light system. R2's Minimum Data Set (MDS) dated [DATE], Documents in Section C a BIMS score of 13 which indicates R2 is cognitively intact. Section GG documents that R2 requires partial/moderate assistance with toileting hygiene and requires supervision or touch assist with toilet transfers. Section H documents that R2 is occasionally incontinent of bladder and always continent of bowel. On 01/25/24 at 10:25AM, R2 who was alert and oriented to person, place, and time, stated that there have been problems with her call light not being answered in a timely manner. R2 stated that she has had incontinent episodes while waiting for staff to answer her call light. A facility document titled Grievance Report with R2's name and dated 11/17/23, states under summary of the grievance that R2's son states that R2 is not getting taken to the bathroom when needed. R2's son states that the light is turned on and it takes a long time for anyone to answer which causes R2 to sit in a soiled incontinence brief. R2's son states that on Tuesday he was at the facility and the call light was going off for a while and nobody came. R2's son states that he went to the nurse's station and there were 3 to 4 nurses just sitting in the little station in the middle. R2's son stated that he told them that R2 needed to use the bathroom, and one stated that the certified nurse assistants do that, but one nurse did get up and take her. R2's son said that R2 feels embarrassed when she has accidents. 3. R7's Face Sheet, undated, documents R7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non dominant side, unspecified abnormalities of gait and mobility, constipation, obstructive and reflux uropathy, encounter for orthopedic aftercare, need for assistance with personal care, glaucomatous flecks right eye, pain, essential hypertension, hypothyroidism, hyperlipidemia, depression, anxiety disorder, personal history of transient ischemia attack and cerebral infraction without residual deficit, fractures of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 2 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R7's Care Plan, dated 12/27/23, documents Resident Care Information with interventions of: bowel incontinent blader incontinent/catheter, continent/incontinent toileting: Toileting, with pull up incontinence products. Transfer method- stand pivot transfer to right side level assist of one. R7's Minimum Data Set (MDS), dated [DATE], Documents in Section C a BIMS score of 9 which indicates that R7 has moderate cognitive impairment. Section GG documents that R7 requires substantial/maximal assistance with toileting hygiene, dependent with dressing, R7 requires substantial/maximal assistance with standing and transfers. Section H documents that R7 is occasionally incontinent of bladder and frequently incontinent of bowel. On 01/25/2024 at 10:58am, R7 who was alert and oriented to person, place, and time during interview, stated that sometime staff will answer her light and other times they don't. R7 said that staff will answer the call light and say they will be back and then don't come back. R7 said that she has had to wait for an hour to an hour and a half on more than one occasion. R7 said that she has timed how long is it on her watch. R7 said when she hits her call light and has to wait for a long period of time, she will start yelling for staff. R7 said that this has happened on several occasions. 4. R8's Face Sheet, undated, documents R8 was admitted on [DATE] with diagnoses of acute respiratory disease, neurocognitive disorder with Lewy bodies, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, stiffness right knee, pain, diarrhea, cellulitis of right toe, depression, osteoarthritis, obstructive sleep apnea, normal pressure hydrocephalus, hyperlipidemia and Parkinson's disease. R8's Care Plan, dated 12/30/23 documents Resident Care Information with interventions of: transfer method: dependent, alternative call light, instruct R8 to call for assistance before getting out of bed or transferring. Turning and repositioning dependent. Bowel and bladder incontinent with incontinence products of medium incontinence briefs. R8's Minimum Date Set (MDS), dated [DATE], Documents in Section C a BIMS score of 4 which indicates that R8 has severe cognitive impairment. Section GG documents that R8 needs substantial/maximal assistance with toileting hygiene and with standing and transfers. Section H documents that R7 is occasionally incontinent of bladder and bowel. On 01/25/2024 at 11:24am, V3 (Family Member) stated that she knows R8 is incontinent at times, but that other times he knows when he has to go to the bathroom. V3 said that if R8 gets dirty or wet he becomes very agitated. V3 said that she knows that staff are not checking R8 every two hours. V3 said that R8 does not really push the call light button on his own. V3 said that the facility was supposed to be working on getting him a call light that will go off when R8 is moving around. V3 stated she has pushed the call light to ask for assistance for R8 many times. V3 stated that staff will come answer the call light and say they will be back and don't come back. V3 said that if it is mealtime and R8 wants to lay down or is incontinent that he must wait until the meals are passed and every resident is fed. V3 stated she was told by day shift staff that R8 does not get changed on the midnight shift because they do not have enough staff. 5. R9's face sheet, undated, documents R9 was admitted on [DATE] with diagnoses of cellulitis of right lower limb, Chronic lymphocytic leukemia of B cell type not having achieved remission, difficulty in walking, weakness, other abnormality of gait and mobility, cognitive communication deficit, unsteadiness on feet, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, venous insufficiency, obstructive sleep apnea, hypertension, atherosclerotic heart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 3 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disease, cerebral infraction history of, peripheral vascular disease, and chronic obstructive pulmonary disease. R9's Care Plan, dated 12/14/23 documents Resident Care Information with interventions of: bowel incontinent, bladder foley catheter, bed pan for incontinent toileting, mobility of mechanical lift with 2 assist, Safe resident handling procedure- transfer mechanical lift with 2 staff assistance. And turn and reposition every two hours as tolerated. R9 is at risk for falls related to recent illness/hospitalization, new environment, Chronic obstructive pulmonary disease, chronic peripheral venous insufficiency, history of cerebral vascular accident, hypertension, peripheral vascular disease, and anemia with interventions of: orientate resident to room, surrounding areas, and use of call light system. R9's Minimum Data Set (MDS), dated [DATE], Documents in Section C a BIMS score of 15 which indicates that R7 is cognitively intact. Section GG documents that R9 requires substantial/maximal assistance with toileting, showers, and lower body dressing. On 01/25/24 at 1:17PM, R9 stated he has times where staff don't answer the call light in a timely manner, he said I guess it just depends on what is going on. R9 states he requires total assistance with transferring, and often gets stuck in his chair for a long time. R9 said he frequently asks to be put into bed after evening meal which is usually about 06:00PM. He said on one occasion it was after 08:00PM before staff even came back to assist him into bed. R9 said he waited for over two hours and had already been up in his chair for quite some time. 6. R10's Face sheet, undated, documents R10 was admitted [DATE] with diagnoses in part of Type 2 diabetes mellitus with diabetic neuropathy, blindness both eyes-affecting all levels of care, Chronic kidney disease, hypertension, hyperlipidemia, primary insomnia, anemia, recurrent depressive disorder and pain. R10's Care Plan, dated 01/23/24 documents R10 is at risk for falls related to limited mobility, added risk factor of blindness. R10 had a fall prior to placement and experienced fractures to her right humerus, radius, and pelvis. Difficulty with walking, hypertension, muscle weakness. Interventions include: Re-educate on asking for assistance when needed, offer toileting before bedtime as tolerated, alternative call light, educate R10 on risk associated with not using call light to assist with transfers. Resident Care Information- alternative call light, bowel incontinent and bladder incontinent toileting of bedpan and toilet, mobility 1 assist, safe resident handling procedures stand pivot with assist of 1. R10's Minimum Data Set (MDS), dated [DATE], documents in Section C a BIMS score of 9 which indicates that R7 has moderate cognitive impairment. Section GG documents that R9 requires substantial/maximal assistance with toileting, showers, and lower body dressing. Section H documents R10 is always incontinent of bladder and frequently incontinent of bowel. On 01/29/24 at 9:26AM R10 who was alert and oriented to person, place, and time and stated that staff does not answer her call light when she pushes it. R10 says she pushes it 3 to 4 times at least, but sometimes it feels like over 100. R10 stated that she hoped none of this would go against her, but sometimes they shut her call light off and say they will be back, but never come back. A review of facility policy titled Personal Care of Resident (revised 12/02) documents under Purpose To Provide that residents of the facility receive adequate care Procedure: document in part Each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 4 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident shall have proper daily personal attention and/or care, including skin, nails, hair and oral hygiene, in addition to treatment ordered by the physician. A review of facility reports titled Grievance Reports documents on 01/11/24 summary of grievance: Power of Attorney calls with concerns regarding nursing care, 01/11/24 summary of grievance: wife and resident voices concerns about nursing care and dietary, 01/11/24 summary of grievance: Husband and resident voices concerns with nursing care, 12/29/23 summary of grievance: resident voices concerns with certified nurse assistant and care received, 12/29/23 summary of grievance: Resident voices concerns with certified nurse assistant and care received, and 12/27/23 summary of grievance: resident voicing concerns with call light and care. On 01/25/24 at 3:30PM, V2 (Director of Nursing/DON) said he was aware of resident complaining about call lights not being answered in a timely manner. V2 said that he had problems with that in November. V2 said that he believes it was a CNA (Certified Nurse's Assistant) problem and that he educated the CNA's on answering the call lights in a timely manner. V2 said he did have a complaint about staff turning off call lights and saying that they would come back, but they wouldn't come back for a long time. V2 said he was working on a correction plan for this around 12/06/23 and this was the first week of the correction plan. V2 said that some of the complaints about them turning off the lights and not coming back was around the end of November when we had a complaint about it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 5 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 provide residents with an effective means to request assistance in the absence of a functioning call light system for 2 of 17 residents (R1 and R2) reviewed for accommodation of needs in a sample of 17. Residents Affected - Few The Findings include: 1. R1's Face Sheet, undated, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Other pulmonary embolism, Sepsis, unspecified organism, Anxiety disorder, Weakness, Difficulty in walking, not elsewhere classified, Alzheimer's disease, Hyperlipidemia, Pain, Unspecified atrial fibrillation, Unspecified kidney failure, Essential (primary) hypertension. R1's Care Plan, dated 01/05/24, documents R1's Care Information Interventions: Bowel and Bladder: Incontinent, Incontinent Toileting, and incontinent products: medium briefs, Dressing Assist of 1, Grooming assist of 1, Safe resident handling procedure-Transfer Method: Mechanical Lift with level of assist 2 sling size medium. R1 is at increased risk for skin impairment/pressure ulcers r/t (related to) decreased mobility, generalized muscle weakness following recent illness/hospitalization for Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, hypertension, and hypothyroidism. R1 currently has excoriation to rectal area, and Pressure ulcer to mid spine and Moisture associated skin damage: R1 will have decreased risk of skin breakdown during this quarter. Interventions: Provide incontinent care after each incontinent episode. R1 is at risk for constipation due to Chronic Obstructive Pulmonary Disease, Hypothyroidism, history of constipation, diuretic medication use, and Narcotic medication use. Goal: R1 will have a bowel movement at least every 3 days during this quarter. Interventions include Assist R1 to the (toilet, bed pan, commode) to promote bowel movement as tolerated. R1's Minimum Data Set (MDS) dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 10 which indicates that R1 has moderate cognitive impairment. Section GG documents R1 is dependent on staff for toileting, showers, repositioning and dressing. Section H documents that R1 has an indwelling catheter and is frequently incontinent of bowel. On 01/29/24 at 11:10AM, R1 who was alert and oriented to person, place and time during interview stated there was a day or two last week when the call light system wasn't working correctly. R1 said they gave her some kind of bell thing to ring, but it was kind of useless cause she had to turn it to make noise with it. R1 said that she was unable to turn it to make noise so she could alert staff. R1 said it was so hard to turn because you had to hold the top and then use the other hand to turn the bottom, and you had to keep doing it to make some kind of noise. On 01/29/24 11:25AM, V4 (Family Member) said that she knows they did have problems with the call lights system about a week ago or so. V4 said they did give R1 an alternative bell to ring for help. V4 said that R1 couldn't really ring the bell they gave her cause you had to turn the bottom to make noise and R1 couldn't really turn the bottom. V4 said that she even has a hard time turning the bottom of it to make a sound. V4 did demonstrate how hard it was turning the bottom of the noise maker to make a sound, which wasn't very loud when turned. 2. R2's Face sheet, undated, documents R2 was admitted to the facility on [DATE] with diagnoses of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 6 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Type 2 diabetes mellitus with unspecified complications, Nontraumatic subdural hemorrhage, Constipation, Dysuria, Anxiety disorder, Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, Weakness, Muscle weakness (generalized), Unspecified dementia with other behavioral disturbance, Unsteadiness on feet, and Cerebral infarction. R2's Care Plan, dated 10/31/23, documents Resident Care Information and Interventions of: Bowel and bladder: Bathroom Continent/Incontinent Toileting, Incontinence Products- wears underwear, Safe resident handling procedure-Transfer method stand pivot transfers with one assist. Orientate resident to room, surrounding area, and use of call light system. R2's MDS dated [DATE], Documents in Section C a BIMS score of 13 which indicates R2 is cognitively intact. Section GG documents that R2 requires partial/moderate assistance with toileting hygiene and requires supervision or touch assist with toilet transfers. Section H documents that R2 is occasionally incontinent of bladder and always continent of bowel. On 01/25/24 at 10:25AM, R2 who was alert and oriented to person, place, and time stated that call lights were not working one day last week and she was given a cowbell to ring in case she needed staff. R2 states that she had a hard time keeping track of the cowbell. R2 said that the cowbell wasn't attached to anything and most of the time it was on her table tray. R2 said she would bump the table tray with her wheelchair and the cowbell would fall under her bed. V2 said she was unable to reach it under her bed. R2 also stated that they keep her door closed because she had COVID and that no one could hear her ringing the cowbell when she did have it in hand. R2 said it took a long time before anyone came into help her. On 01/25/24 at 10:28AM, a cowbell was observed under R2's bed. On 1/25/24 at 3:30PM, V2 (Director of Nursing/DON) said he was aware that the call light system went down over the weekend. V2 said that he knows that maintenance contacted the call light system company. V2 said that he thought that the call lights system didn't work from Sunday into Monday. V2 said it wasn't just the call light system that wasn't working properly. V2 said that it started out that the lights outside the door wouldn't light up. V2 said then it was the call lights at the nurses station wasn't working then it moved to not working in the rooms or on the hall either. V2 said that he thinks they didn't have enough noise makers for all the residents. V2 stated that residents who didn't get the noise maker was turned into alternative call which is frequent checks every time you walk pass the room you are to look in on that resident. V2 said that he thinks the new call light system had gone down twice in a year. V2 said that they have had multiple times where one call light wouldn't work here and there. V2 stated that they will call the call light company to come and fix the call lights when they aren't working. V2 said if it's in a resident room they may move the resident out to a different room where the call light is working or give the resident an alternative call bell like a noise maker or put them on alternative call and check on them frequently. He said that everyone was alternative call last week when the call lights weren't working until they got noise makers. On 01/29/24 at 2:15PM, V7 (Certified Nursing Assistant/CNA) stated that she was there one of the days that the call lights weren't working. V7 said the light was on in the residents' room, and alarming at the computer at first, but not on the hall. V7 said eventually the computer stopped working also, they had families calling them. V7 stated that every resident was provided with alternative bells that were loud. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 7 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0558 Level of Harm - Minimal harm or potential for actual harm On 01/29/24 at 2:30PM V9 (Certified Nursing Assistant/CNA) stated she was working when the call lights were malfunctioning at the facility. V9 said the call light system was messed up for 2 or 3 days. Review of the facility policy titled Call Light with a revised date 01/04 documents an Objective To respond to resident's request and needs Equipment Functioning call light. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 8 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 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** Based on interview and record review, the facility failed to provide assistance with activities of daily living (ADL) for residents requiring assistance with toileting hygiene for 4 of 17 residents (R1, R2, R7, and R8) reviewed for ADL care in a sample of 17. Residents Affected - Some The findings include: 1. R1's Face Sheet, undated, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Other pulmonary embolism, Sepsis, unspecified organism, Anxiety disorder, Weakness, Difficulty in walking, not elsewhere classified, Alzheimer's disease, Hyperlipidemia, Pain, Unspecified atrial fibrillation, Unspecified kidney failure, Essential (primary) hypertension. R1's Care Plan, dated 01/05/24, documents R1's Care Information Interventions: Bowel and Bladder: Incontinent, Incontinent Toileting, and incontinent products: medium briefs, Dressing Assist of 1, Grooming assist of 1, Safe resident handling procedure-Transfer Method: Mechanical Lift with level of assist 2 sling size medium. R1 is at increased risk for skin impairment/pressure ulcers r/t (related to) decreased mobility, generalized muscle weakness following recent illness/hospitalization for Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, hypertension, and hypothyroidism. R1 currently has excoriation to rectal area, and Pressure ulcer to mid spine and Moisture associated skin damage: R1 will have decreased risk of skin breakdown during this quarter. Interventions: Provide incontinent care after each incontinent episode. R1 is at risk for constipation due to Chronic Obstructive Pulmonary Disease, Hypothyroidism, history of constipation, diuretic medication use, and Narcotic medication use. Goal: R1 will have a bowel movement at least every 3 days during this quarter. Interventions include Assist R1 to the (toilet, bed pan, commode) to promote bowel movement as tolerated. R1's Minimum Data Set (MDS) dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 10 which indicates that R1 has moderate cognitive impairment. Section GG documents R1 is dependent on staff for toileting, showers, repositioning and dressing. Section H documents that R1 has an indwelling catheter and is frequently incontinent of bowel. On 01/29/24 at 11:10AM, R1 who is alert and oriented to person, place and time stated that when she was admitted to the facility on [DATE] that she had hit her call light for assistance to go to the bathroom. R1 said that staff told her to just go in her disposable undergarment and they would change her when she is done. R1 said she now just uses the incontinent brief to have a bowel movement and has staff come in and clean her up after she has gone. On 01/29/24 at 11:20 AM, V4 (Family Member) said that R1 hit her call light to ask for assistance with going to the toilet and that one of the staff told R1 to just go to the bathroom in her incontinence brief and that she would clean it up later after R1 was done. V4 (Family Member) stated that this occurred around 01/04/24 when R1 was admitted . On 01/30/24 at 1:40PM, V2 (Director of Nursing/DON) said he was told that staff has told residents to go bathroom in their incontinence brief instead of using the toilet. V2 said he dealt with the incident right away. V2 said that the staff were educated right away. V2 said that this happened about a month ago. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 9 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0677 Level of Harm - Minimal harm or potential for actual harm 2. R2's Face sheet, undated, documents R2 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus with unspecified complications, Nontraumatic subdural hemorrhage, Constipation, Dysuria, Anxiety disorder, Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, Weakness, Muscle weakness (generalized), Unspecified dementia with other behavioral disturbance, Unsteadiness on feet, and Cerebral infarction. Residents Affected - Some R2's Care Plan, dated 10/31/23, documents Resident Care Information and Interventions of: Bowel and bladder: Bathroom Continent/Incontinent Toileting, Incontinence Products- wears underwear, Safe resident handling procedure-Transfer method stand pivot transfers with one assist. Orientate resident to room, surrounding area, and use of call light system. R2's Minimum Data Set (MDS) dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 13 which indicates R2 is cognitively intact. Section GG documents that R2 requires partial/moderate assistance with toileting hygiene and requires supervision or touch assist with toilet transfers. Section H documents that R2 is occasionally incontinent of bladder and always continent of bowel. On 01/25/24 at 10:25AM, R2 who was alert and oriented to person, place and time stated that there have been problems with her call light not being answered in a timely manner. R2 stated that call lights were not working one day last week, and she was given a cowbell to ring in case she needed staff assistance. R2 stated that she has a hard time keeping track of the bell because it wasn't attached to anything, and the cowbell would often fall on the floor under the bed. R2 said she was unable to reach the cowbell when it fell under the bed. R2 said they kept her door closed recently because she had COVID and no one could hear her ring the cowbell or when she would yell because the cowbell was on the floor. R2 stated that she has had an incontinent episode of bladder while waiting on staff to respond to her call light. A facility document titled Grievance Report with R2's name and dated 11/17/23 states under summary of the grievance that R2's son states that R2 is not getting taken to the bathroom when needed. R2's son states that the light is turned on and it takes along time for anyone to answer which causes R2 to sit in a soiled incontinence brief. R2's son states that on Tuesday he was at the facility and the call light was going off for awhile and nobody came. R2's son states that he went to the nurse's station and there were 3 to 4 nurses just sitting in the little station in the middle. R2's son stated that he told them that R2 needed to use the bathroom, and one stated that the certified nurse assistance does that, but one nurse did get up and take her. R2's son said that R2 feels embarrassed when she has accidents. 3. R7's Face Sheet, undated, documents R7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non dominant side, unspecified abnormalities of gait and mobility, constipation, obstructive and reflux uropathy, encounter for orthopedic aftercare, need for assistance with personal care, glaucomatous flecks right eye, pain, essential hypertension, hypothyroidism, hyperlipidemia, depression, anxiety disorder, personal history of transient ischemia attack and cerebral infraction without residual deficit, fractures of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. R7's Care Plan, dated 12/27/23, documents Resident Care Information with interventions of: bowel incontinent blader incontinent/catheter, continent/incontinent toileting: Toileting, with pull up incontinence products. Transfer method- stand pivot transfer to right side level assist of one. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 10 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0677 Level of Harm - Minimal harm or potential for actual harm R7's Minimum Data Set (MDS), dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 9 which indicates that R7 has moderate cognitive impairment. Section GG documents that R7 requires substantial/maximal assistance with toileting hygiene, dependent with dressing, R7 requires substantial/maximal assistance withstanding and transfers. Section H documents that R7 is occasionally incontinent of bladder and frequently incontinent of bowel. Residents Affected - Some On 01/25/2024 at 10:58am, R7 who was alert and oriented to person, place, and time during interview stated that sometime staff will answer her light other times they don't. R7 said that staff will answer the call light and say they will be back and then don't come back. R7 said that she has had to wait for an hour to an hour and a half on more than one occasion. R7 said that she has timed how long it is on her watch. R7 said when she hits her call light and has to wait for a long period of time, she will start yelling for staff. R7 said that this has happened on several occasions. R7 said when staff finally gets to her, they tell her that they don't have enough staff. 4. R8's Face Sheet, undated, documents R8 was admitted on [DATE] with diagnoses of acute respiratory disease, neurocognitive disorder with Lewy bodies, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, stiffness right knee, pain, diarrhea, cellulitis of right toe, depression, osteoarthritis, obstructive sleep apnea, normal pressure hydrocephalus, hyperlipidemia and Parkinson's disease. R8's Care Plan, dated 12/30/23 Resident Care Information with interventions of: transfer method: dependent, alternative call light, instruct R8 to call for assistance before getting out of bed or transferring. Turning and repositioning dependent. Bowel and bladder incontinent with incontinence products of medium incontinence briefs. R8's Minimum Date Set (MDS), dated [DATE], Documents in Section C a Brief interview for mental status(BIMS) score of 4 which indicates that R8 has severe cognitive impairment. Section GG documents that R8 needs substantial/maximal assistance with toileting hygiene and withstanding and transfers. Section H documents that R7 is occasionally incontinent of bladder and bowel. On 01/25/2024 at 11:24am, V3 (Family Member) stated that she knows R8 is incontinent at times, but that other times he knows when he has to go to the bathroom. V3 said that if R8 gets dirty or wet he becomes very agitated. V3 said that she knows that staff is not checking R8 every two hours. V3 said that R8 does not really push the call light button on his own. V3 said that the facility was supposed to be working on getting him a call light that will go off when R8 is moving around. V3 stated she has pushed the call light to ask for assistance for R8 many times. V3 stated that staff will come answer the call light and say they will be back and don't come back. V3 said she is always told there ae two staff on the hall and that R8 is a mechanical lift that takes 2 staff to assist. V3 said that if it is mealtime and R8 wants to lay down or is incontinent that he has to wait until the meals are passed and every resident is fed. V3 stated she was told by day shift staff that R8 does not get changed on the midnight shift because they do not have enough staff. On 01/29/2024 at 02:30PM, V9 (Certified Nurse Assistant/CNA) stated that she doesn't think people are getting proper incontinent care at night. V9 said in the mornings when she comes to work some of the residents tell her that they have not been changed since the evening shift the day before and you can just tell it's been a while since they have been changed. The Facility's Personal Care of Residents dated 12/02 documents It is a policy of the facility to provide a plan of personal care for resident Purpose: To provide that resident of the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 11 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0677 receive adequate care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 12 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure affected (R2, R3, R7, and R8 ) and has the potential to affect all 104 residents residing in the facility. Findings Include: 1. R2's Face sheet, undated, documents R2 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus with unspecified complications, Nontraumatic subdural hemorrhage, Constipation, Dysuria, Anxiety disorder, Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, Weakness, Muscle weakness (generalized), Unspecified dementia with other behavioral disturbance, Unsteadiness on feet, and Cerebral infarction. R2's Care Plan, dated 10/31/23, documents Resident Care Information and Interventions of: Bowel and bladder: Bathroom Continent/Incontinent Toileting, Incontinence Products- wears underwear, Safe resident handling procedure-Transfer method stand pivot transfers with one assist. Orientate resident to room, surrounding area, and use of call light system. R2's Minimum Data Set (MDS) dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 13 which indicates R2 is cognitively intact. Section GG documents that R2 requires partial/moderate assistance with toileting hygiene and requires supervision or touch assist with toilet transfers. Section H documents that R2 is occasionally incontinent of bladder and always continent of bowel. On 01/25/24 at 10:25AM, R2 who was alert and oriented to person, place and time stated that there have been problems with her call light not being answered in a timely manner. R2 stated that she has had an incontinent episode of bladder while waiting on staff to respond to her call light. A facility document titled Grievance Report with R2's name and dated 11/17/23 states under summary of the grievance that R2's son states that R2 is not getting taken to the bathroom when needed. R2's son states that the light is turned on and it takes a long time for anyone to answer which causes R2 to sit in a soiled incontinence brief. R2's son states that on Tuesday he was at the facility and the call light was going off for a while and nobody came. R2's son states that he went to the nurse's station and there were 3 to 4 nurses just sitting in the little station in the middle. R2's son stated that he told them that R2 needed to use the bathroom, and one stated that the certified nurse assistance does that, but one nurse did get up and take her. R2's son said that R2 feels embarrassed when she has accidents. 2. R3's Face Sheet, undated, documents R3 was admitted to the facility on [DATE] with diagnoses that include dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Difficulty in walking, not elsewhere classified, Parkinson's disease, Type 2 diabetes mellitus without complications, Other abnormalities of gait and mobility, Aphasia following unspecified cerebrovascular disease, Heart failure, unspecified, Chronic Obstructive Pulmonary Disease. R3's MDS (Minimum Data Set) dated 11/13/23 documents R3 has a BIMS score of 6, which indicates R3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 13 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many has severe cognitive impairment. Section GG documents partial/moderate assistance with toileting, substantial/maximum assistance with showering, dressing and personal hygiene. Section H documents R3 is occasionally incontinent of bladder and bowel. R3's Care Plan dated 12/27/23 documents in part R3 is at risk for falls. Interventions include: encourage/assist resident not to reach past base of support, assist resident with activities of interest, and instruct resident to call for assist before getting out of bed or transferring, Resident care information documents in part safe resident handling procedure-transfer with supervision/touch assist. On 01/29/2024 at 12:44pm R3 who was alert and oriented at time of interview, stated that she usually has problems with them answering her call light because they don't have enough staff. R2 stated most of the time they have enough staff to meet my needs, but then there are other times they don't. 3. R7's Face Sheet, undated, documents R7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non dominant side, unspecified abnormalities of gait and mobility, constipation, obstructive and reflux uropathy, encounter for orthopedic aftercare, need for assistance with personal care, glaucomatous flecks right eye, pain, essential hypertension, hypothyroidism, hyperlipidemia, depression, anxiety disorder, personal history of transient ischemia attack and cerebral infraction without residual deficit, fractures of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. R7's Care Plan, dated 12/27/23, documents Resident Care Information with interventions of: bowel incontinent blader incontinent/catheter, continent/incontinent toileting: Toileting, with pull up incontinence products. Transfer method- stand pivot transfer to right side level assist of one. R7's Minimum Data Set (MDS), dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 9 which indicates that R7 has moderate cognitive impairment. Section GG documents that R7 requires substantial/maximal assistance with toileting hygiene, dependent with dressing, R7 requires substantial/maximal assistance withstanding and transfers. Section H documents that R7 is occasionally incontinent of bladder and frequently incontinent of bowel. On 01/25/2024 at 10:58am, R7 who was alert and oriented to person, place, and time during interview stated that sometime staff will answer her light and other times they don't. R7 said that staff will answer the call light and say they will be back and then don't come back. R7 said that she has had to wait for an hour to an hour and a half on more than one occasion. R7 said that she has timed how long is it on her watch. R7 said when she hits her call light and must wait for a long period of time, she will start yelling for staff. R7 said that this has happened on several occasions. R7 said when staff finally gets to her, they tell her that they don't have enough staff. R7 stated that she has no problems with staff, but there are not enough staff to get to the bathroom on time. 4. R8's Face Sheet, undated, documents R8 was admitted on [DATE] with diagnoses of acute respiratory disease, neurocognitive disorder with Lewy bodies, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, stiffness right knee, pain, diarrhea, cellulitis of right toe, depression, osteoarthritis, obstructive sleep apnea, normal pressure hydrocephalus, hyperlipidemia and Parkinson's disease. R8's Care Plan, dated 12/30/23 Resident Care Information with interventions of: transfer method: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 14 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dependent, alternative call light, instruct R8 to call for assistance before getting out of bed or transferring. Turning and repositioning dependent. Bowel and bladder incontinent with incontinence products of medium incontinence briefs. R8's Minimum Date Set (MDS), dated [DATE], Documents in Section C a BIMS score of 4 which indicates that R8 has severe cognitive impairment. Section GG documents that R8 needs substantial/maximal assistance with toileting hygiene and withstanding and transfers. Section H documents that R7 is occasionally incontinent of bladder and bowel. On 01/25/2024 at 11:24am, V3 (Family Member) stated that she knows R8 is incontinent at times, but that other times he knows when he must go to the bathroom. V3 said that if R8 gets dirty or wet he becomes very agitated. V3 said that she knows that staff is not checking R8 every two hours. V3 said that R8 does not really push the call light button on his own. V3 said that the facility was supposed to be working on getting him a call light that will go off when R8 is moving around. V3 stated she has pushed the call light to ask for assistance for R8 many times. V3 stated that staff will come answer the call light and say they will be back and don't come back. V3 said she is always told there ae two staff on the hall and that R8 is a mechanical lift that takes 2 staff to assist. V3 said that if it is mealtime and R8 wants to lay down or is incontinent that he must wait until the meals are passed and every resident is fed. V3 stated she was told by day shift staff that R8 does not get changed on the midnight shift because they do not have enough staff. V3 stated she feels that lack of staff is what she believes is a major contributing factor in R8's lack of care. On 01/29/24 at 2:05PM, V8 (Certified Nurse Assistant/CNA) stated that she believes call lights are answered in a timely manner when they have enough staff. V8 states at times there are only 4 CNA's to cover the four halls outside of the memory care unit. On 01/29/2024 at 02:15PM, V7,(Certified Nurse Assistant/CNA) stated that she felt there is not enough staff, but that it does depend who is working if the work load is manageable. On 01/29/2024 at 02:30PM, V9 (Certified Nurse Assistant/CNA) was asked if she knew of anyone turning call lights off and saying they will be back and then don't return. V9 stated no, but said she knows sometimes it happens unintentionally when we are short staffed. V9 stated they are short staffed all the time. V9 stated sometimes there will be only two people assigned to two different halls. On 01/29/2024 at 03:15PM, V12 (Licensed Practical Nurse/LPN) admits that in her opinion staffing is unsafe. V12 stated that managers (nursing) refuse to cover the floor on off hours because they state that they are salary and will be written up. V12 stated that she has been assigned to multiple halls and expected to cover as both the nurse and CNA. V12 stated that management always says that they have nothing to complain about because they are fully staffed per state guidelines. V12 admits she has refused extra assignments before, she was told to work as the nurse and CNA at the same time on more than one hall. V12 said she was written up for refusing. A review of facility reports titled Grievance Reports documents in part on 01/11/24 summary of grievance: Power of Attorney calls with concerns regarding nursing care, 01/11/24 summary of grievance: wife and resident voices concerns about nursing care and dietary, 01/11/24 summary of grievance: Husband and resident voices concerns with nursing care, 12/29/23 summary of grievance: resident voices concerns with certified nurse assistant and care received, 12/29/23 summary of grievance: Resident voices concerns with certified nurse assistant and care received, and 12/27/23 summary of grievance: resident voicing concerns with call light and care, and 11/27/23 summary of grievance: wife having (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 15 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0725 concerns with resident not getting changed when needed and also with staff being short. Level of Harm - Minimal harm or potential for actual harm The Resident Matrix (undated) provided by the facility on 01/25/24, documents 104 residents reside in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 16 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure a functioning or equivalent notification call system was available for resident use. This failure has the potential to affect all 104 residents residing in the facility. Residents Affected - Many Findings include: On 01/25/24 at 10:25am, R2 states that there have been issues with call lights being answered in a timely manner. R2 said she was just moved to this hallway because of having COVID . R2 said that call lights were not working one day last week, and she was given a cowbell to ring in case she needed staff. R2 states that she has a hard time keeping track of it and it often falls under her bed, and she is unable to reach it. R2 also states that they keep her door closed because she has COVID and that no one could hear her ringing the bell and it was a long time before anyone came into help her. During the interview, the cowbell was observed under the bed. On 01/25/24 at 11:24am, V3 (R8's Spouse) states that the power had gone out a few times, that the call light won't work right for a while, and they were not given an alternative call light. On 01/25/24 at 03:15pm, V5 (Maintenance) said that on 01/17/24 that staff told him that the call lights weren't working right. V5 said that they checked them out and that they were working fine. V5 said that they told him it was 100 hall, but when they checked them out everything was working fine. V5 said the room light came on, the light outside the door worked and it worked up at the computer. V5 said that on Sunday 01/21/24 they had some trouble with the grid. V5 said the electric company did come out and they said it was a level 1 grid problem. V5 said that it effected the lights and various things. V5 said that they had flickering lights in the rooms and dining room. V5 said that some of the call lights weren't working either. V5 said that they were able to call the call light company and they fixed it after the power company fixed the grid. V5 said they did go out again on Monday 01/22/24, V5 said that they weren't able to fix it then, that they had to call the call light company and they had to come out and fix it. V5 said that it took the call light company a little bit to get to the facility because of the ice. V5 said that they were able to fix it when they got there on 01/22/24. On 01/25/24 at 3:00PM, V6 (Maintenance) said that on 01/17/24 that some of the nursing staff said that the call light system wasn't working right, but when they went to check the call lights and they were working. V6 said that they told them that it was the 100 hall that wasn't working right. V6 said when they checked the call lights, all the call lights were working just fine. V6 said they worked in the rooms, hall lights and on the computer. V6 said that he did work on Sunday 01/21/24 and when he came in at 7am, the lights in the dining room weren't working and some of the resident bathrooms didn't have lights. V6 said other lights were flickering on and off. V6 said some of the other equipment, like the beds and stuff, weren't working correctly too. V6 said that staff had told him that the power had been out when he asked them about it. V6 also stated that no one had called and told him anything about the power going out, which is what is normally expected. V6 said he went to check the breakers to see if some of the breakers tripped and they were all fine. V6 said that he noticed the power company pulling up to a transformer outside of the building. V6 said that he went outside and talked to the power company. V6 asked if the power outage was on the facility end or if it was something to do with the power company. V6 said the power company told him that it was a level 1 grid outage and that they were there to work on it. V6 said that some of the call lights were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 17 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0919 Level of Harm - Minimal harm or potential for actual harm working properly. V6 said once the power company got everything working, he called the call light company, and they were able to fix everything over the phone. V6 said then on Monday, 01/22/24, all the call lights stopped working and that they had to call the call light system company to come and fix it. V6 said it was taking them a little longer to get to the facility because of the weather. V6 said that it took them several hours to get to the facility, but that they were able to fix it on Monday 1/22/24. Residents Affected - Many On 01/25/24 at 3:30PM, V2 (Registered Nurse/ Director of Nursing) said he was aware that the call light system went down over the weekend 01/21/24. V2 said that I know that Maintenance contacted the call light system company and I think the call lights didn't work from Sunday 01/21/24 into Monday 01/22/24. V2 said it wasn't just the call light system. V2 said that it started out that the lights outside the door wouldn't light up, then it was the call lights at the nurse's station wasn't working then it moved to not working in the rooms or hallway either. V2 said they did pass out some kind of noise maker to most residents. V2 said that he thinks they didn't have enough noise makers for all the residents. V2 said that the residents who didn't get the noise maker were placed on alternative call which is frequent checks every time you walk past the room you are to look in on that resident. V2 said that he thinks the new call light system had gone down twice in a year. V2 said that they have had multiple times where one call light wouldn't work here and there. V2 said that they will call the company to fix the call light. V2 said if it's in a resident room they may move the resident out to a different room where the call light is working, give the resident an alternative call bell like a noise maker, or put them on alternative call and check on them frequently. V2 said that everyone was placed on alternative call last week when the call lights weren't working until they got noise makers. On 01/29/24 at 9:37 AM, the call light in room [ROOM NUMBER] was checked for proper functioning and it did not work at all. On 1/29/24 at 10:20 AM, room [ROOM NUMBER] was checked and found not to be working at all. There were no residents residing in the room at this time. On 01/29/24 at 10:20am, this surveyor notified V2 of the call lights not functioning in rooms [ROOM NUMBERS]. V2 was not aware that they were not functioning. On 01/29/24 at 10:29AM, 302 and 102 were observed functioning at the light at the door and at the nurse's station. On 01/29/24 at 10:30AM the call light system monitor at the nurse's station was observed, the call light system does have warnings on screen that read: Warning 01/25/24 1:17PM a problem has been detected in the wireless device system. The system may be partially functional. Warning 01/29/24 9:37AM A problem has been detected in the dome light system. The system may be partially functional. On 01/29/2024 at 11:20 AM, V2 said that he spoke to V1 (Administrator) and V1 said that all other call lights are working, and that maintenance fixed the ones that weren't working. On 01/29/24 at 3:00PM, V1 (Administrator) said that she was aware of a problem with the call lights (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 18 of 19 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 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many where the light would come on, but the call light didn't have a dinging sound. V1 said that she has a call out right now for the call light system company to come look at the call lights starting at a negative number when it starts to count down. V1 said that they did call the call light company. V1 said that she was aware they had problems with the call lights over the weekend of 01/21/24, but that to her knowledge, the light was working on the computer. V1 said that they did contact the call light system company and that they were able to come in Monday 01/22/24 to fix it. V1 said that they did offer the residents alternative call lights. V1 said that Maintenance did go today and check all call lights to make sure all of them are working properly due to 102 and 302 not working properly earlier. V1 said that all call lights are working including 102 and 302. V1 said the V5 said he changed the cords earlier on 102 and 302 and mixed them up with the bad cords and that is why they weren't working. On 01/29/24 at 02:15PM, V7(CNA) stated that she was there one of the days that the call lights weren't working. V7 said the light was on in the residents' rooms, and alarming at the computer at first, but not on the hall. V7 said that eventually the computer stopped working also, they had families calling them. V7 said everyone was provided with alternative bells that were loud. On 01/29/24 at 02:30PM, V9 (CNA) said she was working when the call lights were malfunctioning, and it was a mess for 2 or 3 days. A review of the facility policy titled Call Lights with a revision date of January 2004 documents an objective of, Respond to resident's requests and needs. The policy procedure states to Answer the call light promptly. The same policy goes on to state . If the call light is defective, report immediately to maintenance. In the same policy, in the key points it states . Check room frequently until call light is repaired. Fill out a maintenance work request form stating room number and take it to maintenance immediately . The Resident Matrix (undated) provided by the facility on 01/25/24, documents 104 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 19 of 19