Inspection·June 14, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 6/13/24 at 12:17 PM, V22 (Administrator) said via a phone interview, V22 was aware of R78's allegation of missing money. V22 said after reporting R78's allegation to local law enforcement there was not enough evidence to substantiate R78 had missing money. V22 said due to local law enforcement not being able to substantiate R78's allegation V22 had not reported the incident to IDPH and that was a failure on my part. The facility's revised 11/28/19 Abuse Prohibition and Reporting policy documented in part .B. Initial steps and reports of alleged abuse or neglect . 2. If the matter involves alleged abuse or results in serious bodily injury, the Administrator, or designee shall provide the Illinois Department of Public Health with initial notice of the alleged abuse or serious bodily injury as soon as possible, but not more than 2 hours after the matter becomes known or no later that 24 hours if the allegation does not involve abuse and does not result in serious bodily injury . 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 06/14/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of misappropriation of resident property for 1 (R78) of 20 residents in a sample of 38. Residents Affected - Few Findings include: 1. R78's Face Sheet documented an admission date of 8/21/23 with diagnoses including: unspecified dementia, insomnia, bipolar disorder, anxiety disorder, depression, hypothyroidism. R78's 5/22/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R78 was cognitively intact. R78's last reviewed/revised care plan documented in part .(R78) has dementia with anxiety, bipolar disorder, anxiety disorder, and depression . (R78) displays physical and verbal behaviors during hallucinations and delusional episodes. (R78) often misinterprets staff's intentions.) . R78's 5/21/24 Loss Control/Damage Report documented in part . Description of missing/damaged item(s) $100 missing from resident . When was the item(s) last observed: Date 5/19/24 . When was the item(s) discovered to be missing/ damaged: . 5/21/24 . Investigation: Searched room (and) all belongings . Conclusion . Money never found. All staff interviewed. Staff states that they had never seen resident (with) money that (R78's) friend keeps it with her due to resident being confused . On 6/13/24 at 11:04 AM, R78 said she thought she had told the nurse and thought the nurse had found her missing money. R78 was asked if R78 knew who the nurse was she told about her missing money R78 pointed to V20 (Activities Director). R78 said she was not sure when her money had went missing because it had been a while back. R78 stated I'm feeling a little confused today. On 6/13/24 at 11:07 AM, V20 (Activities Director) said she was not aware of R78 missing any money. V20 said R78 had told her R78's phone was missing the morning of 6/13/24 and V20 had assisted R78 in finding R78's phone. V20 said R78 did have a wallet but was not aware if R78 ever had money in R78's wallet. V20 said R78 would have delusions R78 had items missing. On 6/13/24 at 12:11 PM, V1 (Director of Nursing/DON) said no investigation was completed for R78's allegation of missing money and it was not reported to Illinois Department of Public Health (IDPH). V1 said V22 (Administrator) was responsible for completing investigations and reporting to IDPH and V1 was unsure why V22 had not. V1 said he was not able to produce any investigation documentation. On 6/13/24 at 12:17 PM, V22 (Administrator) said via a phone interview, V22 was aware of R78's allegation of missing money. V22 said after reporting R78's allegation to local law enforcement there was not enough evidence to substantiate R78 had missing money. On 6/13/24 at 12:42 PM, V4 (Social Services Director) said she had questioned staff that usually worked on R78's hall. V4 said no staff had ever seen R78 with money. The facility's revised 11/28/19 Abuse Prohibition and Reporting policy documented in part C. Investigation . 1. Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer (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 06/14/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete shall take notes . 2. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident . 3. The Administrator shall keep copies of all notes from the interviews conducted by the Administrator or other facility interviewer in the course of the investigation . 4. The Administrator shall be responsible for supervising the investigation and reporting the results of the investigation to the Illinois Department of Public Health . 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 06/14/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R93's Face Sheet documents an admission date of 3/8/2024. R93 is alert to person only. R93's responsible party is documented on this face sheet as V17 (Family Member/Responsible Party). R93's Progress Notes document on 3/15/2024 that R93 was transferred to the hospital for shortness of breath and V17 was notified via phone. On 6/12/24 at 2:00PM, V1 (DON) stated that they provide the bed hold policy to the resident with their paperwork that they send to the hospital upon transfer. On 6/12/24 at 2:30 PM, V3 (Medical Records) stated that the form is filled out and mailed to the family but no records are available to show that occurred for this hospitalization. On 6/14/24 at 10:00 AM, V4 (Admissions) stated that she does not send written notification to the Ombudsman of resident transfers to the hospital. Based on interview and record review, the facility failed to provide written notification of the reason for transfer/dishcharge to residents, resident representitives and the Long Term Care Ombudsman office for 2 (R39 and R93) of 2 cognitively impaired residents reviewed for notice requirements of transfer/discharge in a sample of 38. Findings include: 1. R39's Face Sheet documents an admission date of 2/15/2022 and includes diagnoses of heart failure, cerebral infarction, chronic kidney disease stage 3, ischemic cardiomyopathy, rheumatoid arthritis, hypertension, chronic systolic heart failure, diarrhea, constipation, GERD (gastroesophageal refulx disease), fatigue, benign prostatic hyperplasia, weakness, paroxysmal atrial fibrillation, anemia, chronic pain, insomnia, vitamin deficiency, hyperlipidemia, gout, and unspecified dementia. R39's Mimimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. R39's Progress Notes dated 2/9/2024 at 8:06 PM document EMS (Emergency Medical Service) in facility to transfer resident at this time. CCD (Continuity of Care), POLST (Practitioner Orders for Life Sustaining Treatment), and bed hold policy sent with them. No documentation was found in R39's record of written notification for the reason for R39's transfer/discharge presented to R39 or V18 (R39's Power of Attorney/POA). R39's Progress Notes dated 3/2/2024 at 5:44 PM document Resident was transported out by EMS, report given to EMS, CCS (Critical Care Split Billing), bed hold and POLST printed and given to EMS. On 3/3/2024 at 12:33 AM, progress note documents Resident out of facility at this time at (name of local hospital Emergency Room). No documentation was found in R39's medical record to indicate written notification for the reason for R39's transfer was provided to R39 or V18 (POA). On 6/14/2024 at 9:40 AM, written documentation of notification of R39's transfers to the local hospital were requested from V1 (Director of Nursing/DON). V1 was unable to present the requested (continued on next page) 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 06/14/2024 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 0623 documentation. Level of Harm - Minimal harm or potential for actual harm On 6/14/2024 at 11:22 AM, V18 (POA) stated she is the POA for R39. V18 states she did not receive any type of notifications in writing for description of reason for transfer to the hospital or bed hold policy information. Residents Affected - Few On 6/14/2024 at 1:05 PM, V1 again verified that there was no documentation available to validate the Transfer/Discharge notifications were presented to R39 or R39's POA. 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 06/14/2024 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R93's Face Sheet documents an admission date of 3/8/2024. R93 is alert to person only. R93's responsible party is documented on this face sheet as V17 (Family Member/Responsible Party). R93's Progress Notes document on 3/15/2024 that R93 was transferred to the hospital for shortness of breath and V17 was notified via phone. On 6/12/24 at 2:00PM, V1 (Director of Nursing/DON) stated that they only provide the bed hold policy to the resident with their paperwork upon transfer to the hospital, regardless of their cognition and do not send written documentation to the family. On 6/12/24 at 2:30 PM, V3 (Medical Records) stated that the form is filled out and mailed to the family but no records are available to show that occurred for this hospitalization. Based on interview and record review, the facility failed to provide written notification of the bed hold policy to resident representatives for 2 (R93 and R39) of 2 cognitively impaired residents reviewed for notice of bed hold policy upon transfer in a sample of 38. The Findings Include: 1. R39's Face Sheet documents an admission date of 2/15/2022 and includes diagnoses of heart failure, cerebral infarction, chronic kidney disease stage 3, ischemic cardiomyopathy, rheumatoid arthritis, hypertension, chronic systolic heart failure, diarrhea, constipation, GERD (gastroesophageal refulx disease), fatigue, benign prostatic hyperplasia, weakness, paroxysmal atrial fibrillation, anemia, chronic pain, insomnia, vitamin deficiency, hyperlipidemia, gout, and unspecified dementia. R39's Mimimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. R39's Progress Notes dated 2/9/2024 at 8:06 PM document EMS (Emergency Medical Service) in facility to transfer resident at this time. CCD (Continuity of Care), POLST (Practitioner Orders for Life Sustaining Treatment), and bed hold policy sent with them. R39's Progress Notes dated 3/2/2024 at 5:44 PM document Resident was transported out by EMS, report given to EMS, CCS (Critical Care Split Billing), bed hold and POLST printed and given to EMS. On 6/14/2024 at 11:22 AM, V18 (R39's POA) stated she is the POA for R39. V18 states she does not receive any type of notifications in writing for description of reason for transfers to the hospital or bed hold policy information. On 6/14/2024 at 9:40 AM, this surveyor requested transfer notification/bed hold policy documents for R39's recent transfers to the local hospital from V1 (Director of Nursing/ DON). V1 was unable to present evidence of the requested documents. On 6/12/24 at 2:00PM, V1 stated that they only provide the bed hold policy/transfer paperwork to the resident upon transfer to the hospital, regardless of their cognition and do not send written (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 06/14/2024 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 0625 documentation to the family. Level of Harm - Minimal harm or potential for actual harm 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 06/14/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate a PASRR (Preadmission Screening and Resident Review) Level II Screening for 1 (R53) of 1 resident reviewed for PASRR Screening in the sample of 38. Findings Include: R53's Face Sheet documented an initial admission date to the facility as 7/31/2023. Diagnoses listed on this form included but were not limited to: major depressive disorder, recurrent, unspecified. R53's current physician orders documents Aripirazole 5mg (milligram) tablet by mouth daily for Major depressive disorder, recurrent, unspecified with a start date of 9/01/2023. R53's Notice of PASRR Level I Screen Outcome dated 4/12/2019 in section PART I states based upon all information and data available to me for this person there is a reasonable basis for suspecting DD (Developmental Disability) or MI (Mental Illness) and is checked No. R53's Minimum Data Set (MDS) admission assessment dated [DATE] in Section A1500 asks is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, and this is documented No. This same MDS in section I5800 documented R53 has Depression (other than bipolar disorder). On 6/13/2024 at 9:57 AM, V4 (admission Coordinator) stated R53 does not have a PASRR Level II completed at this time. V4 stated she was not aware that R53 would need a Level II completed and when she entered R53 into the PASRR electronic system, it did not notify her that she would need the Level II completed. V4 stated, R53 has been at the facility for respite care that ended up being longer than a few days. V4 stated she should have initiated a PASRR screening when R53 did not return home. V4 stated the facility does not have a specific PASRR policy. On 6/14/2024 at 11:40 AM, V2 (Director of Nursing/DON) stated the facility does not have a specific PASRR screening policy. Review of (Corporation Name) Pre-Admission, admission and Orientation of Residents policy with revised date of 6/1/2022 documents on page 2 of 5, under admission Process that all residents admitted shall be pre-screened by the Department of Aging or other State Agency. Admissions Director will ensure that the screening form has been obtained and placed in the electronic medical record. 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 06/14/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 refer a PASRR (Preadmission Screening and Resident Review) Level II Screening for 1 (R19) of 1 resident reviewed for PASRR Screening in the sample of 38. Residents Affected - Few Findings Included: R19's Face Sheet documented an initial admission date to the facility of 4/16/24. Diagnoses listed on this form included but were not limited to: bipolar disorder, current episode hypomanic. R19's Notice of PASRR Level I Screen Outcome dated 3/22/2023 documented No Level II Required-No SMI/ID/RC (Serious Mental Illness/Intellectual Disability/Related Condition) R19's Minimum Data Set (MDS) admission assessment dated [DATE] Section A1500 Preadmission Screening and Resident Review (PASRR) asks - Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, and R19's is documented No. This same MDS in Section I, Active Diagnoses documents I5900 Bipolar Disorder. On 6/13/2024 at 9:57 AM, V4 (admission Coordinator) stated R19 does not have a PASRR Level II completed at this time. V4 stated she was not aware that R19 needed a PASRR Level II completed. V4 stated when she put R19 in the electronic PASRR system it did not notify her that she would need a Level II. V4 stated she is not aware of any resident in the facility who is a Level II. V4 stated the facility does not have a specific PASRR policy. On 6/14/2024 at 11:40 AM, V2 (Director of Nursing/DON) stated the facility does not have a specific PASRR screening policy. Review of (Corporation Name) Pre-Admission, admission and Orientation of Residents policy with revised date of 6/1/2022 documents on page 2 of 5, under admission Process .All residents admitted shall be pre-screened by the Department of Aging or other State Agency. Admissions Director will ensure that the screening form has been obtained and placed in the electronic medical record. 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 06/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview, observation and record review, the facility failed to implement new interventions to prevent falls for 1 (R56) of 2 residents reviewed for falls in the sample of 38 . The findings include: R56's admission Record documented R56 was [AGE] years old with an admission date to the facility of 4/17/2024. Diagnoses listed include, but not limited to traumatic subdural hemorrhage with loss of consciousness status unknown, subsequent encounter, type 2 diabetes mellitus without complications, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, weakness, cellulitis, unspecified. R56's Minimum Data Set (MDS) section C, dated 4/30/2024, documents that R56 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R56 is cognitively intact. The same MDS section GG0170, Mobility documents that R56 needs partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or support trunks or limbs, but provides less than half the effort) for toilet transfer. R56's Fall Risk Assessment dated 4/17/2024 documents a score of 20, which indicates that R56 was a high risk for falls. R56's Investigation Report for Falls dated 4/22/2024 documents resident was found sitting on buttocks on the floor. Resident attempted to get out of bed to use the restroom without assist. New intervention of visual cues to bathroom in place. R56's Progress Notes document on 4/22/2024 at 3:55 PM, R56 was sitting in the floor on her buttocks. When asked, R56 stated she was attempting to use the restroom when she fell. R56's Care Plan dated 4/17/2024 documents a focus area of The resident is at risk for falls, related to recent illness/hospitalization and new environment with a documented goal of the resident will have decreased risk for injury related falls this quarter. Interventions included instruct resident to call for assist before getting out of bed or transferring, orientate resident to room, surrounding areas, and use of call light, encourage resident to use side rails/enablers as needed, therapy to evaluate and treat as ordered, provide resident with specialized equipment: wheelchair and walker, assist resident with activities with an implementation date of 4/17/2024. New interventions included visual cues to bathroom documented after 4/22/2024 fall incident. On 6/12/2024 at 2:10 PM, R56 stated she did have a fall in April. R56 stated she was trying to go to the bathroom when she slipped and fell. R56 stated, she does have a call light that she uses but does not have any reminders in her room to use the call light. On 6/12/2024 at 2:15 PM, R56's room was observed to have no visual cues present in the room, on the bathroom door or in R56's bathroom. V5 (Certified Nurse Assistant/CNA), V6 (Licensed Practical Nurse/LPN), and V7 (CNA) verified that no visual cues are present in R56's room, on the bathroom door or in R56's bathroom as per the care plan. (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 06/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm On 6/12/2024 at 2:29 PM, V5 (CNA) stated R56 does not have a visual cue on her bathroom door. V5 stated the visual cue cards are placed on the bathroom doors and say Stop. Press Call Button in red letters. On 6/12/2024 at 2:32 PM, V6 (LPN) stated R56 does not have a visual cue on her bathroom door. V6 stated she is not aware R56 is supposed to have a visual cue for bathroom assistance. Residents Affected - Few On 6/12/2024 at 2:35 PM, V7 (CNA) stated R56 does not have a visual cue on her bathroom door. V7 stated the visual cue cards are placed on the bathroom doors that say Stop. Press Call Button in red letters. The Accident/Incident Prevention with no date documents when a resident has been identified as a high risk for accidents/incidents, interventions will be put into place per the individual resident assessment and care plan 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 06/14/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow therapeutic dietary recommendations for residents at risk for weight loss for 1 of 1 (R64) resident reviewed for nutrition in a sample of 38. This failure resulted in R64 having a significant weight loss of 16.8% over a period of 6 months. Residents Affected - Few The Findings Include: R64's Resident Face Sheet documents an admission date of 8/7/21 and a date of birth of [DATE]. This same document includes the following diagnoses: unspecified dementia, dysphagia, anxiety disorder, and cognitive communication deficit. R64's 06/2024 Physician Order Sheet documents a diet order for mechanical soft, high calorie/high protein (HCHP) diet. R64's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating that she is cognitively intact. This same MDS Section K0300 documents 'No' under the weight loss category question regarding Loss of 5% or more in the last month or 10% or more in the last 6 months. On 6/13/24 at 12:45 PM, R64's lunch tray was delivered to her room and had turkey, gravy, bread, mashed potatoes/gravy, vegetable medley, pineapple cake, and a red juice drink. R64's meal ticket included that R64 should receive a fortified whole milk-8 ounces, offer ice cream, offer egg salad, tuna salad and hard boiled eggs. R64 stated at this time she doesn't really like the food today and is not very hungry. R64 stated that sometimes she gets a pudding and/or milk but not every time and she is never offered the egg/tuna salad or hard boiled eggs. At this time, R64 had a pudding but not a fortified milk. On 6/13/24 at 1:00 PM, V21 (Certified Nurse Assistant/CNA) stated that the CNA's pass out the supplements that are prepared prior to the meal service, like pudding, milk or ice cream. Review of R64's Comprehensive Care Plan does not include a focus area for nutrition or weight loss. A 'Vitals Report dated 9/1/23-6/14/24 documents the following weights: September 2023-125.8 pounds, October 2023-125 pounds, January 2024-106 pounds, February 2024-100 pounds, March 2024- 104 pounds, and June 2024-96 pounds. R64's Resident Progress Note dated 3/27/24 by V10 (Registered Dietitian/RD) documents that RD wound/wt (weight) note. Weights (3/7) 104# (pounds), 2/27: 100#, 1/23 106#, 1/12 112, and 9/7 125.8#. Resident with 21% weight loss/6 months. Within normal limits of IBW (Ideal Body Weight) 108-138 pounds. Body Mass Index: 18 (underweight). Resident (underweight) with Stage 2 P.U. (pressure ulcer) Rt (right) upper buttock. On a mechanical soft diet (has signed a waiver for regular potato chips). High Calorie High Protein supplement. Intakes 25-27%. On Remeron which can increase appetite. Bilateral heels boggy. Plan: Continue Arginaid daily, MVI (Multivitamin), Vitamin C, and Zn (Zinc) for healing needs. To boost calories/protein. Re-Recommended. Add: Fortified Pudding at lunch and supper. Will monitor. Refer PRN (as needed). (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 06/14/2024 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 0692 Level of Harm - Actual harm Residents Affected - Few R64's Resident Progress Note dated 4/23/24 by V10 documents: Resident with resolved Stage 3 P.U., still has a Stage II P.U. on Rt buttock and P.U. on Lt (Left) buttock. Hx (history) poor-fair meal intakes. Remeron use may stimulate appetite. March 7 Wt 104 #, weights fluctuating. Continue M/S (Mechanical Soft) HCHP supplements all meals. Recommend fortified pudding at lunch and supper for additional protein. Monitor weights, intakes, skin. Refer PRN. On 6/12/24 at 2:00 PM, V2 (Dietary Supervisor) stated that for some reason the two dietary (computer) programs are not communicating. V2 determined that the orders are put in for the supplements, but the labels are not printing for the dietary staff to know to prepare these supplements. V2 further stated that the staff prepares the HCHP food items prior to each meal and delivers to the dining room the resident will be dining in. V2 stated that the staff are alerted to prepare these food supplements from labels generated (from the system). On 6/12/24 at 2:30 PM, V10 (Registered Dietitian) stated that anyone with a HCHP supplement ordered, it is procedure that residents will receive these supplements at all meals. V10 further stated that the only time that it would be specific to a certain meal would be when the order has that specific meal written in. When asked how V10 knows what residents require her assessment, V10 stated that she reviews charts offsite prior to her onsite facility visits twice a month to determine who needs to be evaluated. In addition, while onsite the staff can always let her know of any issues that need to be addressed that she was unaware of. On 6/12/24 at 3:00 PM, V9 (Physician) stated that when a resident has weight loss and/or is at risk and there are supplements ordered, he would then expect those supplements to be provided to prevent weight loss/increase the intake. 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 06/14/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R14's Face Sheet documents an admission date of 8/30/22. This same document includes the following diagnoses: anxiety, urinary tract Infection, diaphragmatic hernia, and chronic kidney disease. R14's 5/1/24 Quarterly MDS documents a BIMS score of 15, indicating R14 is cognitively intact. R14's Physician Order Sheet for June 2024 documents a regular diet with HPHC (High Calorie High Protein) supplement. On 6/13/24 at 12:45 PM, R14 received the following items on her lunch tray: hot turkey with gravy, vegetable medley, pineapple cherry cheesecake and red juice. R14's meal ticket that accompanied her tray delivery for this lunch meal on 6/13/24 lists in the notes section that R14 should be offered something on the always available menu; Serve 1 ounce extra protein at meals (1 ounce meat or cheese, 1 egg, 1/4 cup cottage cheese or 2 tablespoons of peanut butter); HCHP On 6/13/24 at 12:45 PM, R14 stated that she occasionally gets a glass of milk with meals, but not every time. R14 further stated that she does not like eggs and can't say for sure whether she gets extra amounts of protein servings at her meals. R14 stated that she chooses to eat in her room. On 6/13/24 at 1:00 PM, V19 (Dietary Assistant) stated that R14 did not get an extra portion of meat today because she probably would not eat it, due to not being a big eater. On 6/13/24 at 2:30 PM, V2 (Dietary Supervisor) stated that R14 should receive the supplements and the extra protein at her meals as her tray card or diet order state. 4. R23's Face Sheet documents an admission date to the facility of 9/18/18. This same document lists the following diagnoses: Alzheimer's Disease, heart failure, dysphagia and chronic kidney disease. R23's current Physician Orders for June 2024 document a diet order for pureed, HCHP supplement. R23's 5/1/24 Quarterly MDS Section C documents a BIMS score of 8, indicating moderate cognitive impairment. R23's lunch tray was delivered on 6/13/24 at 12:55 PM. R23 received a pureed hot turkey sandwich, mashed potatoes, gravy, pureed pineapple/cherry cake and a red juice drink. No fortified whole milk or fortified pudding was served to R23. On 6/13/24 at 12:55 PM, V21 (Certified Nurse Assistant/CNA) verified that R23 did not receive a fortified whole milk or fortified pudding. V21 stated that she feeds R23 often and she does not typically receive those supplements with her meals. R23's meal ticket that accompanied her lunch tray on 6/13/24 documents that R23 should receive fortified whole milk 8 ounces, fortified pudding 4 ounces and to offer her tomato juice. On 6/13/24 at 2:30 PM, V2 stated that R23 should be receiving those supplements with her meals, but (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 06/14/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is unsure why the system is not printing off the label to direct the kitchen staff to make those supplements up. Based on observation, interview and record review, the facility failed to provide high calorie high protein supplements as ordered for 4 (R14, R23, R26, and R246) of 4 residents reviewed for therapeutic diets in the sample of 38. Findings Include: 1. R246's Face Sheet documents an admission date of 1/9/24 with a diagnosis of End Stage Renal Disease. R246's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R246 is cognitively intact. R246's current Physician Orders documents Regular solids and High Calorie Supplement (HCS). R246's Progress Notes dated 6/7/24 at 11:29 AM by V10 (Registered Dietitian/RD) documents Dietary to emphasize K+ (potassium) in diet: NO high K+ foods. Continue SF HCS (Sugar Free High Calorie Supplement) for additional protein/cals. Include HS (evening) snack (High) protein per MD . On 6/11/24 at 12:32 PM, R246 was served a regular diet of polish sausage, potatoes, sauerkraut, biscuit and a regular size piece of cake. R246's meal card documented R246 should be offered reduced sugar condiments, beverages, and half portion of desserts: Limit dairy to one serving daily, double egg at breakfast, avoid citrus fruits and bananas. On 6/12/2024 at 12:26 PM, R246 was served a regular diet of pork tenderloin with gravy, sweet potatoes and cabbage bake, and 2 salted caramel chocolate chip cookies. R246's meal card documented R246 should be offered reduce sugar condiments, beverages, and half portion of desserts: Limit dairy to one serving daily, double egg at breakfast, avoid citrus fruits and bananas. On 6/13/2024 at 12:33 PM, R246 was served a regular diet of turkey with gravy, mash potatoes, bread and regular size of cherry cheesecake. R246's meal card documented R246 should be offered reduce sugar condiments, beverages, and half portion of desserts: Limit dairy to one serving daily, double egg at breakfast, avoid citrus fruits and bananas. On 6/12/2024 at 1:02 PM, V14 (Dietary Assistant) stated dietary staff are responsible for high calorie supplements and high protein snacks. V14 stated, if a resident is to have high calorie supplements and/or high protein snacks a label would be printed for that resident from the dietary staff, placed on the supplement or snack and noted on the dietary card. V12 stated, R246 does not have a high calorie supplement note on the dietary card. On 6/13/2024 at 9:29 AM, R246 stated he has not received a high protein snack in the evening since he has been admitted to the facility. R246 stated, he is not aware that he is getting a high calorie supplement at meals. R246 stated, he did get 2 salted caramel chocolate chip cookies for lunch on 6/12/2024. R246 stated he ate oatmeal, bacon, eggs and toast for breakfast this morning. R246 stated, he did get double portion of eggs during breakfast. On 6/13/2024 at 12:45 PM, V11 (Certified Nurse Assistant/CNA) stated, R246 does not get a high calorie supplement. V11 stated R246 would have a printed label from dietary if he was to get a high calorie supplement. (continued on next page) 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 06/14/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 6/13/2024 at 12:49 PM, V12 (CNA) stated he works 10:00 AM to 10:00 PM shift. V12 stated R246 does not get a high calorie supplement. V12 stated R246 should have a label printed from dietary if he was to get a high calorie supplement and a peanut butter sandwich in the cooler for his nighttime snack if he were to get a high protein snack. V12 stated he does not remember R246 having a peanut butter sandwich in the cooler when he works. V12 stated if residents are ordered a half size of desert, the kitchen would make smaller portion sizes to serve to those residents. V12 stated R246 is supposed to get half portion dessert. V12 stated, R246 did received regular size dessert today because dietary did not send out smaller portions of dessert. On 6/13/2024 at 12:53 PM, V13 (CNA) stated, dietary prints out labels for residents who are to get a high calorie supplement and/or high protein snacks. V13 stated, R246 does not have a label for high calorie supplement or high protein snack that she knows of. V13 stated dietary will send out half portions of desserts for residents that will be a smaller portion than the regular. V13 stated R246 did get regular size dessert of 2 cookies the day before and regular piece of cherry cheesecake because dietary did not send out half portions. V13 stated she does not ask residents if they want half the portion. On 6/13/2024 at 1:10 PM, V2 (Dietary Supervisor) stated, if residents have an order for high calorie supplement and/or high protein snack, they have a label that will be printed out from the dietary staff with the resident's name that is placed on items for the certified nurse assistances to serve at mealtimes. V2 stated examples of high calorie supplement would include fortified milk and fortified pudding. V2 stated examples of high protein would be a peanut butter sandwich. V2 stated high calorie supplements are scheduled for once daily and served in the morning with breakfast. V2 stated, R246 was ordered to have high calorie supplement and high protein snack, however, it was not put in the correct area for labels to be printed so R246 was not receiving his supplement or snack. V2 stated he does not have a waiver on file for R246 that documents R246 is not in agreement with his diet. On 6/13/2024 at 1:26 PM, V10 (Registered Dietician/RD) stated she assesses residents twice a month. V10 stated when she assesses residents, she will document her evaluation and dietary recommendations on in the resident in the electronic health record and send to V2 (Dietary Manager) to review. V10 stated, she does not have residents sign a waiver if they do not agree with her dietary recommendations. V10 stated she does communicate with (Company Name) Dialysis Center on R246's dietary recommendations. V10 stated, R246 is ordered to have a high calorie supplement with every meal unless she specified only with breakfast and a high protein snack every evening. 2. R26's Face Sheet documents an admission date of 1/31/24 and includes diagnoses of unspecified protein-calorie malnutrition, traumatic subdural hemorrhage without loss of consciousness, cognitive communication deficit, other generalized epilepsy. R26's MDS dated [DATE] documents a BIMS score of 03, indicating severe cognitive impairment. R26's current Physician Orders document a Mechanical Soft with extra gravy/sauce HCHP (High Calorie High Protein) dated 5/16/2024. R26's Progress Notes dated 5/16/24 by V10 (RD) documented No significant WT (weight) changes. However, WT trend -shows slowly declining WT. Est. (estimated) nutritional needs at 1820kcals (kilocalories) (28kcal/kg ABW) (calories/kilogram Adjusted Body Weight), 65g (gram) pro (protein) (1g pro/kg ABW), and 1820cc (cubic centimeter) fluid daily (1cc/kcal). Continue M/S (mechanical soft), extra sauces/gravies, HCHP all meals for additional cals/protein. Monitor WTs closely RT (related to) WT (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 06/14/2024 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 0808 trend. Level of Harm - Minimal harm or potential for actual harm On 5/30/2024, V10's Progress Note documents . Res (resident) with 7.1% WT loss/3mos (months). May 8 WT: 143# (pounds) [DATE] WT: 154# BS (blood sugar):152-tday (today). Dx (diagnosis): DM (diabetes mellitus)-II. Continue M/S, extra gravies/sauces, HCHP. Recommend include SF (sugar free) health shake daily for additional cals. Monitor WTs and refer prn (as needed). Residents Affected - Some On 6/12/2024 at 12:30 PM, R26 was served a regular mechanical soft diet of pork tenderloin with gravy, soft chopped roasted sweet potatoes and chopped cabbage bake, and 2 soft baked chocolate chip cookies. No extra gravy was observed. V15 (Family) was feeding R26 at the dining table. R26's meal card documented Regular Mechanical Soft, extra Gravy to mechanical meat/extra gravy, high calorie/high protein supplement. On 6/12/2024 at 1:02 PM, V14 (Dietary Assistant) stated dietary staff are responsible for high calorie supplements and high protein snacks. V14 stated if a resident is to have high calorie supplements and/or high protein snacks, a label would be printed from the dietary staff with that resident's name to be placed on the supplement or snack and noted on the dietary card. On 6/12/2024 at 1:05 PM, V15 (Family) stated she comes every other day to the facility during lunch to feed and spend time with R26. V15 stated she has not seen a high calorie/high protein supplement or extra gravy being served to R26 any time that she has been here during lunch. On 6/13/2024 at 12:44 PM, R26 was served a regular mechanical soft diet of ground hot turkey sandwich with gravy, mashed potatoes and gravy, vegetable medley (mechanical soft), pineapple cake. No extra gravy was observed. V11 (CNA) was assisting R26 at the dining table. R26's meal card documented Regular Mechanical Soft, extra Gravy to mechanical meat/extra gravy, high calorie/high protein supplement. On 6/13/2024 at 12:47 PM, V11 (CNA) stated R26 did not receive a high calorie/protein supplement or extra gravy with his lunch today. On 6/13/2024 at 12:50 PM, V12 (CNA) stated, R26 did not receive a high calorie/protein supplement or extra gravy with his lunch today. On 6/13/2024 at 1:10 PM, V2 (Dietary Supervisor) stated if residents have an order for high calorie high protein supplement, a label will be printed out from the dietary staff with the resident's name and placed on items for the certified nurse assistants to serve at mealtimes. V2 stated, R26 is ordered to have a high calorie/high protein supplement that would be served at breakfast. V2 stated, R26 was ordered to have a high calorie/high protein supplement, however, it was not put in the correct area for labels to be printed so R26 was not receiving his supplement. V2 stated, he does not have a waiver on file for R26 that documents R26 is not in agreement with his diet. On 6/13/2024 at 1:26 PM, V10 (RD) stated she assesses residents twice a month. V10 stated when she assesses residents, she documents her evaluation and dietary recommendations on the resident in the electronic health record and sends to V2 to review. V10 stated she does not have residents sign a waiver if they do not agree with her dietary recommendations. V10 stated R26 is ordered to have a high calorie/high protein supplement with every meal unless she specified it to only be with breakfast, lunch or dinner. 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 06/14/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to properly label and store foods. This has the potential to affect all 100 residents residing in the facility. Residents Affected - Many The Findings Include: On 6/11/24 at 9:30 AM during the initial tour of the kitchen, the following items were observed: 1. A case of bananas in the dry storeroom were on a stainless cart with multiple gnats swarming around over the ripe fruit. 2. The bulk powdered milk bin was found with a scoop in it and the handle touching the food source. 3. A bag of cookies were found opened, unsealed, and not dated in the dry store room. 4. A loaf of bread was found opened, unsealed, and not dated in the dry store room. 5. Hamburgers were opened, unsealed, and not dated in the freezer. The facility's Food Storage and Labeling procedure with a revision date of 9/22 documents Food Storage: keep all food covered in a a re-sealable bag or container or the original container, if applicable. Keep open bags of food such as pasta, cake mix, gelatin mix closed with tape or rubber band or in a larger re-sealable bag .Labeling of refrigerated foods. The label should include: 1. product name, 2. date, 3. discard date . On 6/11/24 at 10:00 AM, V2 (Dietary Supervisor) stated that he will discard the items that were not sealed and labeled properly and discard the bananas. The Long Term Care Facility Application For Medicare and Medicaid, signed on 6/11/24, documents 100 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