Inspection·September 24, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some GG-Functional Abilities and Goals it documents that R6 requires staff assistance with toileting hygiene, showering and bathing, dressing, personal hygiene, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R6 is incontinent of bladder and bowel. R6's current care plan documents that R6 is at a risk for falls related to recent illness/hospitalization with interventions including, instructing resident to call for assistance before getting out of bed or transferring. On 09/24/2024 at 01:47pm, R6 who appeared alert stated sometimes it isn't easy to get help when you need it. R6 stated she has a hard time remembering somethings, but that she recalls recently she has been left in the bathroom for an extended period of time more than once. R6 states she uses her call light often, she stated sometimes it seems like no one is going to answer it, other times they answer pretty quickly, say they will be back and then don't come back. A document titled, Incident list was reviewed with call light response times listed on it for 09/13/2024 through 09/17/2024. On this document there are two incidents on 09/13/2024 for the call light in R6's restroom. One at 03:53pm for thirty-two minutes and forty seconds. Another one at 09:06pm for ten minutes and fifty-three seconds. 3. R3's face sheet documents an admission date of 12/04/2023 with diagnoses in part; cerebral infarction, unspecified, Difficulty in walking, not elsewhere classified, other reduced mobility, other lack of coordination, weakness, hemiplegia, unspecified affecting left nondominant side, local infection of the skin and subcutaneous tissue, other asthma, flaccid neuropathic bladder, not elsewhere classified, neurogenic bowel, not elsewhere classified. R3's MDS (Minimum Data Set) dated 08/14/2024, documents a BIMS (Brief Interview for Mental Status) of 15, indicating R3 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R3 has an impairment of upper and lower extremities on one side. This section also documents that R3 requires assistance with toileting hygiene, showering and bathing, bed mobility and transfers. In Section HBladder and Bowel, it documents that R3 is frequently incontinent of bladder and bowel. R3's care plan documents she is at a risk for falling related to history of cerebrovascular accident with left sided Hemiplegia and osteoarthritis with interventions including, instructing resident to call for assistance before getting out of bed or transferring. It also documents R6 requires staff assistance with care and that she is to be assisted with turning and repositioning and should be turned and repositioned every two hours. On 09/19/2024, at 12:58pm, R3, who appeared alert and oriented stated sometimes they do not even have a CNA assigned to their hallway on the weekends. R3 stated there is never anyone to take her to the bathroom in a timely manner, she stated often times she is incontinent but does not receive timely incontinence care either. R3 stated she was under the understanding that everyone should be checked every 2 hours if they were not content, she stated that does not happen for her and she tries to hit her call light to get them to come in and they do not. R3 stated call light response times are all over the place, she stated sometimes they will come in and turn it off, say they will come back, and then they don't. R3 stated if she is not in bed, she will go find someone rather than use her light. 4. R12's face sheet documents an admission date of 08/23/2024 with diagnoses in part; displaced (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 2 of 10 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 09/24/2024 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 fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, nausea, other abnormalities of gait and mobility, pain, need for assistance with personal care, chest pain, pain in left hip, muscle weakness (generalized), Weakness, acute cystitis without hematuria. R12's MDS (Minimum Data Set) has not been completed due to being recently admitted . R12's MDS assessment summary dated 09/04/2024, documents a BIMS (Brief Interview for Mental Status) score of 13, indicating R12 is cognitively intact. R12's care plan documents that she is at risk for falls, is incontinent of bowel and bladder and requires staff assistance with turning and repositioning and is toe touch weight bearing on her left lower extremity due to recent fracture. On 09/24/2024 at 1:20pm, R12 who appeared alert and oriented stated the call lights in this facility are basically useless. She stated you can ring your call light and you will wait forever, someone will tell you they will be back and then they are not. R12 stated she has taken herself to the bathroom or transferred off the toilet on multiple occasions because she cannot wait any longer. R12 stated she recalls that her roommate has also experienced issues with her call light being answered timely. On 09/19/2024 at 09:50am, V9 (Certified Nurse Aide) stated call lights rarely get answered in a timely manner on the weekends they are so short. On 09/24/2024 at 12:00pm, V2 (Director of Nursing) stated his expectation would be that call lights were answered within 15 minutes, he stated anything over that makes him sad. V2 stated he expects bathroom call lights to be answered within 5 minutes. V2 stated he knows that it is an issue here and they are trying to work on it. Facility policy titled Call Light with a revision date on 01/04 documents the following under procedure; Answer call light promptly. Listen to resident's request. Do not make him/her feel that you are too busy to help. Respond to request. Return to resident with prompt reply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 3 of 10 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 09/24/2024 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 Based on interview, observation, and record review, the facility failed to provide dependent residents with showers and timely ADL (Activities of Daily Living) assistance for 4 of 9 residents (R1, R3, R8, R10) reviewed for ADL assistance in the sample of 13. Residents Affected - Some Findings include: 1. R1's face sheet documents an admission date of 09/12/2024 and a discharge date of 09/17/2024. R1's face sheet documents the following diagnoses in part; functional urinary incontinence, unspecified, mild cognitive impairment of uncertain or unknown etiology, altered mental status, unspecified, age-related osteoporosis without current pathological fracture, cognitive communication deficit, weakness, disorientation, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R1's Face Sheet documents R1 was discharged on 09/17/2024. R1 did not have a completed MDS due to only residing in the facility for 5 days. R1's baseline care plan with a revision date of 09/16/2024, documents that R1 is incontinent of bladder and requires assistance with toileting/incontinence and dressing. R1's bath days are Monday, Wednesday, and Friday. R1's care plan further documents that she is at increased risk for pressure ulcers with interventions including Turning and Repositioning every two hours as tolerated. Assist with turning and repositioning. Provide incontinence care after each episode. R1's progress notes document the following: 09/14/2024 10:36 AM . POA concerned of un neat appearance of Res. This nurse advised POA to speak to management on Monday during business hours to voice concerns. POA agreed to do so. This nurse assured POA of speaking with CNA (Certified Nursing Assistant) staff to meet the needs of Res. POA voiced thanks for this nurse's care. 09/14/2024 10:47 AM This nurse spoke to CNA staff regarding POA concerns. CNA staff voiced understanding. This nurse et (and) other nurse assessed Res room et (and) res appearance. Room in neat et (and) clean condition. Res in clean bed with clean bedding. Res wearing clean clothing. Res does not appear soiled. Res smiling , stating I am fine. A document in R1's medical record titled Point of Care History dated 9/11/2024-9/18/2024 documents that R1 only received a shower on 09/16/2024 (Monday) at 05:52pm. On 09/18/2024 at 09:47am, V2 (Director of Nursing/DON) stated R1 had only been in the facility for 5 days and that her family just seemed like they were nit-picking everything. On 09/19/2024 at 09:32am, V10 (CNA) stated she was not really sure of the staffing on 09/13/2024. V10 stated she did not make it too far off her hallway that day, she was giving showers and that kept her pretty busy. V10 stated that she showered R1 on 09/13/2024 (Friday), she stated she gave her a shower just like she would anyone else and washed her hair. On 09/19/2024 at 12:46pm, R2 who was alert to person, place and time stated she was in the same room as R1 and felt that R1 was not properly placed on their hallway, she needed a lot and could not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 4 of 10 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 09/24/2024 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 Residents Affected - Some really speak up for herself. R2 stated R1 did not really get out of bed much, but that she did not notice any undesirable odors coming from her side of the room and could not speak on whether or not she received care. R2 stated R1 had her daughters visiting often. 2. R3's face sheet documents an admission date of 12/04/2023 with diagnoses in part; cerebral infarction, unspecified, difficulty in walking, not elsewhere classified, other reduced mobility, other lack of coordination, weakness, hemiplegia, unspecified affecting left nondominant side, local infection of the skin and subcutaneous tissue, other asthma, flaccid neuropathic bladder, not elsewhere classified, neurogenic bowel, not elsewhere classified. R3's MDS (Minimum Data Set) dated 08/14/2024, documents a BIMS (Brief Interview for Mental Status) of 15, indicating R3 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R3 has an impairment of upper and lower extremities on one side. This section also documents that R3 requires assistance with toileting hygiene, showering and bathing, bed mobility and transfers. In Section HBladder and Bowel, it documents that R3 is frequently incontinent of bladder and bowel. R3's Current Care Plan documents she is at a risk for falling related to history of cerebrovascular accident with left sided Hemiplegia and osteoarthritis with interventions including, instructing resident to call for assistance before getting out of bed or transferring. It also documents R3 requires staff assistance with care and that she is to be assisted with turning and repositioning and should be turned and repositioned every two hours. On 09/19/2024, at 12:58pm, R3, who appeared alert and oriented stated there is never anyone to take her to the bathroom in a timely manner, she stated often times she is incontinent but does not receive timely incontinence care either. R3 stated she was under the understanding that everyone should be checked every 2 hours if they were not continent, she stated that does not happen for her and she tries to hit her call light to get them to come in and they do not. R3 stated call light response times are all over the place, she stated sometimes they will come in and turn it off, say they will come back, and then they don't. 3. R8's face sheet documents an admission date of 12/04/2023 with diagnoses in part; other abnormalities of gait and mobility, unsteadiness on feet, weakness, acute respiratory failure with hypercapnia, essential (primary) hypertension, cellulitis of unspecified part of limb, depression, iron deficiency anemia, generalized anxiety disorder, Obstructive and reflux uropathy, benign prostatic hyperplasia, urinary tract infection, nausea. R8's MDS (Minimum Data Set) dated 07/24/2024, documents a BIMS (Brief Interview for Mental Status) of 14, indicating R8 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R8 requires assistance with toileting hygiene, showering and bathing, dressing, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R8 is frequently incontinent of bladder and bowel. R8's current Care Plan with a revision date of 08/28/2024, documents he is at risk for pressure ulcers with interventions including providing incontinent care after each incontinent episode. Cleanse area of MASD (moisture associated skin damage) to bilateral buttocks and apply zinc twice daily. On 09/18/2024 at 10:47am, R8 stated he did have a grievance earlier this summer about care. R8 stated he was a little sicker than he is now and was pretty dependent on staff. R8 stated he was having (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 5 of 10 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 09/24/2024 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 Residents Affected - Some issues receiving timely incontinence care and assistance with personal hygiene. R8 stated it has gotten a little better and the girls do their best, there just aren't many of them to go around. R8 stated weekends are usually pretty scarce for staff and then other days they are tripping over each other. R8 stated he didn't recall having any issues this past weekend, but when he was out and about he did see the girls running all over the place. R8 stated he does have some soreness/open areas to his buttocks, and they have been treating it all summer, he stated that it has improved some. R8 stated if was able to get to the toilet or cleaned up timelier, it would probably be healed by now. A grievance dated 06/19/2024 by R8 documents that he was having issues with the care given. The documented corrective actions taken were to CNA's on the importance of peri care and what can be caused by a delay in timely hygiene. 4. R10's face sheet documents an admission date of 12/29/2022 with diagnoses in part; urinary tract infection, type 2 diabetes mellitus without complications, other abnormalities of gait and mobility, weakness, cognitive communication deficit, pain in right hip, pain in left hip, pain in right leg, diarrhea, nausea, urge incontinence. R10's MDS (Minimum Data Set) dated 08/20/2024, documents in Section C-Cognitive Patterns a BIMS (Brief Interview for Mental Status) score of 10, indicating R10 is moderately cognitively impaired. It is documented in Section GG-Functional Abilities and Goals that R10 has an impairment of upper and lower extremities on both sides. Section GG also documents that R10 is requires staff assistance for toileting hygiene, Showering/bathing, dressing, bed mobility and transfers. R10's current care plan documents R10 is at risk for pressure ulcers with interventions including applying antifungal powder to groin twice daily as needed. Provide incontinent care after each incontinent episode. On 09/24/2024 at 01:28pm, R10 who appeared alert and oriented stated she feels like she always has to wait forever for staff to answer her light, especially in the evening. R10 stated she does not receive timely incontinence care and now has a sore bottom and gets infections. On 09/19/2024 at 09:50am, V9 (CNA) stated the incontinence care provided on the night shift could be better. V9 stated when she comes on shift and starts getting people up, you can tell that they haven't been changed for a while. V9 stated some of the more alert residents on R1's hall have also complained about it. V9 stated they are always short on weekends; this past weekend was pretty bad. V9 stated that Fridays are where it starts, they are usually short and then they have to get people ready for appointments and everything on top of the normal care that has to be provided. V9 stated that there are many times there are only 3-4 aides to 4 hallways, that are basically full right now and some of the hallways should really have 2-3 aides on them due to the needs of their residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 6 of 10 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 09/24/2024 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 provide a sufficient amount of staff to ensure residents receive assistance with care. This has the potential to affect all 111 residents living in the facility. Findings include: 1. R3's Face sheet documents an admission date of 12/04/2023 with diagnoses in part; cerebral infarction, unspecified, difficulty in walking, not elsewhere classified, other reduced mobility, other lack of coordination, weakness, hemiplegia, unspecified affecting left nondominant side, local infection of the skin and subcutaneous tissue, other asthma, flaccid neuropathic bladder, not elsewhere classified, neurogenic bowel, not elsewhere classified. R3's MDS (Minimum Data Set) dated 08/14/2024, documents a BIMS (Brief Interview for Mental Status) of 15, indicating R3 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R3 has an impairment of upper and lower extremities on one side. This section also documents that R3 requires assistance with toileting hygiene, showering and bathing, bed mobility and transfers. In Section HBladder and Bowel, it documents that R3 is frequently incontinent of bladder and bowel. R3's Current Care plan documents she is at a risk for falling related to history of cerebrovascular accident with left sided Hemiplegia and osteoarthritis with interventions including, instructing resident to call for assistance before getting out of bed or transferring. It also documents R6 requires staff assistance with care and that she is to be assisted with turning and repositioning and should be turned and repositioned every two hours. On 09/19/2024, at 12:58pm, R3, who appeared alert and oriented stated there is never anyone to take her to the bathroom in a timely manner, she stated often times she is incontinent but does not receive timely incontinence care either. R3 stated she was under the understanding that everyone should be checked every 2 hours if they were not content, she stated that does not happen for her and she tries to hit her call light to get them to come in and they do not. R3 stated call light response times are all over the place, she stated sometimes they will come in and turn it off, say they will come back, and then they don't. 2. R8's Face sheet documents an admission date of 12/04/2023 with diagnoses in part; other abnormalities of gait and mobility, unsteadiness on feet, weakness, acute respiratory failure with hypercapnia, essential (primary) hypertension, cellulitis of unspecified part of limb, depression, iron deficiency anemia, generalized anxiety disorder, obstructive and reflux uropathy, benign prostatic hyperplasia, urinary tract infection, nausea. R8's MDS dated [DATE], documents a BIMS of 14, indicating R8 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R8 requires assistance with toileting hygiene, showering and bathing, dressing, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R8 is frequently incontinent of bladder and bowel. R8's Current care plan documents he is at risk for pressure ulcers with interventions including providing incontinent care after each incontinent episode. Cleanse area of MASD (moisture associated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 7 of 10 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 09/24/2024 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 skin damage) to bilateral buttocks and apply zinc twice daily. Level of Harm - Minimal harm or potential for actual harm On 09/18/2024 at 10:47am, R8 stated he did have a grievance earlier this summer about care. R8 stated he was a little sicker than he is now and was pretty dependent on staff. R8 stated he was having issues receiving timely incontinence care and assistance with personal hygiene. R8 stated it has gotten a little better and the girls do their best, there just aren't many of them to go around. R8 stated weekends are usually pretty scarce for staff and then other days they are tripping over each other. R8 stated he didn't recall having any issues this past weekend, but when he was out and about, he did see the girls running all over the place. R8 stated he does have some soreness/open areas to his buttocks, and they have been treating it all summer, he stated that it has improved some. R8 stated if was able to get to the toilet or cleaned up timelier, it would probably be healed by now. Residents Affected - Many 3. R10's face sheet documents an admission date of 12/29/2022 with diagnoses in part; urinary tract infection, type 2 diabetes mellitus without complications, other abnormalities of gait and mobility, weakness, cognitive communication deficit, pain in right hip, pain in left hip, pain in right leg, diarrhea, nausea, urge incontinence. R10's MDS (Minimum Data Set) dated 08/20/2024, documents in Section C-Cognitive Patterns a BIMS (Brief Interview for Mental Status) score of 10 , indicating R10 is moderately cognitively impaired. It is documented in Section GG-Functional Abilities and Goals that R10 has an impairment of upper and lower extremities on both sides. Section GG also documents that R10 is requires staff assistance for toileting hygiene, Showering/bathing, dressing, bed mobility and transfers. R10's current care plan documents R10 is at risk for falls, with interventions including instruct resident to call for assistance before getting out of bed or transferring. On 09/24/2024 at 01:28pm, R10 who was alert and oriented stated she feels like she always has to wait forever for staff to answer her light. Especially in the evening. R10 stated she does not receive timely incontinence care and now has a sore bottom. A document titled, Incident list was reviewed for call light response times for 09/13/2024 through 09/17/2024. On this document there are incidents of R10's bedside call light being on over fifteen minutes. On 09/13/2024 at 02:49pm for fifteen minutes and forty-nine seconds, again at 06:06pm for fifteen minutes and forty-seven seconds, and one at 07:55pm that had a response time of one hour and forty minutes. The call light was triggered from R10's bathroom at 06:45pm with a response time of thirteen minutes and forty-nine seconds. 4. R6's face sheet documents an admission date 02/21/2024 with diagnoses in part; chronic obstructive pulmonary disease, unspecified diarrhea, other amnesia, pain, dependence on supplemental oxygen, unilateral primary osteoarthritis, unspecified knee. R6's MDS (Minimum Data Set) dated 05/22/2024 documents in Section C-Cognitive Patterns, a BIMS (Brief Interview for Mental Status) score of 12, indicating R6 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R6 requires staff assistance with toileting hygiene, showering and bathing, dressing, personal hygiene, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R6 is incontinent of bladder and bowel. R6's current care plan documents that R6 is at a risk for falls related to recent illness/hospitalization with interventions including, instructing resident to call for assistance before getting out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 8 of 10 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 09/24/2024 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 of bed or transferring. Level of Harm - Minimal harm or potential for actual harm On 09/24/2024 at 01:47pm, R6 who appeared alert stated sometimes it isn't easy to get help when you need it. R6 stated she has a hard time remembering somethings, but that she recalls recently she has been left in the bathroom for an extended period of time more than once. R6 states she uses her call light often, she stated sometimes it seems like no one is going to answer it, other times they answer pretty quickly, say they will be back and then don't come back. Residents Affected - Many A document titled, Incident list was reviewed with call light response times listed on it for 09/13/2024 through 09/17/2024. On this document there are two incidents on 09/13/2024 for the call light in R6's restroom. One at 03:53pm for thirty-two minutes and forty seconds. Another one at 09:06pm for ten minutes and fifty-three seconds. 5. R12's face sheet documents an admission date of 08/23/2024 with diagnoses in part; displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, nausea, other abnormalities of gait and mobility, pain, need for assistance with personal care, chest pain, pain in left hip, muscle weakness (generalized), weakness, acute cystitis without hematuria. R12's MDS (Minimum Data Set) has not been completed due to being recently admitted . R12's MDS assessment summary dated 09/04/2024, documents a BIMS (Brief Interview for Mental Status) score of 13, indicating R12 is cognitively intact. R12's care plan documents that she is at risk for falls, is incontinent of bowel and bladder and requires staff assistance with turning and repositioning and is toe touch weight bearing on her left lower extremity due to recent fracture. On 09/24/2024 at 1:20pm, R12 who appeared alert and oriented stated the call lights in this facility are basically useless. She stated you can ring your call light and you will wait forever, someone will tell you they will be back and then they are not. R12 stated she has taken herself to the bathroom or transferred off the toilet on multiple occasions because she cannot wait any longer. R12 stated she recalls that her roommate has also experienced issues with her call light being answered timely. 6. On 09/24/2024 at 01:30pm, R13 who was alert and oriented stated that he has been here for about 8 months and his care has been okay. R13 stated you call for help and nobody comes, then they yell at you for taking yourself to the bathroom. R13 stated he has had CNA's lecture him on not toileting himself and using his call light for help, and his call light was still going off from when he tried to get some help. R13 stated that the staff always seems rushed, he stated he thinks there is not enough of them to go around. R13 stated the weekends are always pretty rough for staff. On 09/18/2024 at 09:47am, V2 (Director of Nursing/DON) stated staffing can be a little tight on the weekends especially, but that he would be more than happy to provide documentation of anything needed to prove that staffing was covered. On 09/19/2024 at 09:50am V9 (Certified Nursing Assistant/CNA) stated the incontinence care provided on the night shift could be better. V9 stated when she comes on shift and starts getting people up, you can tell that they haven't been changed for a while. V9 stated some of the more alert residents have also complained about it. V9 stated they are always short on weekends; this past weekend was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 9 of 10 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 09/24/2024 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 pretty bad. V9 stated that Fridays are where it starts, they are usually short and then they have to get people ready for appointments and everything on top of the normal care that has to be provided. V9 stated that there are many times there are only 3-4 aides to 4 hallways, that are basically full right now and some of the hallways should really have 2-3 aides on them due to the needs of their residents. V9 stated no matter how short they are no one floats from the memory care unit; they are basically their own entity and scheduled separately. V9 stated the only staff that will assist the CNA's in the main part of the building, is sometimes the kitchen staff, they will help where they can when they see we are drowning. V9 stated that the staff all try to work together and the aides from the lighter halls will pitch in where they can. But there are only so many of us to go around. V9 stated call lights rarely get answered in a timely manner on the weekends they are so short. On 09/19/2024 at 02:50pm, V11 (CNA) stated the weekends are always a mess when it comes to staffing. He recalled the weekend before he had worked on 09/13/24 and he was sure there were residents waiting longer than they should for assistance, because staffing was not good. On 09/24/2024 at 02:37pm, V2 (DON) stated if he is trying to determine what staffing was like for previous shifts, he will reference a couple of things. He has a text thread with the other administrative staff and the CNA supervisors where they discuss call ins and schedule changes. V2 stated he will also compare the scheduling template and employee timecards. V2 stated the scheduling template and assignments provided were excluding the memory care unit. During the course of this investigation, several requests for a working CNA schedule for 09/12/24-09/17/24 were made from V1 (Administrator) and V2 (DON). On 09/19/2024 a copy of the scheduling template for CNA's and a spreadsheet that was identified by V1 as the time clock punches were produced. On 09/20/2024 a handwritten copy of the CNA assignment schedule and CNA time cards were produced. These documents were reviewed, none of these documents correlate the same information. The facility was not able to provide any reproducible evidence that there was sufficient staffing for CNA's on the dates requested. The facility Resident Bed List Report dated 9/18/24 documents there are currently 111 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 10 of 10