Inspection·February 19, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few stopped pushing the chair immediately. V8 said this is when she saw that R1's foot had went through the rubber strips in the chair. V8 said they went on and pushed her in the shower room for privacy and when they got to the shower room, she pushed the lever to lower the foot rest down and that didn't help to get her foot out. V8 said she held R1's knee with one hand and the foot with the other and this is when she heard a pop. V8 said that R1's foot was turned out after the pop and she sent V13 to get the nurse. V8 said that the nurse came in and called V3 over to look at it also. V8 said that V3 bandaged the skin tear on R1's leg. V3 said that R1's leg was starting to swell a little. V8 said that the nurse said they were sending her to the emergency room for evaluation. V8 said they cleaned R1 up and got her dressed and put R1 back in bed while waiting on the ambulance to come. On 2/18/25 at 2:10pm, V13 (CNA) said she was working with V8 when the incident with R1 occurred. V13 said that her and V8 had transferred R1 from her bed to the shower chair using a mechanical lift. V13 said when they were pushing R1 to the shower room, R1 said my foot, my foot. V13 said they stopped and looked and then noticed R1's foot was caught in the rubber strips on the shower chair. V13 said that V8 was trying to get R1's foot out, and felt and heard a pop. V13 said she immediately went to get the nurse. V13 said that V3 bandaged the skin tear that was bleeding. V13 said they got R1 cleaned up and dressed and put her back in bed to wait on the ambulance. On 2/18/25 at 10:30 am, V3 (RN/Registered Nurse) said she was on duty the evening of 1/24/25. V3 said the nurse on R1's hall was new, and she called V3 to come over and help her. V3 said when she got there, the CNA's (V8 and V13) told her they heard a pop when they were getting her foot out of the rubber strips. V3 said the mechanical lift pad was underneath R1 and she was sitting like normal in the shower chair. V3 said that R1's right shin was bleeding from a skin tear and she cleaned the wound and applied steri strips. V3 said she agreed with the nurse on that hall that R1 needed to be sent out for evaluation. V3 said she was not aware of any problems with the shower chairs prior to the incident. V3 said the chair was taken out of use until maintenance could look at it. On 2/18/25 at 9:20 am, V2 (DON/Director of Nurses) said the incident with R1 was reported after it happened on 1/24/25 by one of the nurses. V2 said that V8 (CNA/Certified Nurse Assistant) and V13 (CNA) were taking R1 to the shower by pushing her in the shower chair from R1's room. R1 said the shower chair has a foldable layout with rubber strips. V2 said that R1 yelled my foot, my foot. V2 said staff looked and found that R1's foot had went through the rubber strips. V2 said he did an in-service later that evening on proper transfers. V2 said the chair was taken out of use until maintenance could look at it. V2 said the corporate guy (V5/Regional Therapy Consultant) and V4 (Maintenance Director) both looked at the chair and said the rubber strips were a little loose. V2 said that the nurses on duty that night were V3 (RN/Registered Nurse) and the other nurse was on vacation at this time. On 2/18/25 at 10:40 am, V4 (Maintenance Director) said the chairs have rubber strips on them and they do get stretched out with use. V4 said he did inspect the shower chair the next day and the rubber strips were loose and stretched out. V4 said he tightened them up. V4 said that he checks the kitchen equipment monthly, but does not check shower or bathroom equipment except on an as needed basis. V4 said he is now doing daily checks of bathroom/shower equipment. On 2/18/25 at 10:50 am, V5 (Regional Therapy Consultant) said he looked at the shower chair with V4. V5 said one of the strips was loose and it was fixed immediately. V5 said that they do monthly checks on equipment like mechanical lifts, sit to stands but that bathroom equipment like shower chairs is done on an as needed basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 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 - Actual harm Residents Affected - Few R1's Resident Progress note dated 1/24/25 at 4:05 pm documents, CNA alerted this nurse that during a transfer to the shower chair her right foot got tangled up and they heard a snap/pop and the patient yelled in pain also received a skin tear to the front of her shin, measures 4.5 cm (centimeters) x 4 cm, well approximated with 6 steri strips and optifoam on top for bleeding. This nurse assessed the foot/ankle and noticed swelling and that the skin is hot to the touch. The patient also yelled when this nurse tried to move her foot to look at it resident is being sent to ED (Emergency Department) for eval. Local Hospital Document labeled Hospital Discharge Summary notes R1's admission date of 1/24/25 and discharge date of 2/5/25. The same document notes R1's initial encounter presented from Nursing Home for Right ankle pop .X-ray of Right ankle reveals open distal tibial fracture per my read ortho has been consulted, plans to see in the am, patient had right ankle splinted, now being admitted for further evaluation. The same document notes an X-ray done on 1/25/24 with an impression of mildly displaced oblique fracture of the distal right tibia. Facility Document labeled Policy, revised on 11/12 note Our safe Resident Handling Program is designed to meet the following Goals Protect staff and Residents from injury. The same document also noted under Procedure .#7. To ensure equipment is in proper operating condition, maintenance personnel will be designated to make regular equipment checks. Prior to the survey date, the facility took the following corrective actions to correct the non-compliance: On 2/18/25, V1 provided a form labeled Department Head meeting dated 1/28/25. V1 said that the incident with R1 was discussed at their morning meeting on 1/28/25. V1 said they discussed all of the residents it effected, and preventing accidents in the future. V1 said their next QAPI meeting is the end of February, and this topic will be discussed again then. On 2/19/25 at 1:20pm, V1 said that all department heads attend morning meeting and they are also members of the QAPI (Quality Assurance and Performance Improvement) committee. On 2/18/25 at 2:30pm, V1 said that the DON did an in-service on 1/24/25 on proper transfers. 1. Immediate Corrective Action: Staff were in-serviced on 1/24/25 on Safe Resident Handling. 2. System Maintenance: Plan of Correction Audit Tracking note that equipment (shower chair) are being checked for safety at least weekly. 3. Other Residents with the Potential to be Affected: All residents have the potential to be affected by the alleged deficient practice FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146171 If continuation sheet Page 3 of 3