Health inspection·June 27, 2025

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete timely quarterly Minimum Data Set (MDS) assessments for 2 (R27 and R76) of 19 residents reviewed for quarterly MDS assessments in a sample of 37. Residents Affected - Few The Findings Include: 1. R27's Resident Face Sheet documented an admission date of 10/4/22. The same document does not document when the last qualifying hospital stay was. R27's most recent completed quarterly MDS is documented as being completed on 5/3/25. An MDS 3.0 NH (Nursing Home) Final Validation Report with a submission and print date of 6/27/25 documented a Target Date of 5/3/25 for R27's MDS submission. This same report included a warning than 14 days after A2300 (assessment reference date). 2. R76's Resident Face Sheet documented an admission date of 1/29/24. This same document does not document when the last qualifying hospital stay was. R76's most recent completed quarterly MDS is documented as being completed on 5/1/25. An MDS 3.0 NH (Nursing Home) Final Validation Report with a submission and print date of 6/27/25 documented a Target Date of 5/1/25 for R76's MDS submission. This same report included a warning than 14 days after A2300 (assessment reference date). On 6/27/25 at 11:00 AM, V1 (Director of Nursing/DON) confirmed that these warning messages confirm that the quarterly assessments transmitted were considered to be past due/late. The facility policy with the subject of MDS Completion, revised 4/1/25, documented it is the policy to provide a system to complete standardized assessments in a timely manner, according to the current Resident Assessment Instrument Manual. Under Compliance Guidelines #9. Medicare PPS (Pay Per Service) assessments, scheduled and unscheduled, will be completed within 14 days of the assessment reference date. The type of assessment reference date will adhere to Medicare guidelines for each assessment. Under Transmission and Validation, documents 1. PPS and Quarterly Assessments will be Coordinator will obtain validation report, review error messages, and correct any substantiated errors. If an error is identified, the MDS Coordinator will modify or inactivate per the RAI manual Page 1 of 3 146171 146171 06/27/2025 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0638 guidelines and transmit. 4. The MDS Coordinator will transmit a minimum of weekly to ensure timely validation of MDS acceptance. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146171 Page 2 of 3 146171 06/27/2025 Manor Court of Carbondale 2940 W Westridge Place Carbondale, IL 62901

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain aseptic technique while providing wound care for 1 (R88) of 1 resident reviewed for infection control in a sample of 37. Residents Affected - Few Findings included: R88's Resident Face Sheet documented an admission date of 4/15/2025 and included diagnoses of prediabetes, bacterial infection, unspecified-RLE (right lower extremity), and non-pressure chronic ulcer of right calf with unspecified severity. R88's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, indicating R88 has severe cognitive impairment. Under section M, Skin Conditions, C.1, documented one stage 3 pressure ulcer. R88's Physician Order Sheet (POS) dated 5/20/2025 documented an order for clindamycin 100 mg (milligrams)/mupirocin 20 mg/gentamicin 80 mg. Empty 2 capsules into mixing container to reconstitute with 2 vials of NaCl (Sodium Chloride) 0.9% solution: transfer to spray bottle and apply to wound on Right LLE (Lower Leg Extremity) PRN (as needed) for soiled/excessive draining cover with ABD (abdominal) Pad, roll with kerlix, secure with tape and tubi grip PRN. On 06/25/25 at 1:56 PM, V2 (Licensed Practical Nurse/LPN) provided wound care to R88's right lower leg extremity. No barrier was placed under R88's right calf during wound treatment. V2 removed the old elastic tubi grip with scant amount of drainage noted. V2 placed the dirty tubi grip on the clean field with supplies. V2 then removed the dressing with moderate amount of drainage noted. V2 wrapped the dirty dressing up in her gloves while removing them and placed the dirty gloves with the dressing on her clean field with supplies. On 06/25/25 at 2:03 PM, V2 (LPN) stated, she should have placed a barrier under R88's right lower leg extremity prior to starting her wound treatment. V2 also stated she should not have put dirty elastic tubi grip, the dirty gloves or dirty dressings on her clean field. V2 stated the dirty items should have gone in a trash bag. On 06/25/25 at 2:57 PM, V1 (Director of Nursing/DON) stated, his expectations are for all staff to follow standard infection control precautions and he would not contaminate a clean field with dirty items. The facility policy for Wound Dressing Change (Clean) (undated) documents under Objective .To protect wound and promote healing, to prevent irritation, and to prevent infection and spread of infection. Documented under Procedure .prepare bag for discarding waste, use towel to establish clean field .remove soiled dressing and discard in biohazard bag. 146171 Page 3 of 3