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 message that documented Assessment Completed Late: Z0500B (assessment completion date) is more 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 message that documented Assessment Completed Late: Z0500B (assessment completion date) is more 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 transmitted within 14 days of the completion date in Z0500B. Reference Chapter 5, Section 5.2 3. The MDS 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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 146171 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 06/27/2025 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)