Integrity Hc Of Carbondale

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

5/30/25 MDS documented a BIMS score of 4, indicating Resident R4 was severely cognitively impaired.Resident R4's Order Summary Report printed 8/21/25 documented a 7/22/24 diet order for regular diet mechanical soft texture with thin liquid consistency, pudding at supper, extra butter/ margarin and extra sauces/ gravies with meals. Resident R4's Care Plan Report documented a focus area revised on 3/23/35 documenting in part .(Resident R4) is at risk for nutritional deficit r/t (related to) Dx TBI (Traumatic Brain Injury), dementia, rectal cancer. On 6/18/25 at 5:57 PM, Resident R4 was served a meal tray containing large pieces of pizza dietary staff had torn up by hand, larger than 1-inch by 1-inch pieces of varying size, with some pieces containing the hard outer crust, pureed green beans, and a whole breadstick. Resident R4 was observed to be unable to bite through the hard outer pizza crust or the breadstick. Resident R4 did not receive any desert, pudding, butter/ margarin, sauce/ gravy.The facility's 2024 Weight Assessment and Intervention policy documented in part . The multidisciplinary tea will strive to prevent, monitor, and intervene for undesirable weigh loss for our residents. 4. The Dietitian will review the Weight Records each month to follow individual weight trends over time. 1. Interventions for undesirable weight loss may be based on careful consideration of the following: a. Resident choice and preferences; b.

Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating. e.

Chewing and swallowing abnormalities and the need for diet modifications. g. The use of supplementation and/or feeding tubes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Integrity Hc of Carbondale

120 North Tower Road 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to provide 8 consecutive hours of Registered Nurse (RN) services 7 days a week. This failure has the potential to affect all 50 residents residing in the facility.Findings include:The facility's June, July, and August 2025 licensed nurse's schedules documented

on June 7, 8, 14, 15, 21, 22, 28, and 29, July 6, 12, 13, 19, 20, 26, and 27, [DATE REDACTED], 9, 10, 16, and 17 there was no RN working in the facility for a consecutive 8 hours.On 8/22/25 at 9:38 AM, V2 (Director of Nursing/ DON) verified on June 7, 8, 14, 15, 21, 22, 28, and 29, July 6, 12, 13, 19, 20, 26, and 27, [DATE REDACTED], 9, 10, 16, and17 there was no RN working in the facility for a consecutive 8 hours.On 8/22/25 at 2:13 PM, V1 (Administrator) said the facility did not have a policy pertaining to 8 consecutive hours of RN services. V1 said the facility followed Illinois Department of Public Health (IDPH) staffing guidelines.The facility's 9/20/25 Resident List Report documented 50 residents residing in the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Integrity Hc of Carbondale

120 North Tower Road 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

have food cut up in 1 inch by 1 inch pieces and V5 was not sure if a resident on a mechanical soft diet should be served the hard crust on the pizza. V5 said she did not sample the breadsticks before serving them. V5 said if the breadsticks were hard, they should not be served to residents on a mechanical soft diet. V5 said she was not sure why V4 had not followed the Diet Spreadsheet for what residents on a mechanical diet should have been served. V5 said any puree should be a smooth texture.On 8/20/24 at 10:15 AM, V6 (Dietary Manager) said she expected pureed dishes to be a smooth cake batter like consistency without chunks. V6 said she expected mechanical soft dishes to be chopped or ground with no pieces being larger than a dime. V6 said pizza with a hard crust, hard breadsticks, and raw vegetables should not be served to a resident on a mechanical soft diet.On 8/22/25 at 10:58 AM, V9 (Registered Dietitian) said she expected staff to follow diet orders. V9 said she expected puree dishes to be the consistency of mashed potatoes or applesauce with no chunks. V9 said hard pizza crust, hard breadsticks, and shredded lettuce were not appropriate to be served to residents requiring a mechanical soft diet.The facility's 2022 Pureed policy documented in part .The Pureed Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency. Foods that cannot be adequately pureed are substituted or altered as indicated on the menu spreadsheet. Pureed regular bread and specialty breads such as corn bread, muffins, garlic bread, etc., continue to be pureed as a separate menu item. Add measured amounts of hot liquid for cooked foods and cold liquid for cold foods (if required) and process until there is a smooth, pudding-like or smooth mashed potato consistency. Please note: some menu items do not require any liquid added during the pureeing process in order to achieve the desired pureed consistency.The facility's 2022 Dental Soft (Mechanical Soft) policy documented in part .This consistency modified diet is for individuals with limited or difficulty in chewing regular textured foods. As with any diet modification, this diet should be individualized to meet the resident's needs and chewing abilities.

Generally, the diet consists of food of nearly regular textures but eliminates very hard, sticky, crunchy or hard to chew foods. Foods should be moist and fork tender. Meat is ground or chopped into bite-size pieces (1/2 inch or smaller) and should be held with a minimal amount of prepared broth, gravy, or other type of moistening agent (NO WATER) to keep the product moist. Hot ground meats should be topped with gravy or sauce at the point of service. Dry, hard crusty breads are excluded.The facility's November 2015 Therapeutic Diets policy documented in part .Therapeutic diets shall be prescribed by the Attending Physician. 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. Examples of therapeutic diets include: a. Diabetic/ calorie controlled diet; b.

Low sodium diet; and c. Altered consistency diet. 2. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 6. Routine menus are planned by the Food Services Manager, and approved by a Registered Dietitian for nutritional adequacy. The Food Service Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Integrity Hc of Carbondale

120 North Tower Road 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 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review the facility failed to provide hot palatable foods for 4 (Resident R2, Resident R3, Resident R7, and Resident R9) of 12 residents reviewed for dietary services out of a sample of 12.Findings include:1.Resident R7's admission Record documented an admission date of 6/23/21 with diagnoses including: type 2 diabetes mellitus, anxiety disorder, chronic pain syndrome. Resident R7's 6/5/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident R7 was cognitively intact.Resident R7's Order Summary Report printed 8/21/25 documented a 1/20/23 diet order for low concentrated sweets, regular texture, thin liquid consistency, and offer double protein portions with all meals.On 8/16/25 at 5:55 PM, Resident R7's evening meal tray was delivered containing 1 piece of cheese pizza, salad, breadstick, and ambrosia. Resident R7 said the pizza was cold and unappetizing. Resident R7 said he bought his own frozen hamburgers in case he did not like the main course being served. Resident R7 said he was angry because for the noontime meal he had ordered 2 hamburgers, and the cook had burned them. Resident R7 provided a picture on his cellular telephone of 2 hamburgers that appeared charred with black burned spots on the cheese.2.Resident R3's admission Record documented an admission date of 12/31/24 with diagnoses including: chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease stage 3. Resident R3's 6/6/25 MDS documented a BIMS score of 15, indicating Resident R3 was cognitively intact.On 8/16/25 at 6:09 PM, Resident R3's evening meal tray was delivered containing a piece of cheese pizza, salad, and breadstick. Resident R3 said the pizza was cold and the breadstick was too hard to eat. Resident R3 stated to staff take that back! I'm not eating that. Staff removed Resident R3's meal tray and no substitution was offered.3. On 8/16/25 at 7:15 PM, a test tray was provided directly from the steam table.

The temperature of the cheese pizza was taken with a metal stemmed thermometer calibrated on 8/16/25 at 5:30 PM using the ice point method. The temperature measured 116.2 degrees Fahrenheit, which felt too cool, and when tasted the pizza lacked flavor. The breadstick was sampled and was hard and crunchy.4. Resident R2's admission Record documented an admission date of 10/9/23 with diagnoses including: chronic venous hypertension idiopathic with ulcer of bilateral lower extremity, type 2 diabetes, hypertension. Resident R2's 6/27/25 MDS documented a BIMS score of 15, indicating Resident R2 was cognitively intact.On 8/21/25 at 12:38 PM, Resident R2 who was eating lunch stated the scalloped potatoes weren't cooked and were not good.5. Resident R9's admission

Record documented an admission date of 6/8/21 with diagnoses including: type 2 diabetes, chronic obstructive pulmonary disease, hypertension. Resident R9's 7/3/25 MDS documented a BIMS score of 15, indicating Resident R9 was cognitively intact.On 8/21/25 at 1:32 PM, Resident R9 said the scalloped potatoes weren't completely cooked and her noon time meal tray was cold when it arrived. Resident R9 said she always ate in her room, and her meal trays were always cold. Resident R9 stated the food is so bad here. Resident R9's noon time meal tray was sitting on her overbed table and only a few bites had been taken.6. On 8/21/25 at 12:40 PM, Resident R7 said the scalloped potatoes were raw, crunchy, and gross.On 8/21/25 at 12:23 PM, the scalloped potatoes were sampled from

the steam table and were undercooked and crunchy.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Integrity Hc of Carbondale

120 North Tower Road 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 Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation and interview the facility failed to maintain floors and equipment in a safe and sanitary condition. This failure has the potential to affect all 50 residents living in the facility.Findings include:On 8/16/25 at 7:15 PM, the kitchen was observed to have various pieces of food lying on the floor around the cooking area. Black dirt/ debris was noted on the floor in various areas in the kitchen. The dishwashing area had various pieces of food on the floor with black dirt/ debris and dead cockroaches on

the floor.On 8/20/25 at 10:28 AM, the kitchen was observed to have various areas of the floor with black dirt/ debris on it. The backsplash of the stove appeared to have a buildup of grease and other debris. The grease trap emptying from the griddle area of the stove had a large amount of grease on the floor under it measuring approximately 1 foot in diameter. On 8/20/25 at 10:15 AM, V6 (Dietary Manager) said she had only been employed in the facility for about a week. V6 said the kitchen was having some cleanliness problems because staff would not listen to her and would not clean up after themselves. V6 said the kitchen was disgusting.On 8/22/25 at 10:58 AM, V9 (Registered Dietitian) said she expected the kitchen to be clean and sanitary.The facility's 9/20/25 Resident List Report documented 50 residents residing in the facility.

Event ID:

Facility ID:

If continuation sheet