Integrity Hc Of Carbondale

nurses on a full time basis.

interview and record review the facility failed to provide 8 consecutive hours of Registered Nurse

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], 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], 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.

145757 08/27/2025

Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901

vegetables should not be served to a resident on a mechanical soft diet.On 8/22/25 at 10:58 AM, V9

crust, hard breadsticks, and shredded lettuce were not appropriate to be served to residents requiring

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.

145757 08/27/2025

Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901

include:1.R7's admission Record documented an admission date of 6/23/21 with diagnoses including:

(MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R7 was cognitively intact.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, R7's evening meal tray was delivered containing 1 piece of cheese pizza, salad, breadstick, and ambrosia. R7 said the pizza was cold and unappetizing. R7 said he bought his own frozen hamburgers in case he did not like the main course being served. R7 said he was angry because for the noontime meal he had ordered 2 hamburgers, and the cook had burned them. R7 provided a picture on his cellular telephone of 2 hamburgers that appeared charred with black burned spots on the cheese.2.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. R3's 6/6/25 MDS documented a BIMS score of 15, indicating R3 was cognitively intact.On 8/16/25 at 6:09 PM, R3's evening meal tray was delivered containing a piece of cheese pizza, salad, and breadstick. R3 said the pizza was cold and the breadstick was too hard to eat. R3 stated to staff take that back! I'm not eating that.

Staff removed 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. 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. R2's 6/27/25 MDS documented a BIMS score of 15, indicating R2 was cognitively intact.On 8/21/25 at 12:38 PM, R2 who was eating lunch stated the scalloped potatoes weren't cooked and were not good.5. R9's admission Record documented an admission date of 6/8/21 with diagnoses including: type 2 diabetes, chronic obstructive pulmonary disease, hypertension. R9's 7/3/25 MDS documented a BIMS score of 15, indicating R9 was cognitively intact.On 8/21/25 at 1:32 PM, R9 said the scalloped potatoes weren't completely cooked and her noon time meal tray was cold when it arrived. R9 said she always ate in her room, and her meal trays were always cold. R9 stated the food is so bad here. 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, 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.

145757 08/27/2025

Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901

serve food in accordance with professional standards.

sanitary condition.

This failure has the potential to affect all 50 residents living in the facility.Findings

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.