Inspection·September 27, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documented V3 had given R5 a hydrocodone/ acetaminophen 5/325mg tablet on 8/19/24, 8/20/24, 8/23/24, 8/26/24, 8/28/24, 8/30/24, and 9/3/24. From 8/19/24 through 9/3/24, V3 was the only nurse to administer R5's hydrocodone/ acetaminophen 5/325mg. On 9/24/24 at 2:30 PM, V11 (Chief Executive Officer) said it was suspicious that V3 was the only nurse administering R5's hydrocodone/acetaminophen 5/325mg tablets. V11 verified that V3 had signed for R5's hydrocodone/acetaminophen 5/325mg on 9/5/24 and no narcotic was added for R5 to the Package Inventory Log on 9/5/24 by V3. On 9/25/24 at 12:45 PM, V2 (DON) stated she had been suspicious that V3 had been diverting narcotic medications since V2 had started at the facility 6 months ago. V2 said she had never been able to prove V3 was diverting medications and V2 had never reported her suspicion to V1. V2 said no investigation had ever been conducted on V3 for narcotic drug diversion. V2 said that V3 did not document when narcotics were administered on the MAR (Medication Administration Record). V2 stated that V3 said her lawyer told V3 that was double charting and documenting narcotics on a resident's MAR and on a resident's Controlled Drug Receipt/Record/Disposition Form and that was unnecessary. On 9/25/24 at 8:39 AM, V3 (LPN) said she did not recall R5 having any hydrocodone delivered to the facility. V3 said she did not recall ordering any hydrocodone for R5 and that R5 did not take any hydrocodone. V3 said she would pull the stickers from the medication cards when the card was half empty for reorder so the facility would have enough medication for the weekend. 2. R7's admission Record documented an admission date of 8/21/23 with diagnoses including: spondylosis, spinal stenosis, chronic pain syndrome, idiopathic peripheral autonomic neuropathy, osteomyelitis, diffuse cystic mastopathy of unspecified breast. R7's MDS dated [DATE] documented a BIMS score of 15, indicating R7 was cognitively intact. R7's Order Summary Report documented an 11/27/23 order for Oxycodone 10mg tablet give 1 tablet by mouth every 6 hours as needed. On 9/20/24 at 12:20 PM, R7 said that on 6/12/24 she had reported to V2 (DON) she suspected V3 (LPN) was not giving R7 her pain medications. R7 said V3 had come into R7's room to give R7 her bedtime medications and R7 asked V3 if R7's pain medications were in the cup. R7 said V3 told her yes and left R7's room. R7 stated she was a pharmacy technician for over 15 years and was very aware of the medications she took and what those medications looked like. R7 said after V3 left the room R7 poured the medications out on the table and no pain medication was in the cup. R7 said she called V3 back into her room and told V3 there was no pain medication in the cup. R7 said V3 took the cup of medications out into the hallway and returned to tell R7 the pain medication was in the cup. R7 said when she poured the medications out on the table again the pain medication was there. R7 said she suspected V3 was stealing her pain medication and had reported it to V2. R7 said V2 had brought her a clipboard and documents for R7 to document when she receives pain medications and R7 and the nurse would sign. A clip board with documents documenting all pain medication R7 had received since 6/7/24 was sitting on R7's bedside table. On 9/25/23 at 12:45 PM, V2 said R7 had never reported any allegations of V3 not giving R7 her pain medications. V2 said R7 had reported an allegation of V3 not giving R7 her pain medications to a staff no longer employed at the facility. V2 said she had spoken with V1 and was told R7's forms documenting when pain medications were given was something that R7 had done previous to V2 being employed at the facility and when R7 made the allegation, the facility had asked R7 to start documenting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 2 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some again. V2 said she was not aware if R7 had ever identified V3 as the nurse that was not giving R7 her pain medications. V2 said she was not aware V3 had previous discipline in her employee file pertaining to V3 refusing to sign R7's pain medication forms or V3 wasting narcotic medications without another nurse present. On 9/24/24 at 9:08 AM, V1 said she was not aware of R7 making any allegations of missing pain medication. V1 said no investigation had been completed. V3's personnel file contained an Employee Action Form documenting in part . Employee name: (V3) . Job title: LPN . Date of Incident: 1/21/24 . Describe what happened: Employee did not comply with having resident sign designated narcotic sheet when administering PRN (as needed) narcotic or having a second nurse waste narcotic as witness on 1/21/24 after education on 12/19/24 . Employee refused to sign . 3. R1's Face Sheet documented an admission date of 4/29/24 with diagnoses including: fracture of neck of left femur, history of falling, depression. R1's 7/17/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. R1's Order Summary Report documented a 7/22/24 order for oxycodone 5mg tablet give 5mg by mouth every 6 hours as needed. On 9/18/24 at 1:59 PM, R1 said all of his pain medication was scheduled. R1 said he rarely asked for pain medication because he did not like the way it made him feel. R1's Proof of Delivery List Report documented a card of 30 oxycodone 5mg tablets were delivered to the facility on 8/7/24. The facility was unable to provide a Controlled Drug Receipt/ Record/ Disposition Form for these medications. R1's Controlled Drug Receipt/ Record/ Disposition Form of oxycodone 5mg give 1 tablet by mouth every 6 hours delivered on 7/26/24 documented V3 administered one 5mg tablet to R1 on 8/4/24 at 1:30 AM and on 8/4/24 at 6:00 AM (30 minutes early). The last tablet of this card was administered on 8/6/24. R1's Controlled Drug Receipt/ Record/ Disposition Form of oxycodone 5mg give 1 tablet by mouth every 6 hours as needed delivered on 7/27/24 documented V3 administered one tablet to R1 as follows: 8/6/24 at 7:00 PM, 8/7/24 at 12:00 AM (1 hour early) and 8/7/24 at 5:30 AM (30 minutes early), 8/8/24 at 10:00 PM, 8/9/24 at 3:30 AM (30 minutes early), 8/13/24 at 12:30 AM, 8/13/24 at 6:00 AM (30 minutes early), 8/13/24 at 7:00 PM, 8/14/24 at 12:00 AM (1 hour early), 8/16/24 at 12:00 AM, 8/16/24 at 5:30 AM (30 minutes early). The last tablet of this card was administered on 8/21/24. R1's Controlled Drug Receipt/ Record Disposition Form of oxycodone 5mg give 1 tablet by mouth every 6 hours as needed delivered to the facility on 8/20/24 documented 3 instances in which V3 administered R1's oxycodone earlier than ordered. R1's MAR from 7/26/24 through 9/26/24 documented V3 administered only 1 dose of oxycodone 5mg to R1 on 8/5/24 at 6:28 PM. R1's Controlled Drug Receipt/ Record/ Disposition Form of oxycodone 5mg delivered to the facility on 7/26/24 documented V3 administered 1 tablet of oxycodone to R1 on 8/5/24 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 3 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0602 5:30 AM and 8/5/24 at 10:00 PM. Level of Harm - Minimal harm or potential for actual harm 4. R6's MDS dated [DATE] documented an admission date of 5/24/24 with diagnoses including: cancer, hypertension, asthma. R6's MDS documented a BIMS score of 15, indicating R6 was cognitively intact. Residents Affected - Some R6's 7/1/24 through 7/31/24 MAR documented an order for hydrocodone/acetaminophen 5/325mg give one tablet by mouth every 6 hours for pain with a start date of 6/13/24 and a discontinue date of 7/22/24 and the same order with a start date of 7/22/24 and discontinue date of 8/19/24. R6's 8/1/24 through 8/31/24 MAR documented an order for hydrocodone/acetaminophen 5/325mg give one tablet by mouth every 6 hours for pain relief with a start date of 7/22/24 and a discontinue date of 8/19/24. R6's 9/1/24 through 9/30/24 MAR documented an order for hydrocodone/acetaminophen 10/325mg give one tablet by mouth every 6 hours as needed for pain with a start date of 9/1/24 and an order for oxycodone 5mg give one tablet by mouth every 3 hours as needed for pain. On 9/18/24 at 12:17 PM, R6 said she suspected V3 was stealing her pain medication. R6 said when V3 was caring for her, V3 would not bring R6 pain medication. On 9/24/24 at 11:28 AM, V14 (R6's Caretaker/LPN) said that recently, V14 could not remember the exact date, she had witnessed V3 enter R6's room with a cup of medications and say it was R6's pain medications. V14 told R6 the two pills in the medication cup where 2 hydrocodone/acetaminophen 5/325mg tablets. V14 said R6 had refused to take them because R6 had a hydrocodone/acetaminophen 10/325 mg tablet ordered and was suspicious. V14 said she comes to the facility every day and most days twice a day to check on R6. V14 said when V14 came to the facility on the mornings when V3 had worked the night before R6 would complain of being in pain and say that V3 had not given R6 any pain medications. V14 said this was strange because V3 had documented giving R6 pain medications during V3's shift. 5. R4's admission Record documented an admission date of 6/17/24 with diagnoses including: cerebral palsy, rheumatoid arthritis, neuromuscular dysfunction of bladder. R4's MDS dated [DATE] documented a BIMS score of 14, indicating R4 was cognitively intact. R4's 8/1/24 through 8/31/24 MAR and 9/1/24 through 9/30/24 documented an order for hydrocodone/acetaminophen 5/325mg give 1 tablet by mouth daily as needed with a start date of 7/22/24. R4's 8/29/24 Controlled Drug Receipt/ Record/ Disposition Form documented an order for hydrocodone/acetaminophen 5/325mg take 1 tablet by mouth every 6 hours and 30 tablets were delivered. From 8/30/24 through 9/15/24, V3 was the only nurse signing out pain medication for R4, and V3 signed out that she had administered 21 tablets to R4 in the evening at the beginning of V3's shift and in the morning at the end of V3's shift. V3 documented on 9/15/24 that V3 had administered 1 tablet to R4 at 3:33 AM and 4:30 AM. R4's MAR documented from 8/30/24 through 9/15/24 no hydrocodone/acetaminophen 5/325mg tablets were administered to R4. On 9/24/24 at 1:20 PM, R4 said he would take his pain medication a couple times a week. R4 said he did not take pain medication daily and had never asked for pain medication more than once in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 4 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0602 12-hour period. Level of Harm - Minimal harm or potential for actual harm 6. R3's admission Record documented an admission date of 6/23/21 with diagnoses including: anxiety disorder, Charcot's Joint, chronic pain syndrome. R3's MDS dated [DATE] documented a BIMS score of 15, indicating R3 was cognitively intact. Residents Affected - Some On 9/19/24 at 12:17 PM, R3 said he had a laptop computer stolen about a month prior to this investigation. R3 said he had purchased a rose gold laptop and had kept it on top of the microwave in his room. R3 said when he had returned to his room from the dining room, he had noticed it was missing. R3 said he had reported it to V1 and had given V1 the receipt and serial number in hopes it could be found. On 9/19/24 at 12:27 PM, V1 said she was aware of R3's missing laptop. V1 said a search of the facility had been completed and another resident's speaker was found under a different resident's bed, and she had hoped R3's laptop would be found. V1 said she had forgot about R3 reporting his laptop was missing until it was mentioned again at this time. R3's Final IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification dated 9/19/24 documented in part . On 9/19/24, IDPH reported that resident (R3's) laptop was missing. No emotional distress noted. Investigation initiated. All parties notified. Through thorough investigation from IDT (Interdisciplinary Team) and the help of CPD (local Police Department), it is determined that the laptop is missing. (Local) Police Department have been notified of the serial and product number and will keep case open. Facility will continue to search and reference serial numbers if a similar laptop is located . The facility's reviewed and updated 2022 Abuse Prevention Training Program documented in part .II . B. Internal Reporting . Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator . All residents, visitors, volunteers, family members, or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to the administrator or an immediate supervisor, who must then immediately report it to the administrator or the designated individual in the administrator's absence. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports will be documented and a record kept of the documentation. The resident's physician and representative, if necessary, shall be notified of any incident or allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property . III . Protection . The facility will remove any alleged perpetrator(s) of abuse or neglect from any further contact with residents pending an investigation. A. Employee. If the alleged perpetrator is an employee, the employee will be sent home and/or advised not to return to work until further notice. If that employee shall be immediately suspended without pay from employment at the facility, not having any further resident contact, pending the outcome of an investigation. If the allegation is found unsubstantiated, the employee will be reinstated with back pay. If the allegation is substantiated, the facility will take all appropriate steps under the circumstances, which may include re-education, discipline, termination and/or reporting to local authorities and/or licensing agencies . IV . Investigation . As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation, which may include the following elements: Interviewing all persons who may have knowledge of the alleged incident, including, but not limited to: All persons who reported the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 5 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some suspicion, allegation or incident.; The alleged victim .; The alleged perpetrator .; Any witnesses or potential witnesses of the alleged occurrence or incident; Any staff having contact with the resident during the period of the alleged incident; Roommates, other residents, family, or visitors; . A review of the medical record, including care plan; A review of all circumstances surrounding the incident; . The investigation shall conclude whether the allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation can be substantiated. Records of the investigation shall be maintained . V. Reporting & Response B. Police. The administrator or designee shall notify the local police of any suspicion of a crime . C. Initial Report. An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the resident has been assessed and the alleged perpetrator has been removed. i. Report contents. The initial report shall include: The name of the resident allegedly harmed; When the allegation was received; The time and date of the alleged incident; Who was notified and when; The steps the facility has taken in response to the allegation, including the steps to protect the resident. A copy of this initial report shall be maintained . E. Final Report & Follow Up. Within five days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken to respond to the allegation, will be sent to the Department of Public Health. i. Report Contents. The final report shall include the following, as appropriate: name, age, diagnosis and mental status of the resident allegedly abused . or from whom property was misappropriated; the original allegation .; a summary of facts determined during the process of the investigation, review of medical record and interview of witnesses; and conclusion of the investigation based on known facts . The facility's May 2024 Narcotic Diversion Policy documented in part . 1. The facility must have a system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. 2. If the facility has discrepancies in their count or suspect diversion of controlled medications, an investigation should be started. 3. The Director of Nursing, the administrator and consultant pharmacist should be informed immediately. 4. The pharmacy will investigate the medication orders in question and provide the facility with reorder dates, quantities sent to the facility and signed manifests. 5. The facility should then try to reconcile the information to determine if loss or theft has occurred. 6. If loss or theft has occurred, the facility will follow their narcotic diversion policy. If the facility does not have a policy, these are recommendations to institute after narcotic diversion is suspected: a) Notification of local law enforcement b) Drug testing of all personnel with access to the missing controlled medications c) Re-educating of all nursing staff regarding storage and shift to shift counts d) Auditing of all controlled substance count sheets by nursing supervisor or Director of Nursing . The facility's December 2018 Controlled Substance Medications policy documented in part . medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations . 1. Only authorized nursing personnel and pharmacy personnel have access to controlled substances. The Director of Nursing is responsible or (sic) the control of these medications once at the facility . 5. A controlled medication delivery manifest will accompany all schedule II, III, IV, or V medication deliveries. The following information will be present. a. Name of resident . c. Prescription number d. Name, strength (if designated) and dosage form of medication e. Date delivery sent from pharmacy f. Quantity dispensed . 6. Controlled substances will be dispensed by the pharmacy along with an Individual Charting Record. This record will be maintained by the nursing staff at the time of each administration of the medication as follows: a. Place charting record in narcotic box or binder b. Record each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 6 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dose at the time of administration c. Confirm the amount of controlled drug remaining is correct prior to assembling required dose for administration . d. When the prescription has been exhausted, the Individual Charting Record becomes a permanent part of the medical record . 9. At each shift change, a physical inventory of specific medications, those selected by the facility, is conducted by two licensed nurses and is documented on an audit record. 10. Current controlled medication accountability records and audit records are kept in the MAR or other specific binder. When completed, audit and accountability records are submitted to the Director of Nursing and kept on file according to facility policy for health records retention. 11. Any discrepancy in controlled substance medication counts is reported to the Director of Nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. Irreconcilable discrepancies are documented by the Director of Nursing and reported to the consultant pharmacist and Administrator. The administrator, pharmacist, and the Director of Nursing will make a determination concerning of any actions that may need to be taken . The facility's revised 2021 Controlled Substances policy documented in part . 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record of delivery. 4. If the count is correct, an individual resident controlled substance record is used for each resident . 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. 10. The Director of Nursing services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties, and shall give the administrator a written report of such findings . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 7 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to report allegations of abuse and misappropriation of property within the required time frames for 4 (R1, R2, R3, and R7) of 6 residents reviewed for abuse in the sample of 9. Findings include: 1. R3's Face Sheet documented an admission date of 6/23/21 with diagnoses including: anxiety disorder, Charcot's Joint, chronic pain syndrome. R3's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 was cognitively intact. On 9/19/24 at 12:17 PM, R3 said he had a laptop computer stolen about a month prior to this investigation. R3 said he had purchased a rose gold laptop and had kept it on top of the microwave in his room. R3 said when he had returned to his room from the dining room, he had noticed it was missing. R3 said he had reported it to V1 and had given V1 the receipt and serial number in hopes it could be found. On 9/19/24 at 12:27 PM, V1 (Administrator) said she was aware of R3's missing laptop. V1 said a search of the facility had been completed and another resident's speaker was found under a different resident's bed, and she had hoped R3's laptop would be found. V1 said she had forgotten about R3 reporting his laptop was missing until it was mentioned again at this time. V1 said no investigation had been conducted for R3's missing laptop and no report had been filed. R3's Initial IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification dated 9/19/24 documented in part . On 9/19/24 IDPH reported that resident (R3's) laptop was missing. No emotional distress noted. Investigation initiated. All parties notified. R3's Final IDPH Incident and/or Abuse Notification report also dated 9/19/24 documented Through thorough investigation from IDT (Interdisciplinary Team) and the help of CPD (local Police Department), it is determined that the laptop is missing. (Local) Police Department have been notified of the serial and product number and will keep case open. Facility will continue to search and reference serial numbers if a similar laptop is located . 2. R1's Face Sheet documented an admission date of 4/29/24 with diagnoses including: fracture of neck of left femur, history of falling, depression. R1's Minimum Data Set (MDS) dated [DATE] documented a BIMS score of 15, indicating R1 was cognitively intact. On 9/17/24 at 1:10 PM, V8 (R1's Power of Attorney) stated that on 9/13/24, he had reported to V2 (Director of Nursing/DON) that R1 made an allegation of verbal abuse by V4 (Certified Nursing Assistant/CNA). V8 said this allegation was reported to V2 with V12 (Business Office Manager) as a witness. V8 said when he reported the allegation, he was told V2 did not believe him and V8 was one of V2's best CNAs. V8 said V2 had told him no investigation would be opened. On 9/18/24 at 10:36 AM, V12 said she had witnessed V8 tell V2 that R1 had made an allegation of verbal abuse by V4. V12 said V8 told V2 that R1 had claimed V4 said on bad words to R1. V12 said she could not remember V8's exact statement but it was something like (V4) had gotten nasty with (R1). V12 said V2 told V8 no (V4) didn't. I don't believe that. (V4) is one of my best CNAs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 8 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm On 9/19/24 at 9:28 AM, V1 (Administrator) said she was aware of V8's reporting of a verbal abuse allegation by V4 to R1. V1 said after V8 had reported the allegation, V1 and V2 interviewed R1 about the allegation. V1 said R1 denied the allegation. V1 said she had written down his statement and had started an investigation but had not reported anything due to R1 denying any allegation of verbal abuse. V1 said due to R1 denying the allegation, V4 had not been suspended from the facility pending an investigation. Residents Affected - Some On 9/25/24 at 12:45 PM, V2 said V8 had come to the facility and was upset with V2 for not giving V8 documentation on R1. V2 said V8 had made the allegation of verbal abuse to R1 in passing. V2 said she did not tell V8 she did not believe him or that an investigation would not be started. On 9/19/24, the facility provided a document dated 9/12/24 signed by V1, V2, and V12 documenting in part . (V8) was in (V12's) office with (V12), and (V2) when (V8) reported that (V4) the CNA had told (R1) to shut the ***k *p. (V8) stormed out of the door, got in his car and sped quickly out of the parking lot and up (road) in front of building. (V2) notified (V1), (V1) and they (sic) to speak with (R1). Has (V4), the CNA, ever cursed at you? No . Has any CNA ever cursed at you? No . How do staff treat you? They treat me good . Do you have any concerns? No . (R1) has a BIMs of 14 . 3. R2's Face Sheet documented an admission date of 8/16/24 with diagnoses including: atresia of foramina of Magendie and Luschka, down syndrome, dysphagia, depression, anxiety disorder. R2's MDS dated [DATE] documented R2 is rarely/ never understood, and no BIMS score was listed. On 9/17/24 at 2:00 PM, V5 (Physical Therapy Assistant/PTA) said on 9/10/24 she was on the phone with V6 (Physical Therapist/PT) completing a telehealth visit with R2. V5 said she was explaining R2's history of living in another healthcare facility and R2's guardian's wishes of R2 returning to that healthcare facility, when V2 came into R2's room and started yelling at V5 and V6, telling them R2 would not be returning to the healthcare facility in front of R2. V5 said V6 had told V2 to watch V2's attitude and there was no need for yelling. V5 said V2 started yelling V6 was out of line. V5 said she did not report this to the Administrator because she feared losing her job if she reported it. V5 said she had reported the incident to her supervisor (V13 - Regional [NAME] President of Operations of a Physical Therapy Company) in an email. On 9/19/24 at 1:03 PM, V6 said she was on a telehealth visit with V5 and R2 and was asking some questions about R2's background. V6 said V5 told V6 that R2's guardian told her R2 was happier at a previous healthcare facility and wanted R2 to return to that healthcare facility. V6 said V2 came into R2's room and raised her voice at V6 in front of R2. V6 said she had reported this incident to her supervisor over email and her supervisor (V13). V6 said V13 had sent her an email back notifying V6 that V13 had notified V1. On 9/19/24 at 1:10 PM, V13 said after V5 and V6 had sent emails to V13 explaining the incident and explaining they felt the situation was inappropriate, V13 had called the facility and spoke with V1. On 9/19/24 at 2:10 PM, V1 said she was aware of the incident that occurred between V2, V5, and V6 in front of R2. V1 said when it was reported, V1 did not think it was abuse and had not started an investigation or completed a report to Illinois Department of Public Health. On 9/17/24 at 2:08 PM, V5 provided an email dated 9/10/24 at 5:35 PM by V6 documenting in part . During the evaluation process for (R2), this therapist was asking questions in regard to this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 9 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some patient's prior level of function, living arrangements, caregivers, etc. Standard questions for evaluation. While speaking with (V5) this therapist, has not gathered all the previous information and was asking as to why (R2) wasn't returning to the group home if she seemed happier there. (V5) was unable to tell this therapist the answer to this question, before the (V2) rudely interrupted a conversation she was not part of, with said statement, Because she wasn't getting the right care there how were you going to ask why doesn't she go back there?! This therapist asked (V2) to please calm down, I was merely asking questions to get to know this information . This therapist calmly said, okay, that's why I'm asking questions, there is no need to have an attitude with your statements. (V2) replied, you're the one with attitude, what's your name? This therapist replied, (V6's name), and (V2) stormed out of the room . On 9/17/24 at 2:32 PM, V5 provided an email dated 9/10/24 at 5:28 PM sent to V13 documenting in part .(V6) was on (telehealth visit) with (V5) doing the (physical therapy evaluation) for (R2). We had just started the evaluation process and I was explaining why this patient was not appropriate to sit (on the edge of the bed) and that the level of care was significant and the wounds had worsened with the last hospitalization. I didn't realize (V2) walked in and overheard (V6) ask why the patient wasn't being sent back to her prior living situation. Before I could explain (V2) became belligerent and no exaggeration at all began hollering at (V6) and asked who she was and her name . I not (sic) accustomed to department directors conducting themselves so unprofessionally and with such a high lever of anger . R2's Initial IDPH Incident and/ or Abuse Notification dated 9/19/24 documented in part . On 9/19/24 at 9:30 am an allegation of verbal abuse from (V2) towards (R2) was reported. Employee suspended immediately. All parties notified. Resident assessed for emotional distress with none noted. R2's Final IDPH INcident and/or Abuse Notification also dated 9/19/24 documented Based on a comprehensive investigation through staff and resident interviews, IDT (Interdisciplinary Team) determines the allegation of verbal abuse to be unsubstantiated. (V2) and (V6) did have a passionate discussion in regard to (R2's) care. Intentions from all parties were to provide the safest environment and highest lever of care for (R2) . 4. R7's Face Sheet documented an admission date of 8/21/23 with diagnoses including: spondylosis, spinal stenosis, chronic pain syndrome, idiopathic peripheral autonomic neuropathy, osteomyelitis, diffuse cystic mastopathy of unspecified breast. R7's MDS dated [DATE] documented a BIMS score of 15, indicating R7 was cognitively intact. On 9/20/24 at 12:20 PM, R7 stated that on 6/12/24, she had reported to V2 she suspected V3 (Licensed Practical Nurse/LPN) was not giving R7 her pain medications. R7 said V3 had come into R7's room to give R7 her bedtime medications and R7 asked V3 if R7's pain medications were in the cup. R7 said V3 told her yes and left R7's room. R7 said she was a pharmacy technician for over 15 years and was very aware of the medications she took and what those medications looked like. R7 said after V3 left the room, R7 poured the medications out on the table and no pain medication was in the cup. R7 said she called V3 back into her room and told V3 there was no pain medication in the cup. R7 said V3 took the cup of medications out into the hallway and returned to tell R7 the pain medication was in the cup. R7 said when she poured the medications out on the table again the pain medication was there. R7 said she suspected V3 was stealing her pain medication and had reported it to V2. R7 said V2 had brought her a clip board and documents for R7 to document when she receives pain medications, and R7 and the nurse would sign. A clipboard with documents documenting all pain medication R7 had received since 6/7/24 was sitting on R7's bedside table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 10 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/25/23 at 12:45 PM, V2 said R7 had never reported any allegations of V3 not giving R7 her pain medications to her. V2 said R7 had reported an allegation of V3 not giving R7 her pain medications to a staff no longer employed at the facility. V2 said she had spoken with V1 and was told R7's forms documenting when pain medications were given was something that R7 had done previous to V2 being employed at the facility, and when R7 made the allegation the facility had asked R7 to start documenting again. V2 said she was not aware if R7 had ever identified V3 as the nurse that was not giving R7 her pain medications. V2 said she was not aware that V3 had previous discipline her employee file pertaining to V3 refusing to sign R7's pain medication forms or V3 wasting narcotic medications without another nurse present. V2 said she had been suspicious V3 had been diverting resident's pain medications for the past 6 months but was not able to prove anything and had not reported her suspicion to V1. V2 said she should have reported her suspicion to V1 and an investigation should have been started. On 9/24/24 at 9:08 AM, V1 said she was not aware of R7 making any allegations of missing pain medication. V1 said no investigation had been completed and no report had been made to IDPH. The facility's reviewed and updated 2022 Abuse Prevention Training Program documented in part .II . B. Internal Reporting . Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator . All residents, visitors, volunteers, family members, or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to the administrator or an immediate supervisor, who must then immediately report it to the administrator or the designated individual in the administrator's absence. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports will be documented and a record kept of the documentation . III . Protection . The facility will remove any alleged perpetrator(s) of abuse or neglect from any further contact with residents pending an investigation. A. Employee. If the alleged perpetrator is an employee, the employee will be sent home and/or advised not to return to work until further notice. If that employee shall be immediately suspended without pay from employment at the facility, not having any further resident contact, pending the outcome of an investigation. If the allegation is found unsubstantiated, the employee will be reinstated with back pay. If the allegation is substantiated, the facility will take all appropriate steps under the circumstances, which may include re-education, discipline, termination and/or reporting to local authorities and/or licensing agencies . IV . Investigation . As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation, which may include the following elements: Interviewing all persons who may have knowledge of the alleged incident, including, but not limited to: All persons who reported the suspicion, allegation or incident.; The alleged victim .; The alleged perpetrator .; Any witnesses or potential witnesses of the alleged occurrence or incident; Any staff having contact with the resident during the period of the alleged incident; Roommates, other residents, family, or visitors; . A review of the medical record, including care plan; A review of all circumstances surrounding the incident; . The investigation shall conclude whether the allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation can be substantiated. Records of the investigation shall be maintained . V. Reporting & Response B. Police. The administrator or designee shall notify the local police of any suspicion of a crime . C. Initial Report. An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 11 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm resident has been assessed and the alleged perpetrator has been removed. i. Report contents. The initial report shall include: The name of the resident allegedly harmed; When the allegation was received; The time and date of the alleged incident; Who was notified and when; The steps the facility has taken in response to the allegation, including the steps to protect the resident. A copy of this initial report shall be maintained . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 12 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0610 Respond appropriately to all alleged violations. 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 initiate and complete investigations of abuse allegations in accordance with required time frames for 4 (R1, R2, R3, and R7) of 6 residents reviewed for abuse in the sample of 9. Residents Affected - Some Findings include: 1. R3's Face Sheet documented an admission date of 6/23/21 with diagnoses including: anxiety disorder, Charcot's Joint, chronic pain syndrome. R3's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 was cognitively intact. On 9/19/24 at 12:17 PM, R3 said he had a laptop computer stolen about a month prior to this investigation. R3 said he had purchased a rose gold laptop and had kept it on top of the microwave in his room. R3 said when he had returned to his room from the dining room, he had noticed it was missing. R3 said he had reported it to V1 and had given V1 the receipt and serial number in hopes it could be found. On 9/19/24 at 12:27 PM, V1 said she was aware of R3's missing laptop. V1 said a search of the facility had been completed and another resident's speaker was found under a different resident's bed, and she had hoped R3's laptop would be found. V1 said she had forgot about R3 reporting his laptop was missing until it was mentioned again at this time. V1 said no investigation had been conducted for R3's missing laptop. R3's Initial IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification dated 9/19/24 documented in part . On 9/19/24 IDPH reported that resident (R3's) laptop was missing. No emotional distress noted. Investigation initiated. All parties notified. R3's Final IDPH Incident and/or Abuse Notification report also dated 9/19/24 documented Through thorough investigation from IDT (Interdisciplinary Team) and the help of CPD (local Police Department), it is determined that the laptop is missing. (Local) Police Department have been notified of the serial and product number and will keep case open. Facility will continue to search and reference serial numbers if a similar laptop is located 2. R1's Face Sheet documented an admission date of 4/29/24 with diagnoses including: fracture of neck of left femur, history of falling, depression. R1's MDS dated [DATE] documented a BIMS score of 15, indicating R1 was cognitively intact. On 9/17/24 at 1:10 PM, V8 (R1's Power of Attorney) stated that on 9/13/24, he had reported to V2 (Director of Nursing/DON) that R1 had made an allegation of verbal abuse by V4 (Certified Nursing Assistant/CNA). V8 said this allegation was reported to V2 with V12 (Business Office Manager) as a witness. V8 said when he reported the allegation, he was told V2 did not believe him and V8 was one of V2's best CNAs. V8 said V2 told him no investigation would be opened. On 9/18/24 at 10:36 AM, V12 said she had witnessed V8 tell V2 that R1 had made an allegation of verbal abuse by V4. V12 said V8 told V2 that R1 claimed V4 had said bad words to R1. V12 said she could not remember V8's exact statement but it was something like (V4) had gotten nasty with (R1). V12 said V2 told V8 No (V4) didn't. I don't believe that. (V4) is one of my best CNAs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 13 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm On 9/19/24 at 9:28 AM, V1 (Administrator) said she was aware of V8's reporting of a verbal abuse allegation by V4 to R1. V1 said after V8 had reported the allegation, V1 and V2 interviewed R1 about the allegation but did not have a summary of her findings. V1 said R1 denied the allegation. V1 said she had written down his statement and had started an investigation. V1 said due to R1 denying the allegation, V4 had not been suspended from the facility pending an investigation. Residents Affected - Some On 9/25/24 at 12:45 PM, V2 said V8 had come to the facility and was upset with V2 for not giving V8 documentation on R1. V2 said V8 had made the allegation of verbal abuse to R1 in passing. V2 said she did not tell V8 she did not believe him or that an investigation would not be started. On 9/19/24 the facility provided a document dated 9/12/24 signed by V1, V2, and V12 documenting in part . (V8) was in (V12's) office with (V12), and (V2) when (V8) reported that (V4) the CNA had told (R1) to shut the f*** u*. (V8) stormed out of the door, got in his car and sped quickly out of the parking lot and up (road) in front of building. (V2) notified (V1), (V1) and they (sic) to speak with (R1). Has (V4), the CNA, ever cursed at you? No . Has any CNA ever cursed at you? No . How do staff treat you? They treat me good . Do you have any concerns? No . (R1) has a BIMs of 14 . 3. R2's Face Sheet documented an admission date of 8/16/24 with diagnoses including: atresia of foramina of Magendie and Luschka, down syndrome, dysphagia, depression, anxiety disorder. V2's 9/13/24 MDS documented R2 is rarely/ never understood, and no BIMS score was listed. On 9/17/24 at 2:00 PM, V5 (Physical Therapy Assistant) said on 9/10/24 she was on the phone with V6 (Physical Therapist) completing a telehealth visit with R2. V5 said she was explaining R2's history of living in another healthcare facility and R2's guardian's wishes of R2 returning to that healthcare facility when V2 came into R2's room and started yelling at V5 and V6, telling them R2 would not be returning to the healthcare facility in front of R2. V5 said V6 had told V2 to watch V2's attitude and there was no need for yelling. V5 said V2 started yelling V6 was out of line. V5 said she did not report this to the administrator because she feared losing her job if she reported it. V5 said she had reported the incident to her supervisor (V13 Regional [NAME] President of Operations of a Physical Therapy Company) in an email. On 9/19/24 at 1:03 PM, V6 said she was on a telehealth visit with V5 and R2 and was asking some questions about R2's background. V6 said V5 told V6 R2's guardian had told her R2 was happier at a previous healthcare facility and want R2 to return to that healthcare facility. V6 said V2 came into R2's room and raised her voice at V6 in front of R2. V6 said she had reported this incident to her supervisor over email and her supervisor (V13). V6 said V13 had sent her an email back notifying V6 V13 had notified V1. On 9/19/24 at 1:10 PM, V13 said after V5 and V6 had sent emails to V13 explaining the incident and explaining they felt the situation was inappropriate V13 had called the facility and spoken with V1. On 9/19/24 at 2:10 PM, V1 said she was aware of the incident between V2, V5, and V6 in front of R2. V1 said when it was reported, V1 did not think it was abuse and had not started an investigation. On 9/17/24 at 2:08 PM, V6 provided an email dated 9/10/24 at 5:35 PM by V6 documenting in part . During the evaluation process for (R2), this therapist was asking questions in regard to this patient's prior level of function, living arrangements, caregivers, etc. Standard questions for evaluation. While speaking with (V5) this therapist, has not gathered all the previous information and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 14 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some asking as to why (R2) wasn't returning to the group home if she seemed happier there. (V5) was unable to tell this therapist the answer to this question, before the (V2) rudely interrupted a conversation she was not part of, with said statement, Because she wasn't getting the right care there how were you going to ask why doesn't she go back there?! This therapist asked (V2) to please calm down, I was merely asking questions to get to know this information . This therapist calmly said, okay, that's why I'm asking questions, there is no need to have an attitude with your statements. (V2) replied, you're the one with attitude, what's your name? This therapist replied, (V6's name), and (V2) stormed out of the room . On 9/17/24 at 2:32 PM, V5 provided an email dated 9/10/24 at 5:28 PM sent to V13 documenting in part .(V6) was on (telehealth visit) with (V5) doing the (physical therapy evaluation) for (R2). We had just started the evaluation process and I was explaining why this patient was not appropriate to sit (on the edge of the bed) and that the level of care was significant and the wounds had worsened with the last hospitalization. I didn't realize (V2) walked in and overheard (V6) ask why the patient wasn't being sent back to her prior living situation. Before I could explain (V2) became belligerent and no exaggeration at all began hollering at (V6) and asked who she was and her name . I not (sic) accustomed to department directors conducting themselves so unprofessionally and with such a high level of anger . R2's Initial IDPH Incident and/ or Abuse Notification dated 9/19/24 documented in part . On 9/19/24 at 9:30 am an allegation of verbal abuse from (V2) towards (R2) was reported. Employee suspended immediately. All parties notified. Resident assessed for emotional distress with none noted. R2's Final IDPH Incident and/ or Abuse Notification also dated 9/19/24 documented Based on a comprehensive investigation through staff and resident interviews, IDT (Interdisciplinary Team) determines the allegation of verbal abuse to be unsubstantiated. (V2) and (V6) did have a passionate discussion in regard to (R2's) care. Intentions from all parties were to provide the safest environment and highest level of care for (R2) . 4. R7's Face Sheet documented an admission date of 8/21/23 with diagnoses including: spondylosis, spinal stenosis, chronic pain syndrome, idiopathic peripheral autonomic neuropathy, osteomyelitis, diffuse cystic mastopathy of unspecified breast. R7's MDS dated [DATE] documented a BIMS score of 15, indicating R7 was cognitively intact. On 9/20/24 at 12:20 PM, R7 said on 6/12/24 she had reported to V2 she suspected V3 (Licensed Practical Nurse/LPN) was not giving R7 her pain medications. R7 said V3 had come into R7's room to give R7 her bedtime medications and R7 asked V3 if R7's pain medications were in the cup. R7 said V3 told her yes and left R7's room. R7 said she was a pharmacy technician for over 15 years and was very aware of the medications she took and what those medications looked like. R7 said after V3 left the room R7 poured the medications out on the table and no pain medication was in the cup. R7 said she called V3 back into her room and told V3 there was no pain medication in the cup. R7 said V3 took the cup of medications out into the hallway and returned to tell R7 the pain medication was in the cup. R7 said when she poured the medications out on the table again the pain medication was there. R7 said she suspected V3 was stealing her pain medication and had reported it to V2. R7 said V2 had brought her a clip board and documents for R7 to document when she receives pain medications and R7 and the nurse would sign. A clipboard with documents documenting all pain medication R7 had received since 6/7/24 was sitting on R7's bedside table. On 9/25/23 at 12:45 PM, V2 said R7 had never reported any allegations of V3 not giving R7 her pain medications. V2 said R7 had reported an allegation of V3 not giving R7 her pain medications to a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 15 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff no longer employed at the facility. V2 said she had spoken with V1 and was told R7's forms documenting when pain medications were given was something that R7 had done previous to V2 being employed at the facility and when R7 made the allegation, the facility had asked R7 to start documenting again. V2 said she was not aware if R7 had ever identified V3 as the nurse that was not giving R7 her pain medications. V2 said she was not aware V3 had previous discipline in her employee file pertaining to V3 refusing to sign R7's pain medication forms or V3 wasting narcotic medications without another nurse present. V2 said she had been suspicious V3 had been diverting resident's pain medications for the past 6 months but was not able to prove anything and had not reported her suspicion to V1. V2 said she should have reported her suspicion to V1 and an investigation should have been started. On 9/24/24 at 9:08 AM, V1 said she was not aware of R7 making any allegations of missing pain medication. V1 said no investigation had been completed. The facility's reviewed and updated 2022 Abuse Prevention Training Program documented in part .II . B. Internal Reporting . Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator . All residents, visitors, volunteers, family members, or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to the administrator or an immediate supervisor, who must then immediately report it to the administrator or the designated individual in the administrator's absence. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports will be documented and a record kept of the documentation. The resident's physician and representative, if necessary, shall be notified of any incident or allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property . III . Protection . The facility will remove any alleged perpetrator(s) of abuse or neglect from any further contact with residents pending an investigation. A. Employee. If the alleged perpetrator is an employee, the employee will be sent home and/or advised not to return to work until further notice. If that employee shall be immediately suspended without pay from employment at the facility, not having any further resident contact, pending the outcome of an investigation. If the allegation is found unsubstantiated, the employee will be reinstated with back pay. If the allegation is substantiated, the facility will take all appropriate steps under the circumstances, which may include re-education, discipline, termination and/or reporting to local authorities and/or licensing agencies . IV . Investigation . As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation, which may include the following elements: Interviewing all persons who may have knowledge of the alleged incident, including, but not limited to: All persons who reported the suspicion, allegation or incident.; The alleged victim .; The alleged perpetrator .; Any witnesses or potential witnesses of the alleged occurrence or incident; Any staff having contact with the resident during the period of the alleged incident; Roommates, other residents, family, or visitors; . A review of the medical record, including care plan; A review of all circumstances surrounding the incident; . The investigation shall conclude whether the allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation can be substantiated. Records of the investigation shall be maintained . V. Reporting & Response B. Police. The administrator or designee shall notify the local police of any suspicion of a crime . C. Initial Report. An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the resident has been assessed and the alleged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 16 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm perpetrator has been removed. i. Report contents. The initial report shall include: The name of the resident allegedly harmed; When the allegation was received; The time and date of the alleged incident; Who was notified and when; The steps the facility has taken in response to the allegation, including the steps to protect the resident. A copy of this initial report shall be maintained . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 17 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to accurately document narcotic medication administration according to facility policy, and failed to consistently and accurately reconcile narcotic medication counts in accordance with professional standards of practice for 4 (R1, R4, R5, and R6) of 6 residents reviewed for pharmacy services in the sample of 9. This failure has the potential to affect all 55 residents residing in the facility. Findings include: 1. R5's Face Sheet documented an admission date of 7/1/20 with diagnoses including: diabetes mellitus with diabetic polyneuropathy, acquired absence of left leg below the knee, Barrett's Esophagus, acquired absence of right leg below the knee. R5's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R5 was moderately cognitively impaired. R5's Order Summary Sheet documented a 2/15/23 order for hydrocodone/acetaminophen 5/325mg (milligram) tablet give 1 tablet by mouth every 6 hours as needed for severe pain. On 9/24/24 at 3:20 PM, V1 (Administrator) said the pharmacy had sent her the hydrocodone/acetaminophen 5/325mg refill request for R5 from 9/1/24 by V3 (Licensed Practical Nurse/ LPN). V1 verified V3's signature on the refill request. The facility's Packing Slip Proof of Delivery documented on 9/5/24 at 5:13 AM, V3 signed for 30 tablets of hydrocodone/ acetaminophen 5/325mg for R5. On 9/24/24 at 2:05 PM, the medication cart's narcotic box contained a card of 12 hydrocodone/acetaminophen 5/325mg delivered on 4/23/24 for R5. R5's card of 30 tablets of hydrocodone/acetaminophen 5/325mg delivered on 9/5/24 could not be found and the Controlled Drug Receipt/ Record/ Disposition Form also could not be found. On 9/25/24 at 12:45 PM, V2 (Director of Nursing/DON) stated when a narcotic medication is delivered to the facility, the nurse receiving it should sign the Packing Slip Proof of Delivery form, put the medication in the narcotic box in the medication cart, and add the medication onto the Package Inventory Log. V2 said the Package Inventory Log is how the facility kept track of how many cards of narcotics were supposed to be in the narcotic box in the medication cart. The facility's Package Inventory Log documented no card of narcotics was added for R5 on 9/5/24 by V3. R5's 4/23/24 hydrocodone/acetaminophen 5/325mg Controlled Drug Receipt/Record/Disposition Form documented V3 had given R5 a hydrocodone/acetaminophen 5/325mg tablet on 8/19/24, 8/20/24, 8/23/24, 8/26/24, 8/28/24, 8/30/24, and 9/3/24. From 8/19/24 through 9/3/24, V3 was the only nurse to administer R5's hydrocodone/acetaminophen 5/325mg. On 9/24/24 at 2:30 PM, V11 (Chief Executive Officer) stated it was suspicious that V3 was the only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 18 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many nurse administering R5's hydrocodone/acetaminophen 5/325mg tablets. V11 verified that V3 had signed for R5's hydrocodone/acetaminophen 5/325mg on 9/5/24 and no narcotic was added for R5 to the Package Inventory Log on 9/5/24 by V3. On 9/25/24 at 12:45 PM, V2 (DON) said she had been suspicious V3 had been diverting narcotic medications since V2 had started at the facility 6 months ago. V2 said she had never been able to prove V3 was diverting medications and V2 had never reported her suspicion to V1. V2 said no investigation had ever been conducted on V3 for narcotic drug diversion. V2 said it was her responsibility to complete medication reconciliations for all resident medications. V2 said when V2 receives the Packing Slip Proof of Delivery when a resident's narcotic is delivered to the facility, V2 is supposed to verify the medication has been added to the narcotic box in the medication cart, the Controlled Drug Receipt/Record/Disposition Form is added the narcotic binder, and the card is added to the Package Inventory Log. V2 said due to V2 working as a floor nurse she did not have time to complete the Director of Nursing duties. V2 said all resident medications could be accounted for when a medication reconciliation was completed when crosschecked with the Packing Slip Proof of Delivery with the resident medications in the medication cart. R5's 4/23/24 hydrocodone/acetaminophen 5/325mg Controlled Drug Receipt/Record/Disposition Form documented from 6/6/24 through 9/3/24, 18 doses had been administered. However, R5's Medication Administration Record (MAR) from 6/6/24 through 9/3/24 documented 1 dose of hydrocodone/acetaminophen 5/325mg had been administered. R5's 7/1/20 Care Plan documented R5 is at risk for pain related to diabetic neuropathy and general discomfort with interventions: administer analgesia as ordered, monitor/document for side effects of pain medication, monitor/record/report to nurse complaints of pain or requests for pain treatment, respond immediately to any complaint of pain. On 9/25/24 at 12:45 PM, V2 stated she expected all nurses to document on the resident's MAR when administering medication and to also document on the Controlled Drug Receipt/Record/Disposition Form when administering a narcotic medication. V2 said V3 had been educated on documenting medications but V3 told V2 she was not going to document it on the MAR. V2 said she did not know how a nurse would know if the medication was effective if they were not documenting it on the MAR or how the facility would know if they needed to update a resident's care plan pertaining to pain if nurses were not documenting how often a resident was taking as needed pain medication. 2. R1's Face Sheet documented an admission date of 4/29/24 with diagnoses including: fracture of neck of left femur, history of falling, depression. R1's 7/17/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. R1's Order Summary Report documented a 7/22/24 order for oxycodone 5mg tablet give 5mg by mouth every 6 hours as needed. R1's Proof of Delivery List Report documented a card of 30 oxycodone 5mg tablets were delivered to the facility on 8/7/24. The facility was unable to provide a Controlled Drug Receipt/Record/Disposition Form for these medications. R1's Controlled Drug Receipt/Record/Disposition Form of oxycodone 5mg give 1 tablet by mouth every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 19 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 6 hours delivered on 7/26/24 documented V3 administered one 5mg tablet to R1 on 8/4/24 at 1:30 AM and 8/4/24 at 6:00 AM (30 minutes early). The last tablet of this card was administered on 8/6/24. R1's Controlled Drug Receipt/Record/Disposition Form of oxycodone 5 mg give one tablet by mouth every 6 hours as needed delivered on 7/27/24 documented V3 administered 1 tablet to R1 as follows: 8/6/24 at 7:00 PM, 8/7/24 at 12:00 AM (1 hour early) and 8/7/24 at 5:30 AM (30 minutes early), 8/8/24 at 10:00 PM, 8/9/24 at 3:30 AM (30 minutes early), 8/13/24 at 12:30 AM, 8/13/24 at 6:00 AM (30 minutes early), 8/13/24 at 7:00 PM, 8/14/24 at 12:00 AM (1 hour early), 8/16/24 at 12:00 AM, 8/16/24 at 5:30 AM (30 minutes early). The last tablet of this card was administered on 8/21/24. R1's Controlled Drug Receipt/ Record Disposition Form of oxycodone 5mg give 1 tablet by mouth every 6 hours as needed delivered to the facility on 8/20/24 documented 3 instances in which V3 administered R1's oxycodone earlier than ordered. R1's MAR from 7/26/24 through 9/26/24 documented V3 administered only 1 dose of oxycodone 5 mg to R1 on 8/5/24 at 6:28 PM. R1's Controlled Drug Receipt/ Record/ Disposition Form of oxycodone 5mg delivered to the facility on 7/26/24 documented V3 administered 1 tablet of oxycodone to R1 on 8/5/24 at 5:30 AM and 8/5/24 at 10:00 PM. 3. R4's admission Record documented an admission date of 6/17/24 with diagnoses including: cerebral palsy, rheumatoid arthritis, neuromuscular dysfunction of bladder. R4's 8/27/24 MDS documented a BIMS score of 14, indicating R4 was cognitively intact. R4's 8/1/24 through 8/31/24 MAR and 9/1/24 through 9/30/24 documented an order for hydrocodone/acetaminophen 5/325mg give 1 tablet by mouth daily as needed with a start date of 7/22/24. R4's 8/29/24 Controlled Drug Receipt/Record/Disposition Form documented an order for hydrocodone/ acetaminophen 5/325mg take 1 tablet by mouth every 6 hours and 30 tablets were delivered. From 8/30/24 through 9/15/24, V3 was the only nurse signing out pain medication for R4, and V3 signed out that she had administered 21 tablets to R4 in the evening at the beginning of V3's shift and in the morning at the end of V3's shift. V3 documented on 9/15/24, V3 had administered 1 tablet to R4 at 3:33 AM and 4:30 AM. R4's MAR however documented from 8/30/24 through 9/15/24 no hydrocodone/ acetaminophen 5/325mg tablets were administered to R4. 4. R6's MDS dated [DATE] documented an admission date of 5/24/24 with diagnoses including: cancer, hypertension, asthma. R6's MDS also documented a BIMS score of 15, indicating R6 was cognitively intact. R6's 7/1/24 through 7/31/24 MAR documented an order for hydrocodone/acetaminophen 5/325mg give one tablet by mouth every 6 hours for pain with a start date of 6/13/24 and a discontinue date of 7/22/24 and the same order with a start date of 7/22/24 and discontinue date of 8/19/24. R6's 8/1/24 through 8/31/24 MAR documented an order for hydrocodone/acetaminophen 5/325mg give one tablet by mouth every 6 hours for pain relief with a start date of 7/22/24 and a discontinue date of 8/19/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 20 of 21 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 145757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R6's 9/1/24 through 9/30/24 MAR documented an order for hydrocodone/acetaminophen 10/325mg give one tablet by mouth every 6 hours as needed for pain with a start date of 9/1/24 and an order for oxycodone 5mg give one tablet by mouth every 3 hours as needed for pain. R6's 9/14/24 through 9/24/24 MAR documented R6 received only 6 doses of hydrocodone/acetaminophen 10/325 mg tablets. R6's 9/13/24 Controlled Receipt/ Record/ Disposition Form for hydrocodone/acetaminophen 10/325mg give 1 tablet by mouth every 6 hours as needed documented R6 received 30 doses for the same time period from 9/14/24 through 9/24/24. The facility's May 2024 Narcotic Diversion Policy documented in part . 1. The facility must have a system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. 2. If the facility has discrepancies in their count or suspect diversion of controlled medications, an investigation should be started. 3. The Director of Nursing, the administrator and consultant pharmacist should be informed immediately. 4. The pharmacy will investigate the medication orders in question and provide the facility with reorder dates, quantities sent to the facility and signed manifests. 5. The facility should then try to reconcile the information to determine if loss or theft has occurred. 6. If loss or theft has occurred, the facility will follow their narcotic diversion policy. If the facility does not have a policy, these are recommendations to institute after narcotic diversion is suspected: a) Notification of local law enforcement b) Drug testing of all personnel with access to the missing controlled medications c) Re-educating of all nursing staff regarding storage and shift to shift counts d) Auditing of all controlled substance count sheets by nursing supervisor or Director of Nursing . The facility's revised July 2017 Charting and Documentation policy documented in part . 2. The following information is to be documented in the resident medical record: . b. Medications administered . 3. Documentation in the medical record will be objective . complete, and accurate . The facility's January 2024 Administering Medications policy documented in part .The individual administering the medication must document the administration in the resident's medical record . As required or indicated for a medication, the individual administering the medication will record in the residence medical record: a. The date and time the medication was administered; b. The dosage . e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . The facility's 9/17/24 Midnight Census Report documented 55 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 21 of 21