Health inspection·October 25, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Start date of [DATE] Jevity 1.2 Cal (calorie) oral liquid give 360 ml via g-tube 3 times a day for supplemental feeding at 6:00 AM, 2:00 PM, and 9:00 PM with a discontinue date of [DATE]. Start date of [DATE] Jevity 1.5 Cal give 270 ml 4 times a day at 6:00 AM, 10:00 AM, 2:00 PM, and 6:00 PM with a discontinue date of [DATE]. Residents Affected - Few R1's [DATE] MAR documented the 6:00 AM feeding for both the Jevity 1.2 cal and Jevity 1.5 cal were blank on [DATE], 16, 19, 21, 22, and 23. The facility's [DATE] nursing schedule documented V9 (Registered Nurse/ RN) was the only licensed nurse in the facility on [DATE], 16, 19, 21, 22, 23 at 6:00 AM. On [DATE] at 10:54 AM, V9 said she did recall R1 but had never taken care of R1. V9 said she had never administered any tube feeding to R1. V9 said she did not work the hall R1 resided on. V9 said she was the only nurse in the facility from 11:00 PM until 7:00 AM. V9 said another nurse cared for R1 and the other residents on that hallway from 3:00 PM until 11:00 PM. V9 said it would be the responsibility of the 3:00 PM to 11:00 PM nurse to make sure all the resident's feedings had been completed prior to them leaving the facility. When V9 was asked if the 3:00 PM to 11:00 PM nurse left the facility at 11:00 PM how would they be responsible for administering a resident feeding scheduled to be administered at 6:00 AM, V9 responded she did not know and would have to get clarification. On [DATE] at 11:03 AM, V2 (Director of Nursing) said she was not aware V9 was not administering R1's 6:00 AM tube feedings. V2 said it would be V9's responsibility to ensure R1's tube feedings were being completed. On [DATE] at 11:50 AM, V6 (RN) said on [DATE] and [DATE] she had documented she had administered the Jevity 1.2 at 2:00 PM, the Jevity 1.5 at 10:00 AM, and the Jevity 1.5 at 2:00 PM to R1. V6 said she was not sure if she administered the Jevity 1.2 or the Jevity 1.5 to R1. V6 said cases of Jevity solution are kept in the residents room when the resident has a bolus tube feeding and V6 would have used whatever Jevity was being kept in R1's room at that time. On [DATE] at 12:11 PM, V5 (RN) said she was unsure why nursing staff were documenting they were administering both Jevity 1.2 three times a day and Jevity 1.5 four times a day. V5 said R1 was receiving Jevity 1.5 four times a day. V5 said she knew nursing staff were giving Jevity 1.5 because she was the nurse that had placed the case of Jevity 1.5 in R1's room. V5 said when nursing staff are documenting tube feedings there are several boxes that have to checked in the Electronic Medical Record (EMR) for g-tube flushes and other things so perhaps the nursing staff did not notice there was a difference in the two. On [DATE] at 11:03 PM, V2 said R1 was receiving the Jevity 1.5 four times a day. V2 said she knew R1 was receiving Jevity 1.5 because the facility did not have Jevity 1.2. V2 said she did not know why there were two different orders in R1's EMR for Jevity but the nursing staff should have noticed they were documenting and administering the wrong Jevity. R1's [DATE] Request for Diet Change PCP (Primary Care Provider) FAX Report documented in part . (Registered Dietitian Tube Feeding) Change note. Family would like continuous feedings. Recommend Jevity 1.5 45ml hour continuous rate, 180ml flush every 6 hours . Will adjust as needed . This document was not signed or dated by R1's PCP. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 2 of 4 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 10/25/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 3:13 PM, V10 (Regional Nurse Consultant) said R1's Physician signed [DATE] Request for Diet Change PCP FAX report could not be found and R1's PCP's office had no note of it. V10 stated I guess R1's [DATE] Request for Diet Change PCP FAX Report was never sent to R1's PCP. On [DATE] at 3:05 PM, V5 said on [DATE] V12 had asked her why R1 had not been changed to continuous tube feeding from bolus tube feeding. V5 said she told V12 she was not sure and would find out. V5 said she called V7 (MDS Coordinator/ Licensed Practical Nurse) and was told V4 (Dietitian) had made the recommendation for R1's tube feeding order to be changed to continuous, but an order had not been received from R1's PCP to change the order. V5 said she called R1's PCP and obtained a verbal order to change R1's tube feeding to V4's recommendation. V5 said due to R1's g-tube being of a new design the facility did not have the tubing required to complete a continuous feeding. V5 said she called a local hospital to see if they had any of the tubing R1 required and the hospital had delivered some tubing to the facility that day on [DATE]. V5 said she changed R1's tube feeding order to continuous on [DATE] and discontinued R1's bolus tube feeding. R1's [DATE] MAR documented an order with a start date of [DATE] for Isosource 1.5 Cal continuous at 45 ml per hour every 24 hours. On [DATE] at 9:36 AM, V4 said she was told by the facility on [DATE] R1's State Guardian had requested to change R1's tube feeding from bolus to continuous and V4 had made that recommendation. V4 said when V4 has completed the resident reviews in a facility and has made her recommendations she emails a copy of the recommendations and the Diet Change PCP FAX Report to V1 (Administrator), V2, and V7. V4 said it is V2 or V7's responsibility to ensure the resident's PCP receives the Diet Change PCP FAX Report in 24 hours and the PCP responds with in 24 to 48 hours. V4 said V2 is responsible to follow up on any unanswered Diet Change PCP FAX Reports. V4 said V4 would follow up the next month when she was in the facility to verify if the resident's PCP had agreed or disagreed with her recommendations. V4 said the facility should have a system to track when recommendations are being sent to resident's PCPs and when they are returned to the facility. V4 said the same calorie intake could be achieved by bolus and continuous tube feeding. V4 said bolus tube feeding was preferred by most residents due to the increase in mobility. V4 said the facility had notified her on [DATE] they could only administer Isosource 1.5 to R1 due to the tubing they had on hand. V4 said Isosouce 1.5 and Jevity 1.5 are comparable in calorie intake and the main difference is Jevity has more fiber. V4 said she had told them Isosource 1.5 would be ok to give R1. On [DATE] at 10:22 AM, V2 said she did not recall V4's [DATE] recommendations and did not know if they had been sent to resident PCP's or not. V2 said due to working as a floor nurse so often she does not have time to complete all the Director of Nursing duties. V2 said V4 would send the recommendations through an encrypted email that required a password to open and V2 did not have the password to open them or to print them. V2 said the previous Dietary Manager had printed V4's recommendations and Diet Change PCP FAX Reports and would give them to V2 or V7 to be sent to the resident PCPs. V2 said the current Dietary Manager was new and was not sure if V11 (Dietary Manager) had printed V4 [DATE] recommendations. On [DATE] at 9:20 AM, V11 said she did get a copy of V4's recommendations but relied on nursing staff to bring the signed copy of the Diet Change PCP FAX Report to her to change the resident's diet. V11 said she would not have received any Diet Change PCP FAX Report for R1 due to R1 being a resident who relied on tube feeding. On [DATE] at 11:22 AM, V13 (Chief Executive Officer) said she was not aware V5 was not caring for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 3 of 4 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 10/25/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents on R1's hall from 11:00 PM to 6:00 AM when V5 was the only licensed nurse in the facility but would investigate further. The facility's Revised [DATE] Dietitian policy documented in part . A qualified Dietitian will help oversee clinical nutritional Dietary Services in the facility . Our facility's Dietitian is responsible for, but not necessarily limited to: . a. Assessing nutritional needs of residents; b. Developing and planning regular and therapeutic diets; . d. Collaborating effectively with other direct care staff and practitioners to assess and address nutritional issues in the facility's population; . The facility's revised [DATE] Charting and Documentation policy documented in part .The medical record should facilitate communication between the interdisciplinary team regarding the residence condition and response to care . 2. 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 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 4 of 4