Inspection·July 23, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide dietary supplements, and the appropriate protein portion size to prevent further weight loss or weight maintenance for 9 of 11 residents (R1, R2, R3, R8, R9, R10, R11, R12, R13) reviewed for weight loss in a sample of 18. This failure further contributes to continued harm to R2 and R10, who have a documented history of severe weight loss. Findings include:1. R2's admission record documents an admission date of 01/09/22 with diagnoses including: chronic obstructive pulmonary disease, acute osteomyelitis of left ankle and foot, malignant neoplasm of upper lobe, anemia, protein calorie malnutrition, major depressive disorder, anxiety disorder, hypothyroidism, drug induced subacute dyskinesia, osteoarthritis, muscle weakness, and cognitive communication deficit.R2's order summary report documents a dietary order of regular diet with mechanical soft texture. Thin liquids consistency, ground meat extra gravy, (nutritional shakes) two times a day, 1 scoop protein powder in oatmeal at breakfast, vanilla pudding at supper, med pass 2 ounces at lunch and supper, (nutritional ice cream) two times a day, offer snacks throughout the day. Assist with meals in dining room and whole milk at breakfast for diet. This order was started on 07/22/24 with no end date listed.R2's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) score of 12 indicating resident is moderately impaired. Section GG documents R2's eating ability as supervision or touching assistance.R2's care plan documents a focus area of R2 is at risk for nutritional deficit related to diagnoses including malnutrition, underweight, poor appetite, and a diagnosis of anemia. R2 is on a regular mechanical soft diet with ground meat with extra gravy, nutritional shakes two times a day, 1 scoop of protein powder in oatmeal at breakfast (likes oats thicker), vanilla pudding daily at supper, and nutritional ice cream two times a day with a revision date of 01/18/24 with interventions including: provide and serve supplements as ordered dated 08/07/23, to be up and in dining room for all meals due to requires assistance with eating dated 04/21/25, add whole milk at breakfast dated 07/10/25 and offer snacks throughout the day dated 07/10/25.R2's nutrition progress note dated 07/08/2025 at 1:12 PM documents: mechanical soft ground meats with extra gravy. Percent of meal intakes is 51 - 100 %, supplement intake: health shakes two times a day, 1 scoop of protein powder in oatmeal at breakfast, vanilla pudding at supper, Med pass and nutritional ice cream. R2's current weight is 82 pounds with low body mass index and weight loss. R2's function is assistance with meals. R2's height is 64 inches and weight on 06/04/25 was 82 pounds with a BMI of 14 % and a December weight of 91 pounds. R2 has a 10 % weight loss over six months. R2's skin is at risk. Continue diet orders of mechanical soft ground meat with extra gravy, nutritional shakes two times a day, 1 scoop of protein powder in oatmeal at breakfast, vanilla pudding at supper and nutritional ice cream two times a day.R2's nurses note dated 07/03/25 at 10:23 AM documents: R2 had weight loss, medical doctor and resident notified and new interventions implemented.On 07/17/25 at approximately 1:01 PM, V4 (Dietary) ground the ham and mixed mayonnaise in with the ground ham, the ham was scooped onto paper plates with the baked beans and microwaved to reach 145 degrees Fahrenheit.On 07/17/25 at approximately 1:01 PM, V4 stated, she is going to mix mayonnaise in with the ham to make the mechanical soft ham because they do not have any gravy for the mechanical soft ham. On 07/17/25 at approximately 1:28 PM, R2 was served her lunch of mechanical soft ham, baked beans and applesauce. R2 did not receive the extra gravy, nutritional shake, or nutritional ice cream with her lunch.On 07/17/25 at 3:10 PM, R2 stated lunch was not enough food, she had asked for something else, but she did not get it. R2 stated, The lunch meal was awful.On 07/17/25 at 5:47 PM, R2 did not receive a health shake with her dinner.On 07/21/25 at 8:10 AM, R2 was brought to the dining room for breakfast. Her food was placed in Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 2 of 9 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 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Actual harm Residents Affected - Few front of her and plastic utensils placed in the food and the staff member walked away. R2 did not receive assistance or encouragement during breakfast with her meal and ate less than 25% of her meal.On 07/21/25 at 12:33 PM, R2 did not receive a health shake with lunch.On 07/21/25 at 6:46 PM, R2 did not receive a health shake with her dinner.2. R10's admission record documents an admission date of 09/06/17 with diagnoses including: dementia, essential hypertension, vitamin D deficiency, thiamine deficiency, alter mental status, Parkinson's disease, epilepsy, muscle weakness, and other symbolic dysfunctions.R10's order summary report documents a dietary order of regular diet with a pureed texture, thin liquids consistency, whole milk three times a day, health shake three times a day, (nutritional ice cream) with lunch and supper, super cereal (nutritional cereal) at breakfast, ice cream two times a day, melted margarine to hot sides at lunch and supper, offer pudding three times a day, 1 scoop of protein powder at all meals with an order date of 01/15/25 and no end date listed. R10's order summary report also documents a dietary order of house supplement two times a day for weight loss, fortified pudding at lunch and dinner with protein powder added with an order date of 01/15/25 and no end date listed.R10's minimum data set (MDS) dated [DATE] documents a brief interview of mental status of 99 indicating resident was unable to complete the interview. Section GG documents R10's eating ability as: not attempted due to environmental limitations (example, lack of equipment or weather constraints).R10's care plan documents a focus area of R10 is at risk for nutritional deficit relating to diagnoses of vitamin D and Thiamine deficiencies, hypertension, Parkinson's and dementia, R10 is on a regular pureed diet dated initiated 02/03/25. Goal: will maintain adequate nutritional status as evidenced by maintaining weight within 5-10% and no signs of malnutrition through review date, date initiated 02/03/25. Interview include: offer pudding two times a day dated initiated 03/24/25, Med pass as ordered at lunch dated initiated 07/18/25, regular pureed diet, whole milk three times a day, health shakes three times a day, nutritional ice cream at lunch and supper, super cereal at breakfast, ice cream two times a day, melted margarine/butter to hot sides with lunch and supper, offer pudding three times a day, one scoop protein power all meals, nutritional ice cream at lunch and supper dated initiated 07/02/25, attempt to assist her with eating at meal times as she allows dated initiated 02/03/25, provide and serve supplements as ordered date initiated 02/03/25.R10's dietary note dated 3/6/25 documents: registered dietician weight note: R10's height is 60 inches. January weight 96 pounds, February weight 85 pounds. Documenting a 11.5% weight loss in 1 month. Continue pureed, med pass three times daily, super cereal at breakfast, whole milk three times daily, ice cream twice daily, melted margarine on hot vegetables, magic cup at lunch and supper, health shakes three times a day. Discontinue fortified pudding with protein powder because supplement is not offered at this facility. Offer pudding twice daily. Encourage intakes. Monitor intakes and weights. R10's dietary note dated 07/08/25 at 2:06 PM documents: registered dietician weight note: R10's height is 60 inches and weight on 06/04 was 93 pounds with a BMI of 18%, March weight was 86 pounds with 8.1% weight gain over 3 months, the weight gain is desirable. R10 has variable meal intakes as reported. Continue pureed (diet), super cereal at breakfast, whole milk three times a day, ice cream two times a day, melted margarine on hot vegetables, nutritional ice cream at lunch and supper, health shakes three times a day, 1 scoop protein powder in all meals. R10 is being offered above nutritional needs. Encourage intakes and monitor intakes and weights. On 07/17/25 at 1:10 PM, R10 did not receive the whole milk, health shake, nutritional ice cream, ice cream, melted margarine, fortified pudding, or the protein powder with her lunch.On 07/17/25 at 2:45 PM, V3 (Business office Manager/Acting Dietary Manager) stated, they did not have any super cereal to serve for breakfast today (07/17/25) so R10 did not receive the super cereal for breakfast.On 07/17/25 at 5:42 PM, R10 did not receive the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 3 of 9 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 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Actual harm Residents Affected - Few health shake or fortified pudding with her dinner.On 07/17/25 at 5:42 PM, R10 received her dinner. R10 did not make any effort to eat any food after it was set in front of her. At 6:00 PM, R10 received assistance with her dinner. On 07/21/25 at 12:22 PM, R10 did not receive the health shake, ice cream or pudding with her lunch.On 07/21/25 at 6:34 PM, R10 did not receive the health shake, ice cream, protein powder or fortified pudding with her dinner.On 07/21/25 at 6:36 PM, V14 (Certified Nurse Aide) stated, R10 needs assistance with eating.3. R3's admission record documents an admission date of 01/05/22 with diagnoses including: unspecified sequelae of unspecified cerebrovascular disease, dementia, essential hypertension, cognitive communication deficit, weakness, vitamin D deficiency, depression and chronic pain.R3's order summary report documents a dietary order of regular diet with a pureed texture with an order date of 05/20/25 and no end date listed. R3's order summary report documents a dietary order of health shakes with meals for weight loss with an order date of 07/22/24 and no end date listed.On 07/17/25 at 1:10 PM, R3 did not receive her health shake with her lunch.On 07/17/25 at 5:20 PM, R3 did not receive a health shake with her dinner.On 07/21/25 at 6:26 PM, R3 did not receive a health shake with her dinner.4. R16's admission record documents an admission date of 04/27/23 with diagnoses including: chronic obstructive pulmonary disease, gastrostomy status, dysphagia, paroxysmal tachycardia, schizoaffective disorder, bipolar disorder, moderate protein calorie malnutrition, muscle weakness, and encounter for surgical aftercare following surgery on the digestive system.R16's order summary report documents a dietary order of regular diet with a pureed texture, super cereal at breakfast, whole milk three times a day with meals, extra margarine/butter, sauces/gravies all meals with an order date of 10/19/24 and no end date listed.On 07/17/25 at 1:10 PM R16 did not receive the whole milk, or extra margarine/butter or sauces/gravies with his lunch.On 07/17/25 at 2:45 PM V3 (Dietary Manager) stated, they did not have any super cereal to serve for breakfast today (07/17/25) so R16 did not receive the super cereal for breakfast.5. R1's admission record documents an admission date of 11/11/2022 with diagnoses including: recurrent depressive disorders, unspecified intellectual disabilities, paranoid schizophrenia, essential hypertension, muscle weakness, and anxiety disorder.R1's order summary report documents a regular diet with regular texture with an order date of 07/22/24 with no end date listed.R1's dietary note dated 05/02/25 at 1:37 PM documents: variable meal intakes as reported. R1's height is 77 inches, and weight on 04/29 190 pounds, having a BMI (body mass index) of 22, no significant weight changes per monthly weights. However, reported weekly weights have declined with overall declining weight trend. Continue regular diet, offer whole milk at breakfast, (nutritional) shake daily, and encourage intakes.On 07/17/25 at approximately 1:40 PM ham slices were served, the slices were, sliced ham that was cut in half. All slices were similarly sized.On 07/17/25 at approximately 1:40 PM, R1 received a piece of ham that was approximately 1.75 ounces.On 07/17/25 at 2:26 PM, V3 (Dietary Manager) weighed one of the slices of ham, the ham weighed 1.75 ounces.On 07/17/25 at 2:26 PM, V3 stated, the ham should have weighed 3 ounces, therefore they did not give enough ham.The Diet Spreadsheet, Emergency menu dated 2025 for Day 5 Thursday documents, Lunch with a handwritten note of Grilled ham, applesauce, chips and baked beans. The portion sizes that were indicated were noted to be for Corned beef hash, canned green bean, assorted cookies and bread that had been marked out. 6. R8's admission record documents an admission date of 11/29/24 with diagnoses including: anxiety disorder, vascular dementia, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, sequelae of unspecified cerebrovascular disease, type 2 diabetes mellitus, seizures. Gastro-esophageal reflux disease without esophagitis, muscle weakness, and syncope and collapse.R8's order summary report documents a dietary order of: no added salt diet, regular texture with nutritional shakes with all meals (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 4 of 9 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 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Actual harm Residents Affected - Few for nutrition with an order date of 11/29/24 and no end date listed.On 07/17/25 at 1:20 PM, R8 did not receive her health shake with her lunch.On 07/17/25 at approximately 1:40 PM, R8 received a piece of ham that was approximately 1.75 ounces.On 07/17/25 at 5:35 PM, R8 did not receive a health shake with her dinner.On 07/21/25 at 6:46 PM, R8 did not receive a health shake with her dinner.7. R9's admission record documents an admission date of 08/28/2014 with diagnoses including: chronic obstructive pulmonary disease, sequelae of unspecified cerebrovascular disease, dementia, essential hypertension, anxiety disorder, dysphagia following unspecified cerebrovascular disease, major depressive disorder, and hypotension.R9's order summary report documents a dietary order of: regular diet with regular texture, whole milk three times a day, health shake two times a day with lunch and supper, offer pudding at lunch, ice cream at supper, peanut butter at snack time and extra margarine/butter at all meals and add 120 ml (milliliters) Med pass two times a day with meals related to weight loss with an order date of 07/22/24 and no end date listed.On 07/17/25 at approximately 1:40 PM, R9 received a piece of ham that was approximately 1.75 ounces.On 07/17/25 at 1:50 PM, R9 did not receive his health shake, pudding, or extra margarine/butter with his lunch.On 07/17/25 at 5:50 PM, R9 did not receive a health shake with his dinner.On 07/21/25 at 6:57 PM, R9 did not receive a health shake with his dinner.8. R11's admission record documents an admission date of 05/31/25 with diagnoses including: cellulitis or right lower limb, cellulitis of left lower limb, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, essential hypertension, chronic pain syndrome, gastro-esophageal reflux disease without esophagitis, schizoaffective disorder, alcohol abuse, depression, and muscle weakness.R11's order summary report documents a dietary order of: regular diet with mechanical soft texture, high protein supplement twice daily between meals, moist soft foods, moistened ground meat, offer health shakes as supplement twice a day, include whole milk at breakfast, and super cereal at breakfast for diet with an order date of 05/31/25 and no end date listed.On 07/17/25 at 1:22 PM, R3 did not receive her health shake with her lunch.On 07/17/25 at 2:43 PM, V3 stated, they did not have super cereal yesterday (07/16/25) for breakfast, so R11 did not receive any super cereal.On 07/17/25 at 5:47 PM, R3 did not receive a health shake with her dinner.On 07/21/25 at 6:53 PM, R3 did not receive a health shake with her dinner.9. R12's admission record documents an admission date of 11/24/21 with diagnoses including: senile degeneration of brain, acquired absence of left leg above the knee, cognitive communication deficit, unspecified intellectual disabilities, anemia, vitamin D deficiency, hyperlipidemia, schizoaffective disorder, dysphagia, anxiety disorder, major depressive disorder, paranoid personality disorder, epileptic seizures related to external causes, hallucinations, and restlessness and agitation.R12's order summary report documents a dietary order of regular texture, assist with meals in dining room, super cereals at breakfast, whole milk at breakfast, nutritional ice cream at lunch and supper, health shakes three times a day with meals, include pudding at lunch, extra butter and gravy with meals with an order date of 09/26/24 and no end date listed.On 07/17/25 at approximately 1:40 PM R12 received a piece of ham that was approximately 1.75 ounces. On 07/17/25 at 1:40 PM, R12 did not receive her health shake, nutritional ice cream, pudding or extra butter and gravy with her lunch.On 07/17/25 at 2:43 PM V3 stated, they did not have super cereal yesterday (07/16/25) for breakfast, so R12 did not receive any super cereal.On 07/17/25 at 5:25 PM, R3 did not receive a health shake with her dinner.On 07/21/25 at 6:26 PM, R3 did not receive a health shake with her dinner.10. R13's admission record documents an admission date of 05/18/17 with diagnoses including: anemia, altered mental status, unspecified severe protein calorie malnutrition, essential hypertension, muscle weakness, vitamin B12 deficiency anemia due to intrinsic factor deficiency, hypocalcemia, age related cognitive decline, ocular hypertension, left eye, and cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 5 of 9 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 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete communication deficit.R13's order summary report documents a dietary order of: regular diet with regular texture, offer whole milk with meals, snack three times a day, health shake two times a day, in between meals, super cereal at breakfast, whole milk with all meals, med pass 90cc (cubic centimeters) and health shake with all meals with an order date of 07/22/24 and no end date listed.R13's order summary report documents a dietary order of house supplement two times a day for supplements, (nutritional) shakes in between meals with an order date of 02/01/25 and no end date listed.On 07/17/25 at approximately 1:40 PM R13 received a piece of ham that was approximately 1.75 ounces. On 07/17/25 at 1:40 PM R13 did not receive her health shake or whole milk with her lunch.On 07/17/25 at 2:43 PM V3 stated, they did not have super cereal yesterday (07/16/25) for breakfast, so R13 did not receive any super cereal.On 07/17/25 at 5:45 PM, R13 did not receive a health shake with her dinner.On 07/21/25 at 6:56 PM, R13 did not receive a health shake with her dinner.On 07/23/25 at 9:47 AM, V18 (Registered Dietician) stated, Even on an emergency menu, I expected all extra sauces, butters, supplements, super cereals and all other interventions that have been indicated to be given. At all times I expect all supplements and interventions to be provided.The facility policy dated 09/2017 titled, Weight Assessment and Intervention documents: the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Interventions: 1. Interventions for undesirable weight loss may be based on careful consideration of the following: g. the use of supplementation and/or feeding tubes. Event ID: Facility ID: 145757 If continuation sheet Page 6 of 9 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 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interview, observation, and record review the facility failed to provide an adequate number of dietary staff to serve dinner in a timely manner. This failure has the potential to affect all 51 residents that reside at the facility.Findings include:The Resident List Report dated 07/17/25 documents 51 residents currently reside at the facility.On 07/17/25 at 2:47 PM, V1 (Administrator) stated, dinner is at 5:15 PM.On 07/17/25 at 2:47 PM, V3 (Business Office Manager/Acting Dietary Manager) stated, lunch is at 12:30 PM and dinner is at 5:15 PM.On 07/21/25 at 3:40 PM, V1 (Administrator) stated they had two kitchen staff members (V8 and V9 (Dietary Aides) not show up for work Sunday night (07/20/25). V1 stated, V6 (Dietary Aide) was called in to work.On 07/21/25 at 4:05 PM V6 (Dietary Aide) stated, she was called in to work on 07/20/25 and there were no other dietary staff present. V6 stated there were Certified Nurse Aides in the kitchen cooking grilled cheese and spaghetti sauce with meatballs. V6 stated, she received a text at 3:16 PM on 07/20/25 to see if she could come into work. V6 stated, the evening shift usually start about 1:30 PM. V6 stated, she was able to get to the facility at 4:00 PM and she just followed what they were already cooking because they had already started that and dinner was supposed to start at 5:15 PM, in an hour and fifteen minutes. V6 stated, some of the dinners did not go out until approximately 7:30 PM.On 07/21/25 at 4:10 PM, R18 stated, they did not eat until late on Sunday night (07/20/25) and CNA's did help cook because there was no dietary staff for a while. R18 stated, a couple residents did try to help by clearing trays and dishes. R18 was alert and oriented to person, place and time.On 07/21/25 at 4:14 PM, R17 stated she did not get her dinner until 7:38 PM last night (07/20/25) and it was a grilled cheese and some awful spaghetti sauce, but the grilled cheese was good. The CNA's went in and helped in the kitchen. R17 was alert and oriented to person, place and time.On 07/21/25 at 4:20 PM, R6 stated he did not get his dinner until late Sunday night, it was probably almost two hours late. R6 stated, it was grilled cheese and spaghetti sauce he thinks. R6 was alert and oriented to person, place and time.On 07/21/25 at 4:30 PM, R9 who was alert to person, place and time stated, dinner was late last night.On 07/21/2025 at 2:00 PM, V6 was the only person in the kitchen.On 07/21/25 at 3:05 PM, V6 was the only person in the kitchen.On 07/21/25 at 4:07 PM, V6 was the only person in the kitchen.On 07/21/25 at 4:12 PM, V1 stated there is more than one staff scheduled to be in the kitchen. V1 stated the second person is scheduled at 1:30 PM.On 07/21/25 at 4:12 PM (after surveyor asked where the second person was) V1 stated, let me text them and see if they are coming. V1 stated dinner is at 5:15 PM.On 07/21/25 at 5:00 PM, V6 was the only person in the kitchen.On 07/21/25 at 6:27 PM the first tray was served, at 6:58 PM hall trays were started to be served.The undated document titled, Meal Times documents: breakfast 7:30 AM, lunch noon, and dinner 5:30 PM.The Facility Assessment Tool dated 05/31/25 documents: average daily census 50, under the section titled, Staffing Plan the category listing: other (e.g. (example), department heads, nurse educator, quality assurance, ancillary staff in maintenance, housekeeping, dietary, laundry) the box is blank.The facility policy revised 07/2017 titled, Resident Nutrition Services documents: 2. Residents shall receive prompt meal service and appropriate feeding assistance. Reasonable efforts will be made to accommodate resident choices and preferences. Event ID: Facility ID: 145757 If continuation sheet Page 7 of 9 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 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to provide food that appeared palatable and attractive for 7 of 7 residents (R2, R3, R6, R8, R10, R15, and R16) reviewed for dining in a sample of 18.Findings include:1. On 07/17/25 at 1:10 PM the individual serving of pureed ham was microwaved in a paper product bowl, the pureed ham was dry looking, crusty around the edges and a grayish color after being microwaved to be heated to a servable temperature. The microwaved pureed ham was served to R3, R10, R15, R16. R3's order summary report documents a dietary order of regular diet with a pureed texture with an order date of 05/20/25 and no end date listed.R10's order summary report documents a dietary order of regular diet with a pureed texture, whole milk three times a day, health shake three times a day, nutritional ice cream with lunch and supper, super cereal at breakfast, ice cream two times a day, melted margarine to hot sides at lunch and supper, offer pudding three times a day, 1 scoop of protein powder at all meals with an order date of 01/15/25 and no end date listed.R15's order summary report documents a dietary order of regular diet with a pureed texture and double desserts with all meals with an order date of 11/26/24 and no end date listed.R16's order summary report documents a dietary order of regular diet with a pureed texture, super cereal at breakfast, whole milk three times a day with meals, extra margarine/butter, sauces/gravies all meals with an order date of 10/19/24 and no end date listed.On 07/17/25 at 2:38 PM, V3 (Business Office Manager/Acting Dietary Manager) stated, the pureed food did not look appetizing after being microwaved.On 07/23/25 at 11:35 AM, V1 (Administrator) stated, the pureed ham did not look appetizing after being microwaved. 2. R2's Minimum Data Set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) score of 12 indicating resident is moderately impaired.R2's order summary report documents a dietary order of regular diet with mechanical soft texture, ground meat extra gravy, nutritional shakes two times a day, 1 scoop protein powder in oatmeal at breakfast, vanilla pudding at supper, nutritional ice creams two times a day. Assist with meals in dinning room and whole milk at breakfast for diet with an order date of 07/22/24 and no end date listed.On 07/17/25 at approximately 1:01 PM, V4 (Dietary) ground the ham and mixed mayonnaise in with the ground ham, the ham was scooped onto paper plates with the baked beans and microwaved to reach 145 degrees Fahrenheit.On 07/17/25 at approximately 1:01 PM, V4 stated she is going to mix mayonnaise in with the ham to make the mechanical soft ham because they do not have any gravy for the mechanical soft ham. On 07/17/25 at approximately 1:28 PM, R2 was served her lunch of mechanical soft ham, baked beans and applesauce.On 07/17/25 at 3:10 PM R2 stated, lunch was not enough food, she had asked for something else, but she did not get it. R2 stated, the lunch meal was awful. R2 was alert and oriented to person, place and time.3. On 07/17/25 at 1:50 PM the individual slices of ham were microwaved to bring the ham up to temperature and appeared dry and burnt around the edges.On 07/17/25 at 3:02 PM, R6 stated the food for the last two days has been messed up and sucky! R6 was alert and oriented to person, place, and time.On 07/17/25 at 5:45 PM, R8 stated dinner tonight is much better than dinner last night. Last night was not good. R8 stated, the ham today was no good either. The ham was dry and burnt. R8 was alert and oriented to person, place, and time.On 07/23/25 at 11:40 AM, V1 stated she does not know how she expected to have food prepared for 51 residents, with sides and gravy and brought to the appropriate temperature on a residential sized grill. It was poor planning. The facility policy dated 07/17 titled, Resident Nutrition Services documents: 4. Nursing personnel or feeding assistants will inspect food trays as they are delivered to ensure that the correct meal has been delivered, that the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 8 of 9 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 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to prepare and distribute food in accordance with professional standards of food safety and failed to maintain appropriate sanitizer levels in the dish machine to prevent foodborne illness. This has the potential to affect all 51 residents living in the facility. Findings include:The facility, Resident List Report dated 07/17/25 documents there are 51 residents currently residing at the facility.On 07/17/25 at 11:45 AM, V1 (Administrator) stated the kitchen is currently closed down by the health department for pests and needing cleaning. V1 stated they are hoping the health department will open the kitchen today. V1 stated, the health department stated they could grill outside, they could just not use the kitchen.The Food Establishment Inspection Report dated 07/15/25 documents item #38 observation: live roach observed at time of inspection that crawled into the square mechanical/electrical compartment above the dish machine drain. General Comments: due to the number of foodborne illness risk factors and public health intervention violations as well as wastewater back up and live pests, the food service permit for (facility name) has been suspended until further notice. You are to cease operations immediately.On 07/23/25 at 8:20 AM, V16 (Local Health Department Inspector) stated she did not say the facility could grill outside and prepare the food in a different room at the facility. V16 stated, she asked V1 if they were getting food from outside, and that it was coming in to go containers, and she was told yes.On 07/17/25 at 11:50 AM, V3 (Business Office Manager/Acting Dietary Manager) stated, they grilled dinner outside on the grill last night (07/16/25) and breakfast that morning outside on the grill.On 07/17/25 at 11:30 AM, V17 (Dietary Cook) was grilling ham slices and warming baked beans on a residential sized grill on a grill outside the facility. At that time V17 stated he was directed by V1 to grill lunch outside and bring it inside and serve it.On 07/17/25 at 12:05 PM, V1 stated all trays were going to be staged and served from the room down the hall from the dining room. V1 stated, that is where they served breakfast from. This was a larger room that contained two eight foot white foldable tables, no handwashing sink or dish washing sinks.On 07/17/25 at 12:15 PM the food staging room contained a container of thickener sitting on one of the white tables with a scoop sitting in the container of thickener.On 07/17/25 beginning at 1:10 PM the first tray was served for lunch; all trays were sent out from the food staging room that was a side room approximately 20 feet down the hall from the dining room.On 07/17/25 between 1:10 PM and 2:23 PM all residents trays were served without any of the drinks covered.On 07/17/25 at 2:25 PM, V3 stated all items on every tray should have been covered, since every tray should have been treated as a hall tray.On 07/21/25 at 5:35 PM, V1 transferred ice to the residents glasses using her gloved hand after touching the ice machine, ice machine lid, and the ice scoop handle without any glove change or any hand hygiene in between.On 07/22/25 at 12:20 PM, V11 (Dietary Aide) transferred glasses onto the residents trays by the rims after touching the health shake cartons, the cooler door, and the gallon milk container with no hand hygiene in between.On 07/22/25 at 3:40 PM, the dish machine sanitizer was tested and measured 10 ppm (parts per million) chlorine.On 07/22/25 at 3:40 PM, V6 (Dietary aide) stated, the chlorine should be reading at least 50 ppm. V6 stated, she had not tested it yet today, she would think the morning shift had tested it. On 07/23/25 at 9:47AM, V18 (Registered Dietician) stated, when she was called and asked about an emergency menu, she reiterated they need to make sure safe temperatures were maintained, food was handled safely and prepared sanitarily. V18 stated she was told by V1 that the kitchen was shut down not that their food permit was suspended, so she directed as per the information she was given. Event ID: Facility ID: 145757 If continuation sheet Page 9 of 9