Inspection·August 27, 2025

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 5/30/25 MDS documented a BIMS score of 4, indicating R4 was severely cognitively impaired.R4's Order Summary Report printed 8/21/25 documented a 7/22/24 diet order for regular diet mechanical soft texture with thin liquid consistency, pudding at supper, extra butter/ margarin and extra sauces/ gravies with meals. R4's Care Plan Report documented a focus area revised on 3/23/35 documenting in part .(R4) is at risk for nutritional deficit r/t (related to) Dx TBI (Traumatic Brain Injury), dementia, rectal cancer. On 6/18/25 at 5:57 PM, R4 was served a meal tray containing large pieces of pizza dietary staff had torn up by hand, larger than 1-inch by 1-inch pieces of varying size, with some pieces containing the hard outer crust, pureed green beans, and a whole breadstick. R4 was observed to be unable to bite through the hard outer pizza crust or the breadstick. R4 did not receive any desert, pudding, butter/ margarin, sauce/ gravy.The facility's 2024 Weight Assessment and Intervention policy documented in part . The multidisciplinary tea will strive to prevent, monitor, and intervene for undesirable weigh loss for our residents. 4. The Dietitian will review the Weight Records each month to follow individual weight trends over time. 1. Interventions for undesirable weight loss may be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating. e. Chewing and swallowing abnormalities and the need for diet modifications. g. The use of supplementation and/or feeding tubes. Event ID: Facility ID: 145757 If continuation sheet Page 2 of 8 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 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide 8 consecutive hours of Registered Nurse (RN) services 7 days a week. This failure has the potential to affect all 50 residents residing in the facility.Findings include:The facility's June, July, and August 2025 licensed nurse's schedules documented on June 7, 8, 14, 15, 21, 22, 28, and 29, July 6, 12, 13, 19, 20, 26, and 27, [DATE], 9, 10, 16, and 17 there was no RN working in the facility for a consecutive 8 hours.On 8/22/25 at 9:38 AM, V2 (Director of Nursing/ DON) verified on June 7, 8, 14, 15, 21, 22, 28, and 29, July 6, 12, 13, 19, 20, 26, and 27, [DATE], 9, 10, 16, and17 there was no RN working in the facility for a consecutive 8 hours.On 8/22/25 at 2:13 PM, V1 (Administrator) said the facility did not have a policy pertaining to 8 consecutive hours of RN services. V1 said the facility followed Illinois Department of Public Health (IDPH) staffing guidelines.The facility's 9/20/25 Resident List Report documented 50 residents residing in the facility. Event ID: Facility ID: 145757 If continuation sheet Page 3 of 8 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 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow dietitian approved recipes and textures an failed to provide ordered supplements for 5 (R4, R5, R6, R7 and R12) of 12 residents reviewed for dietary services out of a sample of 12.Findings include:The facility's Diet Spreadsheet Week 1 day 7 for Dinner, documented residents receiving a mechanical soft diet should have been served ground swiss cheese sandwich with mayonnaise, soft cooked vegetables soft chopped ambrosia, and a soft garlic breadstick. The facility's Diet Spreadsheet Week 1 day 7 for Dinner, documented resident receiving a pureed diet should have been served pureed cheese pizza, pureed soft, cooked vegetables, pureed ambrosia, and pureed garlic breadstick.1. R12's admission Record documented an admission date of 8/6/25 with diagnoses including: sequelae of unspecified cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness. R12's 8/15/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R12 was cognitively intact.R12's Order Summary Report printed 8/26/25 documented an 8/6/25 diet order for low concentrated sweets diet with mechanical soft texture and thin liquids.On 6/18/25 at 5:44 PM, R12 was severed a meal tray containing large pieces of cheese pizza dietary staff had torn up by hand, larger than 1 inch by 1 inch pieces of varying size, with some pieces containing the hard outer crust, a shredded lettuce salad, and a whole breadstick. V3 (Certified Nursing Assistant/ CNA) delivered R12's meal tray and told R12, I know there are some hard pieces in there (referring to the pizza) but if it is too much let us know. Don't choke on it. Tell us and we will see about getting you something else.On 6/18/25 at 5:54 PM, R12 was observed to be trying to bite though the pizza but was not able to.2. R5's admission record documented an admission date of 5/20/25 with diagnoses including: hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, vascular dementia, cerebellar stroke syndrome. R5's 5/28/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R5 was cognitively intact.R5's Order Summary Report printed 8/21/25 documented a 5/20/25 diet order for no added salt, mechanical soft texture, thin liquids consistency. R5's Care Plan Report documented a focus area with a 6/9/25 initiated date documenting in part .(R1) is a risk for nutritional deficit r/t (related to) dx (diagnosis) CVA (Cerebrovascular Accident) with left sided hemiplegia, dementia. with a with 6/9/25 initiated intervention documenting in part . Provide, serve diet as ordered.On 6/18/25 at 6:38 PM, R5 was served a meal tray containing large pieces of cheese pizza dietary staff had torn up by hand, larger than 1 inch by 1 inch pieces of varying size, with some pieces containing the hard outer crust, a shredded lettuce salad, and a whole breadstick. R5 was observed to be unable to bite through the hard outer pizza crust.On 6/18/25 at 7:09 PM, R5's meal tray was observed to have the breadstick with teeth marks on one end but was not bitten off. At that time R5 stated the breadstick was too hard for her to bite through.3. R6's admission Record documented an admission date of 9/12/24 with diagnoses including: dementia, mild cognitive impairment, major depressive disorder, R6's 8/1/25 MDS documented a BIMS score of 1, indicating R6 was severely cognitively impaired.R6's Order Summary Report printed 8/21/25 documented a 1/13/25 diet order for regular diet with pureed texture with honey thick liquids. R6's Care Plan Report documented a focus area with a 7/31/20 initiation date documenting in part .(R6) is on a NAS (No Added Salt) puree diet. (R6's) teeth are in poor condition. (R6) is able to feed himself after setup.On 6/18/25 at 6:04 PM, R6 was served the evening meal tray containing pureed pizza that was chunky more of a ground consistency not a smooth consistency, pureed green beans, and pureed ambrosia. R6's meal tray did not contain a pureed garlic breadstick.On 6/18/25 at 6:15 PM, R6 was observed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 4 of 8 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 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some start coughing after taking a bite of the pureed/ ground pizza becoming red in the face. R6 was able to clear his airway on his own by coughing and did not require intervention by staff.R6's Progress Note on 8/17/25 at 4:19 AM progress note documented in part .The nurse on duty was notified that the resident choked during dinner. The nurse assessed the resident. The resident was not chocking or coughing upon assessment. Lung sounds were clear in all lobes. The MD (Medical Doctor) was notified and an order was placed to obtain a STAT X-ray with two views. The order has been placed.On 8/21/25 at 12:02 PM, V7 (CNA) said she was working on 8/17/25 during the evening meal. V7 said she saw R6 get choked on his beverages and said it was due to the dietary staff not thickening R6's beverages. V7 said after she ensure R6 was ok she returned R6's beverages and alerted the dietary staff R6 was supposed to receive honey thickened liquids.4.R4's admission Record documented an admission date of 4/30/22 with diagnoses including: dementia, personal history of traumatic brain injury, sensorineural hearing loss bilateral. R4's 5/30/25 MDS documented a BIMS score of 4, indicating R4 was severely cognitively impaired. eR4's Order Summary Report printed 8/21/25 documented a 7/22/24 diet order for regular diet mechanical soft texture with thin liquid consistency. R4's Care Plan Report documented a focus area revised on 3/23/35 documenting in part .(R4) is at risk for nutritional deficit r/t (related to) Dx TBI (Traumatic Brain Injury), dementia, rectal cancer. On 6/18/25 at 5:57 PM, R4 was served a meal tray containing large pieces of cheese pizza dietary staff had torn up by hand, larger than 1 inch by 1 inch pieces of varying size, with some pieces containing the hard outer crust, pureed green beans, and a whole breadstick. R4 was observed to be unable to bite through the hard outer pizza crust or the breadstick.5. R7's admission Record documented an admission date of 6/23/21 with diagnoses including: type 2 diabetes mellitus, anxiety disorder, chronic pain syndrome. R7's 6/5/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R7 was cognitively intact.R7's Order Summary Report printed 8/21/25 documented a 1/20/23 diet order for low concentrated sweets, regular texture, thin liquid consistency, and offer double protein portions with all meals. R7's Care Plan Report documented a focus area revised on 9/25/24 documenting in part . (R7) is at risk for complications with weight and nutrition r/t (related to) dx (diagnoses) DM (Diabetes Mellitus), obesity, hyperlipidemia, diabetic foot wound. with a revised 6/30/21 intervention documenting in part . LCS (low concentrated sweets) diet. Offer double protein portions all meals.On 8/16/25 at 5:55 PM, R7's evening meal tray was delivered containing 1 piece of cheese pizza, salad, breadstick, and ambrosia salad.On 8/22/25 at 10:58 AM, V9 (Registered Dietitian) said she expected physician orders for diets and supplements to be followed. V9 said residents with wounds were recommended to be served double portions of protein with all meals to assist with wound healing. V9 said if a resident with a wound was not being served the correct diet and supplements they would be at risk for the wound to decline. V9 said a resident with an order for double protein should have been served 2 pieces of pizza with the 8/16/25 planned evening meal.On 8/21/25 at 1:26 PM, R7 said he had a surgical wound to his left foot he was admitted with that had never healed.On 8/16/25 at 7:15 PM, a test tray was requested, and the outer pizza crust and the breadstick was very hard and crunchy.On 8/16/25 at 7:20 PM, V4 (Cook in Training) said she had been training in the kitchen for about a week. V4 said V5 (Cook) left prior to V4 finishing cooking the meal. V4 said she did not make any pureed breadsticks because V5 had told V4 not to. V4 said she was not sure why V5 told her not to make pureed breadsticks but V4 was just doing what she was told. V4 said V5 told V4 residents on mechanical soft diets could be served the shredded lettuce salad and the pizza just needed to be torn into smaller pieces.On 8/16/25 at 7:22 PM, V5 said she thought since the lettuce was shredded it would be ok to serve to the residents on a mechanical soft diet. V5 said a mechanical soft diet should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 5 of 8 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 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete have food cut up in 1 inch by 1 inch pieces and V5 was not sure if a resident on a mechanical soft diet should be served the hard crust on the pizza. V5 said she did not sample the breadsticks before serving them. V5 said if the breadsticks were hard, they should not be served to residents on a mechanical soft diet. V5 said she was not sure why V4 had not followed the Diet Spreadsheet for what residents on a mechanical diet should have been served. V5 said any puree should be a smooth texture.On 8/20/24 at 10:15 AM, V6 (Dietary Manager) said she expected pureed dishes to be a smooth cake batter like consistency without chunks. V6 said she expected mechanical soft dishes to be chopped or ground with no pieces being larger than a dime. V6 said pizza with a hard crust, hard breadsticks, and raw vegetables should not be served to a resident on a mechanical soft diet.On 8/22/25 at 10:58 AM, V9 (Registered Dietitian) said she expected staff to follow diet orders. V9 said she expected puree dishes to be the consistency of mashed potatoes or applesauce with no chunks. V9 said hard pizza crust, hard breadsticks, and shredded lettuce were not appropriate to be served to residents requiring a mechanical soft diet.The facility's 2022 Pureed policy documented in part .The Pureed Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency. Foods that cannot be adequately pureed are substituted or altered as indicated on the menu spreadsheet. Pureed regular bread and specialty breads such as corn bread, muffins, garlic bread, etc., continue to be pureed as a separate menu item. Add measured amounts of hot liquid for cooked foods and cold liquid for cold foods (if required) and process until there is a smooth, pudding-like or smooth mashed potato consistency. Please note: some menu items do not require any liquid added during the pureeing process in order to achieve the desired pureed consistency.The facility's 2022 Dental Soft (Mechanical Soft) policy documented in part .This consistency modified diet is for individuals with limited or difficulty in chewing regular textured foods. As with any diet modification, this diet should be individualized to meet the resident's needs and chewing abilities. Generally, the diet consists of food of nearly regular textures but eliminates very hard, sticky, crunchy or hard to chew foods. Foods should be moist and fork tender. Meat is ground or chopped into bite-size pieces (1/2 inch or smaller) and should be held with a minimal amount of prepared broth, gravy, or other type of moistening agent (NO WATER) to keep the product moist. Hot ground meats should be topped with gravy or sauce at the point of service. Dry, hard crusty breads are excluded.The facility's November 2015 Therapeutic Diets policy documented in part .Therapeutic diets shall be prescribed by the Attending Physician. 1. Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. Examples of therapeutic diets include: a. Diabetic/ calorie controlled diet; b. Low sodium diet; and c. Altered consistency diet. 2. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 6. Routine menus are planned by the Food Services Manager, and approved by a Registered Dietitian for nutritional adequacy. The Food Service Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. Event ID: Facility ID: 145757 If continuation sheet Page 6 of 8 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 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide hot palatable foods for 4 (R2, R3, R7, and R9) of 12 residents reviewed for dietary services out of a sample of 12.Findings include:1.R7's admission Record documented an admission date of 6/23/21 with diagnoses including: type 2 diabetes mellitus, anxiety disorder, chronic pain syndrome. R7's 6/5/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R7 was cognitively intact.R7's Order Summary Report printed 8/21/25 documented a 1/20/23 diet order for low concentrated sweets, regular texture, thin liquid consistency, and offer double protein portions with all meals.On 8/16/25 at 5:55 PM, R7's evening meal tray was delivered containing 1 piece of cheese pizza, salad, breadstick, and ambrosia. R7 said the pizza was cold and unappetizing. R7 said he bought his own frozen hamburgers in case he did not like the main course being served. R7 said he was angry because for the noontime meal he had ordered 2 hamburgers, and the cook had burned them. R7 provided a picture on his cellular telephone of 2 hamburgers that appeared charred with black burned spots on the cheese.2.R3's admission Record documented an admission date of 12/31/24 with diagnoses including: chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease stage 3. R3's 6/6/25 MDS documented a BIMS score of 15, indicating R3 was cognitively intact.On 8/16/25 at 6:09 PM, R3's evening meal tray was delivered containing a piece of cheese pizza, salad, and breadstick. R3 said the pizza was cold and the breadstick was too hard to eat. R3 stated to staff take that back! I'm not eating that. Staff removed R3's meal tray and no substitution was offered.3. On 8/16/25 at 7:15 PM, a test tray was provided directly from the steam table. The temperature of the cheese pizza was taken with a metal stemmed thermometer calibrated on 8/16/25 at 5:30 PM using the ice point method. The temperature measured 116.2 degrees Fahrenheit, which felt too cool, and when tasted the pizza lacked flavor. The breadstick was sampled and was hard and crunchy.4. R2's admission Record documented an admission date of 10/9/23 with diagnoses including: chronic venous hypertension idiopathic with ulcer of bilateral lower extremity, type 2 diabetes, hypertension. R2's 6/27/25 MDS documented a BIMS score of 15, indicating R2 was cognitively intact.On 8/21/25 at 12:38 PM, R2 who was eating lunch stated the scalloped potatoes weren't cooked and were not good.5. R9's admission Record documented an admission date of 6/8/21 with diagnoses including: type 2 diabetes, chronic obstructive pulmonary disease, hypertension. R9's 7/3/25 MDS documented a BIMS score of 15, indicating R9 was cognitively intact.On 8/21/25 at 1:32 PM, R9 said the scalloped potatoes weren't completely cooked and her noon time meal tray was cold when it arrived. R9 said she always ate in her room, and her meal trays were always cold. R9 stated the food is so bad here. R9's noon time meal tray was sitting on her overbed table and only a few bites had been taken.6. On 8/21/25 at 12:40 PM, R7 said the scalloped potatoes were raw, crunchy, and gross.On 8/21/25 at 12:23 PM, the scalloped potatoes were sampled from the steam table and were undercooked and crunchy. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145757 If continuation sheet Page 7 of 8 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 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview the facility failed to maintain floors and equipment in a safe and sanitary condition. This failure has the potential to affect all 50 residents living in the facility.Findings include:On 8/16/25 at 7:15 PM, the kitchen was observed to have various pieces of food lying on the floor around the cooking area. Black dirt/ debris was noted on the floor in various areas in the kitchen. The dishwashing area had various pieces of food on the floor with black dirt/ debris and dead cockroaches on the floor.On 8/20/25 at 10:28 AM, the kitchen was observed to have various areas of the floor with black dirt/ debris on it. The backsplash of the stove appeared to have a buildup of grease and other debris. The grease trap emptying from the griddle area of the stove had a large amount of grease on the floor under it measuring approximately 1 foot in diameter. On 8/20/25 at 10:15 AM, V6 (Dietary Manager) said she had only been employed in the facility for about a week. V6 said the kitchen was having some cleanliness problems because staff would not listen to her and would not clean up after themselves. V6 said the kitchen was disgusting.On 8/22/25 at 10:58 AM, V9 (Registered Dietitian) said she expected the kitchen to be clean and sanitary.The facility's 9/20/25 Resident List Report documented 50 residents residing in the facility. Event ID: Facility ID: 145757 If continuation sheet Page 8 of 8