Integrity Hc of Carbondale

Inspectors wroteBased on observation, interview, and record review the facility failed to develop individualized discharge plans that incorporated input and preferences from the resident, resident representative, and the interdisciplinary team to ensure safe and orderly transfer/discharge planning for 13 (R13, R14, R17, R18, R21, R22, R23, R24, R25, R27, R28, R30, and R31) of 27 residents reviewed for transfer and discharge in the sample of 46. This failure resulted in R27 and R30 experiencing feelings of upset/worry, sadness, or distress and would cause a reasonable person to feel the same emotions when given the news of having to relocate to another facility on very short notice.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's bed was in the lowest position and the fall mat was in place on the floor next to the bed for 1 (R42) of 3 residents reviewed for falls in a sample of 46. This failure resulted in R42 falling out of a high bed with no floor mat beside the bed and sustaining multiple dark purple contusions to her face, neck, wrist, hand, and forearm, swelling to her eye, eyebrow and forehead area, along with skin tears to the right forearm and left hand. This past non-compliance occurred between 9/1/25 and 9/1/25.

Inspectors wroteBased on interview and record review, the facility failed to provide residents and/or their representatives timely written notification of the reason for transfer out of the facility and failed provide notice to the Ombudsman of resident transfers for 9 (R21, R22, R23, R24, R25, R27, R28, R30, R31) of 9 residents reviewed for discharge process in the sample of 45. On 9/15/25 at 1:35PM, V1 (Former Administrator) provided a list of residents still in the facility and stated there were still 19 in house as of this date/time. V1 said they have provided the IDPH (Illinois Department of Public Health) regional office a list of those residents that have been discharged to date and plan to send weekly updates. V1 said the list includes resident names, the location they were transferred to and the date/time they left. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to promote independence and autonomy with toileting by neglecting to utilize an available room with a functioning toilet for 1 (R40) of 3 residents reviewed for reasonable accommodation of needs/preferences in a sample of 46.

Inspectors wroteBased on interview and record review the facility failed to ensure timely treatment and care in accordance with professional standards of practice after a fall for 1 (R1) of 3 residents in a sample of 26. This failure resulted in R1 not getting immediate treatment for a hip fracture after a fall. A reasonable person would experience feelings of discomfort and distress due to not receiving timely after fall care. This past noncompliance occurred between 8/25/25 and 8/26/25.

Inspectors wroteBased on interview and record review the facility failed to assess and provide pain medication after a fall for 1 (R1) of 3 residents reviewed for pain in a sample of 26. This failure resulted in R1 not receiving any pain medication for a hip fracture for several hours after a fall. A reasonable person would experience feelings severe pain and discomfort due to not receiving pain relief medication. This past noncompliance occurred between 8/25/25 and 8/26/25.

Inspectors wroteBased on interview, observation and record review, the facility failed to assess adaptive equipment and pressure alarms in order to ensure safety and freedom for normal movement for 4 of 4 residents (R3, R5, R9, R18) reviewed for physical restraints in the sample of 26.

Inspectors wroteBased on record review and interview, the facility failed to use person centered behavior interventions and attempt less restrictive alternative treatments prior to administering as needed psychotropic medications for 1 of 3 residents (R5) reviewed for psychotropic medications in a sample of 26.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dietary supplements for at risk residents or residents who have experienced weight loss for 3 (R1, R4, and R6) of 12 residents reviewed for dietary services out of a sample of 12.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide a clean, safe, sanitary environment for 14 residents of 14 residents (R1, R2, R3, R4, R6, R8, R9, R10, R11, R12, R13, R14, R15 and R16) reviewed for environment in a sample of 18.

Inspectors wroteBased 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.

Inspectors wroteFailures at this level require more than one deficienct practice statement. A. Based on observation, interview, and record review the facility failed to ensure a resident with dementia and a diffuse traumatic brain injury was adequately supervised to prevent elopements and failed to develop and implement new interventions to prevent elopements for 1 (R22) of 2 residents reviewed for supervision in a sample of 42. This failure resulted in R22 exiting the facility multiple times without staff knowledge, including on an unknown date in October or November of 2024 in which R22 walked approximately 0.8 miles from the facility down a busy street and across a busy highway in town, and was later located by facility staff walking around a business parking lot. This failure resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were followed, for 1 of 5 residents (R55) reviewed for significant medication errors in the sample of 30. This failure resulted in R55 missing three doses of long- acting insulin from 1/17/25 to 1/19/25, causing R55's blood sugars to be extremely elevated. This has the potential to lead to ketoacidosis which could result in coma and possible death. This failure resulted in an Immediate Jeopardy. An Immediate Jeopardy was identified to have begun on 01/17/25 at approximately 9:00 PM when the facility was unable to provide R55's scheduled long-acting insulin and did not notify the physician. The facility also failed to administer R55's long-acting insulin as ordered on 01/18/25 and 01/19/25. V1 (Administrator) and V2 (Director of Nursing), were notified of the Immediate Jeopardy on 02/04/25 at 3:13 PM. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to serve food at palatable/preferred, appetizing temperatures for 5 (R27, R28, R35, R51, R105) of 22 residents reviewed for appetizing food temperatures in a sample of 42.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide safe and sanitary food and dietary services. This failure has the potential to affect all 54 residents that reside at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for Enhanced Barrier Precautions and for Covid-19 infections as recommended by the CDC (Centers for Disease Control and Prevention) to prevent the development and transmission of communicable diseases and infections for 6 of 9 residents (R5, R24, R36, R47, R49, and R51) observed for infection control in the sample of 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained during dining when staff remained standing to provide feeding assistance for 1 (R205) of 4 residents reviewed for resident rights in a sample of 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's and/or resident representative's preferences for room accommodations and showers to ensure dignity were maintained for 2 (R55 and R51) of 4 residents reviewed for reasonable accommodations/preferences in a sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of missing medications and a change in resident's condition for 1 of 5 residents (R55) reviewed for physician notification in the sample of 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during wound care treatment or urinary catheter treatment for one (51) of 4 residents reviewed for personal privacy in the sample of 42.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from verbal abuse from staff for 1 of 3 residents (R55) reviewed for abuse and neglect in the sample of 42.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of staff to resident verbal/mental abuse resulted in an accurate conclusion and failed to ensure corrective action to prevent further potential abuse for 1 of 3 residents (R55) reviewed for abuse in the sample of 42.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan within 48 hours for 1 of 3 (R105) residents reviewed for care plans in the sample of 42.

Inspectors wroteBased on observation and interview the facility failed to provide indwelling urinary catheter care in accordance with facility policy and standard of practice for 1 (R47) of 2 residents reviewed for catheter care in the sample of 42.

Inspectors wroteBased on record review, observation, and interview, the facility failed to follow facility policy and procedure by failing to check the placement of a gastrostomy tube prior to administering medication and flusing with water and feeding for 1 of 1 resident (R47) reviewed for gastrostomy tube use in the sample of 42.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from neglect when they failed to assess, treat, and implement interventions to prevent pressure ulcers, accurately assess for skin breakdown, discontinue psychotropic medications as ordered by the physician, and provide oral care for 1 of 5 (R12) residents reviewed for neglect in the sample of 19. This failure resulted in R12 being transferred to the local hospital on [DATE] for altered mental status and possible sepsis. Once at the hospital it was determined R12 had received Haldol and Clonazepam without a physician order from 11/23/24 until 12/01/24. R12 had developed 15 new wounds including a Stage 2 and Stage 3 to his buttocks, a Stage 2 to the left knee, and two deep tissue injuries to his bilateral heels. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure oral care was provided for 2 of 5 residents (R2 and R12) reviewed for oral care in the sample of 19. This failure resulted in R12 having a buildup of a hardened yellow/brown coating with cracking and fissures noted to be covering the tongue from lack of oral care. This failure would cause a reasonable person to suffer humiliation with physical and emotional discomfort. Findings Include: 1. R12's admission Record with a print date of 12/5/24 documents R12 was admitted to the facility on [DATE] with diagnoses that include fracture of left femur, hypotension, diabetes, schizophrenia (diagnosis added on 11/07/24), bipolar disorder (added on 11/07/24) difficulty walking, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, treat, and implement interventions to prevent pressure ulcers, and failed to accurately assess for skin breakdown for 4 of 5 (R1, R2, R3, and R12) residents reviewed for pressure ulcers in the sample of 19. This failure resulted in R12 developing a Stage 2 and Stage 3 pressure ulcer to his buttocks, a Stage 2 pressure ulcer to his left knee, and two deep tissue injuries to bilateral heels. Findings Include: R12's admission Record with a print date of 12/5/24 documents R12 was admitted to the facility on [DATE] with diagnoses that include fracture of left femur, hypotension, diabetes, schizophrenia (diagnosis added on 11/07/24), bipolar disorder (added on 11/07/24) difficulty walking, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered per current standards of practice for 5 of 7 (R9, R15, R16, R17, R18) residents reviewed for pharmacy services in the sample of 19. Findings Include: 1. R9's admission Record with a print date of 12/02/24 documents R9 was admitted to the facility on [DATE] with diagnoses that include esophageal obstruction, dysphagia, fracture of sternum, gastrostomy, bipolar disorder, depression, and generalized anxiety disorder. R9's MDS dated [DATE] documents a BIMS score of 13, which indicates R9 is cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of unnecessary medications when they failed to discontinue psychotropic medications as ordered by the physician for 1 of 3 (R12) residents reviewed for unnecessary medications in the sample of 19. Findings Include: R12's admission Record with a print date of 12/5/24 documents R12 was admitted to the facility on [DATE] with diagnoses that include fracture of left femur, hypotension, diabetes, schizophrenia (diagnosis added on 11/07/24), bipolar disorder (added on 11/07/24) difficulty walking, and muscle weakness. R12's MDS (Minimum Data Set) dated 10/17/2024 documents R12 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R12 is cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to administer tube feeding as ordered for 1 (R1) of 3 residents reviewed for gastrostomy tube care in a sample of 3.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure prevention of misappropriation of resident property for 6 (R1, R3, R4, R5, R6, and R7) of 6 residents reviewed for abuse in the sample of 9.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide resident care in a timely and dignified manner for 2 (R1, R3) of 3 residents reviewed for timely assistance in the sample of 3. The Findings Include: R1's admission Profile documents an admission date of 8/21/23 with diagnoses to include: encounter for surgical aftercare following surgery on the nervous system, spinal stenosis, obesity, difficulty in walking, bipolar, and anxiety. R1's care plan documents a focus area of being at risk for falls due to bilateral lower extremity weakness with diagnoses of neuropathy, cervical spondlyosis, spinal stenosis, use of anti anxiety and antidepressant medication and opoid use. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain resident rights and dignity by not providing adequate grooming and providing food on non-disposable ware for 15 of 16 residents (R24, R6, R39, R33, R36, R41, R49, R5, R8, R11, R29, R17, R50, R28 and R12) reviewed for resident rights and dignity in a sample of 53.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a safe sanitary bathroom/shower room for 24 (R4, R32, R52, R8, R11, R26, R6, R2, R23, R1, R34, R53, R44, R48, R51, R16, R50, R31, R28, R47, R30, R12, R18 and R38) of 24 residents reviewed for environment in a sample of 53.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide incontinent care, showers, and assistance with eating for 6 (R24, R25, R35, R38, R40, and R43) of 11 residents reviewed for activities of daily living in a sample of 53.

Inspectors wroteBased on interview, observation and record review the facility failed to provide a call light system near the toilet in the hall bathroom for 24 (R4, R32, R52, R8, R11, R26, R6, R2, R23, R1, R34, R53, R44, R48, R51, R16, R50, R31, R28, R47, R30, R12, R18 and R38) of 24 residents reviewed for call light systems in a sample of 53.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure reasonable accommodation of a wheelchair to assist in maintaining and/or achieving independent functioning for 1 of 6 residents (R24) reviewed for accommodation of needs in a sample of 53.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer gastronomy tube water flushes per physician's orders for 1 of 2 residents (R45) reviewed for tube feeding in a sample of 53.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician of a significant change in a residents condition for 2 of 3 (R1 and R2) residents reviewed for physician notification in the sample of 15. Findings Include: 1. R2's admission Record with a print date of 11/01/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, heart failure, heart disease, hypertension, anemia, hyperlipidemia, anxiety disorder, obstructive sleep apnea, and muscle weakness. R2's MDS (Minimum Data Set) dated 10/16/23 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area initiated 10/25/23 of (R2) is at risk for complications r/t (related to) dx (diagnosis) of HTN (hypertension). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were monitored, assessments were documented, and physicians were notified of a significant change in condition for 1 of 3 (R2) residents reviewed for change of condition in the sample of 15. Findings Include: R2's admission Record with a print date of 11/01/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, heart failure, heart disease, hypertension, anemia, hyperlipidemia, anxiety disorder, obstructive sleep apnea, and muscle weakness. R2's MDS (Minimum Data Set) dated 10/16/23 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R2 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written Notice of Transfer for one hospitalized resident (R17) of one resident reviewed for transfer/discharge in the sample of 24.