Integrity HC of Carbondale

In the surveyor’s words

From the most serious findings on record at Integrity HC of Carbondale, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 10, 2025

  Failures 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. […]

• Immediate jeopardy, isolatedF760Feb 10, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Dec 19, 2024

  Based 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 12/01/24 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. […]

• Actual harm, patternF627Oct 9, 2025

  Based 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. […]

• Actual harm, isolatedF689Oct 9, 2025

  Based 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. […]