Health inspection·January 21, 2025

F 0755 Benedryl. R1 said she did not get her Requip (Ropinirole) for her restless leg syndrome. Level of Harm - Minimal harm or potential for actual harm On 1/17/25 at 11:40 am, R2 said it was about 9:30 or so when the incident happened. R2 said she was in her bed but awake. She said she heard the nurse ask R1 if she was R2's first name. R2 said the curtain was pulled between their beds. R2 said she then spoke up and said, I am and said her first name. R2 said the nurse said Oh wait you are not (R2's first name). R2 said the nurse said, Oh it doesn't matter, its just Tylenol and benedryl. R2 said R1 did not swallow the medications. Residents Affected - Few On 1/17/25 at 2:20 pm, V7 (RN/Registered Nurse) said she was working the night of the incident. V7 said she worked from 6pm to 6am on the 400 hall where R1's room was. V7 said there were 2 new admissions that she had never seen. V7 said she had R2's MAR (Medication Administration Record) open. V7 said she entered the room and went to the resident in the first bed by the door and said R2's first name, and R1 said yes, yes so she gave R1 the medications and took a sip of water. V7 said there was 2 Tylenol 325 mg and 1 Benadryl 50 mg in the cup. V7 said she handed R1 the cup, and after they were in her mouth and she took a sip of water, the lady in the next bed said, I am (R2). V7 said R1 did not swallow the medications. V7 said R1 then spit the meds out. V7 said prior to spitting the meds out R1 said, I can spit them out. V7 said the medications were as needed orders, so she wasn't too worried about it. V7 said R1 was asking for her Requip pill and V7 told her it had not arrived from the pharmacy yet. V7 said she did go to the emergency kit and there was no Requip in it. V7 said she did not deem it an emergency, and therefore did not notify the physician the medicine was not available to give. On 1/17/25 at 12:15pm, V1 (Administrator) said she would expect the nurse to notify the physician if a medication was not available, and use 2 identifiers when passing medications. On 1/17/25 at 9:30 am, V2 (DON/Director of Nurses) said R1 was a new resident, and V7 should have used 2 identifiers before giving the medication. V2 also said the physician should have been notified when the medication was not available to give to the resident. Facility Document labeled 5.1: Drug Administration-General Guidelines, dated July 2024, document Residents are identified before medication is administered. a. Check identification band, b. Check photograph attached to medical record, header card, or facility approved location, c. Call resident by name, d. If necessary, verify resident information with other facility personnel. Prior to the survey date, the facility took the following actions to correct the noncompliance: According to the QAPI review on 1/15/25. R1 was assessed on 1/15/25 with no negative outcome noted. IDT team reviewed and discussed in clinical meeting on 1/15/25. The facility has educated the licensed nursing staff to notify M.D. of medications not available and using 2 identifiers when identifying residents. You are to ask for their full name and date of birth . Inservice completed for all nursing staff on 1/15/25 on the following: New admissions should have scripts for the listed medications. If you are aware of any issues, delays, or missing medications be sure to communicate with the DON/ADON (Assistant Director of Nursing), pharmacy and family to ensure your residents have all of their medications upon admission. Any additional concerns can be addressed with the Doctor. Be sure to notify him. Also use 2 identifiers when identifying residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145863 If continuation sheet Page 2 of 3 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 145863 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Marion 1301 East Deyoung Marion, IL 62959 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 0755 during med pass. These consist of Full name and date of birth . Level of Harm - Minimal harm or potential for actual harm The Director of Nursing or designee will complete random checks three times a week for four weeks and then weekly for eight weeks to ensure staff is notifying M.D. of medications not available and staff is identifying residents correctly. Three times a week with educational needs will be discussed. The results of the audits will be reviewed in the QA meeting 01/31/2025. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145863 If continuation sheet Page 3 of 3