Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to adjust the type and frequency of interventions
and needed level of supervision for a resident with a history of self inflicted burns with hot liquids for one
resident (R1) of four residents reviewed for incidents/accidents in the sample of four. This failure resulted in
R1 spilling hot water onto his groin, sustaining second degree burns to nine percent of his body, causing
pain and the need for increased pain medication, and requiring placement of an indwelling catheter to
prevent urine from irritating the wounds.
Findings Include:
R1's Face Sheet documented an admission Date of 4/5/24, and listed Diagnoses including Spinal Stenosis
with Fusion of the Lumbar Spine, Schizoaffective Disorder, and Diabetes Type 2.
R1's Minimum Data Set, dated [DATE], documented R1 has no deficits in cognition, has impaired range of
motion to both lower extremities, requires substantial/maximal assistance from staff for bed mobility, is
dependent on staff for transfers, and requires set up or clean up assistance from staff for eating.
R1's Care Plan, dated 12/30/24, documented a problem area, (R1) displays adverse behaviors. He has
been educated to let staff get him hot water to prevent burns and he continues to be non-compliant with
this, with corresponding interventions, Remind (R1) too let staff get his hot water for safety. Educate (R1)
about the risk of burns. Provide appropriate non-spill cup for safety.
R1's 2/4/25 Hot Liquid Burn Incident Report documented, Staff heard resident yelling, staff went in to
assess resident, resident continued to yell, 'Help I spilled hot water on myself,' staff noted the bed sheets
were wet with hot water. (R1) stated, 'I was trying to take the lid off the water pitcher with hot water in it and
the lid popped off and the water went all over me. Injury type: Burn(s) to the coccyx, groin, right thigh (rear)
and left leg (rear). Intervention: Non spill cup for hot water.
R1's 2/6/25 Wound Evaluation and Management Summary documented, Patient has wounds on his left
posterior leg, right posterior thigh, posterior scrotum, left thigh, left medial foot. Burn on the left medial foot
resolved on 2/6/25. Follow up: Evaluation by (V12, Wound Care Physician) weekly, or sooner as needed,
with further intervention as indicated based on response to current treatment plan.
R1's 2/4/25 untitled note authored by V14, Nurse Practitioner, documented, Physical Examination: Burn.
Acute. Patient spilled hot water for tea into his bed. (V12) has given orders for management.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145863
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
03/18/2025
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 0689
Level of Harm - Actual harm
Residents Affected - Few
R1's 2/12/25 Nurses Notes documented: New order to increase oxycodone (as needed) to every twelve
hours. February 2025 Physicians Orders (POS) documented a 1/21/25 order for oxycodone 5 milligrams
(mg) one tablet every 24 hours for moderate pain. The same POS documented a 2/12/25 Pain Scale pain
level of 7, and a 2/12/25 order to increase the oxycodone to 5mg one tablet every 12 hours for moderate
pain.
On 3/13/25 at 11:30am, R1 was alert and oriented to person, place, and time. R1 was observed to have an
indwelling catheter draining clear straw colored urine. R1 stated on 2/4/25 at about 7:30am, he asked V9,
Certified Nursing Assistant, to heat him up some water so he could make instant coffee. R1 stated V9 took
his water pitcher and took it out of the room. R1 stated in a few minutes, V9 returned with hot water in the
pitcher. R1 stated he was sitting up in the bed when V9 gave him the pitcher and left the room. R1 stated he
was trying to get the lid off, when the lid suddenly came off and steaming hot water was spilled all over his
crotch area. R1 stated he was in immediate pain and yelled for help. R1 stated one of the nurses came and
got him out of the wet bed linens and assessed his burns. R1 stated he has since been treated weekly by
V12. R1 stated he has burned himself previously in similar circumstances, although during those
occurrences, he was able to walk to the dining room and microwave hot water himself. R1 stated he had
spinal surgery in January, and as a result, has decreased sensation in both lower extremities. R1 stated
initially, he did not have a lot of pain, but as time went on he did, and his pain medication had to be
increased. R1 stated it has been effective, but has caused him to be more sleepy during the day.
On 3/13/25 at 12:00pm, R4, R1's Roommate/Family Member, who was alert and oriented to person, place,
and time stated she was woken up on 2/4/25 by R1 yelling that he had been burned. R4 stated R1 later told
R4 that V10, Hall Monitor, had been the staff member who brought him the hot water.
On 3/13/25 at 2:55pm, V12 stated R1 sustained second degree burns over nine percent of his body. V12
stated R1's wounds are healing, there were no signs of secondary infection, and R1 will not require skin
grafts. V12 stated he has previously treated R1 for non intentional self inflicted burns in similar
circumstances. V12 stated he has repeatedly told R1 to not handle hot water, but R1 will not comply. V12
stated R1 temporarily requires an indwelling catheter to prevent urine from irritating the wounds.
On 3/14/25 at 8:40am, V9 denied giving R1 the hot water, and stated she does not know who did. V9
stated, I would not give him a pitcher of hot water and not supervise him with it. V9 stated she did not think
there was any staff re-education after the incident.
On 3/14/25 at 9:00am, V4, CNA Supervisor, stated after R1's 2/4/25 burns, staff were educated to make
sure R1 is sitting up in his chair and not in bed when given hot water.
On 3/14/25 at 10:40am, V10 stated she did not give R1 the hot water, and does not know who did. V10
stated, I wouldn't have, because everybody knows he spills it and he's not supposed to have it. V10 stated
she did not recall getting re-educated after the incident.
On 3/14/25 at 12:30pm, V3, Assistant Director of Nurses, stated on 2/4/25 at about 7:30am, she heard R1
yelling for help, and she and V1, Regional Nurse/Director of Nurses, responded. V3 stated they got R1 into
dry linens and V3 assessed R1, noting he had areas of redness, peeling skin to his left posterior leg,right
posterior thigh, posterior scrotum, left thigh, and left medial foot. V3 stated she notified V12 and sent him
pictures of the burns, and V12 responded with treatment orders. V3 stated R1 has burned himself on hot
liquids previously, and was treated by V12. V3 stated she does not
(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
03/18/2025
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 0689
Level of Harm - Actual harm
Residents Affected - Few
know who gave R1 the hot water. V3 stated R1 did not have complaints of pain that morning past the time
of the burn itself. V3 stated several days after the burns occurred, R1 complained of increased pain, and
V15, Primary Care Physician, increased R1's pain medication.
On 3/14/25 at 2:20pm, V1 corroborated V3's account of the incident as stated above. V1 stated when he
investigated the incident, no staff members took responsibility for giving R1 the hot water. V1 stated staff
should have put the water in a handled cup with a lid, not a water pitcher. V1 stated R1 has burned himself
on hot liquids several times, when he ambulated to the dining room and microwaved the water himself. V1
stated as a result, the microwave was removed from the dining room, and R1 has been educated numerous
times about the need for staff assistance with hot liquids. V1 stated on 2/5/25, staff were re-educated R1 is
to get hot water in the handled cup with lid.
A 2/5/25 State of Education for Employees Sign In Sheet documented, The following area of instruction
were covered: We have got (R1) adult sippy cups for him to use. There is 2 cups-clear, with handles.
The facility's Safety and Supervision of Residents Policy, dated July 2017, stated, Systems approach to
safety: The facility oriented and resident oriented approaches to safety are used together to implement a
systems approach to safety, which considers the hazards identified in the environment and individual
resident risk. factors, and then adjusts interventions accordingly. Resident supervision is a core component
of the systems approach to safety. The type and frequency of resident supervision is determined by the
individual residents assessed needs and identified hazards in the environment. The type and frequency of
resident supervision may vary among residents and over time for the same resident. For example, resident
supervision may need to be increased when there are temporary hazards in the environment. (such as
construction) or if there is a change in the residents condition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145863
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the March 18, 2025 survey of INTEGRITY HC OF MARION?
This was a inspection survey of INTEGRITY HC OF MARION on March 18, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at INTEGRITY HC OF MARION on March 18, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.