Inspection·August 15, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the facility was free of rodents. This failure has the potential to affect all 94 residents residing in the facility.Findings include:On 8/14/25 at 9:46 AM, R2 said she had seen a couple of mice in her room and had found a small mouse dead in her trashcan. R2 said she had seen a mouse in the room next to hers that was connected through a bathroom. R2 said she thought the mice may have been coming into her room from the room next door. R2's 5/19/25 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R2 was cognitively intact.On 8/14/25 at 9:45 AM, the room next to R2 connected by a bathroom had pieces of breakfast foods scattered around the floor and a black mouse bait box in the corner. On 8/14/25 at 10:15 AM, R3 said she had seen a mouse in the corner of her room earlier in the week. R3 said she had scared the mouse away and it ran out into the hallway. R3 said she had a box under her bed that she kept shoes in and it had a large amount of mouse droppings in it, but her daughter had cleaned it out a few days prior. R3's room had an overturned cup in the floor with milk spilled around and a few pieces of breakfast food scattered around the floor. R3's 6/8/25 MDS documented a BIMS score of 13, indicating R3 was cognitively intact.On 8/14/25 at 10:05 AM, R4 said she had a mouse that lived in her room in her dresser. R4 said she had seen the mouse that morning in the corner of her room behind her yarn basket and had saw him run back to the dresser. R4 pulled her yarn basket out of the corner and a large amount of mouse droppings were scattered on the floor. R4's room had an assortment of open snacks such as chips, crackers, and cakes. R4's bottom drawer of her nightstand had a large amount of mouse droppings scattered around the bottom. R4 said she had not seen any mouse traps in her room and did not want the mouse to be killed. R4 stated, He (the mouse) isn't hurting anybody. R4's 7/27/25 MDS documented a BIMS score of 12, indicating moderate cognitive impairment.On 8/14/25 at 1:38 PM, R5 said about a month prio, V3 (Certified Nursing Assistant/ CNA) had come into her room one night and turned on the light and started screaming because there was a mouse on R5's shoulder in the bed. R5 said the mouse had jumped off her bed onto the nightstand and went into an open bag of chips. R5 said the mouse then ran down her call light cord and jumped to the floor like a little acrobat. R5 said she had other mice in her room, but that was the only time one had been in bed with her, to her knowledge. R5's 5/26/25 MDS documented a BIMS score of 15, indicating R5 was cognitively intact.On 8/14/25 at 2:04 PM, V3 (CNA) stated she had not seen any mouse on R5's shoulder or on any residents. V3 said she had been asked by R5 if V3 recalled seeing the mouse in R5's bed, and V3 told R5 it must have been another staff member because it was not V3. V3 said she recently saw a mouse running down the hallway and into the shower room, but was unsure of the exact date. V3 was asked if she told anyone about the mouse running down the hallway and into the shower room, and V3 said she did not because there were mice all over the building.On 8/14/25 at 10:39 AM, V4 (CNA) stated. I have heard there is a mouse on 100 hall, I have never seen a mouse but there are signs of them on 100 hall. On 8/14/25 at 11:50 AM, in the dry storage room in the kitchen, there was a pile of small pieces of plaster/wood with a hole above it noted in the corner. Several mouse droppings were noted on the food storage shelves. On 8/14/25 at 11:55 AM, the door leading to the maintenance room off of the main dining room was left open to the outside with no one in the maintenance room.On 8/14/25 at 12:04 PM, V1 (Administrator) stated, That's new in dry storage area the mice have chewed through it, they were getting in in the other corner and they put steel mesh in and sealed it up so I guess we are going to have to put the steel mesh over here. He (Maintenance) shouldn't be leaving the door open. On 8/14/25 at 2:10 PM, V1 said the facility had been told by the pest control company the mouse bait boxes in the facility were not going to be effective as Residents Affected - Many (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 08/15/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete long as there were other foods for the mice to eat. V1 said she had ordered a large number of sticky traps in hopes they would be more effective than the mouse bait boxes. Pest Control Report, dated 8/11/25, documents in part, Service Description.Rodent- Interior Maintenance.Rodent Bait Station, With Activity: 2, Without Activity: 11.The facility's May 2008 Pest Control policy documented in part .1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.The facility's 8/14/25 Midnight Census Report documented 94 residents residing in the facility. Event ID: Facility ID: 145863 If continuation sheet Page 3 of 3