Health inspection·September 19, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some processor because they feel it balls up. V5 stated, she will make sure they chop the vegetables from now on and they will use diced fruit. R46's admission record documents an admission date of 06/12/25 with diagnoses including: cerebral infarction, encephalopathy, muscle weakness, unspecified intellectual disabilities, major depressive disorder, vitamin D deficiency, anxiety disorder. R46's medication review report documents a dietary order of general diet, mechanical soft texture, thin liquids consistency, chopped meat, add gravy as needed, avoid thick sticky foods with an order date of 06/12/25 and an order status of active. R46's care plan documents a focus area of: R46 receives a regular mechanical soft diet with thin liquids, chopped meat and add gravy as needed, and avoid thick sticky foods. Encourage R46 to not talk while eating dated 06/24/25 with an intervention listed as: staff will serve diet as ordered per physician. R11's admission record documents an admission date of 01/21/16 with diagnoses including: Alzheimer's disease, chronic lymphocytic leukemia of B-cell type not having achieved remission, non-Hodgkin lymphoma, paranoid schizophrenia, major depressive disorder, splenomegaly, vitamin D deficiency, and anxiety disorder. R11's medication review report documents a dietary order of regular diet, mechanical soft texture, thin liquids consistency, ground meat, with extra sauces and gravies, with no bread, no pasta and all food to be served in bowls, and double portions all meals with an order date of 09/10/24 and an order status of active. R11's care plan documents R11 receives a mechanical soft diet with double portions of all meals with ground meats with extra sauces and gravies, no bread or pasta dated 04/04/23 with an intervention listed as staff will serve diet as ordered per physician.R28's admission record documents an admission date of 02/06/18 with diagnoses including: major depressive disorder, schizoaffective disorder, venous insufficiency, atherosclerotic heart disease, adjustment disorder with mixed disturbance of emotions and conduct, and other dietary vitamin B12 deficiency anemia. R28's medication review report documents a dietary order of low concentrated sweets diet with mechanical soft texture, thin liquids consistency, no added salt, can have regular hamburger (not mechanical soft), seconds only fruit and veggies with an order date of 07/22/24 with an order status of active. R28's care plan documents a focus area of R28 receives a mechanical soft, no added soft, low concentrated sweets diet with seconds only on fruits and vegetables and is able to have a regular hamburger that is not mechanical soft dated 04/09/2020 with an intervention listed of: staff will serve diet as ordered per physician. R8's admission record documents an admission date of 05/31/23 with diagnoses including dementia, type 2 diabetes mellitus, diaphragmatic hernia, anxiety disorder, edema, allergic rhinitis, and depression. R8's medication review report documents a dietary order of low concentrated sweets diet with mechanical soft texture, thin liquids with an order dated of 07/17/25 with an order status of active. R8's care plan documents R8 receives a mechanical soft low concentrated sweets diet, R8 has her own teeth and has no chewing or swallowing problems dated 04/14/25 with an intervention of: staff will serve diet as ordered per physician. 5.R1's admission record documents and admission date of 11/11/24 with diagnoses including: emphysema, chronic obstructive pulmonary disease, endocarditis, cerebral infarction, vitamin B12 deficiency anemia, hypothyroidism, panic disorder, major depressive disorder, anxiety disorder, atherosclerotic heart disease, pericardial effusion, chronic atrial fibrillation, and shortness of breath.R1's medication review report documents a dietary order of no added salt diet with mechanical soft texture, thin liquids consistency, chocolate pudding and gelatin with every meal with an order date of 11/21/24 with an order status of active. R1's care plan documents R1 receives a regular mechanical soft no added salt diet, give pudding and gelatin at all meals. R1 has no natural teeth, no chewing or swallowing problems dated 11/20/24 with an intervention listed as staff will serve diet as ordered per physician. 4. R32's admission record documents an admission date of 07/23/19 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145922 If continuation sheet Page 2 of 5 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 145922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Cobden 430 South Front Street Cobden, IL 62920 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete diagnoses including: dementia, schizophrenia, major depressive disorder, anxiety disorder, essential hypertension, conversion disorder with seizures or convulsions, and scoliosis. R32's medication review report documents a dietary order of regular diet with a pureed texture, nectar thick liquids consistency, hand feed as needed, give super cereal at breakfast, provide bowls for the patient at meals to reduce spillage and improve self-feeding abilities with an order date of 07/22/24 with an order status of active. R32's care plan documents R32 receives a regular puree diet with nectar thick liquids with super cereal at breakfast. R32 has no chewing or swallowing problems noted with current consistency, resident has no natural teeth or dentures with a diagnosis of schizophrenia, seizure disorder, anxiety, hypertension, depression with a date initiated of 04/24/23 with an intervention listed of staff will serve diet as ordered per physician. The facility document titled, Diet spreadsheet day, documents pureed lunch; pureed rosemary pork #8 scoop, pureed au gratin potatoes #8 dip, pureed zucchini and tomatoes #16 scoop, pureed frosted cake #10 dip, pureed dinner roll/margarine #20 scoop, and beverage 8 ounce.On 09/15/25 at 12:32 PM, R32 received tapioca pudding with visible seeds in it with whipped topping on top. The pudding had visible tapioca pearls in the pudding. On 09/15/25 at 12:35 PM, V5 (Dietary Manager) stated, they lost power last night and they did not have time to make an extra cake so the pureed diet residents received pudding, either tapioca or chocolate. On 09/15/25 at 3:22 PM, V5 stated, residents on a puree diet should not receive tapioca pudding unless the pudding is pureed. Event ID: Facility ID: 145922 If continuation sheet Page 3 of 5 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 145922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Cobden 430 South Front Street Cobden, IL 62920 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow enhanced barrier precautions for 1 of 5 residents (R67) reviewed for infection control in a sample of 34 Findings include:R67's admission Record dated 09/18/25 documents an admission date of 09/02/25 with diagnoses in part of chronic obstructive pulmonary disease, unspecified protein-calorie malnutrition, and dysphagia.R67's MDS (Minimum Data Set) dated 09/08/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 14 which indicates cognitively intact. Section GG documents eating as partial/moderate assistance.R67's Care Plan documents a Focus area of R67 requires tube feeding when he eats 50% or less of his meals. He is at risk for complications. R67 has protein calorie malnutrition and dysphagia. R67's order summary report dated 09/18/25 documents, flush G-Tube (Gastrostomy tube) with 60 cc (cubic centimeters) H20 (water) every shift. Verify placement via external tube length. 32cm (centimeters) every shift with an order date of 09/17/25 no end date. R67's order summary report dated 09/18/25 documents, Initiate EBP (Enhanced Barrier Precautions) with an order date of 09/02/25 order status documents discontinued. R67's order summary report date 09/18/25 documents Initiate EBP precautions with an order date of 09/17/25. R67's progress note date 09/10/25 at 5:54PM by V2 (Director of Nursing/DON) documents Resident is now off of EBP precautions. On 09/15/25 at 10:16AM observed R67's door. No EBP signage noted to door. Observed no PPE (Personal Protective Equipment) outside of doorway along with no bins inside of R67's room. On 09/16/25 at 11:00AM observed R67 door which had no signage located on outside of doorway. Observed no PPE outside of doorway. Observed no isolation bins in R67's room. On 09/17/25 at 10:35AM observed R67's door which had no signage located on door, no PPE noted outside of doorway, and no bins noted inside of R67's room. On 09/17/25 at 1:00PM observed V8 (Certified Nurse Assistant/CNA) and another staff member taking R67 to the restroom not donning any gown or PPE prior to providing care. On 09/17/25 at 1:44PM observed R67 door no signage noted to door, no PPE noted outside of room. On 09/17/25 at 1:44PM observed V9 (Licensed Practical Nurse) performing flush to R67's G-tube. V9 had a new gradual which she placed 60cc of water in container. V9 then donned a gown, gloves, and mask. V9 then measured R67's G-tube which measured 36cm with end and 32 cm without the end. V9 stated that placement was correct. V9 then opened G-tube end and flushed with 60cc of water. V9 then closed the cap and removed PPE and placed in trash bag. On 09/17/25 2:00PM, V2 (DON) stated that he did write on 09/10/25 that R67 was off EBP. V2 stated R67 had a surgical wound to his hip from a recent hip surgery and they were doing a dressing change to the hip and having the wound care doctor see R67 for the surgical wound. V2 said the surgical wound healed and so he took R67 off EBP. V2 stated he didn't know for sure if R67 should be on EBP for the G-tube since R67 had only been getting the flushes and hasn't required any feedings. V2 said he did question if R67 should still be on EBP since he had the G-tube. V2 stated that he could see now were R67 still needed to be on EBP. V2 stated that he was going to put R67 back on EBP right away. V2 stated that the nurses usually always wear a gown and gloves when they flush R67 G-tube. On 09/17/25 at 2:43PM, V8 (CNA) stated that R67 was on enhanced barrier precautions, but that he was taken off it now. V8 couldn't remember when R67 was taken off of the EBP. V8 stated when she has been providing care to R67 she has not been donning a gown since he has come off the EBP. V8 stated that she knew when R67 came off EBP because they removed the signage from his door. V8 said when a resident is on EBP that they have a sign on the outside of their door along with a bin outside of the door with PPE and isolation bins inside of their rooms for trash. On 09/18/25 at 10:00AM observed R67's room which had a EBP signage on the outside of the door along with a bin on the outside of the room with PPE of gloves and gowns The facility policy titled Isolation-Categories of Transmission -Based Precautions with a reviewed and updated Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145922 If continuation sheet Page 4 of 5 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 145922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Cobden 430 South Front Street Cobden, IL 62920 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete date of 2023 documents under Enhanced Barrier Precaution 1. In addition to Standard Precautions, implement Enhanced barrier Precautions for all residents with any of the following. A. Infection or colonization with a MDRO (Multidrug-Resistant Organism) when Contact Precautions do not apply. B. wounds and /or indwelling medical devices (e.g central line, urinary catheter, feeding tubes, tracheostomy/ventilator) regardless of MDRO colonization status. 7. Signs- the facility will implement a system to alert staff and visitors to the type of precautions the resident requires. 8. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed then at higher risk.According to https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html. Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs356. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing. Event ID: Facility ID: 145922 If continuation sheet Page 5 of 5