Health inspection·July 28, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review, the facility failed to refer a resident for Preadmission Screening and Resident Review (PASRR) as recommended for 2 (R46 and R7) of 4 residents reviewed for PASRR's in the sample of 30. Findings Include: 1. R46's Face Sheet documents an initial admission date to the facility as 1/27/23, with diagnoses including but not limited to Diffuse Traumatic Brain Injury without loss of consciousness, subsequent encounter, Depression, Unspecified, and Anxiety, Unspecified and Other Seizures. R46's Notice of PASRR Level I Screen Outcome documents under the section labeled Ascend Outcome with a review date of 01/25/2023, Level I Outcome: Exempted Hospital Discharge. Rationale: Exempted Hospital Discharge 30 Day Approval- A 30 day or less stay in the NF (nursing facility) is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. The individual meets criteria for a 30-day hospital exemption admission, due to known or suspected Serious Mental Illness diagnosis indicated by the reported medication regimen. There are no reports of recent symptoms, no reported history of inpatient psychiatric hospitalization. If they require more than 30 days or they have an increase in mental health symptoms, a Conclusion of a Time Limited approval Level I screen should be submitted and a Level II referral will be initiated. Review of R46's Clinical Record next documents a PASRR Level I and II screening was completed at the facility for R46 on 6/6/23 and 6/7/23, respectively. On 7/27/23 at 2:45 PM, although requested from V3 (Director of Clinical Reimbursement), the facility was unable to provide documentation that a PASRR screening was completed within 30 days from the 1/25/23 screening outcome recommendations. 2. R7's Face Sheet documents an initial admission date to the facility as 4/23/21, with diagnoses including, but not limited to Bipolar Disorder, Unspecified; Major Depressive Disorder, Recurrent, Unspecified; Anxiety Disorder, Unspecified; and Cerebral Palsy, Unspecified. R7's OBRA-I Initial Screen dated 4/1/21 documents all answers to questions as being No in section Part III. Reasonable basis to suspect a Mental Illness. A document titled 110.00 Scope and Purpose of the OBRA-1 Initial Screen, as found at https://www.dhs.state.il.us/page.aspx?item=53020 stated, Cerebral palsy and epilepsy are related conditions that (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: 146006 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 146006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Anna 315 South Brady Mill Road Anna, IL 62906 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)