Inspection·April 18, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some deficit, and other recurrent depressive disorders. R15's Minimum Data Set (MDS) dated [DATE] Section C Brief Interview of Mental Status (BIMS) score of 99, indicating severely impaired cognition. R15's Section GG documents oral hygiene and toileting as partial/moderate assistance and showering, upper and lower body dressing as substantial/maximal assistance. R16's Face Sheet, dated 04/18/24 documents an admission date of 01/27/23, and diagnoses in part as diffuse traumatic brain injury without loss of consciousness, depression, anxiety disorder, and seizures. R16's MDS dated [DATE], documents in Section C a Brief Interview of Mental Status (BIMS) score of 10, indicating moderately impaired cognition. R16's Section GG documents toileting, showers, upper and lower body dressing and putting on and taking off shoes as supervision or touch assistance. R17's Face Sheet, dated 04/18/24 documents an admission date of 12/30/22, and diagnoses in part as secondary malignant neoplasm of other specified sites, other disorder of psychological development, personal history of malignant neoplasm of prostate, and personal history of malignant neoplasm of bone. R16's Minimum Data Set (MDS) dated [DATE] document in Section C a Brief Interview of Mental Status (BIMS) score of 99, indicating severely impaired cognition. R16 s Section GG documents dependent for eating, toileting, showering, upper and lower body dressing, and personal hygiene. On 04/17/24 at 12:00PM, V1(Administrator) stated she was not aware of any abuse to any resident until this surveyor reported the allegations that V7 and V9 reported concerning R14, R15, R16, and R17. V1 stated she will start investigations on those allegations. The Facility Abuse Prevention Training Program-Protocol reviewed and updated 2022, documents under Internal Reporting Employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Any employee who knows or suspects that abuse has occurred and has not reported the abuse or makes false allegations of abuse will face possible termination. Any employee who knows or suspects that abuse has occurred and makes an immediate report out of a legitimate concern shall not be penalized or reprimanded for making such report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 2 of 6 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 04/18/2024 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents who require assistance with transfers into bed were assisted in a timely manner for 1 of 1 resident (R1) reviewed for Activities of Daily Living (ADL) in the sample of 17. Residents Affected - Few Findings include: R1's Face Sheet, dated 04/17/24, documents an admission date of 03/14/23 to the facility with diagnoses of Type 2 diabetes mellitus, Hypertension, Chronic Kidney Disease Stage 4, and Arthritis. R1's Minimum Data Set (MDS) dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) score of 8, indicating that R1 has moderately impaired cognition. Section GG documents R1 is dependent for transfers, toileting, showers, and personal hygiene. R1's Current Care Plan, documents a focus of Skin at risk for skin complications r/t related to incontinence, potential for friction/shearing and weakness. At increased risk for further skin breakdown due to refusal of pressure relieving boots with intervention of turn and position per facility protocol. At minimum every 2 hours, Focus of Dialysis renal hemodialysis r/t (related to) severe chronic kidney disease, Focus of R1 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness and impaired cognition. R1 is dependent with mobility and self-care task due to the need of 2 staff assist. He is able to feed himself with set-up assistance but may require verbal ques at times. He uses a w/c (wheelchair) for locomotion in which he is propelled by staff, Focus of R1 has a diagnosis of CKD (chronic kidney disease) stage 4 intervention includes plan rest periods as needed. On 04/15/24 at 3:15PM, R1 stated he has had to wait on several occasions to be laid down after getting back from dialysis. R1 stated that he is always so sick and very tired after he gets back from dialysis and just wants to lay down right away. R1 stated that one day last week it took staff a very long time to lay him down because they didn't have enough staff to help lay him down. R1 wasn't sure how long he had to wait, but he knows it took a very long time before they came and laid him down. R1 stated that they could use more staff at nighttime. On 04/17/24 at 8:30AM V5 (Transit Operation Director) stated that R1 was dropped off at the facility from dialysis at 6:23PM on 04/08/24. On 04/15/24 at 2:15PM, V3 (Regional Nurse) and V2 (Director of Nursing/DON) stated that they only had 1 nurse and 1 laundry staff on 04/08/24 until V4 (Care Plan Coordinator Nurse/CPC) came in at around 9:00pm. V3 and V2 stated that another staff member did come in to help V4 on the floor at around 10:00PM. They both stated that they had one certified nurse's assistant call off and the other one showed up but wouldn't clock in because she didn't want to work by herself. On 04/16/24 at 10:35AM, V4 (Care Plan Coordinator Nurse/CPC) stated that she did come in to work on 04/08/24 when they only had 1 nurse and 1 laundry staff in the building. V4 said that she got to the facility around 9:00PM. V4 stated that all nurses and certified nurse assistance work 12-hour shifts. V4 said on 04/08/24 that 2 certified nurse assistance's were scheduled to work 7:00PM to 7:00AM shift along with one nurse. V4 said that one of the certified nurse assistance's called off on 04/08/24 for the 7:00PM to 7:00AM shift. V4 stated that the other certified nurse assistance showed up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 3 of 6 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 04/18/2024 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and came into the building, but found out the other certified nurse assistance called in so she said that she wasn't clocking in to work unless there were other staff in the building besides her and one nurse. V4 said that since the certified nurse assistant didn't clock in to work it only left one nurse on the floor from 7:00PM until she arrived around 9:00PM on 04/08/24. V4 said that the administrator contacted her, and she came in to work at around 9:00PM. V4 said that they did have another staff member a certified nurse assistant come in around 10:00PM to work on the floor with her. V4 said that R1 was still up when she got to the facility at around 9:00PM and that she had to wait for the other certified nurse assistant to come in before she could put R1 to bed, because R1 was a mechanical lift transfer and she needed assistance with the transfer. V4 said that R1 was not put to bed until after 10:00PM on 04/08/24. V4 said that there was a couple of other residents she had to wait to lay down as well until the other certified nurse assistant came in. V4 said the facility usually has 1 or 2 nurses on the 7:00PM to 7:00PM shift and around 2-6 certified nurse assistants for the 7:00PM to 7:00AM shift every night. On 04/16/24 at 3:00PM, V2 (Director of Nursing/DON) said that she was aware that they only had 1 nurse and 1 laundry person in the building on 04/08/24 for several hours to take care of all the residents. V2 said that V4 came in around 9:00PM on 04/08/24 to work the floor as a CNA. V2 said she had another staff member a certified nurse assistant come in around 10:00PM to also work. V2 said that she has never had this happen before. V2 said night shift is normally 2 certified nurse assistants she would like to have 3-4 certified nurse assistants at nighttime. V2 said that they will normally have 2 nurses on nights as well. V2 said that she has never had just 1 nurse and 1 certified nurse assistant on night shift. V2 stated that she believes that they usually have enough staff on nights shift but that the staff that are working don't provide quality work when they are here. V2 said that she does think they could use some more staff on nights. On 04/17/24 at 12:00PM, V1 (Administrator) said that she was aware that they only had 1 nurse and 1 laundry person in the building on 04/08/24 for several hours from around 7:00PM to 9:00PM. V1 stated at 9:00PM that another nurse came in to work as a certified nurse assistant. V1 said then a certified nurse assistant came in at around 10:00PM to help out as well. V1 said they called her to let her know that one of the certified nurse assistants called off and that the other certified nurse assistants would not clock in because she didn't want to work by herself until they found someone. On 04/17/24 at 1:30PM, V1 stated that they do not have an activities of daily living (ADL) policy because they are just standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 4 of 6 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 04/18/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient staff were available to meet resident needs. This failure has the potential to affect all 56 residents living in the facility. Findings include: 1. On 04/15/24 at 3:15PM, R1 On 04/15/24 at 3:15PM, R1 stated he has had to wait on several occasions to be laid down after getting back from dialysis. R1 stated that he is always so sick and very tired after he gets back from dialysis and just wants to lay down right away. R1 stated that one day last week it took staff a very long time to lay him down because they didn't have enough staff to help lay him down. R1 wasn't sure how long he had to wait, but he knows it took a very long time before they came and laid him down. R1 stated that they could use more staff at nighttime. R1's Face Sheet, dated 04/17/24, documents an admission date of 03/14/23 to the facility with diagnoses of Type 2 diabetes mellitus, Hypertension, Chronic Kidney Disease Stage 4, and Arthritis. R1's Minimum Data Set (MDS) dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) score of 8, indicating that R1 has moderately impaired cognition. Section GG documents R1 is dependent for transfers, toileting, showers, and personal hygiene. R1's Care Plan, documents a focus of Skin at risk for skin complications r/t related to incontinence, potential for friction/shearing and weakness. At increased risk for further skin breakdown due to refusal of pressure relieving boots with intervention of turn and position per facility protocol. At minimum every 2 hours, Focus of Dialysis renal hemodialysis r/t (related to) severe chronic kidney disease, Focus of R1 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness and impaired cognition. R1 is dependent with mobility and self-care task due to the need of 2 staff assist. On 04/17/24 at 8:30AM, V5 (Transit Operation Director) stated that R1 was dropped off at the facility from dialysis at 6:23PM on 04/08/24. On 04/15/24 at 2:15PM, V3 (Regional Nurse) and V2 (Director of Nursing/DON) stated that they only had 1 nurse and 1 laundry staff on 04/08/24 until V4 (Care Plan Coordinator/CPC) came in at around 9:00PM. V3 and V2 stated that another staff member did come in to help V4 on the floor at around 10:00PM. They both stated that they had one certified nurse's assistant call off and the other one showed up but wouldn't clock in because she didn't want to work by herself. On 04/16/24 at 10:35AM, V4 (Care Plan Coordinator Nurse/CPC) stated that she did come in to work on 04/08/24 when they only had 1 nurse and 1 laundry staff in the building. V4 said that she to the facility around 9:00PM. V4 stated that all nurses and certified nurse assistance work 12-hour shifts. V4 said on 04/08/24 that 2 certified nurse assistance's were scheduled to work 7:00PM to 7:00AM shift along with one nurse. V4 said that one of the certified nurse assistance's called off on 04/08/24 for the 7:00PM to 7:00AM shift. V4 stated that the other certified nurse assistance showed up and came into the building, but found out the other certified nurse assistance called in so she said that she wasn't clocking in to work unless there were other staff in the building besides her and one nurse. V4 said that since the certified nurse assistant didn't clock in to work it only left one nurse on the floor from 7:00PM until she arrived around 9:00PM on 04/08/24. V4 said that the administrator contacted her, and she came in to work at around 9:00PM. V4 said that they did have another staff member a certified nurse assistant come in around 10:00PM to work on the floor with her. V4 said that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 5 of 6 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 04/18/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R1 was still up when she got to the facility at around 9:00PM and that she had to wait for the other certified nurse assistant to come in before she could put R1 to bed, because R1 was a mechanical lift transfer and she needed assistance with the transfer. V4 said that R1 was not put to bed until after 10:00PM on 04/08/24. V4 said that there was a couple of other residents she had to wait to lay down as well until the other certified nurse assistant came in. V4 said the facility usually has 1 or 2 nurses on the 7:00PM to 7:00PM shift and around 2-6 certified nurse assistants for the 7:00PM to 7:00AM shift every night. On 04/16/24 at 11:12AM, V13 (Certified Nurse Assistant/CNA) stated that they do have some problems with staffing especially the night shift. V13 said she did work on 04/08/24 when they had only one nurse and a laundry aid working. V13 said that she got off work at around 7:00PM that day. V13 said that one of the certified nurse assistants called in for night shift that night and the other certified nurse assistant wouldn't clock in. V13 said they let her leave because there were 2 certified nurse assistants from day shift still in the building at that time. On 04/15/24 at 11:16AM, R5 who was alert to person, place and time stated she feels like they could use some more help on the night shift. R5 said usually its one nurse and two certified nurse assistants at nighttime. On 04/15/24 at 11:35AM, R7 who was alert to person, place and time stated they don't have a lot of people on the night shift. R7 said that there is only a couple of people here in the building at night. On 04/15/24 at 12:00PM, R9 who was alert to person place and time stated he thinks they need more help in the evening. On 04/16/24 at 11:40AM, V9 (CNA) said that evening shift is usually always where it is short. V9 said she thought there have been only one staff on evening on a couple of occasions. V9 said that when she comes in the morning you can tell they were short. On 04/16/24 at 3:00PM, V2 (DON) said that she was aware that they only had 1 nurse and 1 laundry person in the building on 04/08/24 for several hours to take care of all the residents. V2 said that V4 came in around 9:00PM on 04/08/24 to work the floor as a CNA. V2 said she had another staff member a certified nurse assistant come in around 10:00PM to also work. V2 said that she has never had this happen before. V2 said night shift is normally 2 certified nurse assistants she would like to have 3-4 certified nurse assistants at nighttime. V2 said that they will normally have 2 nurses on nights as well. V2 said that she has never had just 1 nurse and 1 certified nurse assistant on night shift. V2 stated that she believes that they usually have enough staff on nights shift but that the staff that are working don't provide quality work when they are here. V2 said that she does think they could use some more staff on nights. On 04/17/24 at 12:00PM, V1 said that she was aware that they only had 1 nurse and 1 laundry person in the building on 04/08/24 for several hours from around 7:00PM to 9:00PM. V1 stated at 900PM that another nurse came in to work as a certified nurse assistant. V1 said then a certified nurse assistant came in at around 10:00PM to help out also. V1 said they called her to let her know that one of the certified nurse assistants called off and that the other certified nurse assistants would not clock in because she didn't want to work by herself until they found someone. The Resident Listing Report dated 4/17/24 documents there are 56 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 6 of 6