Inspection·October 3, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm 3. R47's face sheet documents an admission date of 6/5/24. This same document lists the following diagnosis: unspecified psychosis, cognitive communication deficit, and dementia without behaviors, mood disturbance, anxiety, and psychotic disturbance. Residents Affected - Few R47's admission MDS in Section A1500 documents that R47 does not have a serious mental illness or intellectual disability. On 9/26/24 at 11:00 AM, V1 (Administrator) confirms that a Level II PASRR was not complete for R47 due to him having a dementia diagnosis she didn't think it needed to be completed. On 9/24/24 at 1:00 PM, V1 stated that they do not have a PASRR policy, they just follow the regulation. Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 3 (R37, R46, R47) of 3 residents reviewed for PASRR Screening in the sample of 30. Findings Include: 1. R37's Face Sheet documented an initial admission date to the facility as 7/11/2024. Diagnoses listed on this form included unspecified psychosis not due to a substance or known physiological condition. R37's Notice of PASRR Level I Screen Outcome dated July 8, 2024, documented No Level II Required- No SMR (Serious Mental Illness). On 9/26/2024 at 9:23 AM, V4 (Business Office Manager) stated, she does complete the PASRR screening for residents in the facility. V4 stated, R37 did not get referred for a PASRR level II evaluation because he did not have a diagnosis that would qualify for a PASRR Level II. V4 stated, it is her understanding that the dementia diagnosis overrules the unspecified psychos diagnosis. 2. R46's Face Sheet documented an initial admission date to the facility as 11/24/2023. Diagnoses listed on this form included post-traumatic stress disorder (PTSD). R46's Notice of PASRR Level I Screen Outcome dated November 24, 2023, documented No Level II Required- No SMR (Serious Mental Illness). On 9/26/2024 at 9:25 AM, V4 stated, R46 did not get referred for a PASRR Level II evaluation. V4 stated, she had never had a resident admitted to the facility with a diagnosis of post-traumatic stress disorder (PTSD) to the facility and she did not know that the PTSD diagnosis would have been considered a serious mental illness. 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 10/03/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed identify, evaluate and intervene to prevent or improve a resident with significant weight loss's nutritional status in 1 (R42) of 5 residents reviewed for nutrition in the sample of 30. This failure resulted in R1 continuing to lose weight over the next 9 months. Residents Affected - Few The findings include: R42's admission record notes he was admitted to the facility on [DATE]. The same admission record lists some of his diagnoses as mild protein- calorie malnutrition, Benign Prostatic Hyperplasia without lower urinary tract symptoms. R42's MDS (Minimum Data Set) dated 8/28/24 note that R42 has a BIMS (Brief Interview of Mental Status) of 08 which indicates R42 has moderate cognitive impairment. Section K of the same MDS note that R42 has not had a weight loss of 5% or more in the last month or greater that a 10% weight loss in 6 months. Section K also notes that R42 has had no nutritional approaches provided while a resident at the facility. R42's Care Plan has a focus area of potential for nutritional problems related to dental impairment with date initiated 6/21/23. R42 likely has cavities and broken natural teeth. R42 is able to feed himself with set up and supervision assistance. R42 likes to eat meals in his room mostly, but will eat in the dining room at times. R42 has a fair appetite. He enjoys eating snacks throughout the day and will also keep snacks at the bedside. Some of the interventions listed are: Provide and serve diet as ordered, RD (Registered Dietitian) to evaluate and make diet recommendations prn (as needed). Staff will assist with oral care, monitor/record/report to MD (Physician) prn s/s (signs or symptoms) of malnutrition, emaciation (cachexia), muscle wasting, significant weight loss of 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. All of interventions were initiated on 6/21/23. R42's Order Entry printed 9/26/24 documents, order date 8/21/23 under additional directions: Health Shakes TID (three times daily), double protein all meals. R42's Order Entry printed 9/26/24 documents, order date 5/21/24 under additional directions: health shake BID (may mix with ice cream). R42's Order Entry printed 9/26/24 documents, order date 7/22/24 under additional directions: health shake between meals. Whole milk with meals. snacks TID. R42's Order Summary Report printed 9/26/24 documents, Regular diet, Regular texture, Thin liquids consistency, health shake TID for Diet order date 7/22/24 and start date 7/22/24. The order also documented, regular diet, regular texture, thin liquids consistency, health shake BID (may mix with ice cream) for diet. Discontinued 5/21/24. On 9/26/24, R42's diet card listed shakes and whole milk at breakfast, lunch and dinner. Double protein all meals. Review of document labeled Document profile dated 6/7/23 note under likes and dislikes, there is no answer provided. There were no other Nutritional assessments provided by the facility. (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 10/03/2024 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 0692 Document labeled Clinical Weights and vitals document R42's weight on 1/10/24 as 175.0 lbs (pounds). The same titled document note that on 2/19/24, R42's weight was 148.0 lbs. Level of Harm - Actual harm Facility document labeled Weights and Vital Exceptions note on 3/12/24, R42 weighed 150.0 lbs. Residents Affected - Few Document labeled Facility Progress note *NEW* dated 9/26/24 notes that on 3/13/24, V5 (Registered Dietician) documented the following: High Risk RD note d/t (due to) weight loss 5% x 1 month. CBW (Current body weight) 150# (pounds), BMI (Body mass index) 20.9. Diet: Regular diet, regular texture, thin liquids consistency, Health shakes TID with meals, Double protein at all meals. Meds (medications) include atorvastatin, Vitamin D3, Ca (calcium) - Vit (vitamin) D w/min (with minerals) Remains at risk of weight loss d/t refusing meals at times. Is encouraged to eat in dining room and does refuse at times. Receiving health shakes with varied PO (by mouth) intake. Appropriate to consider appetite stimulant to support improved PO intake. Recommend- consider appetite stimulant. Unlabeled document provided by V1 as IDT/QA notes note for 3/3/24 to 3/9/24, there were no residents with weight losses over 3 pounds. Notes for 3/10/24-3/16/24 note R42's weight as 150 lbs, continue supplements. monitor, poor appetite, refuses supplements at times. There were no other IDT/QA meeting notes provided that mentioned R42's weight loss. Facility document labeled Weights and Vital Exceptions note that R42 was not weighted in April 2024. There was no dietary notes by V5 for the month of April 2024. R42's document labeled Weights and Vital Exceptions note on 5/21/24, R42 weighed 139.0 lbs which notes -10.0% change (comparison weight 12/5/23, 176.0 lbs , -21.0%, -37.0 lbs). There was no dietary note by V5 for the month of May 2024. There was no documentation of progress notes by the Registered Dietician (V5) for April and May 2024. R42's document labeled Weights and Vitals Exceptions document R42 weighed 137.0 lbs on 6/10/24 which notes a -7.5% change (comparison weight 3/12/24, 150.0 lbs, -8.7%, -13.0 lbs), -10.0% change (Comparison weight 1/10/24, 175.0 lbs, -21.7%, -38 lbs). R42's Dietary note dated 6/12/24 note high risk RD note d/t weight loss -5% in 1 month. The same document notes a CBW (current body weight) 150#, diet: Regular diet, regular texture, thin liquid consistency. Meal intake varied and improving after recent acute illness. Requesting health shakes. Will add and may mix with ice cream to improve acceptance. Recommend: add health shake BID, may mix with ice cream. R42's document labeled Weights and Vitals Exceptions note R42 weighed 134.5 lbs on 7/9/24 which is a -10.0% change (Comparison weight 3/12/24, 150.0 lbs, -10.3%, -15.5 lbs) Dietary note dated 7/24/24 note high risk RD note d/t weight loss >10% x 6 months. CBW: 134.5 Diet: Regular diet, regular texture, thin liquid consistency, health shakes BID. Meal intake varies at times. Typically eats breakfast well. Health shakes added 7/22/24. Appropriate to continue current interventions to support nutrition needs for weight maintenance. Monitor prn (as needed). R42's document labeled Weights and Vitals Exceptions documents no weight for the month of August 2024. There is no progress note by V5 for the month of August 2024. (continued on next page) 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 10/03/2024 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 0692 R42's document labeled Weights and Vitals Exceptions documents R42 weighed 131.0 lbs on 9/9/24 which is a -10.0% change (Comparison weight 3/12/24, 150.0 lbs, -12.7%, -19 lbs). Level of Harm - Actual harm Residents Affected - Few Dietary note dated 9/18/24 notes high risk RD note d/t weight loss >10% x 6 months. CBW: 131#. Diet: Regular diet, Regular texture, thin liquid consistency, health shakes BID (twice daily) weight decline continues with recent interventions. Staff reports he typically eats well at lunch meal. Usually skips breakfast and eats light dinner meal. Likes to snack. Appropriate to add snacks between meals and add whole milk. On 9/26/24 at 2:35pm, V5 (Registered Dietician) said that she did not see R42 in April, May and August 2024 due to not being flagged for weight loss. V5 said there were no weights done for him to be flagged. V5 said that R42 tends to skip meals or skip breakfast and also has a tendency to refuse meals. V5 said the fact of him missing her recommendations versus the fact he often refuses meals or skips meals would not really make a difference. V5 said she sends her recommendations to the Administrator, the Director of Nursing and the Dietary manager and they are to speak with the doctor. V5 said she usually sees a resident with significant weight loss monthly. On 9/27/24, V6 (Dietary Manager) said that they do not document when supplements are given. V1 said he could not provide any documentation that they were given. V1 also said that R42 did not have any weekly weights documented from January 2024 to August 2024. R42 was placed on weekly weights on 9/27/24. On 10/3/24 at 12:10pm, V7 (friend/POA/Power of Attorney) said that R42 was not eating good prior to his admission to the facility. R42 said he just didn't really want to get up or eat. V7 said she was not made aware of R42's weight loss until 9/27/24 when the facility called to get her approval for starting an appetite stimulant. R42 said she has not been notified of R42 having any weight loss until then. On 10/3/24 at 11:51am, V5 said she did not know if R42 was being given supplements or not. V5 said she was told he refuses them a lot and in June they were requesting health shakes and said they could add with ice cream. V5 also said they tried other foods. V5 was asked how she knew his preferences since there was no documentation of those and replied she was told he likes snacks and cookies. V5 said that R42 was getting an appetite stimulant and was told he was eating better and was snacking well and since his appetites were improving, she didn't get more aggressive with her interventions. V5 was informed that R42 was not getting an appetite stimulant, however it was begun on 9/27/24. V5 said if she would have known R42 possibly wasn't getting health shakes and the appetite stimulant, her approach would have been more aggressive. On 9/26/24 at 2:00pm, V1 (Administrator) said the Dietician does not have to see a resident monthly. V1 said that R42 refused his weights for the month of August and April. V1 said she did not have any documentation for refusals by R42. V1 said that R42 was getting his health shakes with meals. V1 said that the team meets every morning and discusses weight loss/gains and wounds. V1 said she does receive the Dietary recommendations from V6 each month. V1 said that is a residents weight is off from the last weight, they weigh the resident again, but can not provide any documentation to that. On 9/27/24 at 1:00pm, V1 also said that the IDT (Interdisiplinary Team) meet weekly and discuss weight loss on all of the residents. V1 was asked should R42 have been put on weekly weights and she replied Yes, I guess he should have. V1 said they had a problem with scales and felt that was the problem with weights being off. V1 said she bought new scales in January of 2024. V1 was asked if they (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 10/03/2024 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 0692 Level of Harm - Actual harm Residents Affected - Few calibrated them and she replied yes. V1 said she don't know why the doctor didn't order the stimulant since they always agree with the dietary recommendations. V1 said the called the previous physician's office and they sent a copy to them that said she did not want to order the stimulant. V1 said that V6 asks residents about their likes and dislikes of food. V1 could not provide any documentation of where V6 asked about it. V1 said she would think with weight loss, you should ask about the resident's likes and dislikes. V1 said they do not notify the dietician in writing about a resident's weight loss, she stated they may by phone. On 10/2/24 at 2:35pm, V8 (CNA/Certified Nurse Assistant) said she works the hall R42 was on and she has not given him any health shakes until the other day and now they have a list of names and have to sign them off. V8 said they can not put their weekly weights in the computer and they do them on paper. V8 said she did re-weigh R42 but don't remember when, possibly in the past couple months. On 10/2/24 at 2:45pm, V9 (LPN/Licensed Practical Nurse) said to her knowledge, R42 has not been given any health shakes until last week. On 9/26/24 at 1:45pm, V6 (Dietary Manager) said that the dietician does see residents monthly if they have a significant weight loss. V6 said that R42 has been getting health shakes with his meals and when they are given with meals, they do not sign them off any where and can not provide any documentation that they were actually given. V6 said each month he gives the weights to the DON (Director of Nursing) the weights on each resident. V6 said he does receive the recommendations made by V6 each month. R42's DiningRD Request for Diet Change PCP Fax Report provided by the Facility on 9/26/24 dated 3/13/24 from V5 documents in part, Appropriate to consider appetite stimulant to support improved PO (by mouth) intake. Recommend: -consider appetite stimulant. This document did not have any comments from the physician or a signature. On 9/27/24 at 3:30pm V1 emailed another version of R42's DiningRD Request for Diet Change PCP Fax Report dated 3/13/24 from V5 that now had marked under comments, Do no Change current orders with an unrecognizable signature and a date of 3/15/24. On 9/27/24 at 2:30pm, V2 (DON/Director of Nurses) said that he faxed the unsigned March dietary recommendation for an appetite stimulant to the physician and he ordered Remeron 7.5 mg (milligrams) daily. Facility Document labeled Weight Assessment and Intervention (revised September 2017) note any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. The Dietician will review the unit Weight record by the 15th of the month to follow individual weight trends over time. The same document notes Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the dietician, the Consultant Pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss, b. Goals and benchmarks for improvement and c. time frames and parameters for monitoring and reassessment. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choices and preferences c. Functional factors that may inhibit independent eating, d. Environmental factors that may inhibit appetite or desire to participate in meals .g. The use of supplementation and/or feeding tubes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 6 of 6