Inspection·June 9, 2025

F 0550 intact. Section GG documents toileting as substantial/maximal assistance. Section H documents that R5 is frequently incontinent of bladder and bowel. Level of Harm - Actual harm Residents Affected - Few R5's Care Plan (with a revision date of 5/7/25) documents focus areas of with a revision date of R5 is at risk for falls and R5 is at risk for pressure injury. On 06/04/25 at 3:27PM, R5 stated he does have a problem with running out of his size incontinence briefs. R5 said they also want him to go without incontinent briefs at nighttime. R5 said that the facility doesn't order enough briefs and sometimes he has had to use a smaller brief. R5 said that they run out of his size incontinence briefs often. R5 said that he has even went without a brief at times, because they didn't have any for him to wear. R5 said that he doesn't like his clothes getting wet or peeing on himself. R5 said that he also doesn't like not having one at nighttime. R5 said he wakes up soaking wet and his bed is sometimes wet as well. R5 said that it is embarrassing to have your clothes all wet in urine and your bed soaked. 3. R7's admission record dated 06/06/25, documents an admission date of 05/20/25 to the facility with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, type 2 diabetes mellitus, presence if cardiac pacemaker, and old myocardial infarction. R7's MDS dated [DATE] documents in Section C a BIMS score of 13 which indicates R7 is cognitively intact. Section GG documents that R7 requires set-up and supervision with toileting. Section H documents R7 is occasionally incontinent of bladder and continent of bowel. R7's Care Plan (revision date of 5/20/25) documents a focus area of R7 has an ADL deficit related to needing assistance with ADL's related to dx (diagnosis) of hemiplegia and hemiparesis following CVA affecting the left non-dominant side. R7 is able to feed himself with set-up assistance only. R7 requires weight bearing assistance with most ADL's. R7 uses a wheelchair for locomotion and is able to propel himself. On 06/05/25 at 10:08AM, R7 stated that there are days he has had to go without an incontinent brief because the facility doesn't have any. R7 said that he does have a couple of staff members that will hide some of his size incontinent brief to make sure he has some for the daytime. R7 said that he has gone days without any incontinent briefs, and he didn't like it. R7 said that it embarrassed him to be wetting himself. R7 said that they also make him go all night without wearing an incontinent brief now. R7 said that he asked if he could wear one during the night, but that staff told him they don't use them at nighttime now. 4. R6's admission record dated 06/06/25, documents an admission date of 04/11/23 to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, transient cerebral ischemic attack, retention of urine, aphasia, and chronic kidney disease. R6's MDS dated [DATE] documents in Section C a BIMS score of 03 which indicates severe cognitive impairment. Section GG documents that R6 is dependent for toileting. Section H documents R6 is frequently incontinent of bladder and bowel. R6's Care Plan has a focus area of R6 has an ADL (Activities of Daily Living) self-care performance deficit r/t hemiparesis to the right side following CVA (Cerebral Vascular Accident). R6 has weakness to the RUE (Right Upper Extremities) and RLE (Right Lower Extremities) which is dominant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 2 of 17 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 06/09/2025 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 0550 Level of Harm - Actual harm Residents Affected - Few On 06/03/25 at 1:54PM, V19 (Family Member) stated that sometimes the facility runs out of incontinent briefs. V19 said that they stopped putting incontinent briefs on R6 at nighttime. V19 said that now R6 must sit and lay in urine or stool until someone cleans him up. V19 said when R6 use to wear the incontinent briefs at nighttime when he urinated the incontinent brief would pull the urine away from his skin, now he just lays in it. On 06/03/25 at 11:08AM, V8 (Certified Nurse Assistant/CNA) stated that the facility stopped using incontinent briefs at nighttime on residents. V8 said that the facility had ran out of incontinent briefs and that they have had to let the resident go without an incontinent brief during the day and at nighttime. V8 said that residents will wet themselves, and they will just clean up the resident and change them. On 06/03/25 at 12:51PM, V1 (Administrator) stated that the reason the facility runs out of incontinent briefs is because staff isn't putting stuff on the list for her to order. V1 said that they stopped putting incontinent briefs on residents at nighttime, so the residents have time to air out. On 06/03/25 at 1:15PM, V9 (CNA) stated that they ran out of incontinent briefs for the residents just last week. V9 said that they have went several days with some residents not having any incontinent briefs. V9 said that they just check and change the residents often and try to make sure they stay dry. On 06/03/25 at 12:06PM, V10 (CNA) stated that the facility has ran out of incontinent briefs at times and they had to put resident in clothes without an incontinent brief on. V10 said that they checked and changed the resident to make sure they did not have an accident and if they had an accident then they would clean the resident up and change their clothes. V10 said they ran out of the larger incontinent sizes the most. V10 said that V1 would have some supplies in her office and that they had to ask for the supplies for the residents. On 06/03/25 at 3:02PM, observed storage room on B hall which had 2 boxes of gloves and at least 24 x-large incontinent briefs and 22 medium incontinent briefs. There were no other sizes of briefs noted. On 06/03/25 at 3:10PM, observed storage room on A hall which had 6 boxes of gloves and 30 x-large incontinent briefs and 34 medium briefs. There were no other sizes of briefs noted. On 06/03/25 at 3:12PM, observed the shed outside which is used to store extra supplies. There were 2 boxes of Medium incontinent briefs and 1 x-large incontinent brief box. On 06/04/25 at 1:46PM, V13 (CNA) stated that they have run out of incontinent briefs at times and they had to call V1 to get them some incontinent briefs for residents. On 06/04/25 at 2:05PM, V1 stated that she provides incontinent briefs for all residents and all sizes. V1 said that she doesn't order many incontinent briefs. V1 stated that she did have an order in for some incontinent briefs but the order did not come in today so she had to get an order from the local store until her shipment comes in. On 06/04/25 at 3:00PM, V1 stated that her supplies from the local store arrived, but she still did not receive her supplies from the company she normally orders from. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 3 of 17 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 06/09/2025 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 0550 On 06/04/25 at 2:15PM, V14 (CNA) stated that she has been told by V1 not to put incontinent briefs on residents at nighttime unless they ask to have one on. Level of Harm - Actual harm Residents Affected - Few On 06/05/25 at 7:19AM, V6 (CNA supervisor) stated they do have a problem with running out of incontinent briefs at times. V6 said that she will let V1 know when they run out of something and V1 will go get what she needs. V6 said that resident do not wear incontinent briefs at nighttime now unless they request to wear one then we put one on them. V6 said that they use to have a problem with running out of 2 x large incontinent briefs and larger. On 06/05/25 at 7:30AM, V1 stated that she does not like to use depends at nighttime because she feels like it increases skin breakdown on residents. V1 said that she feels like the residents need time to dry out. V1 said that a doctor did not give her an order to not put an incontinent brief on the residents at nighttime. V1 said that if a resident is alert and requests to wear an incontinent brief at nighttime they should be allowed to wear one. V1 stated she did not call and see what the families of the resident who are not alert would prefer if they would like their family member to wear a brief at nighttime or not. V1 said that she did find in the contract that it says the facility is to provide incontinent care and supplies. V1 said that she knows that it doesn't have to be a specific brand, but it does have to be the appropriate size. On 06/05/25 at 7:44AM, observed storage room on B hall which had 1 box of gloves and 15 x-large incontinent briefs and 10 small incontinent briefs. On 06/05/25 at 7:46AM, observed storage room on A hall which had 25 x-large incontinent briefs and 20 medium incontinent briefs. On 06/06/25 at 10:46AM, V17 (Business Office Manager) stated that the facility is to provide incontinent briefs to all resident regardless of their payor source. On 06/06/25 at 2:00PM, V1 stated that the facility did not have a policy on incontinent care or incontinent supplies. The facility document titled Resident Grievance/Concern Follow-up Form dated 04/02/25 and completed by the Resident Council documents under describe the nature of the grievance/concern documents get bigger size pull-ups (incontinent briefs). The sections documenting recommendations and efforts made by the facility to resolve the concern is left blank. Another Resident Grievance/Concern Follow-up Form dated 05/06/25 documents still running out of bigger size pull-ups. Under the section that describes what efforts were made by the facility to resolve the concern it documents see attached. The facility document titled Resident Council Memorandum dated 04/02/25 documents an issue of bigger sized pull-ups and a response of staff educated to use appropriate size and update order board when stock getting low signed by V1. Under Follow up in Resident Council with a date of 05/06/25 documents residents feel that they are still running out. The facility document titled Resident Council Memorandum dated 05/06/25 documents an issue of running out of pull-ups in bigger sizes and a response of CNA meeting in progress this wk (week) discussing pull-ups and depends (incontinent briefs) educated to use appropriate size and to not place on residents in bed signed by V1. The facility Resident admission Packet with a revision date of 12/24 documents under Statement of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 4 of 17 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 06/09/2025 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 0550 Level of Harm - Actual harm Residents Affected - Few Resident Rights under section I. Services included in Medicare and Medicaid payment documents During the course of a covered Medicare or Medicaid stay, facilities must not charge a resident for the following categories of items and services. (E) routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, hair hygiene supplies, comb, brush, bath soap, disinfesting soap or specialized cleansing agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing assistance, and basic personal laundry. The facility policy titled Dignity Policy with a revision date of 08/2009 documents the policy statement as Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 5 of 17 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 06/09/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review facility failed to maintain a clean comfortable home like environment for 5 of 5 residents (R7, R8, R9, R10, R11) reviewed for environment in a sample of 16. Findings include: 1. R7's admission Record documents an admission date of 5/20/25 with diagnoses including in part hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side and aphasia following cerebral infarction. R7's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13 indicating R7's cognition is intact. R11's admission Record documents an admission date of 3/27/25 with diagnosis including in part mild cognitive impairment of uncertain or unknown etiology, anxiety, and depression. R11's MDS dated [DATE] documents a BIMS of 15 indicating R11's cognition is intact. A facility Midnight Census Report dated 6/3/25 documents that R7 and R11 are roommates. On 6/5/25 at 10:08AM, R7 stated he has had problems with not having bed linens or not having bed pads on his bed at times. R7 stated that it might take all day before he gets a sheet or blanket for his bed if they take the linens off of it. R7 stated that he has went late in the evening sometimes before he gets bed linens. On 6/5/25 at 2:30 PM, duct tape was observed on the wall above the air conditioner wall unit in R7 and R11's room. The duct tape was peeled back and there was a large hole noted. On 6/5/25 at 3:15 PM, R11 stated he doesn't know how long the hole has been in his wall, stated it was there when he moved in. On 6/6/25 at 10:51 AM, V4 (Maintenance Director) measured the hole in the wall in R7 and R11's room above the wall air conditioner unit with a tape measure and it measured 1 foot wide by 5 inches long. 2. R8's admission Record documents an admission date of 12/27/22 with diagnosis including in part hemiplegia and hemiparesis following cerebral infarctions affecting left non-dominant side, emphysema, borderline intellectual functioning, dysuria, neuromuscular dysfunction of bladder, and paranoid schizophrenia. R8's MDS dated [DATE] documents a BIMS of 12 indicating R8's cognition is moderately impaired. R9's admission Record documents an admission date of 11/22/24 with diagnosis including in part history of falling, mild cognitive impairment of uncertain or unknown etiology, exudative age-related macular degeneration bilateral, pigmentary retinal dystrophy, and major depressive disorder. R9's MDS dated [DATE] documents a BIMS of 02 indicating R9's cognition is severely impaired. A facility Midnight Census Report dated 6/3/25 documents that R8 and R9 are roommates. On 6/5/25 at 10:16 AM, R8 stated she does have some issues with bed linens, stated sometimes it's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 6 of 17 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 06/09/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm 2:00 PM before they get linens to put on her bed to make it. R8 stated there are times she would like to take a nap but she can't because they don't have linens for her bed so she has to stay up. On 6/5/25 at 2:37 PM, observed duct tape on the wall above the air conditioner wall unit in R8 and R9's room. The duct tape was peeled back and there was a large hole observed. Residents Affected - Some On 6/6/25 at 10:50 AM, V4 (Maintenance Director) measured the hole in the wall in R8's room above the wall air conditioner unit with a tape measure and it measured 1 foot wide by 7 inches long. On 6/5/25 at 3:01 PM, R8 stated the hole doesn't bother her because it isn't next to her bed, she sleeps next to the door and her roommate (R9) sleeps next to the hole. 3. R10's admission Record documents an admission date of 6/11/22 with diagnosis including in part morbid obesity due to excess calories, major depressive disorder, anxiety, urinary tract infection, other lack of coordination, and muscle weakness. R10's MDS dated [DATE] documents a BIMS score of 15 indicating R10's cognition is intact. The same MDS documents R10 is occasionally incontinent of bladder. On 6/6/25 at 9:15 AM, R10 stated there has been times when they do not have bed pads for the bed, and they will use a bath towel, or a bed sheet folded up. R10 stated she doesn't like when they use the bath towel or bed sheet because when she is incontinent of urine the bath towel and the bed sheet don't soak the urine up properly and it make the fluid stay on her skin and makes her feel wet and gross, and the urine goes all over the bed and other bed linens. On 6/5/25 at 11:19 AM, V9 (CNA) stated she has had to cut up towels before to use as wash cloths so she could clean the residents up. V9 also stated they do run out of bed linens during the day, and she has had to use sheets, towels, or bath blankets as bed pads. V9 stated she thinks the termites are on mostly all of B hall. V9 stated R9 and R7's rooms have them too. V9 stated she placed her hand on the wall in R9's room and her hand went through it and there is duct tape covering the hole. On 6/5/25 at 10:44 AM, V12 (CNA) stated sometimes they would run out of bed sheets and be pads and they would use bath blankets or towels. On 6/3/25 at 11:08 AM, V8 (CNA) stated they do have problems with not always having enough linens. V8 stated that it has gotten better because their dryer has been fixed. V8 stated that the dryer burnt up and now that they have a new dryer it has gotten better. V8 stated that they would also run out of wash cloths at times this was mainly when they didn't have a dryer. V8 stated that it has gotten better since the dryer is working. V8 stated that they have run out of fitted sheets at times, but they will put a flat sheet on the bed. V8 stated if they didn't have linens for beds, they would keep resident up until the linens were dry. On 6/3/25 at 12:51 PM, V1 (Administrator) stated there were days that they didn't have the linens that they needed when the dryer was broken but they ended up sending a staff member to the laundry mat to dry some laundry. On 6/3/25 at 1:28 PM, V11 (CNA) stated they are short on linens at times but that is only because laundry is backed up a lot. On 6/3/25 at 1:35PM, V2 (Licensed Practical Nurse/Assistant Director of Nursing) stated when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 7 of 17 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 06/09/2025 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 0584 dryer was down they did have a hard time keeping up with the laundry and linens. Level of Harm - Minimal harm or potential for actual harm On 6/4/25 at 12:06 PM, V10 (CNA) stated there were times when they didn't have any wash cloths and laundry would be backed up so they would have to use whatever they could. V10 stated they would cut up towels and make their own wash cloths. Residents Affected - Some On 6/4/25 at 1:46 PM, V13 (CNA) stated they did have a problem with being short of linens and laundry supplies when the dryer was down. V13 stated they would run out of bed pads at times and they would have to use a bath blanket or a towel until the bed pads were dry. On 6/5/25 at 7:19 AM, V6 (CNA supervisor) stated they do run out of wash cloths often so they will use towels that they cut up or toilet paper to clean up the residents. V6 stated they also have been short on bed pads at times as well and they use bath blankets, towels or folded up sheets, whatever they can use. On 6/4/25 at 10:21 AM, V4 (Maintenance Director) stated he has a lot of maintenance request slips and he has been trying to get them completed as soon as possible. A facility policy titled Work Orders, Maintenance dated April 2010 documents 2. It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director. A facility policy titled Dignity Policy dated August 2009 documents Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 8 of 17 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 06/09/2025 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 receive a shower for 4 of 6 residents (R1, R3, R5, and R6) reviewed for Activities of Daily Living assistance in the sample of 16. Residents Affected - Some Findings include: 1.R1's admission record, dated 06/06/25 documents an admission date of 04/28/25 to the facility with diagnoses in part of Type 2 diabetes mellitus, emphysema, chronic obstructive pulmonary disease, diarrhea, anxiety disorder, major depressive disorder, and heart failure. R1's MDS (Minimum Data Set) dated 05/05/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 is cognitively intact. Section GG documents showers/bathing as dependent. R1's Care Plan dated 05/28/25 documents a focus area titled Activities: R1 is dependent on staff for activities, cognitive stimulation and social interaction r/t (related to) limited mobility. On 06/05/25 at 8:30AM, R1 stated that he believes the facility is short on staff. R1 said he feels that they are short on staff especially on day shift. R1 said he does get a shower maybe once a week he thought he was supposed to be getting two showers a week. R1 said that he doesn't know if he isn't getting showers because they are so short of staff. The facility shower schedule (undated) documents R1 is to have showers on Wednesday and Saturday. R1's skin monitoring: Comprehensive CNA (Certified Nurse Assistant) Shower Review sheets since admission document showers were completed on 05/31/25, 5/21/25, 05/17/25 (R1 at hospital), 05/08/25, 04/30/25. There were no shower review sheets for 05/03/25, 05/07/25, 5/10/25, 05/14/25, 05/24/25,05/28/25, and 06/04/25 to indicate showers were completed. 2. R3's admission record dated 06/06/25, documents an admission date of 03/07/22 to the facility with diagnoses in part of pressure ulcer of sacral region stage 4, pressure ulcer of other site stage 3, type 2 diabetes mellitus with foot ulcer, and non-pressure chronic ulcer of buttock with unspecified severity. R3's MDS dated [DATE] documents in Section C a BIMS score of 10 which indicates moderately impaired cognition. Section GG documents showers/bathing as dependent. R3's Care Plan documents a focus area of R3 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) multiple health issues including cerebral palsy, DM (Diabetes Mellitus), IBS (irritable bowel syndrome) and vertigo. R3 utilizes a wheelchair for locomotion in which she can propel herself very short distance with a revision date of 08/02/21. On 06/06/25 at 9:20AM, R3 stated that she doesn't always get her showers like she is supposed to. R3 said that she thinks she maybe gets one shower a week. The facility shower schedule (undated) documents that R3 is to get a shower on Monday and Thursday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 9 of 17 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 06/09/2025 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 - Some R3's skin monitoring: Comprehensive CNA Shower Review sheet for the past 3 months documents that R3 received a shower on 05/29/25, 05/26/25, 05/22/25, 05/15/25, 05/12/25, 04/29/25, 04/25/25, 04/22/25, 04/16/25, 04/11/25, 04/08/25, 04/03/25, 03/28/25, 03/07/25, and 03/01/25. There were no shoer review sheet for R3 on 03/03/25, 03/06/25, 03/10/25, 03/13/25, 03/17/25, 03/20/25, 03/24/25, 03/27/25, 03/31/25, 04/07/25, 04/10/25, 04/14/25, 04/17/25, 04/21/25, 04/24/25, 04/28/25, 05/01/25, 05/05/25, 05/08/25, 05/19/25, 06/02/25, and 06/05/25. 3.R5's admission record, dated 06/06/25, documents an admission date of 01/26/25 with diagnoses in part of chronic obstructive pulmonary disease, type 2 diabetes mellitus, obesity, non-pressure chronic ulcers of other part of right foot with fat layer exposed, lymphedema, and chronic kidney disease. R5's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R5 is cognitively intact. Section GG documents showers/bathing as substantial/maximal assistance. R5's Care Plan documents a focus area with a revision date of 05/07/25 of Falls: R5 is at risk for falls. Another Focus area of Skin: R5 is at risk for pressure injury. On 06/04/25 at 3:27PM, R5 said that sometimes he doesn't get his showers like he is supposed to. R5 said he doesn't know if it is because they don't have enough help or why he doesn't get his showers. The facility shower schedule (undated) documents that R5 is to have a shower on Monday and Friday. R5's Skin Monitoring: Comprehensive CNA Shower Review sheet for the past 3 months documents that R5 received a shower on 05/30/25 (R5 refused), 05/26/25, 05/19/25, 05/16/25, 05/12/25, 04/29/25, 04/24/25, 04/21/25, 04/17/25, 04/14/25, 04/10/25, 04/08/25 (R5 refused), and 03/26/25 (R5 refused). There were no shower review sheets for R5 indicating that a shower had been given for 03/03/25, 03/07/25, 03/10/25, 03/14/25, 03/17/25, 03/21/25, 03/24/25, 03/28/25, 03/31/25, 04/04/25, 04/07/25, 04/11/25, 04/18/25, 04/25/25, 04/28/25, 05/02/25, 05/05/25, 05/09/25, 05/23/25, and 06/02/25. 4. R6's admission record dated 06/06/25, documents an admission date of 04/11/23 to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, transient cerebral ischemic attack, retention of urine, aphasia, and chronic kidney disease. R6's MDS dated [DATE] documents in Section C a BIMS score of 03 which indicates R6 has severe cognitive impairment. Section GG documents showers/bathing as dependent. R6's Care Plan has a focus area of R6 has an ADL (Activities of Daily Living) self-care performance deficit r/t hemiparesis to the right side following CVA (Cerebral Vascular Accident). R6 has weakness to the RUE (Right Upper Extremities) and RLE (Right Lower Extremities) which is dominant. On 06/03/25 at 1:54PM, V19 (Family Member) said that she is having problems with R6 getting his showers like he is supposed to. V19 said that a lot of the times that R6 doesn't get his showers. V19 didn't know if they have enough staff, she feels like they are short of staff at times. The facility shower schedule undated documents R6 is to have showers on Tuesday and Sunday. R6's Skin Monitoring: Comprehensive CNA Shower Sheets for the past 3 months document that R6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 10 of 17 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 06/09/2025 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 received a shower on 05/26/25, 05/20/25, 05/18/25, 05/15/25, 05/05/25, 05/01/25, 04/28/25, 04/24/25, 04/21/25, 04/16/25, 04/14/25, 04/13/25, 04/08/25, 03/25/25, 03/18/25, 03/12/25, 03/11/25, and 03/09/25. There are no shower sheets indicating that R6 received a shower for 03/02/25, 03/04/25, 03/16/25, 03/23/25, 03/30/25, 04/01/25, 04/06/25, 04/15/25, 04/20/25, 04/22/25, 04/27/25, 04/29/25, 05/04/25, 05/06/25, 05/11/25, 05/13/25, 05/25/26, 05/27/25, 06/01/25, and 06/03/25. Residents Affected - Some On 06/03/25 at 1:15PM, V9 (Certified Nurse Assistant/CNA) stated that they are short of staff often. V9 stated that she tries her best to get her job done to the best of her ability. V9 stated that they have a hard time making sure all the residents get their showers done when they are supposed to. V9 said that she doesn't feel like the facility has enough staff to properly care for the residents. On 06/04/25 at 12:06PM, V10 (CNA) stated the facility is always short of staff. V10 said that she would have a hard time making sure all the residents showers got done because they didn't have enough staff. V10 said that she always tried to do the best she could to care for the residents. On 06/04/25 at 1:46PM, V13 (CNA) stated that the facility is frequently short of staff. V13 said that she tries her best to get all the residents showers done when they are short, but she has had to pass the showers on to the next shift a couple of times and she doesn't know if they got done or not. On 06/05/25 at 8:00AM, V1 (Administrator) stated that the facility does not have a policy on bathing or showers. On 06/06/25 at 1:00PM, V2 (Assistant Director of Nursing/ADON) stated that she didn't have anymore shower sheets for R1, R3, R5, and R6 and that it could mean that they didn't get showers on the days that are missing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 11 of 17 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 06/09/2025 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement interventions to prevent future falls for 1 of 3 (R2) residents reviewed for falls in a sample of 16. This failure resulted in R2 falling and sustaining a laceration on his face requiring sutures. Findings include: R2's admission Record documents an initial admission date of 12/10/20 and a discharge date of 5/23/25 with diagnoses including in part Alzheimer's disease, legal blindness, abnormalities of gait and mobility, and lack of coordination. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 0 indicating that R2 is rarely/never understood. R2's most recent Care Plan documents a focus area of Falls: R2 is at risk for falls related to severely impaired mobility and very poor safety awareness with an initiation date of 12/16/20. Interventions documented include R2 is to be promptly laid down after all meals to reduce sleeping in his wheelchair, thus reducing risk of fall dated 2/6/25, staff educated to recline back of high back wheelchair and to ensure it is pushed under the table and locked for safety dated 3/31/25, and wheelchair to be tilted back in reclining position for safety dated 6/21/21. R2's Fall Risk assessment dated [DATE] documents a score of 10 with a score of 10 or greater indicating that the resident is at a high risk for falls. R2's Fall Risk assessment dated [DATE] documents a score of 10 and the assessment dated [DATE] documents a score of 15. R2's Nurse's Note dated 2/6/25 at 9:30 AM documents this nurse was at med (medicine) cart, alerted by CNA (Certified Nursing Assistant) to look further down the hallway where (R2) was noted to be laying in the floor on R (Right) side beside wheelchair. Fall was not witnessed. Head to toe assessment completed. No evidence of pain/discomfort noted at this time. No skin injury or redness noted. No physical injury or deformities noted. Neuro (Neurological) at baseline for (R2) at this time, neuro checks initiated. vitals BP (Blood Pressure) 127/75, HR (Heart Rate) 79, RR (Respiratory Rate) 16, temp (Temperature) 97.8, O2 sat (Saturation) 92%. (R2) assisted back to w/c (Wheelchair) x3 staff. immediate intervention - CNA's educated to lay resident down promptly after all meals, verbalized understanding. RCA (Root Cause Analysis): (R2) post meal sleeping in w/c, fell forward onto floor. R2's Nurse's Note dated 3/31/2025 at 5:30 PM documents Nurse was notified that (R2) was laying in the floor in the dining room and had fallen out of his wheelchair. (R2) was observed laying on his right side. (R2) has a laceration to right eyebrow measuring approximately 2cm (centimeters) x 0.4cm and can't measure depth d/t (Due To) hair present. Laceration cleansed with NS (Normal Saline) and pressure applied to stop bleeding. (R2) assisted back into wheelchair with staff x2. (R2) unable to express how fall occurred. Neurological exam performed and within normal limits. Vital signs obtained: 97.4, 69 pulse, 18 respirations, 121/87. ROM (Range of Motion) x4 without s/s (signs/symptoms) of pain. No shortening or deformity of extremities. Environment was dry floor, adequate lighting, non-skid socks on. Physician and POA (Power of Attorney) notified. Resident sent to (Local Hospital) ER for eval (evaluation) & treat. R2's Nurse's Note dated 3/31/25 at 10:51 AM documents (R2) returned back to facility at 2132 (9:32 PM) via facility van. 5 stitches to the R (Right) eyebrow, remove in 10 days. Monitor for s/s (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 12 of 17 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 06/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few (Signs/Symptoms) of infection. MD (Physician) notified. Attempted to call Resp (responsible) party but no answer. Left a voicemail for her to call us back. (R2) in bed at this time. Resp (respirations) even and unlabored. Bed in lowest position. Floor mat at bedside. VS (Vital Signs) wnl (within normal limits). No SOB (Shortness of Breath). MA (Moves All) extremities. PERL (Pupils Equal and Reactive to Light). Call light within reach. CT (Computed Tomography scan) of head and spine done with no findings. R2's Nurse's Note dated 5/22/25 at 4:34 PM documents CNA called for this nurse to entrance hallway. (R2) noted to be laying on R side in fetal position, DON (Director of Nursing) sitting at head, blood noted to be coming from head. Applied pressure w/ (With) guaze [SIC]. Previous laceration site reopened at R (Right) eyebrow, laceration noted tobridge [SIC] of nose, nose noted to be slightly deviated to the R. Pressure dressing about [SIC] to laceration at eyebrow. (R2) nonverbal and unable to vocalize what happened or if he was in pain. CNA states resident refused to extend legs and remained in fetal position when got out of bed for dinner, and en route to dining room, (R2) leaned forward and fell out of w/c (wheelchair). EMS (Emergency Medical Services) called for transport to (Local Hospital) ER for eval (Evaluation) and treatment. EMS place c-collar upon arrival. (R2) assisted to stretcher x4 staff. MD notified. attempted to notify POA (Power of Attorney), no answer at this time, voicemail left to return phone call to facility. RCA (Root Cause Analysis): (R2) in fetal position in w/c, leaned forward, and fell. Immediate intervention: resident sent to (Local Hospital) ER for eval and treatment, (R2) will use geri chair (reclining chair with wheels) upon return as he is unable to self-propel. R2's Nurse's Note dated 5/22/25 at 10:16 PM documents (R2) returned back to facility via Ambulance from (Local Hospital) at 2208 (10:08 PM). (R2) has 6 sutures to the R eyebrow and a laceration to the bridge of the nose. CT of the facial bones, head and spine all came back as no acute fx (fracture). (R2) vs wnl and stable at this time. Resp even and unlabored. POA notified. MD notified. Sutures to be removes [SIC] in 1 week on 5/29. Keep area clean and monitor for any s/s (signs and symptoms) of infection u/h (until healed). Bed in lowest position. Floor mat at bedside at this time. Call light within reach. R2's Nurse's Note dated 5/23/25 at 1:21 AM documents Alert with baseline confusion. PERL. Moves all extremities at this time. Hand grasp equal. Pain expressed when site to R eyebrow or nose is touched. R2's Nurse's Note dated 5/27/25 at 11:26 AM documents On 5/22/25 at approximately 1630 (4:30 PM) (R2) had a fall from wheelchair. (R2) was assessed for injury, ROM (Range of Motion) and pain. (R2) was noted to have a laceration to the R eyebrow. MD, and POA notified. MD order to send resident to ER. (R2) returned with 6 sutures to R eyebrow area and per CT possible anterior mandible fracture vs. variant anatomy, no findings of acute facial bone fracture. Investigation was immediately initiated. During the investigation it was found that while the resident was being assisted to dining room, he put his foot down and fell forward. Resident is not educatable related to BIM of 99, upon his return the immediate intervention is assist to geri recliner (reclining chair on wheels) as he keeps his positioning in knees up/fetal position and occassionally [SIC] puts feet down, he also leans forward frequently, he is unable to propel self so thichair [SIC] would not be a restraint. R2's hospital records dated 5/22/25 at 5:19 PM documents under Physical Exam, Skin: Laceration to right forehead, eyebrow, and bridge of nose. In the same document under Laceration Repair, it documents Face location: right eyebrow, Length: 2.3 centimeters, and Depth: 1 millimeter. Layers/structure repaired: Deep dermal/superficial fascia number of sutures: 2 and Skin repair number of sutures: 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 13 of 17 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 06/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few In the same document it documents under Medical Decision Making: laceration repaired with suture to face and adhesive skin over bridge of nose without complication. Final Impression: 1. Laceration of multiple sites of face, 2. Contusion of face due to delivery. On 6/5/25 at 10:45 AM, V21 (CNA) stated she was pushing R2 on 5/22/25 when he fell forward out of his wheelchair. V21 stated she was pushing him to dinner and all his weight shifted forward then he fell forward out of the wheelchair, and she doesn't remember if he had foot pedals on the wheelchair. V21 stated the back of the reclining wheelchair was straight up and not reclined when she was pushing him when the fall occurred. On 6/6/25 at 7:44 AM, V1 (Administrator) stated R2 did not have foot pedals on his wheelchair, and he did not propel himself around in his wheelchair. V1 stated he would keep his feet pulled up under his chair and she didn't think foot pedals would be appropriate. On 6/6/25 at 7:46 AM, V2 (Assistant Director of Nursing) stated R2 did not propel himself in his wheelchair and she didn't think foot pedals on his wheelchair would work because he pulls his feet under the chair. On 6/6/25 at 9:30 AM, V4 (Rehab Director/Physical Therapy Assistant) stated R2 had a high back wheelchair that reclined, and they added a neck support to it to help with posture. V4 stated when he was eating the chair should be sitting straight up and other times it should be reclined for comfort and safety. V4 stated he didn't have the body strength to sit straight up on his own, his hip tendons were getting tight so that made him lean forward. V4 stated he was also getting contractures in his hips and knees making him lean forward and making his feet go back under the chair. V4 stated the wheelchair should be reclined for safety and comfort unless eating. A facility policy titled Fall Management dated 2019 documents under Standards: 3. Safety interventions will be implemented for each resident identified at risk using a standard protocol, 4. The admitting nurse and assigned CNA and/or designees are responsible for initiating safety precautions at the time of admission. Facility staff are responsible for assuring ongoing precautions are put in place and consistently maintained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 14 of 17 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 06/09/2025 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 provide sufficient staff to meet resident's needs. These failures have the potential to affect all 63 residents living in the facility. Findings include: 1.R1's admission Record, dated 06/06/25 documents an admission date of 04/28/25 to the facility with diagnoses in part of Type 2 diabetes mellitus, emphysema, chronic obstructive pulmonary disease, diarrhea, anxiety disorder, major depressive disorder, and heart failure. R1's MDS (Minimum Data Set) dated 05/05/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 is cognitively intact. Section GG documents that R1 is dependent for toileting, showers, and personal hygiene. R1's Care Plan dated 05/28/25 documents a focus area titled Activities: R1 is dependent on staff for activities, cognitive stimulation and social interaction r/t (related to) limited mobility. On 06/03/25 at 10:49AM, R1 stated that sometimes it takes staff 30 minutes or more to answer his light. On 06/05/25 at 8:30AM, R1 stated that he believes the facility is short on staff. R1 said he feels that they are short on staff especially on day shift. R1 said he does get a shower maybe once a week and he thought he was supposed to be getting two showers a week. R1 said that he doesn't know if he isn't getting showers because they are so short of staff. 2. R5's admission Record, dated 06/06/25, documents an admission date of 01/26/25 with diagnoses in part of chronic obstructive pulmonary disease, type 2 diabetes mellitus, obesity, non-pressure chronic ulcers of other part of right foot with fat layer exposed, lymphedema, and chronic kidney disease. R5's MDS dated [DATE] documents in Section C a BIMS score of 15 which indicates R5 is cognitively intact. Section GG documents that R5 requires substantial/ maximum assistance with toileting, bathing, and personal hygiene. R5's Care Plan documents a focus area with a revision date of 05/07/25 of Falls: R5 is at risk for falls and another Focus area of Skin: R5 is at risk for pressure injury. On 06/04/25 at 3:27PM, R5 stated that he has had to wait over 30 minutes to get someone to help him. R5 said that there have been times when it has even taken them up to an hour to come assist him. R5 said that he thinks sometimes they have enough help and other days they don't. R5 said that sometimes he doesn't get his showers like he is supposed to. R5 said he doesn't know if it is because they don't have enough help or why he doesn't get his showers. 3. R6's admission Record dated 06/06/25, documents an admission date of 04/11/23 to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, transient cerebral ischemic attack, retention of urine, aphasia, and chronic kidney disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 15 of 17 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 06/09/2025 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 R6's MDS dated [DATE] documents in Section C a BIMS score of 03 which indicates R6 is severe cognitive impairment. Section GG documents that R6 is dependent for toileting, bathing, and personal hygiene. R6's Care Plan has a focus area of R6 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) hemiparesis to the right side following CVA (Cerebral Vascular Accident). R6 has weakness to the RUE (Right Upper Extremities) and RLE (Right Lower Extremities) which is dominant. On 06/03/25 at 1:54PM, V19 (Family Member) said that she is having problems with R6 getting his showers like he is supposed to. V19 said that a lot of the times that R6 doesn't get his showers. V19 didn't know if they have enough staff, she feels like they are short of staff at times. 4. R7's admission Record dated 06/06/25, documents an admission date of 05/20/25 to the facility with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, type 2 diabetes mellitus, presence if cardiac pacemaker, and old myocardial infarction. R7's MDS dated [DATE] document in Section C a BIMS score of 13 which indicates R7 is cognitively intact. Section GG documents that R7 requires set-up and supervision with toileting, bathing, and personal hygiene. R7's Care Plan documents a focus area of R7 has an ADL deficit related to needing assistance with ADL's related to dx (diagnosis) of hemiplegia and hemiparesis following CVA affecting the left non-dominant side with a revision date of 5/20/25. R7 is able to feed himself with set-up assistance only. R7 requires weight bearing assistance with most ADL's. R7 uses a wheelchair for locomotion and is able to propel himself. On 06/05/25 at 10:08AM, R7 stated that he thinks the facility is short of staff especially on day shift. R7 said that sometimes they have a lot of staff and other days they have hardly any. On 06/03/25 at 1:15PM, V9 (Certified Nurse Assistant/CNA) stated that they are short of staff often. V9 stated that she tries her best to get her job done to the best of her ability. V9 stated that they have a hard time making sure all the residents get their showers done when they are supposed to. V9 said that she doesn't feel like the facility has enough staff to properly care for the residents. On 06/03/25 at 2:32PM, V12 (CNA) stated the facility could use some more staff. On 06/04/25 at 12:06PM, V10 (CNA) stated the facility is always short of staff. V10 stated they did get some new hires, but they would let them leave early and then you would be short again and sometimes they wouldn't even let you know that staff had left and you have to cover the other hall. V10 said she would be working one hall then they would let someone leave on the other hall and she didn't know she had to cover both halls which is very hard to do. V10 said that she would have a hard time making sure all the resident showers got done because they didn't have enough staff. V10 said that she always tried to do the best she could to care for the residents. On 06/04/25 at 1:46PM, V13 (CNA) stated that the facility is frequently short of staff. V13 said that the shortage of staff has been more frequently. V13 said that the 7AM to 7PM shift used to have 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 16 of 17 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 06/09/2025 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 staff on each hall, but lately they have only had 2 staff members. V13 said that it is hard to make sure that all the care for the resident is done. V13 said that she heard that they let people go home early or other times they just don't have the staff. V13 said that she has never witnessed the staff going home early they just usually don't have staff when she was working. V13 said that she tries her best to get all the residents showers done when they are short, but she has had to pass the showers on to the next shift a couple of times and she doesn't know if they got done or not. On 06/04/25 at 2:10PM, V14 (CNA) said that they are not short but could use extra staff especially on days when they have call ins and no one to cover. V14 said that staffing is like a roller coaster sometimes you have staff other times you don't. V14 said when she works that she always makes sure to get showers and resident care done. V14 said that she might have to push off charting and she will let the next shift know she didn't get charting done and see if they will chart for her so she can get the resident care done. On 06/05/25 at 8:00AM, V1 (Administrator) stated that the current census at the facility is 63 residents. V1 said that the facility assessment tool was completed for today with 63 resident and it shows that the facility should have a 108 hours of nurse aide time in a day. V1 said that there are days the facility does not have 108 hours of nurse aide hours. On 06/05/25 at 9:20AM, V2 (Assistant Director of Nursing) stated when they have 4 certified nurse assistants on days that she feels like they could take care of all the residents that it might be a little bumpy, but she thinks they could do it. V2 said that they would like more staff, but it is hard to find new staff. V2 said that she doesn't update the daily assignment sheet to show when staff go home or leave early or when staff quit and didn't show up to work. V2 said that on 5/23/25 on the 7AM to 7PM shift that they only had 3 CNA's and one new girl doing orientation on day shift. V2 said that it was probably not enough staff to be able to care for the residents. On 06/06/25 at 10:00AM, V1 stated that the facility does not have a policy on staffing. The facility schedule for May 11- June 8, 2025, documents for the day shift 7AM to 7PM shift 4 CNA's on 06/01/25, 05/31/25, 5/17/25 and 3 CNA's and an orientee on 05/23/25. The facility schedule for night shift 7PM to 7AM documents 2 CNA's for 06/06/25, 06/05/25, and 5/21/25. The Midnight Census report dated 06/03/25 documents a census of 63. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146006 If continuation sheet Page 17 of 17