Health inspection·September 9, 2022

F 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 of 8 residents (R22) reviewed for comprehensive assessments in a sample of 29. Residents Affected - Few Findings include: R22's admission Record documented, admission date of 7/30/2022 and initial admission date of 10/8/2022. Diagnosis included, Pressure ulcer of right elbow, stage 4 effective and Pressure Ulcer of sacral region, stage 4. R22's Minimum Data Set (MDS) dated on 7/18/2022 documented in part, section c. Brief Interview for Mental Status (BIMS) a score of 00 which indicates severe cognitive impairment. The Section G. for Functional Activities of Daily Living (ADL) assessment documented resident required extensive assistance of 2 staff for bed mobility, transferring, and toileting. On Section M. skin assessment resident was at risk for pressure ulcer development and no pressure ulcers or other skin issues were present. R22's Initial Skin Alteration Record dated on 7/18/2022 documented in part, wound to right elbow measuring 2 x 2 centimeter non blanchable ulcer with some slough and open. Stage 2, pressure injury, wound bed pink, slough (yellow/stringy/gray). Comments: Resident being sent out to hospital for Covid related symptoms. Signed by V7 (previous Director of Nurses). R22's Hospital Records dated on 7/30/2022 documented in part, Discharge Summery, Physical Exam: Skin: right elbow and sacrococcygeal area pressure injury pictures noted in Electronic Medical Record (EMR). R22's Physician Orders Sheet (POS) dated on 7/30/2022 documented in part, Barrier cream to buttocks as needed for minor skin irritation due to episodes of bowel and bladder incontinence. Every 6 hours for excoriation. R22's MDS dated on 8/3/2022 documented, on section G. totally dependent for bed mobility, and transfers. Section M. Skin assessment Documented 1 unstageable pressure ulcer had acquired in the hospital. Section M did not document any other skin issues were present. On 9/8/2022 at 12:20 PM, V7 Previous Director of Nurses (DON) stated, she assessed (R22)'s right elbow on 7/18/2022 before he was sent to the hospital for Covid symptoms, and she may have documented a stage 2 pressure ulcer in error and was not sure what the stage of it was, but it could have been unstageable or a stage 3. V7 also stated, (R22) was very sick and sent out to the hospital for Covid (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 146092 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 146092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Integrity Hc of Herrin 1900 North Park Avenue Herrin, IL 62948 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)