Health inspection·August 7, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/07/2023, at 1:05 p.m., observed R17 in roommate's bed, (R1), sleeping with the covers pulled over her head. R17's medical record Profile Sheet documents that R17 was admitted to facility 10/22/2021 with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia, severe, with other behavioral disturbance. R17's Minimum Data Set (MDS) dated [DATE], documents Section C, a Brief Interview for Mental Status (BIMS) score of 00, indicating R17 has severe cognitive impairment. R17's Care Plan (7/13/2023) documents R17 has a behavior problem related to R17 is known to wander and lacks safety awareness. R17 is easily redirected by staff most of the time. R17 has a history of agitation related to dementia. On 8/2/2023, at 3:15 p.m., V2 (Director of Nursing), stated that the staff utilize a lot of redirection with R17 to keep her out of other residents' rooms. V2 stated that's all we can really do, she has dementia. V2 stated that it is hard to keep R17 occupied for any period of time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 2 of 28 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 08/07/2023 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure allegations of abuse were reported to the Administrator/designee immediately for 1 of 1 (R2) residents reviewed for abuse in the sample of 41. Findings Include: R2's admission Record with a print date of 8/7/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include unspecified convulsions, history of traumatic brain injury, muscle weakness, major depressive disorder, mild cognitive impairment, and unspecified mental disorder. R2's MDS (Minimum Data Set) dated 7/3/2023 documents a BIMS (Brief Interview for Mental Status) score of 05, which indicates a severe cognitive impairment. On 8/2/2023 at 8:45 AM, V6 (Certified Nursing Assistant/CNA) stated she worked on 7/28/2023, at night and during that shift, V14 (LPN/Licensed Practical Nurse) reported to V6 she witnessed on 7/24/2023, V15 (CNA) punch R2 twice in the head. V6 stated she reported this incident to V2 (Director of Nursing) on Saturday morning, 7/29/2023. On 8/2/23 at 1:09 PM, V14 (Licensed Practical Nurse/LPN) stated she had never witnessed a resident being hit by any staff member at the facility. V14 stated she was working on the night of 7/28/23 and tempers were a little high. V14 stated two CNA's (V6 and V15) got into a verbal argument on the morning of 7/29/23. V14 stated she told them to stop and there was no cursing or threatening on either side. V14 stated she doesn't know why V6 brought her name into it because she has never seen or said that she saw V15 hit R2. On 8/2/23 at 1:33 PM, V15 (CNA) stated she was not aware of an allegation of a resident being hit. V15 stated she hadn't been to work since 7/29/23. V15 stated she had never hit a resident. On 8/2/23 at 9:40 AM, V8 (CNA) stated she was taking R2 to the bathroom with V6 present, on 8/1/23. V8 stated R2 reported to them V15 (CNA) hit her in the head (date unknown) because she wasn't getting on the toilet fast enough. V8 stated R2 told her she couldn't tell anyone because V15 would hurt her if she did. V8 stated they reported it to V2 (Director of Nurses). On 08/02/23 at 9:35 AM, R2 stated no staff had ever hurt her in anyway. R2 stated she does have a hard time remembering stuff at times. R2 stated her mother used to hit her in the head and began to tear up. R2 stated when she has had problems with staff she reports it to administration and they will take care of it. On 8/2/23 at 1:56 PM, V2 (Director of Nurses) stated on 7/29/23 at approximately 6:15 AM she received a phone call at home from V6 and V6 sounded emotionally upset. V2 stated V6 told her V15 had yelled and cursed at her at the nurse's station. V2 stated V6 reported to her, V15 is mean and wanted to take her (V6) outside and fight her. V2 stated V6 reported no residents were around and/or heard the altercation. V2 stated she received another call from V6 around 1:00 PM on 7/29/23 and V6 stated to V2 that she had to report to her, V15 had yelled at and hit R2 in the head. V2 stated V6 reported it was the day V15 was working by herself (7/24/23). V2 stated V1 (Administrator) was out of town and she attempted to contact her but didn't hear back so she and V5 (MDS/Care Plan Coordinator) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 3 of 28 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 08/07/2023 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few started the process of the investigation with the assistance of another administrator. V2 stated she called the nurse working and told her to have V15 leave the floor. V2 stated they submitted the initial report and notified the police. On 8/2/23 at 3:35 PM, V1 (Administrator) stated she interviewed R2, V6, and V15 related to the allegation of abuse. V1 stated she told V6 she hadn't reported it right away and V6 confirmed to V1 that she hadn't. V1 stated her investigation was still ongoing at this time and she still had peer reviews to complete. The undated Final IDPH Incident and/or Abuse Notification documents, On 7/29/23 an allegation of abuse was reported by staff involving (R2). Nursing assessed (R2) for any injuries with none noted. An investigation immediately began. (V6) reported to (V2) that (V14) told her that she witnessed (V15) make contact with (R2). V14 denied the conversation and the incident ever occurred. She stated that (V6) was not accurate. (V15) denied the incident occurred. (R2) denied that any incident involving staff member had ever occurred. (R2) did not exhibit any new behaviors nor did she seem emotionally distressed. Based on a comprehensive investigation which included statements and interviews, abuse could not be substantiated citing conflicting information. Both (V14), (V15), and the resident denied that incident occurred .ID (Interdisciplinary Team) reviewed (R2's) clinical record which included behavior tracking, care plan, and medication records. In addition, a review of the incident/accident log, behavior tracking, grievance log, and the resident council meeting minutes was completed. (V15's) employment record was reviewed for disciplinary actions regarding abuse. None were noted. Her employment background check was updated along with the Healthcare Workers Registry Verification. No issues noted. (V6) was disciplined for failing to notify Administration of the incident in a timely manner. (R2) was monitored for any emotional distress or change in her demeanor. None noted. The facility Abuse Prevention Training Program dated 2022 documents, The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention Under Internal Reporting the program documents, 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 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 4 of 28 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 08/07/2023 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)

F 0610 Respond appropriately to all alleged violations. 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 a thorough investigation was completed after an allegation of abuse was reported to the facility for 1 of 1 (R2) resident reviewed for abuse in the sample of 41. Residents Affected - Few Findings Include: R2's admission Record with a print date of 8/7/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include unspecified convulsions, history of traumatic brain injury, muscle weakness, major depressive disorder, mild cognitive impairment, and unspecified mental disorder. R2's MDS (Minimum Data Set) dated 7/3/2023 documents a BIMS (Brief Interview for Mental Status) score of 05, which indicates a severe cognitive impairment. The undated Final IDPH Incident and/or Abuse Notification documents, On 7/29/23 an allegation of abuse was reported by staff involving (R2). Nursing assessed (R2) for any injuries with none noted. An investigation immediately began. (V6) reported to (V2) that (V14) told her that she witnessed (V15) make contact with (R2). V14 denied the conversation and the incident ever occurred. She stated that (V6) was not accurate. (V15) denied the incident occurred. (R2) denied that any incident involving staff member had ever occurred. (R2) did not exhibit any new behaviors nor did she seem emotionally distressed. Based on a comprehensive investigation which included statements and interviews, abuse could not be substantiated citing conflicting information. Both (V14), (V15), and the resident denied that incident occurred .ID (Interdisciplinary Team) reviewed (R2's) clinical record which included behavior tracking, care plan, and medication records. In addition, a review of the incident/accident log, behavior tracking, grievance log, and the resident council meeting minutes was completed. (V15's) employment record was reviewed for disciplinary actions regarding abuse. None were noted. Her employment background check was updated along with the Healthcare Workers Registry Verification. No issues noted. (V6) was disciplined for failing to notify Administration of the incident in a timely manner. (R2) was monitored for any emotional distress or change in her demeanor. None noted. On 8/2/2023 at 8:45 AM, V6 (Certified Nursing Assistant/CNA) stated that she worked on 7/28/2023, at night and during this shift, V14 (LPN/Licensed Practical Nurse) reported to V6 on 7/24/2023, she witnessed V15 (CNA) punch R2 twice in the head. V6 stated she reported this incident to V2 (Director of Nursing) on Saturday morning, 7/29/2023. On 8/2/23 at 1:09 PM, V14 (Licensed Practical Nurse/LPN) stated she had never witnessed a resident being hit by any staff member at the facility. V14 stated she was working on the night of 7/28/23 and tempers were a little high. V14 stated two CNA's (V6 and V15) got into a verbal argument on the morning of 7/29/23. V14 stated the told them to stop and there was no cursing or threatening on either side. V14 stated she doesn't know why V6 brought her name into it because she has never seen or said that she saw V15 hit R2. On 8/2/23 at 1:33 PM, V15 (CNA) stated she was not aware of an allegation of a resident being hit. V15 stated she hadn't been to work since 7/29/23. V15 stated she had never hit a resident and was trained on abuse/neglect. On 8/2/23 at 9:40 AM, V8 (CNA) stated she was taking R2 to the bathroom with V6 present, on 8/1/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 5 of 28 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 08/07/2023 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V8 stated R2 reported to them V15 (CNA) hit her in the head (date unknown) because she wasn't getting on the toilet fast enough. V8 stated R2 told her she couldn't tell anyone because V15 would hurt her if she did. V8 stated they reported it to V2 (Director of Nurses). On 08/02/23 at 9:35 AM, R2 stated no staff had ever hurt her in anyway. R2 stated she does have a hard time remembering stuff at times. R2 stated her mother used to hit her in the head and began to tear up. R2 stated when she has had problems with staff, she reports it to administration, and they will take care of it. On 8/2/23 at 1:56 PM, V2 (Director of Nurses) stated on 7/29/23 at approximately 6:15 AM she received a phone call at home from V6 and V6 sounded emotionally upset. V2 stated V6 told her V15 had yelled and cursed at her at the nurse's station. V2 stated V6 reported to her, V15 is mean and wanted to take her (V6) outside and fight her. V2 stated V6 reported no residents were around and/or heard the altercation. V2 stated she received another call from V6 around 1:00 PM on 7/29/23 and V6 stated to V2 that she had to report to her, V15 had yelled at and hit R2 in the head. V2 stated V6 reported it was the day V15 was working by herself (7/24/23). V2 stated V1 (Administrator) was out of town, and she attempted to contact her but didn't hear back so she and V5 (MDS/Care Plan Coordinator) started the process of the investigation with the assistance of another administrator. V2 stated she called the nurse working and told her to have V15 leave the floor. V2 stated they submitted the initial report and notified the police. When asked if anyone spoke with R2, V2 stated she spoke to R2 on 8/1/23. V2 stated she gave R2 enough information to let R2 know what they were talking about but R2 was unable to give any clear information. V2 stated she didn't know if anyone asked R2 about the allegation on the day it was reported, but V5 may have. V2 stated V15 has been suspended but V15 believes she was suspended because she and V6 got into an argument. On 08/07/23 at 10:13 AM, V5 (MDS Coordinator/LPN) stated she was notified by V2 they had a reportable on 7/29/23. V5 stated she spoke with R2 briefly on 7/29/23. V5 stated R2 appeared fine and is cognitively impaired so she didn't want to upset her. When asked if a physical assessment was done V5 stated, Just briefly. V5 stated she didn't see anything with the brief physical assessment. V5 stated her understanding was the alleged incident happened a few days earlier. V5 stated she knew R2 had a traumatic past and may bring that up. When asked if she had asked R2 if she had been physically harmed by a staff member, V5 stated she asked R2 if she was doing ok. V5 stated R2 was doing a puzzle in the dining room and other staff seemed to think it was over an issue with two employees, so she didn't want to upset the care environment. When asked where an assessment of R2 would be documented if someone had assessed her, V5 stated it would be on her risk assessment that was completed by V2. V5 provided the risk assessment report with no title, dated 7/29/23 to this surveyor and it documented, DON (Director of Nurses/V2) notified by CNA of alleged abuse of resident (R2) by another staff member. Resident showing no s/s (signs/symptoms) of injury or emotional distress as assessed by V5 (MDS) that day of report. Resident unable to give description. On 8/7/23 at 10:41 AM, V5 stated she didn't do a full body assessment of R2 after the allegation of abuse was reported. R2's progress notes did not document an assessment or documentation related to the allegation of abuse. R2's assessments tabs in the Electronic Health Record did not document an assessment related to the allegation of abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 6 of 28 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 08/07/2023 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/2/23 at 3:35 PM, V1 (Administrator) stated she interviewed R2, V6, and V15 related to the allegation of abuse. V1 stated she interviewed R2 on 7/31/23 and again on 8/1/23. V1 stated R2 was talking about a history of abuse with her mother. V1 stated she interviewed V15 on 7/31/23 and V2 spoke with V15 and V6 on 7/29/23. V1 stated when V2 reported the allegation to her on 7/29/23 she told her she let V15 assume she was suspended for an issue with V6. V1 stated she made V15 aware of the allegation of abuse. V1 stated her investigation was still ongoing at this time and she still had peer reviews to complete. Review of the peer interviews documents peers (staff and residents) were asked the following question, Have you witnessed V15 (CNA) act physically inappropriate with R2. All of the responses are documented as no. There are no other peer interview questions documented. On 08/07/23 at 11:35 AM, V9 (Regional Director of Clinical Operations) stated she would expect a skin assessment and an emotional assessment to be done as soon as an allegation of abuse was reported. V9 stated it didn't matter if the abuse was alleged to have occurred several days prior to the report. The facility Abuse Prevention Training Program dated 2022 documents, The objective of the Abuse Prevention Program is to comply with the seven-step approach to abuse and neglect detection and prevention Under Investigation the program documents, As soon as possible after an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designees will initiate an investigation into the allegation which may include the following elements: Interviewing all persons who may have knowledge of the alleged incident, including, but not limited to: All persons who reported the suspicion, allegation or incident; The alleged victim (if the victim is unable to be interviewed, this shall be documented); The alleged perpetrator (if the alleged perpetrator is a resident who cannot be interviewed, this shall be documented); Any witnesses or potential witnesses to the alleged occurrence or incident; Any staff having contact with the resident during the period of the alleged incident; Roommates, other residents, family or visitors; A review of the medical record, including care plan; A review of all circumstances surrounding the incident; and Physicians will be notified of any incident and any medical treatment will be done as ordered Under Final Report and Follow Up the program documents, Report Contents. The final report shall include the following, as appropriate: name, age, diagnosis, and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated; the original allegation (note day, time, location, the specific allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence and any noted injuries) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 7 of 28 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 08/07/2023 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)

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 residents received incontinence care and showers for 2 of 2 (R36 and R87) residents reviewed for Activities of Daily Living (ADL's) in the sample of 41. Residents Affected - Few Findings Include: 1. R87's admission Record dated 8/1/23 documents R87 was admitted to the facility on [DATE] with diagnoses that include traumatic hemorrhage of cerebrum, disorientation, sepsis, nontraumatic subarachnoid hemorrhage, heart failure, hypertension, and hypothyroidism. R87's MDS (Minimum Data Set) dated 6/11/2023 documents R87 has a BIMS (Brief Interview for Mental Status) score of 00, which indicates R87 has a severe cognitive deficit. R87's MDS documents under Section G, R87 requires extensive assistance of two staff for toileting. R87's undated care plan documents a Focus Area of, (R87) has an ADL Self Care Performance Deficit r/t (related to) Confusion, Impaired balance, Limited Mobility, and falls. This focus area has an initiation date of 6/16/2023. The interventions documented for this focus area include, Toilet Use: (R87) requires, assistance wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet to use toilet (sic). R87's progress notes dated 7/9/23 document R87 was transferred to the local hospital emergency room via emergency medical services for evaluation of possible dehydration related to diagnosis of clostridium difficile (C-diff). On 7/31/23 at 7:05 PM, V20 (local hospital-Registered Nurse) stated she provided care to R87 when he was transferred from the facility to the local hospital emergency room on 7/9/23. V20 stated R87 had a diagnosis of C-diff/diarrhea and upon admission to the emergency room, R87 was covered in dried feces. V20 stated it took several hospital staff an hour to clean the feces off R87. V20 stated the feces was dried so she knew it had been on R87 for a while. V20 stated the emergency medical technicians (EMT's) knew R87 had feces on him when they transported R87 to the hospital. When asked if it was documented in R87's hospital records that he had dried feces on him when he arrived at the emergency room, V20 stated she should have but didn't document it in R87's hospital record. On 08/01/23 at 4:07 PM, V21 (Paramedic) stated he remembered the facility telling him to wear gloves when he transported R87. V21 stated he remembered R87 wasn't cleaned prior to him being transported. V21 stated he also remembered the nurse at the emergency room asking his partner why they weren't wearing gloves since R87 had C-diff and there was feces present on R87. When asked if it would be documented if R87 was incontinent while on the ambulance, V21 stated it would and he knew R87 had not been incontinent of bowel while in the ambulance. On 8/2/23 at 3:54 PM, V16 (Hall Monitor) stated he normally worked night shift and he couldn't remember if he was working on the night of 7/9/23. V16 stated he didn't really go in and provide care to the residents, so he didn't have any specific knowledge related to R87's care and/or needs. On 8/3/2023 at 4:05 PM, V17 (Certified Nursing Assistant/CNA) stated he was working and provided care to R87 on the night of 7/9/23, when R87 was transferred to the hospital. V17 stated C-diff was wreaking havoc on R87 and the nurse (V22) and himself were worried about R87 being dehydrated. V17 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 8 of 28 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 08/07/2023 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated on 7/9/23 he did rounds when arriving to work and reported to V22 that R87 looked worse than he did when V17 had last worked. V17 stated V22 asked him to make sure R87 got plenty of fluids and so he was offering him drinks often. V17 stated then V22 told him R87 needed to go to the hospital for evaluation and so he cleaned R87 up and then the EMT's were there to transport him to the hospital. V17 stated he couldn't remember who was working with him on that night, but believed it was him and another CNA. V17 stated he didn't remember if it was V16 (Hall Monitor) V17 stated V16 is a Hall Monitor and can't do resident care. V17 stated he had worked with V16 and a nurse before. V17 stated when that happens, they do the best they can to provide the needed care. When asked what care doesn't get provided when he is working with V16 and a nurse, V17 stated, I can't do bed checks like I should. V17 stated he tries to do a minimum of three bed checks but when he is working with just V16 and a nurse, he does good to do two bed checks. The CNA and Hall Monitor Schedule dated July 2023 documents on 7/9/23 V17 worked with V16 (Hall Monitor) from 6 PM to 6 AM. On 08/01/23 at 5:01 PM, V22 (Registered Nurse/RN) stated she couldn't remember if R87 had an incontinence episode prior to being transferred to the hospital on 7/9/23. On 08/07/23 at 8:35 AM, V23 (CNA) stated she didn't remember working on the evening R87 was sent to the hospital. V23 stated she remember R87 had declined and had diarrhea but was not able to provide information related to the care R87 was provided prior to being transferred to the local hospital on 7/9/23. On 8/2/23 at 1:56 PM, V2 (Director of Nurses/DON) stated she had not been made aware of any concerns/complaints of a resident being transferred to the hospital with dried feces on them. When asked if it was possible for someone to go to the hospital with dried feces on them, V2 stated, Yes. On 8/2/23 at 3:35 PM, V1 (Administrator) stated she was not aware of any complaints/concerns residents weren't being provided timely incontinence care. 2. R36's admission Record with a print date of 8/1/23 documents R36 was admitted to the facility on [DATE] and discharged on 6/13/23 with diagnoses that include diabetes, sepsis, muscle weakness, kidney failure, heart disease, and acquired absence of left and right legs above the knee. R36's MDS dated [DATE] documents R36 had a BIMS score of 15, which indicates R36 is cognitively intact. This same MDS documents under Section G that R36 is totally dependent on staff for bathing. R36's undated Care Plan documents a Focus Area of (R36) has an ADL Self Care Performance Deficit r/t (related to) R36 requires weight bearing assist with ADL's. R36 is a bilateral amp (amputee) to both LE (lower extremities). (R36) uses a trapeze for positioning while in bed. (R36) continues to work with therapy for slide board transfers. This focus area has an initiation date of 6/9/23. The interventions documented for this Focus Area include, (R36) is totally dependent on staff to provide a bath 2x/wk (times per week) and as necessary. On 8/2/23 at 10:40 AM, V4 (Licensed Practical Nurse/LPN) stated they are short staffed all the time. V4 stated there are times she has one CNA (Certified Nursing Assistant) and herself providing care to the residents. When asked if there was care that didn't get provided when she was working with less CNA staff, V4 stated, showers, bed checks, ADL's. V4 stated the residents just don't get the proper care. On 8/2/23 at 1:09 PM, V14 (LPN) stated staffing was hit or miss. V14 stated some shifts are staffed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 9 of 28 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 08/07/2023 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few really well and then the next day they may have a couple of call ins. V14 stated she had worked with just one CNA. When asked if everyone was provided with necessary care, V14 stated they were but it was not as much as she would have preferred. When asked if residents were given showers, V14 stated showers weren't done on that shift. Review of R36's electronic health record did not document showers/baths were provided throughout R36's stay at the facility. On 08/02/23 at 12:50 PM, V9 (Regional Director of Clinical Operations) stated they were unable to locate documentation R36 had received showers/baths. On 8/7/23 at 11:41 AM, V9 stated they don't have an ADL policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 10 of 28 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 08/07/2023 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 wounds were identified, assessed, and treated for 2 of 2 (R36 and R87) residents reviewed for wounds. The facility failed to ensure appointments with a specialist were obtained for 1 of 1 (R25) resident reviewed for infection control in the sample of 41. Residents Affected - Few Findings Include: 1. R87's admission Record with a print date of 8/1/23 documents R87 was admitted to the facility on [DATE] with diagnoses that include traumatic hemorrhage of cerebrum, sepsis, non-traumatic subarachnoid hemorrhage, heart failure, hypothyroidism, hypertension, history of falls, and a cardiac pacemaker. R87's MDS (Minimum Data Set) dated 6/11/23 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates a severe cognitive deficit. R87's undated Care Plan documents a Focus Area of, (R87) is incontinent of B&B (bowel and bladder) and requires assist with ADL's (Activities of Daily Living). (R87) currently has no pressure wounds. (R87's) skin is fragile. Date Initiated: 6/16/23. The interventions for this focus area include, 7/5/23 tx (treatment) as directed to blister on left heel 6/16/23- follow facility policies/procedures for the prevention/treatment of skin breakdown, 6/16/23 inform (R87)/family/caregivers of any new area of skin breakdown' 6/16/23monitor/document/report to MD (physician) PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. R87's progress notes dated 7/9/23 at 7:00 PM documents, Called V18 (Physician) regarding (R87) order for bumex 2 mg (milligrams). (R87) is still having loose stools. Monitoring for signs of dehydration. VS (vital signs) 96.8- 74- 22- 99% on RA (room air)- 101/60. Received order to D/C (discontinue) bumex and have CMP (comprehensive metabolic panel) and CBC (complete blood count) with Diff (differential) drawn in AM (morning). Call results to V18. Remains on contact isolation. In bed at this time. Cont (continue) with plan of care. R87's progress notes dated 7/9/23 at 8:24 PM documents, V18 called back, and V/S were given to him. Order to send to hospital for dehydration related to C-diff (Clostridium difficile) infection. Also (R87) still actively having watery stools. Called V2 RN, DON (Registered Nurse/Director of Nurses) and gave her the info (information) also. On 7/31/23 at 7:05 PM, V20 (local hospital/Registered Nurse) stated she provided care to R87 at the hospital emergency room on 7/9/23. V20 stated R87 had wounds/open areas on his left heel, spine, coccyx, groin, penis, and testicles. V20 stated the assessment of the areas would be located in R87's hospital medical record. R87's local hospital record with an admission date of 7/9/23 documents the following wounds that were all present on admission to the hospital; penis- described as yellow, crusted wound with no measurements documented. groin- described as moist pink wound with no measurements documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 11 of 28 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 08/07/2023 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)

F 0684 medial back- described as pink wound, with no measurements documented. Level of Harm - Minimal harm or potential for actual harm heel- described as moist, black, red, shallow, shiny blister with no measurements documented. coccyx- described as pink, red, blanchable wound with no measurements documented. Residents Affected - Few On 08/01/23 at 4:07 PM, V21 (Paramedic) stated he transported R87 from the facility to the local hospital on 7/9/23. V21 stated the facility did not report any wounds to him prior to transporting R87. On 08/01/23 at 5:01 PM, V22 (RN) stated the facility did weekly skin assessments on R87 and he had skin tears on his arms that he would pick at and a pressure ulcer/blister to his left heel that was being treated at the facility. On 8/2/23 at 8:28 AM, V6 (Certified Nursing Assistant/CNA) stated the only wound R87 had prior to going to the hospital was the area on his heel and some skin tears. On 8/2/23 at 9:40 AM, V8 (CNA) stated R87 had wounds on his heel and arms and had what looked like herpes blisters on his penis. V8 stated she had another CNA look at it and reported it to an unknown nurse. On 8/2/23 at 10:40 AM, V4 (Licensed Practical Nurse/LPN) stated R87 had a wound on his heel and skin tears but she didn't recall any other wounds. On 8/2/23 at 1:09 PM, V14 (LPN) stated she didn't remember any wounds on R87's testicles, groin, back, or coccyx. On 8/3/2023 at 4:05 PM, V17 (CNA) stated he provided care to R87 on 7/9/23 and assisted in getting R87 ready for transfer to the local hospital. V17 stated he didn't remember any wounds other than the one on R87's heel and the skin tears. On 08/07/23 at 8:35 AM, V23 (CNA) stated R87 had sleeves on his arms because his skin would tear very easily. V23 stated they turned and repositioned R87 and used wedges to off-load him. V23 stated she didn't remember R87 having any wounds/pressure ulcers. R87's shower sheets dated 6/7/23, 6/21/23, 6/24/23, 6/28/23, and 7/5/23 document no new skin breakdown areas. R87's Initial Skin Alteration Record dated 3/29/23 documents, (R87) has multiple scabbed areas to BUE/BLE (bilateral upper extremities/bilateral lower extremities) et (and) abrasions to right elbow r/t (related to) falls @ (at) home. Noted dark purple sized area to mid abdomen. R87's Initial Skin Alteration Record dated 6/8/23 documents, Has scabby areas that are covered by dressing from (name of local hospital). (R87) picks at there (sic) areas constantly. Skin very dark and scaly bilateral forearms. R87's Initial Skin Alteration Record dated 6/25/23 documents, (R87) has multiple scabbed areas and S.T. (skin tear). (R87) has pulled off steri-strips and made into open areas on BUE. Tx (treatment) cont (continues) as prior to hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 12 of 28 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 08/07/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R87's Initial Skin Alteration Record dated 7/5/23 documents, appears to be ruptured blister to the left heel with skin remaining over the area that can be moved. The date of onset is documented as 7/5/23 and the area is measured at 3 x 3 cm (centimeters). The treatments are documented as provide relief on bed, turning and repositioning, wound care. R87's Initial Wound Evaluation and Management Summary dated 7/6/23 documents, At the request of the referring provider . a thorough wound care assessment and evaluation was performed today Details about current wound(s) and any skin conditions are outlined below Under Focused Wound Exam (Site 1) the summary documents a Stage 3 pressure wound of the left heel that measures 6 x 4 x 0.1 centimeters (cm). The summary documents treatment orders for calcium alginate and betadine to be applied daily and documents a surgical debridement was done. Under Focused Wound Exam (Site 2) the summary documents a skin tear on the left forearm that measured 2 x 2 x not measurable cm. The summary documents treatment orders for calcium alginate, collagen powder, and silver sulfadiazine (SSD) to be applied daily. R87's Order Summary Report dated 8/1/23 documents the following physician orders; 7/5/23 apply betadine, calcium alginate to left heel and wrap with kerlex daily and 7/5/23 apply SSD, collagen, and calcium alginate to skin tear and cover with border gauze daily. On 8/2/23 at 1:56 PM, V2 (Director of Nurses) stated she was aware of the wound on R87's heel and skin tears. When asked if she was made aware of any other wounds prior to R87 being transferred to the hospital on 7/9/23, V2 stated she had heard the wound specialist say that when someone is actively dying their skin can break down within an hour or two. When asked if she had the impression R87 was actively dying prior to being transferred to the hospital V2 stated she didn't. On 8/2/23 at 3:35 PM, V1 (Administrator) stated she had never received a complaint or a concern that residents were not receiving wound care. V1 stated she would expect the nursing staff to follow the clinical standards of practice for wound care. 2. R36's admission Record with a print date of 8/1/23 documents R36 was admitted to the facility on [DATE] and discharged from the facility on 6/13/2023. This same admission Record documents R36 was admitted with diagnoses that include sepsis, acquired absence of right and left leg above the knee, kidney failure, anemia, heart failure, peripheral vascular disease, and diabetes. R36's MDS dated [DATE] documents a BIMS score of 15, which indicates R36 was cognitively intact. This same MDS documents under Section G, R36 requires assist of two staff for dressing, bathing, transferring, and toileting. R36's Order Summary Report dated 8/1/2023 documents a physician order for a weekly skin check but does not document any wound treatment orders. R36's undated Care Plan documents a Focus Area of, (R36) has Amputation of r/t (related to) (sic) of both lower ext (extremities). (R36) recently had a R (right) AKA (above the knee amputation). This focus area as an initiation date of 6/9/23. The interventions for this focus area includes, Check and document on wound daily for s/sx (signs/symptoms) of infection, drainage, bleeding, any breakdown of skin and impaired circulation (edema or pain). Date Initiated: 06/09/2023. On 8/2/23 at 8:28 AM, V6 (Certified Nursing Assistant/CNA) stated R36's surgical incision to right knee looked really bad in the week prior to being transferred to the hospital on 6/9/23. V6 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 13 of 28 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 08/07/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R36 would throw himself on to the floor and scoot around. V6 stated the incision was dirty looking. V6 stated they would try to keep it clean and R36 would get it dirty again. V6 stated the incision line was ripped open so you could see the inside of his (R36's) flesh showing. V6 stated the incision looked like this longer than a couple of days. V6 stated the nurses were aware of it. On 8/2/23 at 9:40 AM, V8 (CNA) stated R36's surgical incision to the right knee looked, bad. V8 stated it was partially open and looked infected. When asked what the nursing staff was doing to treat the area, V8 stated, I don't think anything. V8 stated she didn't think they were doing anything because R36 wouldn't stay in the wheelchair and liked to pull himself around on the floor. V8 stated she thought the area always looked like that but began to look worse. On 8/2/23 at 10:40 AM, V4 (Licensed Practical Nurse/LPN) stated she was working on 6/9/23 when R36 was sent to the hospital but V2 (Director of Nurses) assessed and sent R36 to the hospital. V4 stated the surgical incision line was closed up and she never saw any drainage from the area. V4 stated they weren't doing a treatment and she would assume they would do one if the area was opened. On 8/2/23 at 9:17 AM, V7 (CNA) stated R36's surgical incision to his right knee was open a smidge and had pus in it but was unable to recall when she last saw it. On 8/2/23 at 1:09 PM, V14 (LPN) stated when R36 first admitted to the facility the surgical incision line looked red. V14 stated by the time R36 was transferred to the hospital on 6/9/23 the area looked infected. V14 stated it was her understanding the facility wound specialist was going to see R36 when he did rounds at the facility. V14 was unable to recall who told her the wound specialist was going to see R36 and/or when he would be seen. V14 stated R36 was very reluctant with care so a lot of time it was just a quick look in his room. V14 stated it was just a visual assessment that she was not able to complete a physical assessment of the area. R36's Progress Notes were reviewed from 5/24/23 to 6/13/23 and document the following: 5/24/23, Resident (R36) admitted to this facility via EMS (Emergency Medical Services) from (name of regional hospital) .(R36) is a Bilateral AKA with most recent amputation on 05/21/23. Assessment reveals there are 31 intact staples to operative incision; free of s/s infectious process; no drainage or edema noted . 5/25/23, (R36) in low bed for safety precautions. Is double amputee. Rt (right) AKA with surgical incision with surgical staples intact. Incision is well approximated and has no drainage. Receives Norco for post surgical pain. Is effective for pain at surgical site RT AKA is open to air. Call light in reach. Did go to ER (emergency room) today for eval (evaluation) regarding mood. Cont (continue with plan of care.) 5/28/23, (R36) in low bed for safety precautions. Is double amputee. Incision RT amputee staples intact and well approximated. Open to air. Has been deconstructing room. 5/29/23, Incision RT amputee staples intact and well-approximated. Resident is a double amputee. Resting quietly at this time. 5/29/23, Staples to R stump intact. No s/sx of infection noted. Resting comfortably with call light in reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 14 of 28 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 08/07/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5/29/23, Staples to R stump dry/intact, no s/s of infections noted. PRN (as needed) pain medication given for pain control w/(with) fair results. Resident frequently refuses care and becomes very agitated w/staff. (R36) is not easily redirected . 5/31/23, This DON (Director of Nurses) was in (R36's) room discussing his future plans when he stated he was going to electrocute himself with the call light cords. He said he was going to die. Sad persons scale completed with a score of 9. (name of physician) consulted and ordered psych eval at (name of hospital). (name of physician) also ordered this nurse to communicate to the (name of hospital) that the patient had AKA on 5/21 and needed evaluation of surgical site for staple removal. RN (Registered Nurse) called (name of hospital) nurse to give thorough report. 911 called for ambulance . 5/31/23, (R36) returned at 1920 (7:40 PM) per EMS from (name of hospital) Staples removed and steri strips applied. RN stated that (R36) stated that he will not keep them on 6/1/2023, (R36) in bed. Call light in reach. RT AKA incision well healed. Steri Strips intact. Incision is dry . 6/1/23, (R36) post amputation. Wound edges well approximate. (R36) cont (continues) to have behaviors and is throwing food around room . 6/5/23, (R36) left the facility at this time via ambulance for altered mental status. (R36) appeared weak and had trouble verbalizing needs . 6/5/23, (R36) returned to facility via (name of ambulance). He was taken to (name of local hospital) for evaluation. All tests completed and no new orders received . 6/6/23, R36 was transferred to local hospital for a psychiatric evaluation after threatening to break an unknown staff member's legs. R36 returned to the facility the same day with an order for an antibiotic. 6/9/23 at 10:45 AM, (R36) transferred to (name of local hospital) d/t (due to) wound infection and drainage from L (left) (sic) stump. Transferred via ambulance. Stable at time of transfer. 8/7/23, .(R36) was discharged from (name of local hospital) to a healthcare facility (name of brother) did stated that his brothers (R36) stump was healing well. R36's weekly skin record dated 6/9/23 at 2:59 AM, and signed by V22 documents, No open areas. Incision RT AKA is well approximated. (R36) took steri strips off incision site. No drainage well-healed. The facility was unable to provide reproducible evidence R36's surgical incision line to right leg amputation was assessed daily per the care plan intervention. On 08/01/23 at 4:55 PM, V22 (Registered Nurse/RN) stated R36 was admitted to the facility three days post operative. V22 stated R36 was evaluated at the local hospital for psychiatric evaluations a couple of times after admitting to the facility. V22 stated she thought R36 intentionally infected the surgical site. V22 stated she charted that it was almost healed. When asked how he would have intentionally infected the surgical site, V22 stated, He must have found a very weak spot. V22 stated the last time she saw the surgical site (6/9/23) it looked good. V22 stated, It is a total mystery. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 15 of 28 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 08/07/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few just don't know. V22 stated the area was well approximated with no drainage and she just didn't know what happened. On 8/2/23 at 1:56 PM, V2 (Director of Nurses) stated the first time R36 had any symptoms that concerned her was on 6/9/23 when she sent him to the hospital for evaluation. V2 stated the Nurse Practitioner was at the facility on 6/8/23 and the area was open about two millimeters and had a few steri strips on it. When asked if the Nurse Practitioner did an assessment of the area, V2 stated not that she could find. V2 stated she (V2) also didn't document the assessment. V2 stated the next day (6/9/23) the area was open between seven and eight centimeters. When asked to compare her descriptions of the surgical site on 6/8/23 and 6/9/23 to V22's assessment on 6/9/23, V2 stated she would say there was no difference in the assessments. V2 stated it didn't show in the documentation, but they treated R36 well. V2 stated there was no treatment orders for the area, but a dry dressing was being place on it. V2 stated she would have expected the nurses to document assessments. On 8/2/23 at 3:35 PM, V1 (Administrator) stated R36 had not been followed by the wound specialist while at the facility. V1 stated she would expect a nurse to assess surgical wound sites and then document the assessments. The facility Skin Care-Wound Care Teaching Protocols dated January 2014 documents under CNA's .Report any changes in skin to the charge nurse Charge Nurse .Report wound area to physician during same shift discovered when possible. Obtain order for treatment of wound .Initiate daily skin check on TAR (treatment administration record) per risk score .Document on in Nurses Note notification, interventions, and current skin condition/wound description .Notify the physician of any changes in skin integrity or lack of progress . 3. R25's Face sheet documents R25 is a [AGE] year old female with diagnosis including: Bacterial Meningitis, Sequelae of Cerebral Infarction, Aphasia, Dysphagia following Cerebral Infarction, Paraplegia, Muscle Weakness, Psychosis not due to a Substance or known Physiological condition, Dementia with mild Agitation, Cerebral Aneurysm, Enthesopathy, and Cognitive Communication Deficit. R25's Order Summary Report date 08/01/23 documents: Referral to GI (Gastrointestinal) Specialist for diarrhea with an order date of 07/14/23 and an end date of 07/15/23 and documented as completed. R25's Order Report for 07/01/23 and 08/01/23 does not document any appointment for R25 for the GI specialist. On 08/01/23 at 4:00 PM, V9 (Regional Director of Clinical Operations) stated, V11 (transportation/appointments) would have made the appointment for R25 to see the GI specialist and would know when that appointment was. On 08/01/23 at 4:15 PM, V2 (Director of Nursing/DON) stated, R25 still has diarrhea, it will get better for a day or two then it will go back to being watery. On 08/02/23 at 7:55 AM, V11 (transportation/appointments) stated, she had not made an appointment for R25 to see the G I specialist. She stated she does not even know who the specialist is, she did not know that she was supposed to find that information out. On 08/02/23 at 8:55 AM, V6 (Certified Nurse Aide/CNA) stated, she does provide care for R25. V6 stated, R25 is still on isolation precautions for C. diff (Clostridium difficile) and still has diarrhea and it is bad. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 16 of 28 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 08/07/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/02/23 at 9:33 AM, V7 (CNA) stated, R25 is still on isolation precautions for C. diff and still has diarrhea. She stated yesterday she thought it might have looked better but today it does not look good again and it is kind of green and slimy. On 08/02/23 at 11:15 AM, V9 (Regional Director of Clinical Operations) stated, she could not find the appointment for R25 to see the GI specialist, she did see the referral on 07/14/23 and the appointment should have been made. On 08/02/23 at 3:55PM, Peri care was given to R25 by V6 (CNA) and V7 (CNA). V6 and V7 donned goggles, gloves, gown, foot covers which was the appropriate PPE (Personal Protective Equipment) for C-diff precautions. During peri care a large amount of loose slimy brown stool was noted in R25's brief. R25's Bowel Movement documentation documents: between 07/18/23 to current (08/07/23) R25 has had episodes of diarrhea every day except 07/24/23 and 07/25/23 with response not required documented and 07/28/23 with a checkmark in the box for formed/normal. R25's Order Summary Report date 08/01/23 documents: Difficid oral tablet 200 mg (milligrams) for 10 days with an order date of 06/28/23, Flagyl Oral tablet 500 MG every 8 hours for diarrhea for 10 days with an order date of 06/28/23, Flagyl Oral tablet 500 MG 500 mg every 8 hours for diarrhea for 14 days with an order date of 07/14/23, Metronidazole oral tablet 500 mg one tablet by mouth three times a day for C. diff diarrhea for 14 days with an order date of 05/31/23. R25's Care Plan with an initiated date of 05/18/23 documents: R25 will have no complications related to C. difficile through the review date with interventions listed including: give all meds (medications) and IV (intravenous) therapy as ordered and give anti-emetics, antipyretics and analgesics for complaints of discomfort. Monitor/document for side effects and effectiveness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 17 of 28 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 08/07/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide supervision. This failure led to an elopement of 1 (R17) of 1 resident reviewed for elopement in a sample of 41. The findings include: R17's medical record Profile Sheet documents that R17 was admitted to facility 10/22/2021 with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia, severe, with other behavioral disturbance. R17's Minimum Data Set (MDS) dated [DATE], documents in Section C, a Brief Interview for Mental Status (BIMS) score of 00, indicating that R17 has severe cognitive impairment. Section G, Functional Status documents that R17 requires extensive assistance with one person physical assist with bed mobility, supervision with two person physical assist with transfers, limited assistance with one person physical assist with ambulation and eating, extensive assistance with two person physical assist with dressing, personal hygiene, and toilet use. Section E, Behavior, under Wandering-Presence & Frequency, it documents that behavior of this type occurred daily. Under Wandering - Impact it documents yes that wandering places the resident at significant risk of getting to a potentially dangerous place, and significantly intrudes on the privacy or activities of others. R17's Care Plan documents under Focus that R17 is at risk for elopement related to dementia and poor safety awareness, R17 likes to walk to the doors and windows, R17 has a history of elopements with an initiation date of 3/15/2022 and a revision date of 2/02/2023. Under the section Goal it documents that R17 will remain free from making elopement attempts throughout next review with an initiation date of 3/15/2022 and a target date of 9/24/2023. Documented Interventions (last revision date 5/19/2023) include 15 minute checks for R17's whereabouts with an initiation date of 5/22/2023, 1:1 with staff until R17's behavior deescalates, adjust timer to door alarm with an initiation date of 6/13/2022 and 8/1/2023, 15 minute checks until directed otherwise with an initiation date of 8/2/2023, allow concerns to be expressed, encourage R17 to keep busy with activities, primary physician notification as needed, praise R17 when cooperative, reality orientation if appropriate, redirect R17 to activities of choice or social services group, and wander-guard in place with an initiation date of 3/15/2022. R17's admission Elopement/Wandering Risk Assessment dated 10/22/2021 documents under section 1a. Summary of Elopement Assessment, 1. Resident is at risk for elopement at this time, 2a. Summary of Wandering Assessment, 1. Resident is at risk for wandering at this time. The most recent Elopement/Wandering Risk Assessment dated 4/07/2023 documents under section 1a. Summary of Elopement Assessment, 1. Resident is at risk for elopement at this time, 2a. Summary of Wandering Assessment, 1. Resident is at risk for wandering at this time. R17's Physician's Orders dated 08/01/2023 documents Monitor Wander guard every shift to maintain functioning every day and night shift for elopement risk with a start date of 3/24/2022 with an open end date. On 8/01/2023, at 3:30 p.m., R17 was observed entering the facility by ambulating independently through the front door with staff from the neighboring long term care facility who was returning R17 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 18 of 28 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 08/07/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility. R17's wander-guard alarm was sounding and V5 (MDS/Licensed Practical Nurse-LPN) was observed going to the front door and reset the wander-guard alarm. On 8/02/2023, at 8:45 a.m., (V6, Certified Nursing Assistant-CNA), stated she has worked at the facility for 4 1/2 years and is familiar with R17's care. V6 stated that R17 wanders in and out of other residents' rooms and she has observed R17 go into other residents' rooms. V6 stated that R17 has gotten hurt by other residents by entering their rooms. V6 stated that R17 is very fast when she walks, and she tries to keep her occupied by having her sit with her while she is charting but R17 will not sit long enough to do any kind of activity. V6 stated that R17 wears a wander-guard and the only door that alerts the wander-guard is the front door. V6 stated that the wander-guard alarm was not working about a month ago and when that happens, a staff member sits by the front door. V6 stated all the exit doors have a code that has to be put in to get out the door. V6 stated that the door alarm will sound if the code is not put in. V6 stated that she has observed R17 follow staff out the exit doors that do not have a wander-guard alarm on them. V6 stated she has talked to other staff members about keeping a closer eye on where R17 is when they go out the exit doors to make sure she does not follow them out. V6 stated that R17 has probably gotten out of the facility within the past year approximately 50 times or so. V6 stated that R17 is usually brought back to the facility by the neighbor nursing center staff when she leaves the facility. On 8/2/2023, at 9:15 a.m., V7 (CNA) stated that she was working yesterday, 8/1/2023, (6:00 a.m. - 6:00 p.m. shift) and did not hear any wander-guard alarm sound. V7 stated that she thinks V5 (MDS/ LPN), and the other nurses check the wander-guards to see if they are working or not. V7 stated that the front door is the only exit door that has the wander-guard alarm. V7 stated the other exit doors in the facility have a code you have to punch in to get out and those doors do not activate the wander-guard alarms. V7 stated that she tries to redirect R17 when she attempts to leave the facility but R17 usually does not stay interested in any activity for very long. On 8/2/2023, at 9:45 a.m., V8 (CNA) stated that she was working yesterday, 8/01/2023, (6:00 a.m. - 6:00 p.m. shift), and did not hear a wander-guard alarm sound yesterday. V8 stated that she observed R17 being brought through the front door and did not know she had left the facility. V8 stated that R17 has been known to follow staff out the exit doors that do not have a wander-guard alarm and walk over to the neighboring long term care facility where she once lived. V8 stated she is not sure who checks the wander-guards to see if they work. V8 stated she tries to redirect R17 as much as possible when she attempts to leave the facility. V8 stated that she will offer R17 something to eat and drink at times and give her a book to look at. On 8/2/2023, at 10:45 a.m., V4 (LPN), stated that she worked yesterday, 8/01/2023, and was not aware that R17 had left the facility unattended until she was notified by V1 (Administrator) that R17 had left facility and was brought back by the neighboring long term care facility staff. V4 stated that she was told by V1 that the back door alarm had been turned off by maintenance and they forgot to turn the alarm back on. On 8/2/2023, at 3:00 p.m., V1 (Administrator) stated that R17 left the facility yesterday unattended and was brought back by the neighboring long term care facility staff. V1 stated she did not know how long R17 had been gone from the facility. V1 stated that the root cause of R17's elopement was the maintenance staff had turned the back door alarm off and forgot to turn it back on. V1 stated the facility has a total of five exit doors. V1 stated the front door is the only exit door that uses the wander-guard alarm. V1 stated the nurse checks the wander-guards daily and if there is ever a time that the alarms are not working, a staff member is placed at the front door to monitor residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 19 of 28 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 08/07/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V1 stated that recently the Social Service's Director and Activity Director had been switching off spending more 1:1 time with R17 but the Social Service's Director has recently broke her leg and the Activity Director has resigned recently. V1 stated she brings in staff from other departments to help provide activities for all the residents. V1 stated that it has been talked about with upper management to place a secure fence around the building to keep residents from eloping. V1 stated that R17 has eloped at least three times that she knows of, and the staff use redirection, offers R17 something to eat, drink, and 1:1 staff when available. R17's Progress Notes dated 8/1/2023, at 3:33 p.m., documents responded to doorbell at front door. Greeted by R17 and 2 staff members from neighboring nursing center with this resident. R17 smiling when greeted. Wander-guard sounding upon entering facility. R17 nonverbal for the most part and offered no explanation. R17 smiling and showed no signs or symptoms of distress. R17 brought into facility and assessed. No apparent signs or symptoms of acute distress. No red areas and/or wounds noted. V/S 97.6-77-158/79-16-99%. R17 given glass of ice water. V1 (Administrator) aware of incident. V12 (Nurse Practitioner/NP) and V13 (Family) notified. R17's Progress Notes dated 6/1/2023, at 3:09 p.m., documents front doorbell sounding. R17 present with staff from nursing home behind this facility. The neighboring nursing center staff reported observing R17 getting out and redirected her back to our facility. R17 assessed no apparent injury. All parties updated. R17's Progress Notes dated 4/2/2023 at 7:00 p.m., documents nurse answered front doorbell. Staff from neighboring nursing center present with this resident. Staff from neighboring nursing center stated they saw R17 and brought her back, knowing she was ours. R17 assessed with no signs or symptoms of injury. Door alarms checked to make sure they are properly functioning. All parties notified and updated. R17's Progress Notes dated 3/27/2023, at 4:33 p.m., documents CNA staff witnessed R17's left forearm being grabbed by R12 and then R12 proceeded to punch R17's upper right arm. R12 upset that R17 continued to set off door alarm. Residents separated. Incident reported to V2 (Director of Nursing/DON) and V1 (Administrator). V12 (Nurse Practitioner/NP) notified. V1 reported to police and public health dept. R17's Progress Notes dated 2/12/2023 at 12:18 p.m., documents R17 walked into another resident's room, other resident punched R17 in stomach and then R17 hit other resident in head. Both residents separated and assessed for injuries, none noted. V13 (Family), V12 (Nurse Practitioner), & V1 (Administrator) notified of situation. R17's Progress Notes dated 1/23/2023, at 8:45 a.m., documents a state surveyor came to nurse's station and stated R17 was in a room on a different hall and was eating yogurt and using a fingernail polish brush as a spoon. Found R17 in R5's room with yogurt in her hand. Nail polish sitting on top of mini fridge in R5's room. R17 making a face and when asked if it tasted bad, she shook her head yes. When R17 was asked if she got nail polish in mouth resident shook head yes. Nail polish removed. V12 (NP) notified and informed nurse to call poison control. Spoke with poison control regarding R17 ingesting nail polish. Poison control stated to monitor resident as she may vomit once or twice if enough was ingested. V1 (Administrator) aware and report given to V5 (LPN/MDS). R17's 15 minute checks dated 8/01/2023 - 8/05/2023 documents no checks being documented on 8/02/2023 (4:45 a.m. - 5:45 a.m. & 5:00 p.m. - 6:00 p.m.), 8/03/2023 (12:00 a.m. - 5:45 a.m. & 9:00 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 20 of 28 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 08/07/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11:45 p.m.), 8/04/2023 (2:30 a.m. - 10:00 a.m. & 5:00 p.m. - 5:45 p.m.), & 8/05/2023 (12:00 a.m. - 5:45 a.m. & 6:00 p.m. - 11:45 p.m.). On 8/2/2023, at 3:15 p.m., documentation for 15 minute checks prior to 8/01/2023 was requested but the facility was unable to provide any further documentation prior to 8/01/2023. On 8/07/2023, at 3:15 p.m., V3 (CNA), stated that R17 has 15 minute checks that are supposed to be documented every shift for elopement and wandering risk. V3 stated that she always documents R17's 15 minute checks when she works. R17's Behavior Tracking Record (Wandering) documents wandering with frequency of 10-20 times every shift daily for March 2023, 15-20 times every shift daily for April 2023, 20 times every shift daily for May 2023, 15-20 times every shift daily for June 2023, and 20 times every shift daily for July 2023. R17's Behavior Tracking Record (Exit Seeking) documents exit seeking frequency of 10-20 times every shift daily for March 2023, 15-20 times every shift daily for April 2023, 20 times a shift daily for May 2023, 10-20 times a shift daily for June 2023, and 10-20 times a shift daily for July 2023. Resident Council meeting minutes dated 7/14/23 document under Discussion Topic residents who wander-extra activities for wanderers. Elopement policy (March 2015) statement: Staff shall investigate and report all cases of missing residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 21 of 28 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 08/07/2023 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review the facility failed to provide adequate staff to meet the care needs of the residents. This has the potential to affect all 34 residents residing at the facility. Residents Affected - Many Findings Include: The Resident Census and Conditions of Residents dated 7/31/23 documents there are 34 residents residing at the facility. This same form documents 17 residents require assist of one or two staff for bathing and 17 residents are dependent on staff for bathing, 34 residents require assist of one or two staff for dressing, 33 residents require assist of one or two staff and one resident is dependent on staff for transferring, 34 residents require assist of one or two staff for toileting, and 33 residents require assist of one or two staff for eating, with one resident documented as dependent on staff for eating. The Midnight Census reports provided to this surveyor on 8/7/23 by V1 (Administrator) document, three residents (R1, R13, R26) require a mechanical lift to transfer and all 34 residents residing at the facility are incontinent and require assist of staff for showers. The facility CNA (Certified Nursing Assistant) and hall monitor schedule dated July 2023 documents the following: 7/2, 7/13, 7/20, 7/23, 7/29, and 7/30/23- two CNA's- 6 AM to 6 PM, 7/14/23- two CNA's-6 AM to 12 PM and one CNA-12 PM to 6 PM, 7/17 and 7/28/23- two CNA's - 12 PM to 6 PM, 7/24/23- one CNA - 6 AM to 6 PM, 7/31/23- two CNA's from 12 PM to 6 PM, 7/4, 7/9, 7/10, 7/16, 7/17/23 - one CNA and a hall monitor (HM)- 6 PM to 6 AM, 7/5, 7/7, 7/11, 7/12, 7/26, 7/27/23- two CNA's - 6 PM to 6 AM, 7/6/23 one CNA - 6 PM to 6 AM 7/8/23- one CNA and a hall monitor from 12 AM to 6 AM. On 8/2/23 at 1:33 PM, V15 (Certified Nursing Assistant/CNA) stated they don't always have enough staff to provide residents with the care they need. V15 stated on days they are fully staffed the residents get the care they need. V15 stated the facility administration said fully staffed is three CNA's. On 8/2/23 at 9:40 AM, V8 (CNA) stated sometimes she didn't know if she was going to have help while working. V8 stated they normally have three CNA's working on each shift unless someone calls in, then they work with just two. When asked if they were able to provide care with two CNA's, V8 stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 22 of 28 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 08/07/2023 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many I don't think so. When asked what care was not able to be provided, V8 stated, incontinence care every two hours. V8 stated they have four people who require a mechanical lift for transfers. When asked if she has ever worked as the only CNA on a shift, V8 stated she had. V8 stated she tried to do her best and get to everyone when that happened. When asked if it was safe working with just one or two CNA's, V8 stated, No. V8 stated if they have to assist someone who requires a two person assist then there is no one to answer the call lights and there are residents who wander out the doors and they aren't able to monitor them to ensure they don't leave. V8 stated the alarm system doesn't always work the way it should. When asked if they have had residents wander out of the building, V8 stated, Yes, R17. On 8/2/23 at 10:40 AM, V4 (Licensed Practical Nurse/LPN) stated they were short staffed all the time. V4 stated on 7/24/23 there was only her and one CNA working on day shift (6 AM- 6 PM). V4 stated on 7/23/23 there was only one CNA working but she came in and worked as a CNA for them. V4 stated on 7/31/23 she had two CNA's, but one only worked until noon, someone came in and covered until 3 but she worked for 3 1/2 hours on 7/31/23 with only one CNA. When asked what care doesn't get provided when they are short staffed, V4 stated, showers, bed checks, ADL's (activities of daily living). V4 stated, They just aren't getting the proper care. On 8/2/23 at 1:09 PM, V14 (LPN) stated staffing was hit or miss. V14 stated some shifts are staffed really well and then the next day they may have a couple of call ins. V14 stated she had worked with just one CNA before. When asked if everyone was provided with necessary care, V14 stated they were but it was not as much as she would have preferred. When asked if residents were given showers, V14 stated showers weren't done on that shift. On 8/3/2023 at 4:05 PM, V17 (CNA) stated he had worked with a hall monitor and a nurse before. V17 stated when that happens, they do the best they can. When asked what care doesn't get provided if he is working with a nurse and a hall monitor, V17 stated, I can't do the bed checks like I should. V17 stated he tries to do a minimum of three bed checks but when he is working with just a hall monitor and nurse, he does good to do two bed checks. The schedule documents V17 works 12 hour shifts. On 8/2/23 at 1:56 PM, when asked if they had enough staff to meet the needs of the residents, V2 (Director of Nurses/DON) stated she was new to long term care (LTC). V2 stated she started on 1/30/23. V2 stated some days they have enough staff and some days it is a struggle. This surveyor reviewed with V2 there were days they only had one CNA working and V2 stated, Yes. When asked if they were able to provide care and keep the residents safe, V2 stated, I am not sure how to answer that question. V2 stated, I am new, and I have been told that is the way it always is in LTC and so we make do. On 8/2/23 at 3:35 PM, V1 (Administrator) stated they have enough staff to meet the needs of the residents. When asked if two staff (one licensed and one certified) could meet the needs of the residents, V1 stated, Well, I try not to have two staff working. V1 stated she always has a hall monitor working if they only have one CNA working. This surveyor reviewed with V1 the interviews with staff saying they worked with just one CNA, V1 stated, Well, that is not what I want. When asked if one nurse and one CNA working would be able to meet the needs of the residents, V1 stated, it would depend on the residents in the building, the time of day, and what was needed for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 23 of 28 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 08/07/2023 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on interview, observation and record review the facility failed to provide food in the form that is ordered by a physician for 7 of 7 residents 7 (R9, R17, R22, R27, R32, R33, and R237) reviewed for mechanical soft diet in a sample of 41. Findings include: 1. The facility document titled, Diet Spreadsheet dated week 2, Day 9 - Monday, documents: Dental Soft (Mech (Mechanical soft) Soft) Lunch: Grnd (Ground) Herb Chicken with Gravy, Creamy Noodles, Chopped Soft [NAME] Beans and Chopped Strawberry Shortcake. The facility document titled, Grnd (Ground) Chicken with Gravy documents: 8. Portion #8 dipper, or adjusted dip size based on test weight, of ground meat on plate. Ladle an additional 1-2 oz (ounces) gravy on top. The facility document titled, Chopped Soft [NAME] Beans documents: Before serving, chop vegetables, as needed, chop vegetable into bit-size pieces (one-half inch or no bigger than 1.5 cm (centimeter) x 1.5 cm (centimeter), which is about the width of a standard dinner fork. One-half inch equals 1.27 cm (centimeter). On 07/31/23 at 12:00 PM as lunch trays were being plated it was noted that R9, R17, R22, R27, R32, R33, and R237 were plated Brussel sprouts, with some of the Brussel sprouts not being chopped and remaining whole and the ground chicken was served without any gravy on top. On 07/31/23 at 12:00 PM R9, R17, R22, R27, R32, R33, and R237 were all noted in the dining room and received the lunch trays that included Brussel sprouts, with some of the Brussel sprouts not being chopped and remaining whole and the ground chicken was served without any gravy on top. 2. The facility document titled, Diet Spreadsheet dated week 2, Day 10 - Tuesday, documents: Dental Soft (Mech (Mechanical) Soft) Lunch: Ground Baked Pork Chop w/Gvy (with gravy), chp (chopped) soft baked Potato w (with)/ sour cream & margarine, Chopped soft Cooked Vegetable Medley, Soft Sugar Cookies. The facility document titled, Ground Baked Pork Chop w/(with) Gravy documents: Portion #8 dipper of ground pork onto plate and ladle 1-2 oz (ounces) prepared gravy over the top. On 08/01/23 at 12:05 PM R9, R17, R22, R27, R32, R33, and R237 were all noted to be sitting in the dining room and for their lunch meals they received pork that was ground with no gravy on top of the pork. 3. The facility document titled, Diet Spreadsheet dated week 2, Day 11 - Wednesday, documents: Dental Soft (Mech (Mechanical) Soft) Lunch: Ground Fiesta Hamburger Steak w (with)/ salsa, Spanish rice- no bacon w (with)/ sauce, creamed corn, and Chopped Soft Cinnamon Baked Apples. The facility document titled, Ground Fiesta Hamburger Steak with Salsa documents: 5. Place cooked patties into a washed and sanitized food processor and grind to the size and texture of fine hamburger. Portion #8 dip ground meat and ladle 1 to 2 oz (ounces) of salsa over the top. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 24 of 28 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 08/07/2023 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 08/02/23 at 12:15 PM R9, R17, R22, R27, R32, R33, and R237 were all noted to be in the dining room and for their lunch meals they received hamburger steak that was not ground and only cut into pieces, and the baked apples were not cut into pieces, some of the pieces of apples were approximately 2.5 inches long. On 08/02/23 at 2:10 PM, V9 (Regional Director or Clinical Operations) stated, the menus and recipes for the mechanical soft diet should be followed as stated on the menu spreadsheet and made as per the recipes' directions. On 08/07/23 at 1:00 PM, Dietary Manager stated, the menus and the recipes for the mechanical soft diet should be followed. The mechanical soft diet residents should not be given whole Brussel sprouts, the meat should be ground with gravy on top, and vegetables and fruit should be bite size. R9's face sheet documents diagnosis including: Non traumatic Subacute Subdural Hemorrhage, Hemiplegia unspecified affecting Left Non-Dominant Side, Dysphagia Oropharyngeal Phase, Bell's Palsy and Other Symptoms and Signs Concerning Food and Fluid Intake. R9's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Low Concentrated Sweets Diet: Mechanical soft texture with an order date of 05/24/2023. R17's face sheet documents diagnosis including: Cerebral Infarction due to unspecified Occlusion or Stenosis of Unspecified Cerebral Artery, Aphasia following Cerebral Infarction, and Unspecified Dementia, Severe, with other Behavioral Disturbance. R17's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Regular diet: Mechanical soft texture with an order date of 03/23/2022. R22's face sheet documents diagnosis including: Alzheimer's Disease, Anxiety Disorder, and Shortness of Breath. R22's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Regular Diet: Mechanical soft texture with an order date of 06/07/2022. R27's face sheet documents diagnosis including: Hydronephrosis, Alzheimer's Disease, Dementia with agitation, and Bipolar Disorder. R27's Order Summary Report dated 08/02/23 documents: Dietary- Diet: NAS (No Added Salt) diet, Mechanical soft texture, Extra Sauces and Gravy with an Order Date of: 06/19/2023. R32's face sheet documents diagnosis including: Cerebral Infarction, Dysphagia following Cerebral Infarction, Aphasia and Hemiplegia unspecified affecting right dominant side. R32's Order Summary Report dated 08/02/23 documents: Regular diet - Mechanical soft texture with an order date of 07/10/23. R33's face sheet documents diagnosis including: Metabolic Encephalopathy, Other Symptoms and Signs Involving the Nervous System, and Anxiety Disorder. R33's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Regular diet: Mechanical soft texture with an order date of 07/10/2023. R237's face sheet documents diagnosis including: Dementia, severe with other Behavioral Disturbance, Unspecified Intestinal Obstruction, and Simple Chronic Bronchitis. R237's Dietary profile dated 07/26/23 documents: chewing problems. R237's Order Summary Report dated 08/02/23 documents: Dietary - Diet: Regular diet: Mechanical soft texture with an order date of 07/26/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 25 of 28 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 08/07/2023 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)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the required 80 square feet of floor space per resident for 34 (R1-R10, R12-R27, R29-R33, R89, R137, and R237) of 34 residents reviewed for room size in the sample of 41. Findings Include: On 8/1/23 beginning at 2:27 PM, V24 (Maintenance Director) accompanied by this surveyor measured all the resident rooms that didn't meet the required 80 square foot of floor space per resident. The measurements were as follows: Rooms 6, 7, 8, 18, and 19 measured at 140 (inches) x 150 which equals 145.83 square (sq) feet, which indicates 72.92 sq feet per person. Rooms 3, 4, 5, 9, 11, 14-17, 20, 21, 24, and 25 measured at 142 x 150 which equals 147.92 sq feet, which indicates 73.96 sq feet per person. rooms [ROOM NUMBER] measured at 145 x 151 which equals 152.05 sq feet, which indicates 76.02 sq feet per person. room [ROOM NUMBER] measured at 147 x 150 which equals 153.13 sq feet, which indicates 76.56 sq feet per person. This surveyor observed all of the rooms that were measured, and they each had one or two beds, one or two nightstands, dressers, and over the bed tables. Some of the rooms observed/measured contained adaptive equipment such as wheelchairs and walkers, and some contained recliners. On 8/1/23 at 2:44 PM, R26 was observed sitting in a wheeled chair in his room with two beds, two nightstands, a chair, an armoire, a second wheelchair, and an IV pole. R26 stated he had enough space in his room. On 8/1/23 at 2:49 PM, R23 was observed lying in bed with a wheelchair, two nightstands, two over the bed tables, a chair, and two beds observed in the room. R23 denied concerns with the size of his room. On 08/01/23 at 4:45 PM, V1 (Administrator) stated all of the rooms at the facility are double occupancy except room number one which is being used as an office. V1 stated rooms 3-12 on A hall were Medicaid certified and rooms 14-22 and 23-26 located on B and C hall were Medicare/Medicaid certified. The Facility Bed Management Tool dated 7/28/23 documents (R1-R10, R12-R27, R29-R33, R89, R137, and R237) reside in rooms 3-12, 14-22, and 23-26. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 26 of 28 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 08/07/2023 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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an environment free of excessive flies. This has the potential to affect all 34 residents residing in the facility. Residents Affected - Many Findings include: On 7/31/2023, at 10:00 AM, 4 flies were observed in R27's room. On 8/01/2023, at 11:30 AM, 3 flies were observed in R33's room. On 07/31/23 at 9:15 AM, three flies were flying around R31's room periodically trying to land on him with him swatting them away. At that time R31 stated the flies are bad. R31's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 13 indicating cognitively intact. On 07/31/23 at 12:30 PM, R29 had two fly strips in her room, one with 5 dead flies and one with 7 dead flies on it with two more flies flying around the room. At that time R29 stated, there are a lot of flies in here. R29's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 07 indicating severely impaired. On 07/31/23 at 12:30 PM, the air conditioning (AC) unit in R9's room had a one inch gap under the AC unit and a 0.5 inch gap under the AC unit's mounting side panel. There were 3 flies flying around his room. R9 was not in the room at that time. On 08/01/23 at 12:20 PM R9 stated, there are a lot of flies here, while sitting in the dining room. On 07/31/23 at 10:15 AM, R8 stated she does not go to the dining room at times due to there being too many flies present. R8's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 15 indicating cognitively intact. On 08/01/23 at 12:18 PM, R18 was trying to sleep when a fly kept landing on her arm, and she kept swatting at it. Finally, the fly left her arm and landed on her food that was left from lunch. On 08/01/23 at 3:30 PM R18 stated, these flies are horrible, I was trying to sleep because I wasn't feeling good, and they kept landing on me. R18's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 15 indicating cognitively intact. On 08/02/23 at 7:45 AM there was a fly on R27's food while he was eating in the dining room. After this R27 did pick up his plate and go eat on the couch on the other side of the dining room. R27's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 00 indicating severely impaired. On 08/02/23 at 12:30 PM R23 was laying in his bed watching TV with two flies repetitiously landing on him and he kept swatting them away. At that time R23 stated, these flies are bad in here. R23's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 15 indicating cognitively intact. On 08/02/23 at 12:15 PM, R32 had a fly walking on the rim and inside of her milk glass while (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 27 of 28 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 08/07/2023 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)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sitting in the dining room. R32 did not say anything about the fly she just stared past it. R32's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 00 indicating severely impaired. On 08/02/23 at 12:15 PM, R237 was in the dining room and had a fly flying around her, landing on her and her food. R237's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 00 indicating severely impaired. On 08/01/23 at 11:45 AM, V11 (transportation/appointments) stated, there are flies in here but that happens with the doors always being opened with residents going outside and coming back in. On 08/02/23 at 1:10 PM, V1 (Administrator) stated, there are flies, but it is just that time of the year. Resident council minutes dated 07/14/23 document under New Business: under the category Maintenance flies. No additional information was provided. The facility policy titled. Pest Control dated 2021 documents: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The Resident Census and Condition of Residents form dated 07/31/23 documents there are currently 34 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146092 If continuation sheet Page 28 of 28