Health inspection·September 11, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assist a resident with incontinence care in a timely manner to promote dignity for 1 of 10 residents (R1) reviewed for dignity in a sample of 10. Findings include:R1's admission Record documents an admission date of 2/15/22 with diagnoses including in part: paranoid schizophrenia, post traumatic seizures, insomnia, anxiety disorder, essential tremor, and personal history of traumatic brain injury.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is rarely/never understood. The same MDS documents R1 is dependent with toileting hygiene, the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. R1's current Care Plan documents R1 is at risk for impaired skin integrity related to impaired cognition and R1 is known to refuse incontinence care at times. On 9/11/25 at 8:15 AM, R1 was sitting on the couch in the dining room watching the television. On 9/11/25 at 8:43 AM, R1 was sitting on the couch in the dining room watching the television. On 9/11/25 starting at 9:15 AM, R1 was under constant observation by surveyor that lasted until 11:51 AM. On 9/11/25 at 9:15 AM, R1 was sitting on the couch in the dining room with his legs crossed, and his pants were visibly wet in the front left groin area. On 9/11/25 at 9:28 AM, R1 uncrossed his legs and there was a large wet circle on the front of R1's pants. On 9/11/25 at 9:33 AM, V5 (Certified Nursing Assistant/CNA) was walking a resident through the dining room and walked in front of R1 while he was sitting on the couch watching TV. V5 said, Good morning to R1 then R1 responded with a smile and a wave. R1's pants were still visibly wet. On 9/11/25 at 10:28 AM, R1 was still sitting on the couch watching the television with visibly soiled pants. V6 (Activities Assistant) went to R1 with a cart of snacks and drinks and offered R1 a snack and drink. R1 was pointing at the cart and V6 was trying to figure out what he was pointing at. V6 finally figured out he was pointing at the ice that snacks were sitting in. On 9/11/25 at 10:49 AM, V8 (CNA) walked by R1 while he was sitting on the couch, R1 still had visibly soiled pants. V8 did not look at R1. On 9/11/25 at 10:50 AM, V2 (Director of Nursing/DON) walked by R1 while he was sitting on the couch, still had visibly soiled pants. V2 did not look at R1. On 9/11/25 at 10:56 AM, V7 (CNA Supervisor) walked by R1 and didn't look at R1. R1 was still visibly wet. On 9/11/25 at 10:59 AM, V9 (CNA) walked by R1 and didn't look at him. R1 was still visibly wet. On 9/11/25 at 11:00 AM, V8 (CNA) walked by R1 to the resident sitting 2 down from him and took his vital signs. R1 was still visibly wet. On 9/11/25 at 11:03 AM, R1 stood up with visibly wet pants and walked to the door to the back patio area for smoke break. R1 sat down on a bench in the smoking area. On 9/11/25 at 11:05 AM, V10 (Housekeeping) lit R1's cigarette and sat outside with R1 and other residents while they smoked. R1 still had visibly wet pants. On 9/11/25 at 11:16 AM, V10 walked R1 back into the building after he finished smoking. R1's pants were still visibly wet. On 9/11/25 at 11:17 AM, R1 was sitting on the couch and still had visibly wet pants. V7 walked R1 to the scale in the dining room and weighed him. V7 then asked R1 if he wanted to take a shower. R1 did not Page 1 of 2 146092 146092 09/11/2025 Integrity Hc of Herrin 1900 North Park Avenue Herrin, IL 62948

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few respond and walked back to the couch in the dinner room to watch the television. On 9/11/25 at 11:24 AM, V8 walked by R1 while he was on the couch with visibly wet pants and did not look at R1. On 9/11/25 at 11:25 AM, V7 asked R1 if he wanted to go take a shower and R1 held his pointer finger up at V7. V7 responded with, 1 hour and R1 shook his head yes. R1's pants were still visibly wet. On 9/11/25 at 11:36 AM, V8 walked by R1 while he was on the couch with visibly wet pants and did not look at R1. On 9/11/25 at 11:39 AM, V2 walked by R1 while he was on the couch with visibly wet pants and did not look at R1. On 9/11/25 at 11:41 AM, V6 walked up to R1 and asked him if he is ready for lunch. V1's pants were still visibly wet. On 9/11/25 at 11:46 AM, V8 was near R1, this surveyor pointed out to V8 that R1 had visibly wet pants. V8 asked R1 if she could take him to change his pants and R1 held up his pointer finger at her. V8 said they can usually get R1 to change his pants if they catch him at his smoke breaks, when he is already up off the couch. V8 stated around 8am today she asked R1 if he wanted to shower, and he told her no.On 9/11/25 at 11:50 AM, V7 come up to R1 while this surveyor and V8 were talking to him and asked him if she could take him to the shower after lunch and R1 shook his head yes. V7 stated R1 should be checked on every 2 hours and cleaned up if he is wet as soon as someone notices it. V7 stated R1 does refuse getting cleaned up at times but sometimes it just takes a new face to get him to agree to care. V7 stated if he refuses to one person then a different person should ask and sometimes, he will agree. On 9/11/25 at 1:07 PM, V7 took R1 to the shower room and shaved R1's face. Then stood R1 up and pulled his pants and depends down. R1 had redness on his buttocks and in his groin. V7 then set R1 in the shower chair in the shower room. On 9/11/25 at 2:41 PM, V5 stated she checked on R1 around 9:30 AM. V5 stated she asked him if he wanted to go to the bathroom and he said no. On 9/11/25 at 2:43 PM, V3 (Assistant Director of Nurses) stated she started her morning rounds at 8:00 AM today and when she talked to him this morning, he wasn't visibly wet. On 9/11/25 at 2:51 PM, V10 stated when she took R1 out to smoke around 11:00 AM today she did not notice he had wet pants. On 9/11/25 at 2:54 PM, V6 (Activities Assistant) stated she was over by R1 when he was sitting on the couch around 8:30 AM or 9:00 AM this morning and she smelled a strong urine smell so she asked R1 if he needed to use the bathroom and he told her no. V6 stated when she was passing snacks to R1 at 10:28 AM this morning she did not notice his pants were wet and she did not ask him if he needed to use the restroom or needed cleaned up. On 9/11/25 at 3:26 PM, V4 (Regional Director of Clinical Services) stated residents should be checked at least every 2 hours for incontinence. V4 stated he couldn't find a policy regarding how often residents should be checked for incontinence or a policy related to dignity/visibly wet pants. 146092 Page 2 of 2