Integrity Hc of Anna

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served at regularly scheduled times in accordance with resident needs/preferences. This has the potential to affect all 64 residents residing in the facility. On 7/23/2026 at 8:50AM, R9 was asked how her meals are and R9 stated well they are late sometimes and supper is usually always late. R9 said it has been as late at 8:00PM when she has gotten a supper tray. On 7/23/2026 at 8:56AM, R10 stated she usually eats her meals in the dining room. R10 stated if she eats on the halls then the meals are always late. On 7/24/2026 at 5:40PM, the supper meal was observed, and the first tray was served out at 5:45PM. On 7/24/2026 at 5:45PM, the mealtimes were observed posted in the Dining Room and documented that Breakfast is at 7:30AM, Lunch is at 12:00PM and Dinner is at 5:30PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and resident representative written notification of transfer and Bed-Hold Policy information at the time of transfer or as soon as practicable for 1 (R1) out of 3 residents reviewed for discharge process in the sample of 13. Findings Include:R1's admission Record documented an admission date of [DATE], a discharge date of [DATE], and included diagnoses of generalized anxiety disorder, hypothyroidism, hyperlipidemia, depression, lack of coordination, muscle weakness, and schizophrenia. R1's admission Record documents R1 as Responsible Party but also lists V4 (Office of State Guardian/OSG Representative) as R1's Guardian. R1's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R1's cognition is intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were provided to ensure a resident's highest level of practicable functioning for 1 (R4) of 3 residents reviewed for quality of care in a sample of 20. This failure resulted in R4 not receiving timely follow-up and treatment of known suspicious masses which have since metastasized. This failure resulted in Immediate Jeopardy, which was identified to have begun on 1/30/26 when the facility failed to follow through with referrals to an outside provider. V1 (Administrator), V3 (Senior Regional Administrator), and V7 (Regional Director of Clinical Services) were notified of the immediate jeopardy on 4/9/26 at 11:25 AM. The immediacy was removed on 4/9/26, but non-compliance remained at a Level Two because time is needed to evaluate the implementation and effectiveness of in-service training.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure cognitively impaired residents were adequately supervised and failed to implement interventions to prevent elopement for 2 (R1, R2) of 3 residents reviewed for accidents and supervision in the sample of 3. This failure resulted in R1 exiting the facility on 2 occasions, accompanied by R2 on one of those occasions, without staff knowledge. This failure resulted in Immediate Jeopardy, which was identified to have begun on 10/26/25 when the facility failed to prevent R1 from exiting the facility without staff knowledge and failed to put effective interventions in place to prevent a second occurrence on 3/6/26 when R1 and R2 exited the facility without staff knowledge. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a sufficient amount of staff to meet the needs of the residents in a timely manner. These failures have the potential to affect all 67 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly Quality Assurance meetings were held and failed to ensure the Medical Director attended the Quality Assurance meetings. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were trained on effective communications. This has the potential to affect all 67 residents currently residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dependent residents with timely ADL (Activities of Daily Living) assistance for diabetic toenail care and shaving for 5 of 5 residents (R4, R11, R17, R18, R25) reviewed for ADL assistance in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to pass water to 4 of 4 residents (R4, R7, R21, R22) reviewed for hydration in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to answer call lights in such a manner to promote resident dignity and provide timely assistance for 2 of 2 residents (R6 and R24) reviewed for resident rights in the sample of 25.

Inspectors wroteBased on interview and record review the facility failed to notify the physician and resident representative of an elopement event for 2 of 5 residents (R1 and R2) reviewed for notifications in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive care plan that includes interventions to effectively communicate with a hearing-impaired resident for 1 of 3 residents (R4) reviewed for resident rights in a sample of 25.

Inspectors wroteBased on interview and record review the facility failed to ensure the safety of 1 of 3 (R5) residents reviewed for accidents in the sample of 20. This failure resulted in R5 falling out of his wheelchair when the van made a sudden stop, resulting in R5 sustaining fractured ribs and clavicle. This past non-compliance occurred between 2/13/26 and 2/16/26. Findings Include:R5's admission Record with a print date of 2/26/26 documents R5 was admitted to the facility on [DATE] with diagnoses that include history of myocardial infarction, heart failure, hypertension, and atrial fibrillation. R5's Minimum Data Set, dated [DATE] documents R5 has a Brief Interview Mental Status Report score of 13, indicating R5 is cognitively intact. R5's current Care Plan documents a Focus area of, ADLs: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility was kept clean for 4 of 5 (R2, R3, R13, and R15) residents reviewed for safe and home like environment in the sample of 20. Findings Include: 1. R2's admission Record with a print date of 2/26/26 documents R2 was admitted to the facility on [DATE] with diagnoses that include heart disease, osteoarthritis, muscle weakness, and fatigue. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating a moderate cognitive deficit. R2's current Care Plan does not address R2's activities of daily living (ADL) status in a Focus area or intervention. On 2/25/26 at 9:45 AM, R2 stated the facility staff clean, ok. R2 stated later in the day the room does not get clean. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident preferences were honored for 5 of 5 (R3, R4, R12, R13, and R18) residents reviewed for preferences in the sample of 20. Findings Include: 1. R4's admission Record with a print date of 2/26/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, spondylolysis, repeated falls, chronic obstructive pulmonary disease, heart disease, adult failure to thrive, anxiety, and cognitive communication deficit. R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating R4 has a moderate cognitive deficit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the food was served at a safe temperature. This has the potential to affect all 63 residents currently residing at the facility. Findings Include: The facility Daily Census dated 2/24/26 documents 63 residents currently reside at the facility. R13's admission Record with a print date of 2/26/26 documents R13 was admitted to the facility on with diagnoses that include diabetes, morbid obesity, heart failure, and chronic kidney disease. R13's MDS dated [DATE] documents a BIMS score of 14, indicating she is cognitively intact. R13's current Care Plan documents a Focus area of, Nutritional: She is on a NAS (no added salt), regular texture, thin liquids, two liter fluid restriction. She also is given protein supplement BID (twice daily). Date Initiated: 08/12/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure they maintained linens to fit specialty mattresses for 1 of 3 (R1) residents reviewed for accommodation of needs in the sample of 20. Findings Include: R1's admission Record with a print date of 2/26/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease and morbid obesity. R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating she is cognitively intact. R1's current Care Plan does not address R1's linens/mattress in a Focus area or Intervention. On 2/25/26 at 9:40 AM, R1 was sitting in her wheelchair near her bed. Her bed had a flat sheet on the mattress that was partially tucked in under the mattress. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure supplements were served as ordered by the physician for 1 of 3 (R4) residents reviewed for nutritional supplements in the sample of 20. Findings Include:R4's admission Record with a print date of 2/26/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, spondylolysis, repeated falls, chronic obstructive pulmonary disease, heart disease, adult failure to thrive, anxiety, and cognitive communication deficit. R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating R4 has a moderate cognitive deficit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure diets were served in the consistency ordered by the physician for 1 of 3 (R4) residents reviewed for nutrition in the sample of 20. Findings Include: R4's admission Record with a print date of 2/26/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, spondylolysis, repeated falls, chronic obstructive pulmonary disease, heart disease, adult failure to thrive, anxiety, and cognitive communication deficit. R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating R4 has a moderate cognitive deficit. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement intervention to promote safety and healing of a diabetic ulcer for 1 of 3 residents (R1) reviewed for wounds in a sample of 7.

Inspectors wroteBased on interviews, observations and record reviews, the facility failed to implement interventions for preventing deterioration of a pressure ulcer for 1 of 3 (R2) residents reviewed for wounds in a sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a fall during transport and failed to implement interventions to prevent future falls for 3 (R11, R18, R49) of 6 residents reviewed for falls in a sample of 52. This failure caused R18 to fall backwards in her wheelchair while being transported in a facility van requiring R18 to be taken to the emergency room, given pain mediciation, suffering a skin tear, a knot to the head, bruising, and pain to the back and shoulders. Findings Include: 1. R18's admission record documents an admission date of 09/25/24 with diagnoses including: [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to provide supplements or provide supplements in an accessible manner for 2 (R8 and R16) of 6 residents reviewed for nutrition in a sample of 52. This failure further contributes to continued harm to R16, who has a documented history of severe weight loss.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide a pest free environment. This failure has the potential to affect all 66 residents residing at the facility. 1. On 08/18/25 at 12:16PM observed R68 in the dining room she was waving her hands in the air she was trying to wave the flies away from her hair and face. R68 stated she is so tired of these flies being all over her and on her food. R68's MDS (Minimum Data Set) dated 07/17/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 08 which indicates R68 has moderately impaired cognition. On 08/18/25 at 12:18PM observed R14 sitting at the table in the dining room she had pork, au gratin potatoes, zucchini with tomatoes and frosted cake. R14 was trying to take a bite of her frosted cake and she was waving over her cake trying to get the flies off of her cake. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were within reach for 4 of 4 (R11, R38, R41, and R49) residents reviewed for call lights on the sample list of 52.

Inspectors wroteBased on interview, observation, and record review the facility failed to dispose of medications properly and failed to check expiration dates for 5 of 5 (R3, R7, R31, R45, and R61) residents reviewed for medication expiration and storage in the sample of 52.

Inspectors wroteBased on interview, observation, and record review the facility failed to perform hand hygiene while performing eating and drinking assistance for 4 (R52, R57, R8 and R68) of 6 residents reviewed for dining in a sample of 52.

Inspectors wroteBased on Interview and record review the facility failed to provide Influenza and Pneumococcal Immunizations for 4 of 5 residents (R17, R51, R59 and R66) reviewed for Influenza and Pneumococcal Immunizations in the sample of 52.

Inspectors wroteBased on interview and record review the facility failed to develop and implement Covid-19 immunization policies and offer and/or provide Covid-19 immunizations for 4 residents of 5 residents (R17, R51, R59, and R66) reviewed for immunizations in a sample of 52.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with dignity for 3 of 4 residents (R21, R35, R48) reviewed for dignity in the sample of 52.

Inspectors wroteBased on interview and record review, the facility failed to complete an initial comprehensive assessment for 1 of 3 residents (R21) reviewed for assessments in a sample of 52. Findings Include: R21's Transfer/Discharge Report documents an admission date of 7/16/25 with the following diagnoses in part, Parkinsonism, major depressive disorder, anxiety, and repeated falls. R21's medical record only contains the entry Minimum Data Set (MDS) dated [DATE], it does not document a Brief Interview for Mental Status. There was no admission assessment for R21 in R21's medical record. On 8/21/25 at 12:00pm, V1 (Administrator) stated under the assessment tab, there is a baseline assessment that should be completed by nursing on admission, and they believe that staff are mistaking this for other things. V1 stated staff have been educated. V1 stated they do not have a policy for MDS assessments. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan and failed to develop a plan of care for indwelling urinary catheter use for 2 of 4 residents (R11, R21) reviewed in a sample of 52.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with meal supplements, toenail care and incontinence care for 3 of 3 (R38, R48 and R50) residents reviewed for help with Activities of Daily Living (ADL's) in a sample of 52.

Inspectors wroteBased on interview and observation the facility failed to handle cups/glasses in a manner to prevent contamination for 2 (R38 and R48) of 6 residents reviewed for dining in a sample of 52.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure residents were treated with dignity by not providing incontinence products for 4 of 6 residents (R3, R5, R6 and R7) reviewed for resident rights in a sample of 16. This failure resulted in R3, R5, and R7 feeling embarrassed after incontinence episodes.

Inspectors wroteBased on interview and record review the facility failed to implement interventions to prevent future falls for 1 of 3 (R2) residents reviewed for falls in a sample of 16. This failure resulted in R2 falling and sustaining a laceration on his face requiring sutures.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staff to meet resident's needs. These failures have the potential to affect all 63 residents living in the facility.

Inspectors wroteBased on interview, observation, and record review facility failed to maintain a clean comfortable home like environment for 5 of 5 residents (R7, R8, R9, R10, R11) reviewed for environment in a sample of 16.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents who require assistance receive a shower for 4 of 6 residents (R1, R3, R5, and R6) reviewed for Activities of Daily Living assistance in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed identify, evaluate and intervene to prevent or improve a resident with significant weight loss's nutritional status in 1 (R42) of 5 residents reviewed for nutrition in the sample of 30. This failure resulted in R1 continuing to lose weight over the next 9 months.

Inspectors wroteBased on record review and interview the facility failed to ensure that assessments were transmitted timely for 2 of 2 (R12 and R31) residents reviewed for assessments timely transmitted in a sample of 30. The Findings Include: 1. R12's face sheet documents an admission date of 12/7/21 and includes the following diagnosis: cognitive communication deficit, dementia, anxiety and weakness. R12's most recent MDS (Minimum Data Set) which was a quarterly documents it was completed 8/22/24. 2. R31's face sheet documents an admission date of 5/8/24 and includes the following diagnosis: cognitive communication deficit, depression, Parkinson's, and diabetes. R31's most recent MDS which was a quarterly documents it was completed 8/21/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 3 (R37, R46, R47) of 3 residents reviewed for PASRR Screening in the sample of 30. Findings Include: 1. R37's Face Sheet documented an initial admission date to the facility as 7/11/2024. Diagnoses listed on this form included unspecified psychosis not due to a substance or known physiological condition. R37's Notice of PASRR Level I Screen Outcome dated July 8, 2024, documented No Level II Required- No SMR (Serious Mental Illness). On 9/26/2024 at 9:23 AM, V4 (Business Office Manager) stated, she does complete the PASRR screening for residents in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff were available to meet resident needs. This failure has the potential to affect all 56 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to immediately report allegations of abuse to the Administrator for 4 of 13 residents (R14, R15, R16, and R17) reviewed for abuse in a sample of 17.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents who require assistance with transfers into bed were assisted in a timely manner for 1 of 1 resident (R1) reviewed for Activities of Daily Living (ADL) in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and implement treatment and interventions for pressure ulcers for 2 (R1, R2) of 3 residents reviewed for pressure ulcers in a sample of 6. This failure resulted in R1 developing a stage III pressure ulcer area to her left buttock.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions for self-injurious behaviors and obtain necessary behavioral health services for 1 (R1) of 1 resident reviewed for behavioral health in a sample of 6. This failure resulted in R1 developing cellulitis to a self-inflicted wound to the chest wall.

Inspectors wroteBased on interview and record review, the facility failed to complete baseline care plans for 4 of 4 residents (R1, R2, R4, R6) reviewed for assessments in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans for 4 of 4 residents (R1, R2, R4, R6) reviewed for care plans in a sample of 6.

Inspectors wroteBased on interview, observation, and record review, the facility failed to assess and monitor for proper physical restraint use for 3 of 3 residents (R1, R4, R5) reviewed for restraints in a sample of 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) coding was completed for 3 of 4 (R1, R2 and R4) residents reviewed for accuracy of assessments in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to assess and seek timely treatment for a self- inflicted injury for 1 (R1) of 3 residents reviewed for skin impairment in a sample of 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were following the proper PPE (Personal Protective Equipment) protocols for residents in isolation. This has the potential to affect all 59 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility is free of flies. This has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident for Preadmission Screening and Resident Review (PASRR) as recommended for 2 (R46 and R7) of 4 residents reviewed for PASRR's in the sample of 30. Findings Include: 1. R46's Face Sheet documents an initial admission date to the facility as 1/27/23, with diagnoses including but not limited to Diffuse Traumatic Brain Injury without loss of consciousness, subsequent encounter, Depression, Unspecified, and Anxiety, Unspecified and Other Seizures. R46's Notice of PASRR Level I Screen Outcome documents under the section labeled Ascend Outcome with a review date of 01/25/2023, Level I Outcome: Exempted Hospital Discharge. Rationale: Exempted Hospital Discharge 30 Day Approval- A 30 day or less stay in the NF (nursing facility) is authorized. [...]