Integrity Hc of Herrin

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 39 residents who currently reside at the facility. Findings Include: The facility Daily Census dated 6/23/25 documents there are 39 residents currently residing at the facility. 1. R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide pericare after each incontinent episode. Date Initiated: 04/12/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure call lights were answered timely for 6 of 8 (R1, R4-R8) residents reviewed for call lights in the sample of 18. Findings Include: 1. R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post-traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's MDS (Minimum Data Set) dated 4/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for bathing. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely assistance with activities of daily living (ADL's) for 8 of 8 (R1-R8) reviewed for ADLs in the sample of 18. Findings Include: 1. R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post-traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide pericare after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also includes the Focus Area of (R1) has an ADL Self Care Performance Deficit r/t (related to) impaired mobility. Date Initiated: [...]

Inspectors wroteBased on interview and record review the facility failed to maintain an effective bed bug control program to ensure the facility was free of bed bugs. This has the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to serve an appropriate non-emergent involuntary discharge and allow the resident and resident's family time to appeal the notice for 1 of 1 resident (R185) reviewed for discharge in the sample of 32. This failure resulted in R185 being removed from her environment and suffering psychosocial harm that any reasonable person would after being placed over two hours away from her family and friends without notice.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure transmission based precautions were implemented, and failed to ensure hand hygiene was performed per current standards of practice for 2 of 6 (R85 and R3) residents reviewed for infection control in the sample of 32. Findings Include: R85's admission Record with a print date of 9/19/24 documents R85 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and bipolar disorder. R85's MDS (Minimum Data Set) dated 7/9/24 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates R85 has a severe cognitive deficit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a method to call for assistance while in the shower stall. This has the potential to affect all 32 residents residing at the facility.

Inspectors wroteBased on observation and interview the facility failed to provide a dignified and respectful dining experience by removing plates from the table while other residents are still eating for 4 (R30, R27, R16 and R18) of 4 residents reviewed for dignified dining.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean and sanitary bathroom for 14 (R3, R24, R23, R14, R17, R21, R10, R22, R28, R29, R18, R19, R5 and R30) of 14 residents reviewed for environment in a sample of 32.

Inspectors wroteBased on interview and record review the facility failed to prevent physical abuse of a resident from another resident with a known history of abuse for 1 of 3 residents (R16) reviewed for abuse in the sample of 32.

Inspectors wroteBased on interview and record review the facility staff failed to report an allegation of resident to resident physical abuse to the Administrator immediately for 1 of 3 (R16) residents reviewed for abuse and neglect in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to provide a resident or representative and the Ombudsman with a written notice of discharge with appeal rights for 1 of 1 resident (R185) reviewed for discharge in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to provide a discharge summary for 1 of 1 resident (R185) reviewed for discharge in a sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's orders as prescribed for one (R14) of one resident reviewed for respiratory concerns in a sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supplements as ordered and follow the facility policy for weight management for 2 (R27 and R15) of 4 residents reviewed for nutrition in a sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to provide diets as ordered for 2 (R18 and R24) of 4 residents reviewed for nutrition in a sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the required 80 square feet of floor space per resident for 8 of 8 (R6, R7, R14, R15, R17, R22, R28, and R32) residents reviewed for room size in the sample of 32.

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and observation the facility failed to provide privacy and security of possessions for 3 (R4, R12, & R20) of 3 residents reviewed for resident rights in a sample of 41.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain adequate levels of quaternary sanitizer used to sanitize food contact surfaces and stationary equipment. This has the potential to affect all 25 residents living in the facility. The Findings Include: On 9/6/22 at 9:30 AM, during the initial tour of the kitchen it was observed that there was a bucket of sanitizing solution setting in the sink with a rag in it. V3 (Cook) stated that this is a quaternary ammonium solution that is used to wipe down surfaces and stationary equipment. V3 checked the solution for the sanitizer level in the bucket with a hydrion test strip to detect quaternary levels. V3 stated the level was below manufacturer suggested level of 200 PPM (parts per million) likely due to being setting out for a few hours. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 of 8 residents (R22) reviewed for comprehensive assessments in a sample of 29.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide 80 square feet of space per resident for 25 of 25 residents (R1-R2, R4-R9, R11-R26, and R127) reviewed for room size in the sample of 29. The Findings Include: On 09/8/22 at 12:14 PM, V1 (Administrator) stated all rooms on A, B, and C Hall are covered under the room waiver. All of the rooms have been measured and do not provide the required 80 square feet per resident bed. V1 also stated at this time that the A Hall (rooms 1-12) are Medicaid Certified only and B and C Hall are dually certified for Medicare and Medicaid. These rooms (1-12, 14-26) were all double occupancy rooms measuring 73.4 square feet. Inquiries regarding these rooms throughout the survey from 09/6/2022 to 09/9/2022 found no negative interviews from residents or families of residents who reside in these rooms. [...]