Integrity HC of Marion

In the surveyor’s words

From the most serious findings on record at Integrity HC of Marion, in the surveyor’s own words.

• Immediate jeopardy, widespreadF610May 19, 2026

  Based on interview and record review, the facility failed to conduct a thorough investigation and report factual information of an injury of unknown origin that resulted in R1's death and failed to investigate allegations of sexual abuse for 3 of 6 residents (R1, R3, R10) reviewed for abuse in a sample of 46. The facility's failure has the potential to affect all 114 residents residing in the facility by failing to protect them from potential abuse.The Immediate Jeopardy began on [DATE] at 12:00 PM when R1 was found expired in the floor next to her bed with her head in a trash can and a plastic trash bag covering her face. V1 (Administrator) and V3 (Regional Clinical Director) were notified of the Immediate Jeopardy on [DATE] at 1:00 PM. […]

• Immediate jeopardy, isolatedF684Jun 16, 2025

  Deficiencies at this level require more than one Deficient Practice Statements A. Based on interview and record review, the facility failed to prevent the development of unstageable ulcers, identify and assess newly developed ulcers, consistently implement interventions to promote healing of the ulcers, and implement physician orders to treat ulcers for 1 (R149) of 7 residents reviewed for ulcers in the sample of 52. This failure resulted in R149 developing unstageable ulcers to bilateral heels and subsequently being admitted to the hospital with diagnoses of sepsis, gangrene, and necrosis of the bone, tendon, and surrounding tissue. R149 underwent surgery to debride the ulcers on bilateral heels. […]

• Actual harm, isolatedF600May 19, 2026

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse for 2 (R3 and R10) of 6 residents reviewed for abuse in a sample of 46. This failure resulted in R10 feeling intimidated and scared for her safety.Findings include:1. R10's admission Record documented an admission date of [DATE], with diagnoses including depression, major depressive disorder, and anxiety disorder. R10's [DATE] Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.R4's admission Record documented an admission date of [DATE], with diagnoses including vascular dementia. […]

• Actual harm, isolatedF697Aug 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure pain was treated for 1 of 1 (R3) resident reviewed for pain in the sample of 19. This failure resulted in R3 experiencing severe pain with no treatment for the first 24 hours of admission, resulting in a lack of sleep and emotional distress. Findings Include:R3's facility admission Record, with a print date of 8/4/25, documents R3 was admitted to the facility on [DATE], with diagnoses that include sacroiliitis, surgical aftercare, diabetes, asthma, anemia, restless leg syndrome, Alzheimer's disease, and radiculopathy of lumbar region.R3's Baseline Care Plan, dated 7/30/25, documents R3 is alert with cognitive impairment. This Care Plan documents, family states resident gets confused at times. […]

• Actual harm, isolatedF697Jun 16, 2025

  Based on interview, observation, and record review, the facility failed to manage pain for 1 of 2 residents (R81) reviewed for pain in a sample of 52. This failure resulted is R81 experiencing decreased mobility and participation in daily activities related to uncontrolled severe pain. Findings include: R81's admission Record documents an admission date of 05/14/24, with diagnoses including: polyneuropathy, injury of left ankle, bilateral primary osteoarthritis of knee, osteoarthritis, myalgia, depressive episodes, anxiety disorder, bipolar disorder, chronic pain, lumbago with sciatica on right side, and lumbago with sciatica on left side, age related osteoporosis, and anxiety disorder. […]