Integrity HC of Marion: Resident Elopement Failure - IL
The resident, identified in inspection records only as R1, had been assessed as an elopement risk. Staff knew it. A licensed practical nurse identified in the report as V6 told inspectors R1 would pack his belongings and announce he was leaving with his family, though he had never actually made it out the door before. He did this time.
V6 said R1 was not wearing a wander guard at the time he left.
A second nurse, V7, was working the 100 hall that afternoon while R1 was assigned to the 200 hall. She remembered something that stood out before he disappeared: R1 had asked for a meal tray, which she described as unusual. About 20 minutes later, staff realized he was gone.
A certified nursing assistant, V8, put the timeline slightly later, saying it was around 3:00 p.m. when a nurse noticed R1 was missing. At that point, staff began checking every room and the facility's exterior, cycling through multiple times before calling police. V8 also noted that V6 had already been asking staff to keep a closer watch on R1 that afternoon because he had been restless.
Restless, known to pack his bags, not wearing the device meant to stop him from leaving. He left anyway.
His family brought him back that evening. Inspectors noted he was assessed head to toe upon return, with no injuries documented and vital signs stable. His physician and family were notified.
What happened in the hours R1 spent outside the facility, where he went, and how far he traveled are not detailed in the inspection report. The document records only that he was located and returned safely.
The facility's own elopement policy, last revised in February 2025, states that staff shall investigate and report all cases of missing residents. The policy existed. The risk was documented. The wander guard system, according to V7, was functioning at the time.
After the incident, the facility moved quickly, at least on paper. R1 was relocated from the 200 hall to the 400 hall and fitted with an electronic monitoring device. The Regional Director of Clinical Services, V3, told inspectors the facility had identified the problem and already had a correction plan in place by the time surveyors arrived.
A Quality Assurance and Performance Improvement committee convened on October 20, 2025, with the administrator, the director of nursing, and the regional director of clinical services all present. The meeting produced a list of corrective steps: a facility-wide audit of all residents with elopement risk factors, a review of staff rounding and supervision schedules in high-risk areas, and re-education of all staff on elopement prevention and response.
The director of nursing, or a designee, was assigned to complete audits five times a week for four weeks, then monthly for three months, checking whether elopement risk assessments were current and whether staff were actually following the interventions listed in care plans.
The violation was cited at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale. That classification reflects the outcome, not the gap it exposed. R1 came back uninjured. The wander guard he should have been wearing was not on him when he walked out. Staff were already watching him because he was agitated. None of it stopped him.
The inspection covered only this complaint. It does not assess the broader care environment at Integrity HC of Marion or identify other residents who may have similar risk profiles.
What the record shows is a man who told staff, repeatedly, that he wanted to leave, and one afternoon, he did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Integrity Hc of Marion from 2025-11-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
INTEGRITY HC OF MARION in MARION, IL was cited for violations during a health inspection on November 12, 2025.
The resident, identified in inspection records only as R1, had been assessed as an elopement risk.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.