Health inspection·January 10, 2025

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to adequately staff the dietary department to ensure meals were served in a timely manner for 1 of 5 residents (R9) reviewed for food and nutrition services in the sample of 9. Findings include: R9's Physician Orders document R9 was admitted to the facility on [DATE]. R9's Face Sheet documents R9 has diagnoses including heart disease, peripheral vascular disease, and protein calorie malnutrition. R9's Minimum Data Set (MDS) dated [DATE] documented R9 was cognitively intact, independent with eating, and ambulated with wheelchair and walker. R9's Care Plan documents goal to improve nutritional status. R9's Physician Orders document 12/16/24 order for carbohydrate controlled diet. On 1/9/25 at 12:47 PM, R9 stated dinner is never on time and has recently received dinner as late as 6:30 PM and 6:35 PM. On 1/9/25 at 12:57 PM, V10, Certified Nursing Assistant (CNA) stated meal service tends to run slower in the evenings. On 1/9/25 at 2:40 PM, V16, Dietary Aid, stated he occasionally has to work by himself during meals and services the entire facility. On 1/9/25 at 2:50 PM, V15, Dietary Manager, stated sometimes meal trays are late, and it is more of a problem for residents who eat in their rooms because the dining room is served first. On 1/9/25 at 3:00 PM, V14, Activities Director, stated meal timing was previously discussed as a problem in the Resident Council Meeting. He was unsure if the issue has been resolved but was told the kitchen has been sending food a little later in effort to keep it hot. On 1/9/25 at 11:35 AM, V7, Licensed Practical Nurse (LPN), stated meals run late if there is only one person running the kitchen. Page 1 of 2 145121 145121 01/10/2025 Alton Memorial Rehab & Therapy 1251 College Avenue Alton, IL 62002

F 0802 On 1/9/25 at 11:37 AM, V11, CNA, stated meals are served late on occasion. Level of Harm - Minimal harm or potential for actual harm On 1/9/25 at 11:48 AM, there was a posting on the steam table documenting breakfast is served from 7:30-8:00, lunch is served from 11:30-12:00, and dinner is served from 5:30-6:00. Residents Affected - Few On 1/9/25 at 2:15 PM, V1, Administrator, stated she was unaware of any meals being served late. She stated the facility does not have a policy regarding acceptable time frames for meals, but should be base times on resident preference. On 1/9/25 at 4:20 PM, V1 stated she will address this issue. The Facility's Resident Council Meeting Minutes dated 11/19/24 document, Food needs to be on time. The Facility's Meal Times posting documents breakfast is served from 7:30-8:00, lunch is served from 11:30-12:00, and dinner is served from 5:30-6:00. The Facility's Dietary Schedule documents only one staff member was working during the dinner service on 12/7/24, 12/8/24, 12/13/24, 12/14/24, 12/15/24, 12/26/24, 12/27/24, and 1/6/25. The facility's 1/9/25 Census documents there are 54 residents living in the facility. 145121 Page 2 of 2