Health inspection·January 15, 2025

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide three meals daily at regular times for 4 of 6 residents (R6, R7, R8, and R10) reviewed for food and nutrition services in the sample of 10. Findings include: 1-R6's Face Sheet documents R6 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction and abnormalities of gait and mobility. R6's Minimum Data Set (MDS) dated [DATE] documented R6 was cognitively intact, ambulated with walker and wheelchair, required supervision with eating, and was on a therapeutic diet. R6's Physician Order dated 6/11/21 documents regular diet order with fortified cereal at breakfast and fortified pudding or ice cream with all meals. R6's Facility Grievance dated 12/19/24 documents, Fri (Friday) the 13th dinner was not given to (R6) when ask (asked) kitchen said they would get - but was on phone it took from 6 PM to 8:10 (PM) to get grilled cheese. The Facility's Grievance response dated 12/20/24 documents items need to go out in a timelier manner and staff members need to stay off their phones. On 1/15/25 at 9:50 AM, R6 stated the food is always late. She said, I don't want to eat at 8:00 PM. 2-R7's Face Sheet documents R7 was admitted to the facility on [DATE] with diagnoses including moderate protein calorie malnutrition, oral dysphagia (difficulty swallowing), and weakness. R7's MDS dated [DATE] documented R7 was cognitively intact, ambulated with wheelchair and walker, required supervision with eating, had weight loss not on physician-prescribed weight-loss regimen, and was on a therapeutic, mechanically altered diet. R7's Physician Order dated 12/30/24 documents renal diet with regular texture and thin liquids. On 1/15/25 at 7:45 AM, R7 stated the meals are always late and you never know when they are going to come. Page 1 of 2 145655 145655 01/15/2025 Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095

F 0809 Level of Harm - Minimal harm or potential for actual harm 3-R8's Face Sheet documents R8 was admitted to the facility on [DATE] with diagnoses including protein calorie malnutrition and ileostomy status. R8's MDS dated [DATE] documented R8 was cognitively intact, independent with ambulation, required setup or clean up assistance with eating, and was on a therapeutic diet. Residents Affected - Some R8's Physician Order dated 12/16/24 documents regular, low fat, low cholesterol diet with double portions. R8's Facility Grievance dated 10/10/24 documents, I was sitting in the dining hall at 7:35 AM. I received my coffee, 3 milks, apple juice and silverware but no food after sitting for 30 mins (minutes). She said nobody told her that I was there so she continues making trays for the carts for the halls instead of making my plate. I had no breakfast. Something needs to be done about kitchen workers. The Facility's Grievance Response dated 10/10/24 documents the situation should not have happened. On 1/14/25 at 1:45 PM, R8 stated he filed the grievance because he never got breakfast that day and the kitchen issues need to be addressed. 4-R10's Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and chronic kidney disease stage four (severe). R10's MDS dated [DATE] documented R10 was cognitively intact, ambulated via wheelchair and walker, required supervision with eating, and was on a therapeutic diet. R10's Physician Order dated 3/12/22 documents regular diet with no added salt. On 1/15/25 at 9:52 AM, R10 stated the food is always late. On 1/15/25 at 10:25 AM, V2, Director of Nursing, stated she expects residents to receive three meals a day and expects them to be delivered timely. On 1/15/25 at 1:50 PM, V1, Administrator, stated she would expect the Facility to provide three meals a day and serve them on time. The Facility's Frequency of Meals Policy revised 10/2022 documents, At least three daily meals will be provided, at regular times comparable to normal mealtimes in the community. The Dining Services Director will ensure that each meal is served within the designated time frame unless there is an emergency situation or a resident request. The Facility's Meal Times document breakfast is served at 7:30 AM, lunch is served at 11:30 AM, and dinner is served at 5:30 PM. 145655 Page 2 of 2