Health inspection·January 8, 2025

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 are served in a timely manner for 4 of 5 residents (R1, R2, R4, R5) reviewed for food and nutrition services in the sample of 5. Findings include: 1. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, required supervision with eating, and ambulated via wheelchair. R1's Physician Order dated 9/28/24 documents R1 is on a regular diet with no added sodium. R1's Grievance Form dated 12/27/24 documented, (R1) came to me about issues with not getting her dinner last night until late. On 1/7/25 at 11:43 AM, R1 stated everyone else was eating dinner, but she did not get served. She was supposed to get grilled cheese and soup, but they brought her something different which she did not like. She stated she then went back to her room and did not receive her grilled cheese and soup until around 7:00 PM. She stated, It is always late. It's supposed to start at 5:00 PM, and we are lucky if they start at 5:30 PM or a quarter 'til (6:00 PM). 2.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and blindness in right eye. R2's MDS dated [DATE] documented R2 was severely cognitively impaired and required substantial assistance with eating, bed mobility, and transfer. R2's Physician Order dated 7/27/16 documents R2 is on a regular diet. On 1/7/25 at 12:46 PM, V14, Licensed Practical Nurse (LPN), obtained a meal tray from the cart on the 200 Hall and delivered it to R2 in her room. This was one hour sixteen minutes after the lunch meal was scheduled to begin. 3.R4's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including type Page 1 of 2 145729 145729 01/08/2025 Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231

F 0802 2 diabetes mellitus and pressure ulcers. Level of Harm - Minimal harm or potential for actual harm R4's MDS dated [DATE] documented R4 was cognitively intact, required setup with eating, and was dependent with bed mobility and transfer. Residents Affected - Some R4's Physician Order dated 10/25/24 documents R4 is on a mechanical soft diet. On 1/7/25 at 12:56 PM, V13, Certified Nursing Assistant (CNA), took a meal tray from the cart on the 200 Hall and delivered it to R4 in her room. V13 stated, We have good days (with timing) and bad days, but there usually aren't so many hall trays. There have been more (hall trays) with Covid, and it takes longer (to pass them). R4's tray was passed one hour and twenty-six minutes after the lunch meal was scheduled to begin. 4.R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease and type 2 diabetes mellitus. R5's MDS dated [DATE] documented R5 was cognitively intact, required supervision with eating, and was dependent with bed mobility and transfer. R5's Physician Order dated 10/10/24 documents R5 is on a low concentrated sweets diet. On 1/7/25 at 1:05 PM, V13 took a meal tray from the cart on the 200 Hall and delivered it to R5 in her room. R5's tray was delivered one hour and thirty-five minutes after the lunch meal was scheduled to begin. On 1/7/25 at 8:55 AM, V4, Environmental Services and Dietary Supervisor, stated occasionally meals run late at supper. V1, Administrator, stated they have had some delays in meals with the recent snowfall and staff calling off work. On 1/7/25 at 9:20 AM, V11, Licensed Practical Nurse (LPN), stated sometimes there are delays in meals at the Facility. On 1/7/25 at 1:49 PM, V1 stated lunch was late today because three dietary employees that were scheduled to work called off. There was no cook or prep cook, so V4 had to do a lot of the work herself. On 1/7/25 at 2:40 PM, V1 stated she will be working with V4 to correct the issue. The Facility's Weekly Schedule for 1/5/25-1/11/25 documents five dietary staff were originally scheduled to be present during the lunch hour on 1/7/25 before the reported three call offs. The Facility's Mealtimes Posting documents lunch is served at 11:30 AM. The Facility's Frequency of Meals Policy revised 7/2017 documents, Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs preferences, requests and the plan of care. The facility will serve at least three (3) meals or their equivalent daily at scheduled times. 145729 Page 2 of 2