Health inspection·August 30, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the Renal Therapeutic Diet for 1 of 2 residents (R32) reviewed for therapeutic diets in the sample of 35. Residents Affected - Few Findings Include: R32's Minimum Data Set (MDS) dated [DATE] documents R32 is cognitively intact. R32's Physician Order Sheet dated 7/1/24 documents diet order Renal, CCD (Consistent Carbohydrate) regular texture, Regular liquid, and no added salt. R32'S Face Sheet dated 4/9/23 documents R32's has the diagnoses End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus without complications. R32's End Stage Renal Failure Care Plan dated 11/5/23 documents compliance with treatment plan, fluid restrictions, and dietary restrictions. R32's Meal Card does not reflect a Renal, CCD (Consistent Carbohydrate) no salt added diet. For breakfast her meal card documents 4 ounces of ham and potato casserole, sausage links, oatmeal, fresh cantaloupe, rye toast. For lunch the meal card documents garden salad, Italian wedding soup, salami sandwich, potato chips, and frosted vanilla cupcake. On 8/29/24 at 3:30 PM, two CNA's (Certified Nursing Assistants) were on the 200 hall with meal cards asking the residents what they want to eat for dinner. V11, CNA stated I'm sorry I don't know what a renal diet is. I couldn't tell you. I know she is diabetic. V12, CNA stated a renal diet means you should watch their salt and fluids. On 08/30/24 at 9:25 AM, V13, Assistant Manager/Day Shift [NAME] stated you limit potatoes, tomatoes, and bananas. I give them what they order on their ticket, which usually shows different choices for the renal diet. (the diet card does not show different choices for the renal diet.) On 08/30/24 at 9:35 AM, R32 stated a renal diet is when you eat less salt. I can have tomatoes; potatoes and I only eat one banana. R32 had a bag of potato puffs lying on her bed. R32 stated that's my snack for dialysis. My kids give me that. The Facility policy titled Therapeutic Diets dated 1/2017 documents: A therapeutic diet must be prescribed by the resident's attending physician. The Physician's diet order should match the terminology used by food services. Page 1 of 3 145993 145993 08/30/2024 Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the Facility failed to ensure the dish machine had the chemical level required for effective sanitation and failed to store food in accordance with professional standards for food service safety. This has the potential to affect all 70 residents residing in the Facility. Findings include: 1. On 8/27/24 at 12:02 PM, V5, Dietary Aid, removed a tray of dishes from the dish machine after the cleaning cycle was completed and placed the tray next to the machine on the clean side of the machine. V5 then placed a tray of dirty dishes in the machine and began another cleaning cycle. When the wash cycle began, V5 placed a sanitizer test strip in the dish water reservoir on the front of the machine. V4, Dietary Manager, was in the room and stated, Not yet prompting V4 to wait before attempting the test. V5 waited until the final rinse cycle began, then placed the strip in the reservoir. The test strip did not change color and remained white. V4 stated the dish machine was tested earlier that morning. On 8/27/24 at 12:15 PM, V4, Dietary Manager, brought a different test strip package into the dish room. She stated they were the sanitizer test strips, because the other strips were not working. V4 placed a test strip in the reservoir during the final rinse cycle. The strip turned light orange which correlated to 100 ppm (parts per million) on the test strip package. V5 stated it was supposed to be 200 ppm. On 8/27/24 at 12:21 PM, V4, Dietary Manager, stated she located a different kind of test strip, because they should be turning purple. V4 placed the strip in the water reservoir during the final rinse, and the strip remained white. V4 stated she would call the maintenance technician who comes monthly, because there is not much sanitizer coming out of the tubing during the rinse. 2. On 8/27/24 at 12:12 PM, There was a box of uncooked pork loin fritters on a shelf directly above a box of cookie dough. There was a box of uncooked beef loin fritters on a shelf directly above another box of cookie dough. There was a box of uncooked beef Philly steak that was placed on top of a box of pizza dough. There was a box of frozen uncooked shrimp on a shelf directly above a box of nutritional shakes. On 8/27/24 at 12:40 PM, V4, Dietary Manager, stated I was thinking it would be ok (to store uncooked animal protein on higher shelves) since they're frozen. On 8/28/24 at 2:30 PM, V1, Administrator, stated she was unable to find the dish machine specifications and may have to order a new user manual. On 8/30/24 at 9:45 AM, V2, Director of Nursing (DON), stated she expects dietary staff to follow all dietary policies. The Facility's Undated Dish Machine Operation Policy documents, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Check the dishwashing machine 145993 Page 2 of 3 145993 08/30/2024 Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many each morning before first set of dishes are to be washed. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. If a chemical sanitizer is used, check the concentration using the correct test tape for type of sanitizer in use. The Facility's Undated Food Storage (Dry, Refrigerated, and Frozen) Policy documents, Guideline: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/27/24 documents there are 70 residents living in the Facility. 145993 Page 3 of 3