Health inspection·March 3, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure the dignity of four (R1, R5, R6, R8) residents out of five residents reviewed for dignity in a sample list of nine residents. Findings include: 1.) R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. This same MDS documents R6 as requiring moderate assistance for mobility and transfers. R6's Careplan initiated 11/27/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as moderately cognitively impaired. This same MDS documents R5 requires moderate assistance for mobility and transfers. R5's Careplan dated 10/4/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. On 3/3/24 at 10:20 AM V2 Director of Nurses (DON) stated V4 (R1's) family member was yelling at V19 Social Service Director (SSD). V2 stated V19 SSD came to get V2 DON to help resolve V4's concerns. V2 stated V2 and V19 both walked back to the nurses station on E hall where V4 was waiting. V2 stated V4 (R1's) family member was yelling and using the 'F' word. V2 stated (V4) said 'I can't believe this F******(expletive) place.' and using other profanities. V2 stated (R5, R6) were both sitting in their wheelchairs next to the nurses station 'about a few feet from (V4)'. V2 stated (V4) had her finger out and pointing within an inch of (V19's) face and was yelling, screaming, using the 'f' word multiple times and was just hysterical. V2 stated V2 told V4 to calm down because [NAME] needed to be subjected to that kind of language. V2 stated I was trying to calm (V4) down but nothing was working. Then (V1) walked up and escorted (V4) over to a private area where she could vent her concerns. On 3/3/24 at 11:25 AM V19 Social Service Director (SSD) stated V4 (R1's) family member was screaming and yelling at staff. V19 stated V4 was upset that R1 had not gotten his recliner yet. V19 stated (V4) was pointing fingers, yelling and saying 'this f******(expletive) place' and this is 'b*******(expletive)' with (R5, R6) sitting a few feet from (V4). (V4) was out of control. (V2) Director of Nurses (DON) witnessed (V4's) behavior. On 3/3/24 at 12:05 PM R6 stated R6 has known V4 'all his life'. R6 stated (V4) has always cussed and ranted about everything. That is just the way (V4) is. Of course I heard everything (V4) said. I Page 1 of 6 146046 146046 03/03/2024 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0550 Level of Harm - Minimal harm or potential for actual harm was sitting right next to (V4). The staff all thought (V4) was cussing, yelling and pointing her finger at me. I told them '(V4) is p***** (expletive) off at you not me'. That will be one for my journal. (R6 laughing). R6 denies concerns of being abused but stated I don't think it is right (V4) yell and carry on like that in front of other residents. That is no way to conduct yourself in public. Residents Affected - Some 2.) R8's Minimum Data Set (MDS) dated [DATE] documents R8 as severely cognitively impaired. R8's Physician Order Sheet (POS) dated March 2024 documents R8's physician ordered diet as Low Concentrated Sweets (LCS), Mechanical soft, ground mechanical minced and moist texture with thin liquids. On 3/2/24 at 12:50 PM R8 sitting at dining room table eating lunch. R8 had poured cup of red juice over lunch meal which consisted of ham slices, mixed vegetables, boiled yams and chocolate pudding. R8 was using his spoon to try to eat the juice soaked vegetables while dripping liquid onto lap. Facility staff in dining room watching R8. No facility staff offered to help R8 or offer to get another plate of food for R8. On 3/2/24 at 12:51 PM V16 Certified Nurse Aide (CNA) stated (R8) always does that. (R8) always makes a mess. We (staff) just let him eat it like that. On 3/3/24 at 10:30 AM V2 Director of Nurses (DON) stated R8 has behaviors sometimes. V2 DON stated the staff should help R8 if R8 allows them to help. V2 stated The staff should have at least tried to help (R8). They could have gotten (R8) another plate. (R8) is very focused on food and he would not like the staff removing his food but if you had more food to replace it with, then I think (R8) would be ok with that. That is definitely a dignity issue. I will inservice the staff on making attempts and monitoring more closely. 3.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 as being dependent on staff and total body mechanical lift for transfers and maximum assistance for dressing, personal hygiene and eating. R1's Physician Order Sheet (POS) dated March 2024 documents a physician ordered diet of Low Concentrated Sweets (LCS), regular texture and thin liquids diet. This same POS documents medical diagnoses of Paraplegia, Urine Retention, Muscle Weakness, Anemia, Type II Diabetes Mellitus, Colostomy, Need for Assistance with Personal Care, Epilepsy and Epileptic Syndromes. R1's Careplan documents an intervention dated 2/26/24 which instructs staff R1 requires limited assistance of one person for eating. On 3/2/24 at 12:10 PM R1 sitting in recliner chair in room. R1's lunch tray was on food cart outside R1's room with mixed vegetables, yams and chocolate pudding sitting on tray. R1 was attempting to use both hands to feed himself a slice of dry looking ham in between two pieces of bread. R1's sandwich fell into R1's lap directly on R1's hospital gown due to R1's lack of coordination of fingers/hands. R1 attempted to pick up the three pieces of food to reassemble his sandwich and dropped it a second time. R1 stated Oh I give up. I am just going to throw this away. I can't eat it by myself and [NAME] will help me. They (staff) didn't even leave me a napkin. Sometimes they (staff) treat me like a toddler. On 3/3/24 at 10:45 AM V2 Director of Nurses (DON) stated facility staff should have stayed to help 146046 Page 2 of 6 146046 03/03/2024 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R1 until R1 was finished with his lunch meal. V2 DON stated (R1) has had a recent weight loss because of his refusals to eat and general decline in health. (R1) has been considering hospice lately due to his own decline in health. The staff should be doing everything we can to help him eat. We (facility) like to let the resident do as much as possible but then the staff should step in and help. It makes me sad that (R1) has to go through that. That is another dignity issue for certain. We (facility) will be re-training our staff to make sure they are assisting residents as needed with meals. The undated Illinois Long Term Care Ombudsman Program Residents' Rights Facility Handout documents the facility must treat residents with dignity and respect and must care for the resident in a manner that promotes the resident's quality of life. 146046 Page 3 of 6 146046 03/03/2024 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to report an allegation verbal abuse of two (R5, R6) residents out of four residents reviewed for Abuse in a sample list of nine residents. Findings include: The facility policy dated 2022 titled 'The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure' documents individuals must report alleged violations, whether it was oral or in writing, to the Administrator or other designated facility representative and the facility must report the alleged violation to the State Survey Agency. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. This same MDS documents R6 as requiring moderate assistance for mobility and transfers. R6's Careplan initiated 11/27/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as moderately cognitively impaired. This same MDS documents R5 requires moderate assistance for mobility and transfers. R5's Careplan dated 10/4/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. The facility was unable to provide an Initial or Final Report to the State Agency of an allegation of verbal abuse towards R5 and R6 by V4 at the facility on 2/27/24 to the State Agency. On 3/3/24 at 10:20 AM V2 Director of Nurses (DON) stated V4 (R1's) family member was yelling and using the 'F' word. V2 stated (V4) said 'I can't believe this f******(expletive) place.' and using other profanities. V2 stated (R5, R6) were both sitting in their wheelchairs next to the nurses station 'about a few feet from (V4)'. A minute or so later (V1) walked up and escorted (V4) over to a private area where she could vent her concerns. I did not report this incident to (V1) because I thought he would have heard all the yelling. On 3/3/24 at 11:25 AM V19 Social Service Director (SSD) stated (V4) was pointing fingers, yelling and saying 'this f******(expletive) place' and this is 'b*******(expletive)' with (R5, R6) sitting a few feet from (V4). I thought (V1) overheard (V4's) yelling and using foul language in front of (R5, R6). I did not report (V4's) yelling and using profanity in front of (R5, R6). I probably should have reported this to (V1). On 3/3/24 at 11:40 AM V1 Administrator stated I was not aware that (V4) was yelling and using profanity in front of other residents (R5, R6). I knew (V4) was upset so I went to the area on E hall to talk to her. I did not realize (V4) had been acting that way in front of other residents (R5, R6). I only found that out today (3/3/24) during the interview with (V19) SSD. I will get this incident investigated and reported to the Illinois Department of Public Health (IDPH). 146046 Page 4 of 6 146046 03/03/2024 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to serve foods that are palatable to four (R1, R2, R4, R7) residents out of five residents reviewed for meal services in a sample list of nine residents. Residents Affected - Some Findings include: 1.) R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact. On 3/2/24 at 12:15 PM R7 sitting in a wheelchair in room with lunch tray on bedside table in front of him. R7's lunch plate held two slices of dry ham, a small portion of mixed vegetables, a small portion of yams and a small portion of chocolate pudding. R7 stated The food is awful. This ham is so tough and dry. I can't even eat it. I tried to cut it with my fork but couldn't get through it. I guess I will just pick it up and see if I can rip it apart with my teeth. Wish me luck. It is like a hockey puck. This is what I guess prison food is like. 2.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. On 3/2/24 at 12:10 PM R1 sitting in recliner chair in room. R1's lunch tray was on food cart outside R1's room with mixed vegetables, yams and chocolate pudding sitting on tray. R1's mixed vegetables were very bland/dull looking and yams were small light brown pieces with no liquid present. R1 was sitting in room attempting to feed self a piece of very dry ham between two dry looking pieces of bread. R1 stated his sandwich was very hard to eat because the ham and bread were so dry and hard to chew. On 3/3/24 at 9:35 AM R1 stated The food isn't very good. That ham yesterday was so dry. Most days I cannot identify what the food is. There is no color to anything. Everything just looks grey. I know they (facility) can't do anything about the flavor because a lot of people can't stand any spice but it would be nice to have the flavor of the food itself. When I taste something, it should taste like whatever it is. If you blindfolded me, I would not be able to even say if I was eating a fruit, a vegetable or meat. The meat is always very dry and hard to chew. Most of time, I just don't eat it because it is too much work. 3.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. On 3/2/24 at 10:40 AM R4 stated I am the president of the resident meetings. The other residents say every month that the staff are really good here. The big problem is the food. The residents do complain about the food all the time. It is really bad. I mean really, really bad. There are days I don't eat because the food is so terrible. It is either burnt or cold or both. The meat is always very tough, especially the pork and chicken. 4.) R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. On 3/2/24 at 9:00 AM V8 Dietary Aide stated (R2) got a burned sausage patty today for breakfast. I put it on (R2's) plate to be served. I saw it and it was black and burned. It got thrown out because (R2) complained about it and couldn't eat it. (R2) complains a lot about the food. On 3/2/24 at 9:30 AM R2 stated The food is terrible. They (facility) served me burned sausage this 146046 Page 5 of 6 146046 03/03/2024 Marshall Rehab & Nursing 410 North Second Street Marshall, IL 62441

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some morning. I got a sausage patty that looked like it just came from a house fire it was so black and hard. I couldn't even bite it. I don't know how you can call yourself a cook and serve that garbage. On 3/3/24 at 12:10 PM V13 Dietary Manager provided lunch meal which consisted of Swedish meatballs, butter noodles and cooked spinach. The Swedish meatballs were minimally covered in a thick brown/grey colored gravy that had a glue like consistency. The butter noodles were extremely soft, clumped together and difficult to separate. V13 Dietary Manager stated Our (facility) lunch doesn't look very appetizing today. We (facility) are struggling in my kitchen. Some of that is because the vendors change all the time or the staff is new and do not know how to cook yet and also because I don't have my Certified Dietary Manager (CDM) yet. Once I can get some staff trained and get my CDM then we will do much better. V13 Dietary Manager stated the residents should not be served burned foods. V13 stated the foods served should look appetizing and should taste palatable 'within reason'. 146046 Page 6 of 6